In Response: A Practical Approach to the Assessment and Management of Psychiatric Emergencies

I would like to respond to the article e n t itled " A Practi ca l Approach to the Assessment and Management of Psychiatric Emergencie s" (Jefferson J ournal of Psychiatry, Vol. 7:8 I -9 1, 1989). The au thors are to be co ngratulated for their concise distillation of the major clinical problems encountered in emergency psychiatry. However, there are several aspects of this r eview which require further amplifica t ion and clarification . The authors tend to emphasize drug therapy. While d rug treat ment is an integral part of emergency psych iatry, an understandin g of th e psychodynamic issues related to violence, su icide, an d adjustment disorders ca n frequently facilita te a psychologica l rein tegration fo r the patient and reduce or obvia te the need for med ica t ion . Furthermore, in the treatment of personal ity d isorders, substance abuse patients and depressed and/or suicida l patients, and ge riatric emergencies, timely family intervention by enlisting the help o f th e pat ien t 's support network ca n frequently atten uate the emergency, minimize med ication and avert hospital izat ion. T he irony of emergency psychiatry is th at like a ll emergency med icine, the em phasis is generally placed on rapid intervention and disposi tion. Paradoxica lly in emergency psych iatry, "tincture of time" is o ften a power ful tr ea tment intervention. Obviously, the abi lit y to em ploy psych o therapeutic interventions is dependent on space and staff availability. Specifica lly addressing severa l issues raised by the authors, I was curiously struck by the sta te ment that " the psych iatrist should never tak e part in any pat ient restrain t, but rather g ive orders an d d irect the action ." It is no t quite clear to me why psychiatrists shou ld never take part in any patient restraint. T here is no ev idence to ind icate that such interventions would di srupt a therape ut ic rela tionsh ip. Assuming that a psyc hiatrist is knowledgeabl e in restrain t procedures and adept at th is techniq ue , I bel ieve that th e psychi at r ist should active ly invol ve him/hersel f since part of his /her task is to rol e-m odel approp riate treatment interventions fo r o ther staff. At o ther times, th e psychiatrist may in fact be th e most ill-equipped member of a team to give orders and di rect ac tio n and frequently psych ia tr ic tech nicians or nursing staff are more experienced and skillfu l in restra int procedures. I think that the invol vement of