The Full Informed Consent: Visiting the Psychiatric Emergency Room

“If you or your child is having a psychiatric emergency, please hang up and call 911 or go to your closest emergency room.” Virtually all mental health providers feature this statement in their voicemail recordings. They also recite it when “safety” planning for acute psychiatric emergencies related to suicide, aggression, and other out of control behaviors. Prominent organizations like the National Alliance for Mental Illness and the American Academy of Child and Adolescent Psychiatrists recommend these options as the surest way to promote safety and prevent further harm. But this unanimous messaging betrays the inequitably distributed dangers and harms embedded within the mental health crisis continuum of care.

Calling 911 and going to the closest emergency room pose multiple risks for trauma and oppressive violence from start to finish. Though some communities have the option to contact mental health crisis teams, for many calling 911 means involving police. Police encounters are known to be criminogenic, traumatizing, and otherwise damaging to children’s health wellbeing. The tragic deaths of Daniel Prude and Ma’Khia Bryant demonstrate how police involvement during crises can be fatal, brutalizing Black people for their suffering and distress, insead of offering the succor and support they or their loved ones were seeking. 

The risk of coercion and violence continues when children arrive in the emergency room. When previously working in these settings, I observed that children of color were far more likely to be brought in by paramedics restrained, meaning their arms and legs were physically tied down or they were forcibly injected with sedatives. Paramedics would inevitably adultify children of color, calling them “male” and “female,” rather than “child,” “boy,” or girl.” They were frequently disengaged, surveilling these children rather than reassuring them they would be ok. White children, by contrast, would be brought in unfettered and covered in a warm blanket, engaged in playful banter, described to emergency room staff as “a good kid,” and presented as deserving of care rather than punishment. These observations are not anecdotal. A slew of recent papers indicate that Black children and adults are more likely to be secluded and restrained in various healthcare settings and described using pejorative language that biases their care. Though intended to be an option of last resort, seclusion and restraint are often invoked as an option of convenience, weaponized as instruments of racist violence against people of color misperceived to be dangerous, rather than worthy of protection. Injuries and broken bones are not unheard of, and the emotional toll of being tied down or subdued is immeasurable. 

Additional sources of harm in the psychiatric emergency room include being subjected to urine drug screens (often without consent), being warehoused for days or even weeks waiting on inpatient beds that never open up, and children being placed side by side with adults experiencing health emergencies that are developmentally inappropriate for them to witness. This last category relates in part to the nature of emergency room settings, which are chaotic and understaffed. Distressed and panicked school-aged children may lay in beds in the hallways (rather than rooms) severel feet away from delirious elderly adults whose genitals are exposed (through no fault of their own) without any kind of adult supervision present. Children may also witness an adult being tied down in restraints in the midst of their own psychiatric emergency. When I witnessed such adverse events happening and requested staff move the children to more peaceful, protected spaces, they often resisted by commenting “oh it’s ok, they’re used to it”--as if the child has been conditioned to be impervious to the violence. Clearly this iatrogenic harm is not named or seen. 

“If you or your child are having a psychiatric emergency, please hang up and call 911 or go to your closest emergency room” should–at the very least–be replaced by “If you or your child are having a psychiatric emergency, the standard of care is to recommend that you hang up and call 911 or go to your closest emergency room.” And this standard of care is problematic. Though the Joint Commission regulates the use of seclusion and restraint, it does not require or oversee practices to prevent racism and abuse. Mental health providers are not mandated to explain these risks as part of their professional code of ethics. Nor are they required to forewarn of their “right” to make decisions infringing upon civil liberties and parental rights during psychiatric emergencies, allowing them to be agents of state violence (by calling police or reporting to child welfare). These oversights raise serious concerns about whose “safety” is being preserved when mental health providers blindly tell children and families to call 911 or go to the emergency room during crises.  

What to do?

Families can protect themselves–first by understanding the risks of calling 911 and going to the emergency room up front and seeking providers who have the expertise to weigh those risks carefully with them. Accessing liberating mental health care treatment from affirming, antiracist providers can prevent emergencies from happening in the first place. Finally, connecting to family members and community supports can create safety nets beyond psychiatric emergency rooms when urgent situations arise. I often tell people, there is the trauma of life and then there is the trauma of mental healthcare. The first kind often cannot be avoided. However, the second category offers more freedom to choose.  

Parenting Tip: When commencing a child's mental healthcare journey, ask your provider: “Can you please tell me what to do during a psychiatric emergency for my child? Can you explain the risks and benefits involved with hese interventions? How do you determine whether the benefit of calling 911 and going to the emergency room outweighs the risk of further violence and trauma? Do you determine whether the benefit outweighs the risk?”

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