A single session therapy model for the psychiatric emergency

A single session therapy model for the psychiatric emergency

Often in the¬†workshops on SST we are asked this question “But can Single Session Therapy be used for the treatment of serious psychopathological disorders?”

With today’s article we will try to answer this question by presenting the¬†Single Session Therapy¬†model¬†for psychiatric emergency¬†applied in the¬†Psychiatric¬†Denver Health Medical Center¬†, in particular in the¬†Psychiatric Emergency Services¬†of the¬†Department of Behavioral Health¬†in¬†Denver¬†in¬†Colorado¬†.

How is the crisis recognized and the trigger identified in Denver’s Emergency Psychiatric Service?

The model uses the¬†concept of crisis¬†as a framework for the¬†assessment¬†and¬†treatment¬†of psychiatric emergencies, assuming that a crisis occurs when a person’s usual¬†coping skills¬†are not adequate to deal with stressful life events.¬†The crisis can therefore arise in different circumstances:

  • may be precipitated by¬†medical illness¬†or¬†interpersonal conflicts¬†;
  • anxiety¬†,¬†depression¬†,¬†feelings¬†of feeling overwhelmed¬†, or¬†suicidal ideation¬†may also occur in patients with a brief history of psychiatric treatment and a high level of functioning;
  • it can occur in patients with¬†primitive¬†coping skills¬†and with somatizations;
  • may refer to worsening of symptoms in patients with¬†chronic psychiatric illness¬†(e.g. increased suicidal ideation in patients with borderline personality disorder).

 

How does Single Session Therapy work in this intervention context?

Single -session therapy leverages the crisis model to help patients and providers understand the origins of the emergency department ( ED ) visit and begin to actively resolve the crisis. This intervention may be delivered by emergency physicians or behavioral health counselors , including social workers or nurse practitioners . Patients most likely to benefit from this therapy are those who have experienced fewer life-long stressful events and who have better functioning and greater psychological insight.

 

What objectives and intervention actions does it pursue?

The goals of this intervention include ameliorating anxiety and depressive symptoms , initiating treatment , and identifying patients who may need to be referred for more intensive psychiatric treatment. These steps and their therapeutic benefits are summarized in the points listed below:

  1.  Recognize the crisis and identify the triggers

Patients presenting to the ED report a range of psychiatric symptoms including anxiety , depression , fatigue, or poor sleep . After ruling out a somatic etiology of psychiatric symptoms, the clinician must clarify the onset of symptoms. Once the patient is admitted, a history of stressors is written together with himthat led to the crisis. This technique is very valid as it allows patients to be encouraged to remember and reconstruct a useful story. Furthermore, the chronology is easy to interpret for both doctors and patients who in the act of writing together, build a therapeutic relationship which in turn will be part of the healing process.

  1. Differentiate the patient’s response

The emotional and behavioral responses of the patient in the crisis state are considered a guide for treatment.

  • The¬†emotional response¬†is often easily described by the patient:¬†stressed¬†,¬†overwhelmed¬†,¬†anxious, or lonely¬†.¬†The clinician can validate the emotional state by viewing it as a response to the obvious stressors described in the timeline.
  • Behavioral responses¬†are¬†characterized by¬†immobility¬†,¬†avoidance¬†, or¬†adaptation¬†.¬†Patients who are immobile and avoidant need help identifying the trigger of the crisis and possible solutions, and being unable to show more adaptive skills may require specialist assistance in psychiatry.
  1. Formulate the assessment together with the patient

Once the chronology of the triggers of the crisis and the patient’s response styles has been written, the clinician¬†formulates the assessment of the crisis aloud with the patient,¬†asking himself the following questions:¬†What are the triggers?¬†How do they make the patient feel?¬†What does the patient need to deal with the crisis?¬†What choices are available?

The conversation turns out to be both¬†diagnostic¬†and¬†therapeutic¬†.¬†The patient may feel relief from an expert’s explanation of the reason for their discomfort.¬†The clinician validates the severity of the patient’s stressors while offering optimism and active problem solving.

  1. Identify behavioral goals and offer concrete support

The clinician helps the patient generate a to-do list to resolve the crisis . Goals should be specific , realistic and achievable in the near future. Patients with more ambitious goals (for example, feeling better) should identify intermediate steps that are specific and achievable.

Solution-focused thinking can be introduced by asking,¬†‚ÄúIf things were going well in your life, what would things look like in four weeks?‚Ä̬†This conversation invites the patient to anticipate potential barriers to crisis resolution and also to begin anticipating discharge from the ED.

  1. Engage social media

Crisis patients often report having no one to help them when supportive friends or family members are available. A hub-and-spoke diagram is used to help the patient identify people close to him who can help him resolve the crisis . In the diagram, the patient is at the center of a wheel and people are placed around the spokes of the wheel. Support people are connected to the hub with a solid line and less supportive contacts are connected with a dotted line.

 

Below is an example of a treatment carried out in Psychiatric Emergency Services in Denver.

An 18-year-old young woman is brought to the ED following her mother’s call to 911 after the girl told her over the phone that she wanted to die.¬†Her mother lived in another country.¬†Upon arriving at the service, the girl was in tears and was¬†‘very stressed’.¬†From the initial medical examination (vital signs check, urine toxicology screen and pregnancy test) there were no notable items.¬†However, the girl had reported having suicidal thoughts for about a week due to failing grades in college, family conflicts and financial obligations.¬†She had missed several appointments with her therapist and the doctor recently missed her on sertraline (Zoloft) which she had run out of.¬†She also refused to give her mother’s phone number.

The girl had described a history of abuse at a young age. She had previously had a psychiatric hospitalization for a suicide attempt at age 15. Other episodes of self-harm started at age 10. Her grandmother had been diagnosed with schizophrenia and she had only minimal contact with her father.

Concerned about multiple risk factors for suicide, the emergency psychiatrist began¬†a one-session psychotherapy¬†, during which he¬†and the patient wrote a timeline of stressful events prior to admission.¬†Ten months earlier, she had had to leave her apartment due to conflicts with roommates.¬†Early in college, she worried about tuition and found two jobs.¬†Despite several attempts to reschedule therapy appointments, the therapist’s office had not returned her calls.¬†The patient had also disclosed that there was a supportive stepfather who lived nearby.¬†On the morning of her ED visit, she had received another reminder about her tuition bill and prior to her admission she was discussing it with a roommate that she couldn’t work out with, so she had called she mother of her.

During the session , the psychiatrist and the patient shared what had been stressful for her. The girl changed her mood and identified some immediate goals to pursue:

  • find a new therapist;
  • talk to his school about a scholarship;
  • identify a tutor;
  • spend more time doing what she enjoyed.

The girl then agreed to have her mother called to help her complete these tasks. The mother in turn had already spoken to the school for help with lessons and started looking for new outpatient supports.

To complete discharge planning, a nurse made an appointment for the patient at an outpatient clinic, and the family was advised of local emergency resources. Simultaneously the patient completed a written safety plan and was offered a follow-up call .

Within an hour¬†, the psychiatrist¬†had assessed¬†that this patient’s acute risk was significantly mitigated through¬†safety planning¬†, mobilizing¬†social¬†supports ,¬†linking treatment¬†with local outpatient clinics to justify discharge.¬†After six months, the young woman had persistent remission of suicidal thoughts with no recurrence of self-harm or hospitalization.

 

Conclusions

This article and the brief psychotherapy case described above highlight how Single Session Therapy can be specifically applied in particular emergency settings , focusing on active problem assessment and resolution . Furthermore, it can be seen that this method of intervention is well suited to multi-session intervention models created for integrated care. Specific single-session psychotherapies have also been described for other psychiatric conditions including insomnia , gambling , agitation , and suicidal ideation .

 

Angelica Giannetti
Psychologist,
Team Psychotherapist of the Italian Center
for Single Session Therapy

 

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