Interacting With the Mental Health Crisis Victim

When a crisis or life-altering event occurs in a person’s life, they typically call 9-1-1. Why? Because who else, at 3 a.m., is willing to rush over and lend a helping hand? The EMS provider is skilled at wearing multiple hats—being not only a medically trained paramedic or EMT but also a counselor who listens and gives life advice, a social worker who recommends assistance in elderly care, a handyman who changes out smoke detector batteries, a chef who can fix a diabetic a sandwich post-insulin shock, a pseudo-family member suggesting a course of medical action, a friend when someone is just lonely and a grief counselor for survivors whose loved one has just died.

EMS providers are jacks of all trades in the field of medicine. We are trained in cardiology, pulmonology, gastroenterology, neurology, gerontology, pediatrics, trauma and pharmacology. However, very little of our training is in mental health or psychology. 

Out of 72 specific primary provider impressions derived from NEMSIS criteria between 2011–2015, behavioral/psychiatric was the second-most-used primary impression for providers, trailing only traumatic injuries.¹ In 2015 data analyzing primary provider impressions, approximately 15% of EMS patient contacts related to substance abuse (alcohol and drugs), overdoses and behavioral/psychiatric cases.¹ The data that was analyzed for behavioral cases saw an increase from 16,511 contacts in 2011 to 40,572 EMS encounters in 2015¹—an increase of 146%.

According to the Centers for Disease Control and Prevention, suicide is the 10th-leading cause of death in the United States, and between 1999 and 2014, there was an increase of 24% from 10.5 to 13 per 100,000 population.² In 2013 there were 494,169 emergency department visits for self-inflicted injuries.³ Of students in grades 9–12, 17% seriously considered suicide, 13.6% made a plan to commit suicide, 8% attempted suicide more than once, and 2.7% attempted suicide that caused an injury, poisoning or overdose.³ 

With one out of every five persons suffering a mental illness event every year, it is highly probable that EMS will encounter a patient whose problem lies outside our traditional curriculum.⁴ EMS data is notoriously hard to decipher, and we truly have a hard time pinning down how frequently we respond to calls that have a mental health component. Consider that those also include the times we have to notify a shocked family member of an unsuccessful resuscitation or dead-on-arrival situation. The percentage of encounters in which we are the first line of dealing with a person’s mental and emotional psyche is probably a lot higher than our data truly shows. 

Psychological and Mental Health First Aid 

There is no formal EMS training in what to say or not say as an impromptu counselor to a freshly grief-stricken widow or an all-hope-is-lost middle-aged man with a noose hanging from the rafters. When the call comes for an intoxicated 17-year-old girl who has vomited all over her designer top and thinks her life is ending because of how traumatic it currently is, how can an older male paramedic relate and intervene helpfully in her crisis?

Without proper training such as Psychological First Aid (PFA) or Mental Health First Aid (MHFA), EMS providers must rely on their life experience to effectively intervene and provide initial counseling. And that initial counseling is important: “Assistance provided by public safety personnel during the first 1–3 hours of the crisis is often more significant in terms of overall crisis than much of the help which is provided by hospital staff and counselors.⁵ Being able to deescalate a situation is crucial, and using the incorrect words or phrases can aggravate a patient into shutting down or, worse, becoming agitated or violent. Our goal on every encounter is to do no harm, but our words, tone and body language can have a negative effect on patients if we’re not aware. 

Psychological First Aid “consists of a systematic set of helping actions aimed at reducing initial post-trauma distress and supporting short- and long-term adaptive functioning.”⁶ PFA has its roots in World War II military debriefings, but the term was coined by the National Child Traumatic Stress Network (NCTSN) and National Center for PTSD (NCPTSD) and gained recognition following the terrorist attacks of Sept. 11, 2001. Skills taught in PFA include what to look for in someone in need of intervention; how to position your body; what to say and not say; recommendations for immediate action; and long-term care advice. 

PFA addresses five core elements: safety, calming, connectedness, self-efficacy and hope.⁷ It’s largely geared toward victims of disasters; however, disasters do not strike as frequently as people attempt suicide or tragically lose a close friend or family member. 

Mental Health First Aid (MHFA) “teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders.”⁸ The training provides the skills to offer initial support and help to a patient developing a substance abuse, mental health problem or crisis. MHF was developed in Australia in 2001 and is now taught in several states as well as other countries. 

Training such as PFA and MHFA is useful for EMS and other first responders because paramedics, EMTs, firefighters, law enforcement and other such personnel often reach victims within the first 1–3 hours after a crisis hits. This window of opportunity is crucial in preserving the psychological well-being and shaping the short- and long-term mental recoveries of the patient or family member. Recognizing how valuable EMS is during this time provides added value to our profession.

Putting It Into Practice

PFA revolves around eight key action areas to help those we encounter: 

• Contact and engagement, 
• Safety and comfort, 
• Stabilization, 
• Information gathering (i.e. current needs and concerns), 
• Practical assistance, 
• Connection with social supports, 
• Information on coping, and 
• Linkage with collaborative services.⁹ 

Here are some useful techniques and tools EMS can use in some of these areas to help engage potential mental health, substance abuse or just plain difficult patients.

Contact and engagement—Enter the room or area in a nonthreatening way. This means one or two crew members make contact—not all three, four or five we normally use to run a call. Once in eyesight say hello, ask the patient’s name, and state your name and who you are. Feel out the situation and work on developing a nonthreatening rapport. If it’s appropriate, ask whether you can sit down either near or next to them so you’re at eye level. 

Start the conversation about them; use an icebreaker topic to begin, then work your way into discussing the situation at hand. Communicate that you are there to help and ask whether they would like to share or talk. It is crucial that we use our listening skills, not outtalk them and push them deeper into a hole. Sometimes silence and patience is better at first, and once the patient feels they can trust you, they will lower their walls. Make the patient feel like they have some control over themselves and their destiny. In addition, early in your encounter, ask whether they have any needs—a blanket if they’re cold, water or food if it’s been a while since they’ve eaten. It’s amazing how a granola bar and coffee can transform an ornery patient into a cooperative one. 

The final thing is to explain the process in a nice way, ask whether they have any questions and do your best to modify plans to meet any requests you can. Sometimes it requires intense negotiations to get them moving to the gurney, and sometimes we might have to make accommodations for it to happen. Use good judgment and never risk crew or patient safety. For example, if a patient refuses the gurney, find out why—maybe they just don’t want to lie down. Use a wheelchair or show them how you can raise their head. Make good on your promises and never lie, even about things that have nothing to do with your encounter. They will remember and, if ever in a similar situation, never trust us again. 

Safety and comfort—Find ways to provide for the patient’s immediate safety if they were exposed to a dangerous environment. If they are injured or sick, provide proper care. This is not the time to teach a lesson to an adolescent who ingested too much alcohol; if it is indicated in protocol, give an antiemetic and possibly some fluids. Find ways to provide comfort measures: Use a familiar blanket, let them hold on to their purse or bag (once it’s been cleared for weapons or other harmful objects), get them into a warm or cool ambulance. If they have children, find out where they are and either let them see their children or communicate whom their children are with and that they are safe. 

Find out their fears and concerns and do your best to get those questions answered. If you don’t know an answer, reach out to someone who does. Our patients most likely are aware we don’t have all the answers, especially if we haven’t left their side. If a patient sees you relay a question to someone else, then return to them with an answer, it builds trust and confidence that you’re seeking to meet their needs, not just making stuff up that they want to hear. 

If there is bad news, use discretion in revealing it. It might be best to have a counselor at the hospital deliver it. Use statements such as, “We’re still determining what happened, and once we find out we’ll let you know.” It is important to stop any exposure to their trauma, provide privacy and avoid or remove trauma reminders, including sights, sounds or smells that may trigger fear.⁹ If you must deliver bad news, try doing it a bit at a time.¹⁰ “Giving painful news in measured doses helps the person hearing it adjust to it and sustain the least amount of psychological and physical damage.”¹⁰ 

Using words like dead, death, died or fatal is better than euphemisms like passed on or no longer with us. If you and your patient have religious backgrounds, don’t be afraid to go down a religious route with them—it may be comforting. If they don’t have religious beliefs, though, don’t impress yours. 

If you are dealing with a fatality, give them the choice to be with the body.¹⁰ Consider describing what they might see and be open to them touching or even kissing the body. Be close for support but let them have the final interaction. If it’s a crime scene, discuss this with law enforcement first so as to not interfere with a criminal investigation. If your system allows you to cover the body, ask the family member whether they have a favorite blanket they would like to use for it.¹⁰ When dealing with grief, try not to say things such as, “I know how you feel,” “It’s for the best,” “They are in a better place now,” “It was their time to go,” “Everything happens for a reason,” etc.⁹ Be caring to the individual and refrain from telling your stories to them. Remember, people don’t care how much you know until they know how much you care. 

Stabilization—At times we encounter people so shocked or overwhelmed they are either overly emotional or completely disengaged. Is there a friend or family member who can be by this person’s side to help calm or talk with them? Speak quietly and try to remove such patients from noisy areas. If it’s safe, try a one-on-one approach instead of having the entire crew with you. If the person is crying, provide tissues. 

Try not to say “calm down” or “feel safe,” but instead ask about what’s bothering them and whether they’d like to talk about it. Give them time to get through it. Mental health cases are not like STEMIs, strokes or trauma activations, where we need to be off scene in 10 minutes; rather, plan to be on scene for 30–45 minutes or up to an hour if needed. This can be difficult in busy systems, but notifying your supervisor about the delay and turning down your radio can help foster patience and give the person a chance to calm down. This creates a safer working environment. 

We are walking billboards, with our patches on our shoulders and huge banners on the sides of our ambulances. Losing our patience with difficult patients and forcing them to the gurney to be wheeled out kicking and screaming is not the best customer service approach and should be avoided if possible. And, barring threats to crew or patient safety, definitely avoid the use of restraints and chemical sedation on a patient who can be talked down. If we can remain calm and collected, we can deescalate most of our agitated or emotional patients. 

Information gathering—As time permits, dig into more of the patient’s concerns and find ways to obtain information that will be helpful to them down the road. Pass this on directly to the patient if possible, or perhaps to hospital staff, so they can connect the patient with the proper social support. Just dropping off a patient at the ED with a brief history and a “your problem now!” does nothing to help the patient and may continue the cycle that brought you to this encounter, leading to similar encounters down the road that could have been avoided.

Practical assistance—Once we have discerned the patient’s or individual’s needs and concerns and found an avenue to assist them, it’s time to come up with the plan. Involving the patient or individual is crucial because it gives them a say and sense of power over their own destiny. With difficult patients, we may have to limit their options to maintain our control over the situation; however, we get more cooperation from patients when they are directly connected to a plan. Even if there is no other option for them, at least they know what the plan is and can ask questions. 

Connection with social supports—In the emergency setting this can be a little out of our realm. The Red Cross is a great resource; you can also activate a trauma intervention support team or chaplain services if you have them. Simple steps such as showing emotional support by placing your hand on their shoulder or arm, being a sympathetic ear and allowing them to feel accepted are ways EMS providers can assist.

Another way to help is by reassuring them of their self-worth and that they are important and needed. Give them a sense of hope and that there is light at the end of the tunnel. Find a safe way to communicate to the patient that perhaps they can use this experience to help someone in their same shoes. Below are some phrases we can use to model support in such an interaction:⁹

• “From what you’re saying, I can see how you would be…”
• “No wonder you feel…”
• “It sounds really hard…”
• “It is such a tough thing to go through something like this.”
• “I’m really sorry this is such a tough time for you.”
• “What have you done in the past to make yourself better when things got difficult?” 
• “Are there any things you think would help you feel better?”
• “People can be very different in what helps them feel better. When things get difficult for me, it has helped me to [fill in the blank]. Do you think something like that would work for you?”

Applying It in Real Life

Let’s look back at the 17-year-old intoxicated girl who feels her life is collapsing around her. My medic ambulance was dispatched to a local hotel for a girl like this. We found her sitting on the ground vomiting outside the building. The engine company was first on scene, along with two police officers who began the initial patient contact and assessment. Upon our arrival I was met by the engine paramedic, who told me the girl had been at a birthday party, ingested a significant amount of alcohol and began vomiting. Now she was unwilling to talk and unable to stand up. 

It was a chilly winter night, and the girl was not dressed appropriately for the weather. Being outside, with vomit covering her designer top and skirt, she was obviously cold and shivering. Recognizing this, I knelt down to her level, introduced myself and placed two blankets around her. I advised her of the process we were going to follow to get her into the back of our warm ambulance and help her start to feel better. 

Once inside the ambulance, she was still verbally locked down like Fort Knox. I told her I was going to start an IV in her arm, and as I opened up her left hand to look for a vein along her forearm, I noticed what looked like old cutting scars. I looked up to her face and said, “Life has been pretty tough for you, hasn’t it?” She cocked her head in my direction and whispered, “Yes, it has.”

I proceeded to ask her if she had something she’d like to talk about, and she whispered back, “I do.” Recognizing that this was an opportune time to employ PFA training, I initiated the crisis intervention and said, “I’m here to listen when you’re ready to share.” I also asked her if she was warm enough and comfortable on the ambulance gurney. 

In my mind I knew I had nothing in common with this girl and was thinking, How hard could her life really be? She’s only 17 and from the looks of it has a great family and lives in a wealthy suburb. I myself have experienced difficult life events, lost friends and family members tragically, been handed dead babies to revive, been a part of horrific scenes. But then again, I do not know her life and have never walked in the shoes of a 17-year-old girl. For all I know, her life may have been hell. But from that point on she started to open up and talk about the events that led up to this night and her current situation. 

Silence Can be Golden

The key to success with this patient was gaining her confidence and showing genuine concern. I knelt down to her level, introduced myself and told her I was there to help. I provided basic needs for her comfort: warm blankets and a warm environment. I assured her she was safe and I was going to help her feel better. I recognized that what she was going through was real and gave her the opportunity to open up if she wanted to. From there I listened and tried to give her hope in my answers. 

Trying to force someone to open up just makes them shut down even more. Sometimes silence is the best approach if a patient refuses to talk.

PFA and MHFA teach EMS providers how to be empathetic and provide a safe environment for those experiencing a crisis situation. The EMS provider can apply these skills to every patient encounter, not just crisis events.  

References

1. Colorado Department of Public Health and Environment. State EMS Volume by Primary Impression for Incidents 2011–2015. Prepared by the EMTS Branch, Nov 2016.
2. Curtin SC, Warner M, Hedegaard H. Increase in Suicide in the United States, 1999–2014. Centers for Disease Control and Prevention, National Center for Health Statistics, NCHS Data Brief No. 241, https://www.cdc.gov/nchs/products/databriefs/db241.htm.
3. Centers for Disease Control and Prevention. Suicide: Facts at a Glance—2015, https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.
4. National Alliance on Mental Illness. Mental Health Facts in America, https://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf.
5. Resnik HL, Mitchell JT. Emergency Response to Crisis. Englewood Cliffs, NJ: Prentice Hall, 1986. 
6. Ruzek JI, Brymer MJ, Jacobs AK, et al. Psychological First Aid. J Mental Health Counseling, 2007 Jan; 29(1): 17–49.
7. Shultz JM, Forbes D. Psychological First Aid: Rapid proliferation and the search for evidence. Disaster Health, 2013 Aug 2; 2(1): 3–12.
8. Mental Health First Aid. About, https://www.mental healthfirstaid.org/cs/about/.
9. Brymer M, Layne C, Jacobs A, et al. Psychological First Aid Field Operations Guide, 2nd ed. National Child Traumatic Stress Network, National Center for PTSD; https://www.nctsn.org/sites/default/files/pfa/english/2-psyfirstaid_final_no_handouts.pdf.
10. Dietz T. Scenes of Compassion: A Responder’s Guide for Dealing with Emergency Scene Emotional Crisis. Ellicott City, MD: Chevron Publishing, 2001.

Additional Resources

• For more information on Psychological First Aid: https://www.nctsn.org/content/psychological-first-aid. 
• For more information on Mental Health First Aid: https://www.mentalhealthfirstaid.org/cs/. 

Matt Concialdi, MS, NRP, is a paramedic in Golden, Colo. He started his EMS career in 2000 and has worked in urban, suburban and rural 9-1-1 systems. He has additional experience as an educator and member of a federal disaster response team and spent time as the EMS system development coordinator for the Colorado Department of Public Health and Environment.