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This chapter looks at how emergency services in general, and psychiatric emergency services specifically, operate within hospitals and mental health systems without ever being fully integrated into either. It examines the pressures exerted on emergency departments (EDs) and the structural incentives under which they operate, many of which create unintentional barriers to optimal treatment of people in psychiatric crisis. Finally, the chapter provides a statistical snapshot of EDs and psychiatric emergency services today, and evaluates some of the most popular prevalent assumptions about the uses and abuses of EDs: that poor people use EDs for non-urgent medical needs; that most users of ED services are uninsured; and that EDs are a focal point of liability, especially in the case of suicidal patients. The research in the field, including the detailed statistical reports produced annually by the National Center for Health Statistics, shows that the first two assumptions are incorrect; surveys of case law show a more complex and ambiguous picture about ED liability issues.

This chapter summarizes the principal complaints that people with psychiatric disabilities voice about their treatment in emergency departments (EDs). These include use of force by security guards and/or emergency room professionals; discrimination against people with psychiatric disabilities by ignoring or minimizing their medical complaints; facing lack of respect and even hostility when seeking emergency care; and delays in emergency room treatment.

This chapter looks broadly at two different kinds of solutions to the problems discussed in this book: the development of alternatives to the use of emergency departments (EDs) by people with psychiatric disabilities, and the improvement and modification of current standards and practices used by general hospital EDs and psychiatric emergency services. The first part of the chapter describes a number of alternatives currently in use around the country, from mobile crisis units to family foster homes and crisis hostels, with practical emphasis on how they are funded, and research regarding their effectiveness. The second part of the chapter discusses proposed solutions to most of the problems discussed earlier in the book relating specifically to ED treatment of people with psychiatric disabilities. In addition, it delineates a number of very specific proposed standards and recommendations that, if adopted, would go a long way to improving the care received by people with psychiatric disabilities in ED settings.

This chapter delineates federal and state legal and regulatory requirements governing the treatment of people with psychiatric disabilities, covering questions such as to whom the laws apply, what standards they impose, and what questions arise uniquely in the context of emergency department (ED) treatment of people with psychiatric disabilities.

This introductory chapter begins with a brief discussion of the common complaints that people with psychiatric disabilities have about their treatment when they are in crisis. It then outlines the purpose of the book, which is to analyze the treatment of people with psychiatric disabilities in emergency department (ED) settings. An overview of the subsequent chapters is presented.

This chapter considers the difficulties that administrators, physicians, nurses, psychiatrists, and other emergency department (ED) staff experience in the treatment of people with psychiatric disabilities. These include accreditation and evaluation systems that create incentives that undermine appropriate psychiatric evaluation and treatment; the lack of standards in emergency room practice; financing emergency room care; and lack of continuity between emergency rooms and community care.

This chapter steps back and examines the factors that make the treatment of people with psychiatric disabilities different from medical patients in emergency department (ED) settings. In addition to the mandate to assess and involuntarily detain certain people with psychiatric disabilities — a mandate that does not extend to medical patients — another difference is the issue of the secondary utilizer of the ED. “Secondary utilizers” include the family members, police officer, or service provider who brings an individual to the ED — often against that individual's will — to solve a family problem or social conflict. Sometimes this happens at night, when regular treatment and service providers are not available. Sometimes the service providers seek a quick solution to a difficult problem by taking a client to the ED. In this way, the availability of EDs may contribute to inappropriate utilization individually and on a larger social level. Emergency departments provide cover for inadequate social service agencies suffering from budget cuts that make it difficult or impossible to provide the preventive and crisis stabilization services, medication, or sometimes just the reassurance and company that individuals in psychiatric crisis need. Thus, the larger solution to some ED problems must come from outside the hospital. At the same time, there is much that hospitals can do to improve their treatment of their patients with psychiatric disabilities without larger social change, and some hospitals are leading the way.