Seems like I will have to start with a common thread amongst my early followers. We work or have worked in the local crisis unit or psychiatric emergency room. Personally and professionally this was such a rewarding experience. There are too many people to name who I enjoyed working with and shaped my clinical skills. Professionally this was a great place to work and gained experience in other areas. Working for a year and half, 40 + hours a week in psychiatric emergency room was an exhausting but valuable experience.
Looking back at I believe every social worker should do some sort of rotation through a psychiatric emergency room setting. Granted it there are some excellent social workers who have not, but this is how it has enhanced my ability to do good clinical work.
1) Be able to do a really good mental status exam and assessment. Doing mental status exams over and over again gets you in the mindset of knowing when someone is at baseline or not. If they are not at baseline then you are aware it is time for something to happen differently. You also begin to think on your toes about assessing and asking questions about all aspects of clients lives.
2) Understanding the criteria and circumstances for inpatient admission. When working in the community, I always thought “why can’t I get this out of control kid in the hospital?” Inpatient admission has to be a departure from the baseline, where they can’t take care of themselves and/or a danger to self, others, or property. There is a lot of gray area’s but having that debate with others on the team furthered my assessment and intervention skills.
3) Working with other disciplines and providers. Mainly working directly with nursing, psychiatrists, and ER doctors there were disagreements (but most of the time agreement) about what should happen with a patient. You learn a lot about the “medical model” of caring for others. Either they “met criteria for admission” or they did not. There was often controversy but from this came an understanding of the system. These debates helped in thinking critically about interventions and preventing admission. It often provided an opportunity to educate families and patients about the admissions process. You also learn A LOT about psychiatric and medical diagnosis and medicines. Knowledge of what BID (twice a day) or QHS (once at bed time) means a lot as a mental health clinician.
4) Sitting with emotional pain when people are at their worst, listen and attempt to instill a sense of hope. 8 years ago I was sitting with parents witnessing their 22 year old son experience his first psychotic break. The look of desperation, sadness, and confusion about what was happening still is with me. It was an honor to attempt to sit with them; listen and respectfully educate them what was happening and how we could help. People in crisis situations do not always invite you in. Consider working with someone in crisis as privilege to listen and instill hope.
5) Keeping perspective. Doing foster care prevention certainly made me feel lucky with what I have. Doing crisis work really makes you appreciate what you have. The amount of homeless and chronically mental ill individuals with no family or any supports is astounding. When stressed, take a step back, and be thankful what you have.
6) The importance of self care. This true no matter what the setting, but this is where I really learned to do it. Not having a specific caseload helped me “turn off” for the day. It was good practice for the community based settings that followed. Make sure that you are taking care of yourself and ready for the next day.
7) Last but not least, maintain as sense of humor. This is again true of every setting, but working in such close quarters with such intense issues you laugh, get angry, and sometimes cry with co-workers. Make sure people are laughing (appropriately) with each other. We were good at this in every setting I worked in but time for laughter is critical.
I would encourage everyone to talk with their supervisors about these issues. If you have not had the opportunity to work in an emergency psychiatric setting, find out if you can. Even it is just for a few hours just to sit in on a few assessments. I think clinicians (no matter what the discipline) should spend at least 2 weeks working in psychiatric ER setting. I think it will enhance your experience and provide a lot of the above (and more) teachable moments.
