Patients with acute psychiatric symptoms often present at the Emergency Department triage. “Psych patients” are frequently identified as one of the main groups involved in violent behaviour in the Emergency Department.
Because of their unpredictable behaviour — often lashing out without displaying obvious signs of distress or frustration — these patients are assessed by staff as being extremely dangerous. The combination of clinical urgency and behavioural volatility creates a uniquely demanding scenario for ED teams.
Why Emergency Departments Struggle with Psychiatric Patients
Patients with psychiatric illness can create serious problems for Emergency Departments, which often lack the nursing or physician expertise to manage psychiatric presentations effectively. Psychiatric patients respond better to a special, therapeutic environment that is generally quiet and controlled.
Emergency Departments are not quiet and are not controlled. They are the loudest and most chaotic departments in the entire hospital, and they do not offer the best environment for patients who are struggling to maintain control in the face of psychosis or dementia.
EDs are the loudest and most chaotic departments in all of the hospital and do not offer the best environment for patients who are struggling to maintain control in the face of psychosis or dementia.
Holleran, quoted in Violence in the Emergency Department, Patricia B. Allen
The Extended Wait Problem
If a hospital does not have an in-patient psychiatric service, a patient waiting for psychiatric admission often waits in the ED for an extended period of time — until a qualified professional can evaluate and admit the patient, or locate a secondary referral source.
Additionally, because of the decreasing availability of psychiatric resources, the use of EDs for medical clearance before individuals are jailed is on the increase. This trend contributes further to the potential for violent patient behaviour in the ED.
⚠️ Warning: Extended wait times for psychiatric patients in a chaotic ED environment are a known risk multiplier for violent incidents. Every hour of waiting in overstimulating conditions increases the likelihood of behavioural escalation.
Building Effective Team Responses
It is well known that patients experiencing an acute psychotic episode or similar degree of arousal can be extremely difficult to manage — particularly if they are attempting to cause harm to themselves or others.
Training in de-escalation, conflict communications, and appropriate physical intervention and restraint should help remedy this situation. The key is improving cooperation between team members during an intervention, whether verbal or non-verbal. When staff share a common language and protocol for managing these incidents, team effectiveness increases through better coordination and technical control of the situation.
Programmes such as Verbal Defense and Influence provide structured frameworks for conflict communication that are directly applicable in the ED context. Combined with physical intervention training, they equip teams to respond proportionately and safely.
💡 Key takeaway: Consistent, team-wide training in both verbal de-escalation and physical intervention skills dramatically improves coordination and safety during psychiatric emergencies in the ED.
About the Author
Gerard O’Dea is a conflict management, personal safety, and physical interventions training consultant. He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes, and the European Adviser for ‘Verbal Defense and Influence’ — a global programme which addresses the spectrum of human conflict.