Training The Emergency Medical System And EMTs In Solution-Focused Crisis Interventions

Emergency Medical System, EMS professionals, handle tens of millions of calls in the United States each year and make life-altering patient decisions daily. Embedding solution-focused crisis interventions within EMS services who already work 24/7 within the medical and mental health system provides an opportunity to mitigate the mental health system crisis. Training EMS providers in Solution-Focused brief crisis interventions have the potential to deliver greater access to mental health services while conserving healthcare resources. Solution-Focused Brief Therapy has been applied successfully across a wide range of professions and fields, in a transdisciplinary manner, for a broad range of mental health conditions (Beyebech, M. et al., 2021). Specially trained paramedics have effectively employed triage algorithms to screen and select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities (Mackey & Qiu 2019). In this article, we are proud to share a conversation of 2 Emergency Medical Technicians, EMTs, who have successfully integrated solution-focused brief crisis interventions within their daily work. Interviewing these two dedicated and talented professionals working on the front lines of the healthcare system was a privilege and highlighted the incredible work EMTs do every day to serve communities around the nation!

The United States is in the midst of a mental health workforce pandemic. The mental health workforce is a key component of mental health care quality, access, and cost. The quality of mental health care is influenced by the skills of the people providing the care. Access to mental health care depends on appropriately skilled providers being available to render treatment. EMS professionals, with little to no training in mental health, are already providing emergency mental health triage and response. EMS practitioners provide much more than transportation while earning a median income of $17.00/hour, $35, 360 a year. They are left out of the medical system feedback loop when delivering patients to the ED, never learning the outcome of their patients, what they did successfully, or gaining learning opportunities for how to improve. EMS professionals endure a high rate of occupational violence that is about 22 times higher than the average for all other U.S. workers. As EMS professionals continue to be undervalued, their work has never been more important, especially in light of their service during the Covid-19 pandemic.

In recent years an ever greater number of patients find themselves seeking care for psychiatric illnesses in the emergency department (ED). 6-10% of ED visits present for psychiatric illness. These visits weigh heavily on the ED system. Patients with psychiatric illnesses occupy 42% more time than non-psychiatric visits. A survey of 1400 ED directors by the American College of Emergency Physicians (ACEP) found 79% having psychiatric patients boarding in their EDs with 62% reporting that no psychiatric services occur while patients are boarding in the ED. Even when services are available, there are prolonged waiting times to see clinicians. ED boarding carries a high-cost burden. In 2017, mental and substance use disorder emergency department (ED) visits had service delivery costs of more than $5.6 Billion, which represented more than 7% of the $76.3 billion in total ED visit costs (Karac & Moore 2020).

911 dispatchers are often the first point of contact after an individual is in an accident, needs emergency assistance, or witnesses a crime. A lack of high-quality training was identified by emergency service call-takers and dispatchers as contributing to increased stress levels. 911 Call Takers must be further trained to navigate police, fire, and medical emergencies, with an ever-increasing focus on crisis intervention and training. They must also be further trained in identifying and allocating the proper resources and services based on the call information that they receive.

Due to the complexities in managing many patients experiencing mental illness, according to a recent Atlanta Journal article, patients are often charged with crimes, typically “nuisance crimes” and include anything from disorderly conduct to trespassing. This often results in arrest and jail for their mental health condition. In most American cities, it is police officers who respond to such calls, an approach law enforcement experts say increases the risk of a violent encounter because they aren’t always adequately trained to deal with the mentally ill. In 2017, police officers spent 21% of their time responding to or transporting people with mental illness, according to preliminary data from a survey of 355 U.S. law enforcement agencies. At least one in every four people killed by police has a serious mental illness, according to the Treatment Advocacy Center, a nonprofit based in Arlington, Va. Basic training for U.S. police officers takes 21 weeks, on average, and rarely includes training on bias, de-escalation of tense situations, recognition of psychiatric symptoms, or mental health first aid techniques. Bringing a uniform and a weapon to the scene creates a power dynamic that is not in the best interest of either party. Even when officers undergo training in these areas, research demonstrates that it is not effective. In the United States, a police encounter with a civilian is 16 times as likely to result in that person’s death if they have an untreated mental illness when compared to someone who does not. (Rafla-Yuan et al., 2021)

Ultimately a cohesive transdisciplinary mental health system that embraces EMS practitioners within the existing mental health system is one intervention that would help address the catastrophic failures of the mental health system. Training EMS providers who already give 24/7 community triage and response interventions in solution-focused brief crisis interventions could help divert patients away from emergency rooms to other more effective and appropriate community provider locations. As can be seen from this interview, EMTs specially trained in mental health emergencies have the potential to strengthen workforce diversity and competency successfully making a difference for all patients, including those experiencing mental health conditions.

Beyebach, M., Neipp, M.-C., Solanes-Puchol, Á., & Martín-del-Río, B. (2021). Bibliometric differences between weird and non-weird countries in the outcome research on solution-focused brief therapy. Frontiers in Psychology, 12. 

Hoge, M. A., & Hirschman, R. (1984). Psychological training of emergency medical technicians: An evaluation. American journal of community psychology, 12(1), 127.

Jacobs, G. A., Gray, B. L., Erickson, S. E., Gonzalez, E. D., & Quevillon, R. P. (2016). Disaster mental health and community-based psychological first aid: Concepts and education/training. Journal of Clinical Psychology, 72(12), 1307-1317.

Karaca, Z., & Moore, B. J. (2020). Costs of emergency department visits for mental and substance use disorders in the United States, 2017: statistical brief# 257.

Mackey, K. E., & Qiu, C. (2019). Can mobile integrated health care paramedics safely conduct medical clearance of behavioral health patients in a pilot project? A report of the first 1000 consecutive encounters. Prehospital Emergency Care, 23(1), 22-31.

Rafla-Yuan, E., Chhabra, D. K., & Mensah, M. O. (2021). Decoupling Crisis Response from Policing — A Step Toward Equitable Psychiatric Emergency Services. New England Journal of Medicine, 384(18), 1769–1773. https://doi.org/10.1056/nejmms2035710 

Riaz, I., Gal Lapid, E. M. T., Mihir Kumar, E. M. T., Trivedi, R., & Sulley Park, E. M. T. (2021). Creating a Protocol for Campus EMS Response to Mental Health Complaints. JCEMS, 4.

Waters, R. (2021). Enlisting Mental Health Workers, Not Cops, In Mobile Crisis Response: The article examines local programs that send health crisis workers and emergency medical technicians, rather than police, to people experiencing serious mental health distress.