Stress: a pervasive dilemma in psychiatric emergency care.

This paper (1) identifies a number of broad social-situational forces which have had stress producing impact upon the treatment climate and procedures of the psychiatric emergency setting. (2) describes several of the major effects of these factors both on patients and on the emergency Unlt, (3) applies a person-environment fit (or “mis-fit”) perspective in conceptualizing the stress-related problems illustrated by examination of the repeating patient as a high misfit group and (4) Suggests several recomendations to help increase the “goodness of fit” between the needs, motives and resources of the patient and of the emergency unit and staff E mergency: urgent necessity; sudden or unexpected occurrence requiring prompt attention; crisis state. Psychiatric emergency cases are, quite literally, defined and characterized by urgent need and stressful conditions. The frequently ambiguous, covert, and complicated nature of the psychiatric component renders these crises all the more difficult to manage and to alleviate. Such cases, perhaps more than any other, would best benefit from an environment which fostered a calm, quiet, thorough exploration of the individual’s troubles. The common irony, however, is that the hospital emergency room environment typically operates quite antithetically to this, actually being constituted by a variety of influences which are likely to have a negative impact on patient behavior and patient care.’ The characteristic “charged atmosphere” of the emergency setting is most saliently evident in the pervasive sense of time pressure.? Emergency staff put a high premium on “cool speedy care” which translates into assessment, intervention, and disposition being administered as quickly as possible with minimal disruption.’ While the reasons for this emphasis on speed and brevity are themselves neither trivial nor contrived, the cumulative effect for psychiatric cases is an exacerbation of the patient’s condition,4 a perception by the clinical staff of their work as “onerous and unrewarding,“5 and an overemphasis on overt symptomotology rather than on problem precipitants and dynamics in diagnosis and disposition.0 Furthermore, the problem tends to fuel itself. That is, the greater are the patients’ need states, the more taxed is the limited time resource, the more perfunctory becomes patient care. and the more strained becomes the interpersonal environment for all involved. Thus, not only is the presence and effect of debilitating stress in a variety of forms a common dominator across settings, but across treatment provider and recipient as well. Some of these issues are simply an inherent part of psychiatric emergency care. Evidence indicates, however, that the hospital emergency room as a psychiatric emergency care setting has experienced a rapid and substantial transformation over the past decade and a half. The patchwork approach which has typified efforts to From the School of Social Work and Institute for Social Research University of‘ Michigan. Address reprint requests to Paula S. Nurius. Ph.D., 5237 ISR, Univercity of Michigan. .4nn .4rhr1r. MI 48109. (St I984 by Grune & Stratton. Inc. 0010-440X/84/2503-0(112$01.1)0/0 Comprehensive Psychiatry, Vol. 25, No. 3, (May/June) 1984 345