Abstract

This qualitative research study explores the lived experiences of twelve Licensed Professional Counselors (LPC’s) that have experience (greater than one year) in facilitating and evaluating suicidal patients in the emergency room ER setting. The ER presents a challenging environment for LPC’s to make a connection with suicidal patients (SP). The LPC`s experiences is at the core of psychiatric care and critical to positive client outcomes. Ultimately, the purpose is to collapse individual experiences into a common description of a universal phenomenon.This study will utilize a phenomenological qualitative research design. This study provides insight into the experiences of counselors in ER settings. Information was obtained from narratives provided by the counsellor. The use of phenomenological questions in this study may help gain insights into the role of the counsellor in an emergency situation and suicide prevention/interventions in an ER setting through narratives of the counselors.

Keywords: Licensed Professional Counselor LPC’s, suicidal ideation, phenomenology, qualitative research.

Chapter 1: Background of the Study

A suicidal patient is a person trying to escape from unbearable life circumstances and unable to find a way to live with life in its present form (U. S. DHHC, 2006). Despite efforts to understand the complexity of suicide, experts have found it impossible to predict if a person will actually commit suicide (Alexander, Klein, Gray, Dewar & Eagles, 2000; Jacobs & Brewer, 2004; WHO, 2010). The ultimate goal of suicidal ideation assessments and interventions is to reduce the risk of someone who may act on suicidal thoughts.

The experience between the suicidal patient and a professional assessing the immediacy of treatment and type of treatment needed is very important to both parties. It is vital for clinicians to be prepared to offer care congruent with that person`s needs and to help function more effectively with life circumstances. However attempting to carry out these services can also provoke a crisis for the helper, triggering fears of making a mistake and provoking feelings of helplessness and uncertainty (Echterling, Presbury & McKee, 2005). LPC’s working with clients in crisis report common physical and psychological stress reactions, ranging from anger, shock, confusion, and insomnia to burnout, demoralization, and vicarious traumatisation (Trippany, Whitekress & Wilcoxon, 2004).

A review of the literature reveals that counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma (Goldstein, 2007). A study in Finland (Suokas, Suominen & Lonnqvist, 2009) examined the experiences of the ER psychiatrists, nurses, and counselors. The findings from the study reveal the general tendency among the ER staff to view attempted suicide patients positively and sympathetically. According to the American Association of Suicidology Task Force Report (Kleespies, 2009), training is needed for those who work with suicide risk assessments and decisions about care. A study in Korea (Sang, Seong, Kissinger & Ogle, 2010) examined the typology of burnout among professional counselors working in the ER. The study suggests that counselors may not immediately recognize burnout and disconnect with the patient and this could increase the likelihood that the counselor will devalue the story that is being presented by the client.

Today, there is also greater recognition of the challenges that crises present to the helping professional. In the midst of a mental health emergency, the counselor must manage multiple tasks rapidly assessing an unstable and potentially dangerous situation, responding in a clinically sound and ethical manner and ensuring the safety of everyone involved (Corey, Haynes, Moulton & Muratori, 2010). Clinical supervision may mitigate the risks associated with providing crisis services. By offering emotional support and guidance, supervisors can help LPC’s to safely manage a hazardous situation, resolve the situation positively, and solidify their professional identity (Corey, Haynes, Moulton & Muratori, 2010; Dupre, 2011).

Purpose of the Study

The purpose of this study is to explore the lived experience of twelve LPC’s that have experience (greater than one year) in facilitating and evaluating suicidal patients in the ER setting.

LPCs who works in the ER must learn to deal with the pressure of time, intensity of affect, disruptiveness of certain behaviors, need for rapid assessment, pressure for a decision, legal and ethical aspects of decisions about dangerousness, and need for interdisciplinary consultation. The purpose of this study is to gain a better understanding of the experiences of LPC’s who evaluate suicidal patients in ERs in order to determine the need for debriefing or other interventions for the counselor and the need to develop a training curriculum in the United States. The purpose of this study is to explore the experiences of LPC’s while providing interventions to suicidal patients in the ER. Furthermore, this investigation will examine the daily experience of interactions and strategic interventions that the clinicians have used when evaluating suicidal patients.

Few studies in the United States have been found examining the effects of suicide assessments and interventions on counselors. Counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma (Currier, 2009). At times, professional counselors take time to recognize the burnout and with the patient, thus making the help accorded less meaningful. A problem is present when there is inadequate counseling for suicidal patients. According to Bore and McCann (2009), suicidal patients in the ERs do not get the full counseling that is required because of lack of expertise in the ER. This situation may create a repeat occurrence among suicidal patients. Suicidal cases in the dynamic world are on the increase and with continuous efforts, more and more about suicide is being learned and emphasis should be placed on the prevention of repeated suicide cases. It is for this reason that a study is needed to examine the experiences of LPC’s who work in ERs in the United States.

Significance of the Study

The study explores the input of experiences by professional counselors in the treatment of suicidal patients in the ER setting. Many LPC’s will experience a client suicide in their career (Lafayette & Stern, 2004; McGlothlin, Rainey & Kindsvatter, 2005; Strom-Gottfreid & Mowbray, 2006). It is one of the most stressful incidents, if not the most stressful incident that may happen to a mental health professional (Alexander, 2007; Coverdale, Roberts & Louie, 2007; Fang, et al., 2007; Jacobson, Ting, Sanders & Harrington, 2004; Knox, Burkard, Jackson, Schaack & Hess, 2006; Sudak, 2007). There is documentation that counselors who have experienced an actual client suicide reported that they felt unprepared to handle the personal and professional reactions they experienced (Christianson & Everall, 2008; Coverdale, et al., 2007; Fang, et al., 2007; Knox, et al., 2006; Spiegelman & Werth, 2005). This exposes clients, LPC’s and supervisors to a number of hazards.

This investigation uncovers conditions that may help LPC’s manage crisis situations and will identify specific practices that promote counselor growth and effectiveness. The above study is a phenomenological study and such yields a description of the lived experience of the counselors working with suicidal patients. In suicidology, most literature concentrates on the victim and suicide survivors and thus rarely, suicidology is approached from the perspective of LPC’s (Echohawk, 2006). Through phenomenology, the study provides a detailed account of the experience of LPC’s in ER situations. Phenomenology is most appropriate research design for this particular study as through the narratives collected, the researcher is in a position to capture some of the details that form part of the behaviour of LPC’s in ER situations.

This research design also gives LPCs increased autonomy and thus is in a position to give detailed information in regards to some of their experiences with suicidal patients in ERs (Dyregov, Nordanger, & Dyregrov, 2003). Provision of detailed accounts by LPC’s provides a basis from which a researcher is in a position to identify some of the key themes that arise from the narratives. Such themes form the basis for conclusion and recommendations under this particular study. Conclusion and recommendations in this case shall focus some of the mechanisms that LPC’s use in a crisis situation and also some of coping mechanisms that LPC’s use. Therefore, knowledge generated from this particular study is useful to LPC’s in crisis situations where such knowledge improves their ability to cope with ER situations.

Research Design

This study provides insight into the experiences of counselors in ER settings. Information was obtained from narratives provided by counselors. The use of phenomenological questions in this study may help gain insights into the role of counselors in an emergency situation and suicide prevention/interventions in ER settings through narratives of the experiences of counselors.

The purpose of this phenomenological study is to gain a better understanding of the experiences of LPC’s who facilitate assessments to suicidal patients in ERs. During the interview, three open-ended questions were asked using a sequential approach. Subjects were encouraged to freely express themselves (Giorgi, 1997) and include detailed information. This study utilizes a phenomenological qualitative research design. Phenomenology relates to the self reporting where participants report their individual experiences under a particular phenomena. Therefore, under phenomenological research, emphasis is placed on personal interpretation and perspective. Individuals are in a position to report their subjective experience and the researcher is expected to facilitate individual’s self reporting (Moustakas, 1994).

Phenomenological qualitative research design encompasses a variety of data collection methods. These include focus meeting, interviews, conversations and participant observation and as such, the researcher is expected to ensure that he or she identifies the method most appropriate for his or her research (Langdridge, 2007). Under the above form of research design, the researcher should ensure that there is maximum output and also minimum interference. Therefore, the researcher should avoid undue influence that affects the self reporting among the participants.

Moreover, under phenomenological qualitative research design, there is a need for delicate balance between establishing confidence and rapport with the study participants and ensuring that the researcher does not interfere with the process of self reporting (Lester, 1999). Establishment of good rapport is important towards ensuring that all participants provide adequate and correct information on the issues under investigation.

The researcher finds phenomenological qualitative research design relevant to the study as the main purpose of the study is to explore the experiences of licensed professional counselors working with suicidal patients in the ERs. The researcher collected information from licensed professional counselors and as such, the researcher is expected to create rapport with counselors. The counselors provided information related to their experiences while working with suicidal patients in the ERs.

Research Question and Hypothesis

The overarching research question was: What is the lived experience of clinicians during an ER encounter with a patient who are suicidal? The result of this study provides a fundamental understanding of the importance of supervision for LPC’s who evaluate suicidal patients in an ER setting.

The following sub questions guided data collection and analysis:

What have you experienced when evaluating suicidal patientswithin the ER setting?
Which cases amongst all the cases that you have treated, have stood out and made your perception of how to handle suicidal cases change?

3.) How have these experiences shaped your personal& professional life as a counselor?

4.) What type of training, supervision, and follow-up did you receive when completing suicidal assessments and interventions in the ER setting?

Alternative Hypothesis

The results of this study provide a fundamental understanding of the importance of supervision for LPC’s who evaluate suicidal patients in an ER setting.

Assumptions and Limitations

Those concerned with the training of licensed professional counselors and their development have discussed the need for counselors to be able to form clinical judgments based on personal and professional awareness, but this may not necessarily be a part of their training (Stoltenberg et al., 2008). Foster and McAdams note that education and preparation for client suicide attenuates the impact of the suicide, and that weekly supervision is a healthy place to provide preparation and education.

McAdams and Foster (2002, p. 234) conducted a study involving 241 professional counselors. In their survey found that almost one fourth of the respondents experienced the suicide of a client they were treating. The impact of client suicide on counselors can result in severe and long-term consequences. From a review of the literature McAdams and Foster (1999) concluded that client suicide could induce acute reactions in therapists (depression, intrusive thoughts and memories, shock, self-blame, and guilt), anniversary stress reactions to the event and pathological grief reactions. Further, the subjects in their study said supervisory support system was the most useful to them in their recovery process, followed by personal support systems, contact with the surviving family, and education and training. While supervision was reported as the most beneficial intervention after a suicide crisis, subjects said it was the least accessible to them.

A review of the literature reveals that good supervision can protect LPC’s from the deleterious effects of crisis work, reduce the incidence of secondary trauma, and enhance the LPC‘s resolve and self-efficacy (Dupre, 2011; Salston & Figley, 2003). However, crisis supervision is frequently not provided and has not been adequately addressed in the literature. Traditional models of supervision do not meet the specific needs of LPC’s working with clients in crisis. The standard practice of providing one hour of scheduled weekly supervision following a client and LPC interaction is both inappropriate and insufficient during crisis events. Nevertheless, virtually all of the supervision literature is based on that assumption (Hipple & Beamish, 2007). Moreover, very little published supervision research has been conducted that focuses exclusively on the crises that LPC’s encounter working in the field. Studies are typically conducted by university-based counsellor educators, utilizing graduate students as research participants (Crockett, Byrd, Erford & Hayes, 2010). Finally, although accreditation boards, such as the Council for Accreditation of Counselling and Relate Educational Programs, require training in crisis services and supervision, they offer no clear guidelines about supervisory responsibilities or protocols during mental health emergencies.

From a review of the literature on crisis intervention, two conclusions become clear. First, most intervention models are protocol driven. The primary focus of crisis response is seen as taking action rather than – being with survivors. Few scholars emphasize the relational aspects of the work. Second, there is virtually no discussion in the crisis intervention literature about the supervision experiences or needs of LPC’s working with suicidal patients in ER setting.

Definition of Terms

Suicidal patient: an individual who has thoughts of wanting to harm themselves or end their life. Suicidal Survivor: people who have lost a loved one to suicide (Jordan & McIntosh, 2011). Licensed Professional Counselor: A master’s level counselor who is licensed by the State of Pennsylvania to practice in a clinical setting to provide therapy to clients

Expected Findings

Most studies related to suicides focus on the victims and thus little focus is given to the other people involved including suicide survivors and professional counselors. A suicide survivor refers to an individual who experiences high levels of emotional and psychological distress as a result of a suicide (Claassen & Larkin, 2005). While adequate support is provided to suicide survivors, professional counselors who experience high levels of vicarious trauma might not be in a position to access such help.

Counselors just like suicide survivors are affected by the death of their clients. This has both personal and professional consequences and yet, professional counselors are expected overcome such obstacles. Due to the nature of the fast-paced environment of an ER setting, professional counselors may not have enough time to recover from traumatic events. This may affect them in many ways including vicarious trauma and compassion fatigue (Reeves, 2010).

Counselors are expected to identify behavior associated with suicide ideation. However, due to work related factors such as fatigue and vicarious trauma, some of the counselors in ER settings might not be in a position to identify signs and symptoms associated with suicide ideation (Baraff, Janowicz & Asarnow, 2006). Counselors, therefore, might experience secondary trauma as a result of suicides in the ERs (Goldstein & Buongiorno, 1984). This may affect a counselors’ productivity and the ability to predict and prevent suicides in ER settings.

This study provides insight into the experiences of counselors in ER settings. Information was obtained from narratives provided by the counselor. The use of phenomenological questions in this study helped gain insights into the role of counselors in an emergency situation and suicide prevention/interventions in ER settings through narratives of the experiences of counselors. A comprehensive review of the literature regarding Licensed Professional Counselors will be explored in the next chapter.

Chapter Two: Literature Review

Introduction

To provide a context for this dissertation, a review of the literature was conducted to provide a foundation and need for the suggested study. In addition, material describing the evaluation and management of suicidal emergencies and models of service delivery in emergency departments are discussed. The chapter concludes with a discussion of the legal and psychological risks in treating patients with behavioral emergencies, which are heightened for professional counselors who lack the needed training and supervision needed to process and reflect on the challenging daily interactions that LPC’s have with suicidal patients in the ER setting.

Effects of Suicidal Patients upon Counselors

Most studies related to suicides focus on the victims and thus little focus is given to professional counselors (Claassen & Larkin, 2005). While adequate support is provided to suicide survivors, professional counselors who experience high levels of vicarious trauma might not be in a position to access such help.

Due to the nature of the fast-paced environment of an ER setting, professional counselors may not have enough time to recover from traumatic events. This may affect them in many ways such as vicarious trauma and compassion fatigue (Reeves, 2010). Counselors are expected to recognize and assess the risk of behavior associated with suicide ideation. However, due to work related factors such fatigue and vicarious trauma, some of the counselors in ER settings might not be in a position to identify signs and symptoms associated with suicide ideation (Baraff, Janowicz & Asarnow, 2006).

The experience between the suicidal patient and a professional assessing the immediacy of treatment and type of treatment needed is very important to both parties. It is vital for clinicians to be prepared to offer care congruent with that person`s needs and to help function more effectively with life circumstances. However, attempting to carry out these services can also provoke a crisis for the helper, triggering fears of making a mistake and provoking feelings of helplessness and uncertainty (Echterling, Presbury & McKee, 2005). Licensed Professional Counselors who evaluate clients in crisis do report common physical and psychological stress reactions, ranging from anger, shock, confusion, and insomnia. Others include burnout, demoralization, and vicarious traumatisation (Trippany, Whitekress & Wilcoxon, 2004).

A review of the literature reveals that counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma (Goldstein, 2007). The findings from Suokas et.al 2009, study reveal the general tendency among the ER staff to view attempted suicide patients positively and sympathetically. According to the American Association of Suicidology Task Force Report (Kleespies, 2009), training is needed for those who work with suicide risk assessments and decisions about care. A study in Korea (Sang, Seong, Kissinger & Ogle, 2010) examined the typology of burnout among professional counselors working in the ER. The study suggests that counselors may not immediately recognize burnout and disconnect with the patient and this could increase the likelihood that the counselor will devalue the story that is being presented by the client.

Today, there is also greater recognition of the challenges that crises present to the helping professional. In the midst of a mental health emergency, the counselor must manage multiple tasks- rapidly assess an unstable and potentially dangerous situation, respond in a clinically sound and ethical manner, and ensure the safety of everyone involved (Corey, Haynes, Moulton & Muratori, 2010). Clinical supervision may mitigate the risks associated with providing crisis services. By offering emotional support and guidance, supervisors can help LPC’s to safely manage a hazardous situation, resolve the situation positively, and solidify their professional identity (Corey, Haynes, Moulton & Muratori, 2010; Dupre, 2011).

A LPC who works in the ER must learn to deal with the pressure of time, intensity of affect, disruptiveness of certain behaviors, need for rapid assessment, pressure for a decision, legal and ethical aspects of decisions about dangerousness, and need for interdisciplinary consultation. The purpose of this study is to gain a better understanding of the experiences of LPC’s who evaluate suicidal patients in ERs in order to determine the need for debriefing or other interventions for the counselor and the need to develop a training curriculum in the United States. The purpose of this study is to explore the experiences of LPC’s while providing interventions to suicidal patients in the ER Furthermore, this investigation examines the daily experience of interactions and strategic interventions that the clinicians have used when evaluating suicidal patients.

McAdams and Foster (2002, p. 234) conducted a study involving 241 professional counselors and surveyed that almost one-fourth of the respondents experienced the suicide of a client they were treating. The impact of client suicide on counselors can result in severe and long-term consequences. From a review of the literature McAdams and Foster (1999) concluded that client suicide could induce acute reactions in therapists (depression, intrusive thoughts and memories, shock, self-blame, and guilt), anniversary stress reactions to the event and pathological grief reactions.

Theoretical Orientation for the Study

This study is grounded in constructivist self-development theory (CSDT) as described by Lisa McCann and Laurie Pearlman (1990). The proposed research provides critical insights into the lived experience of LPC’s working with suicidal patient assessments and interventions in the (E.R) setting and associated cumulative stress. The general panacea for treating trauma has been focused on treating patients and close relatives experiencing suicide trauma in ER. The overwhelming amount of counseling that LPC’s face in ER blurs their emotional and psychological responses to suicide traumas (Alexander, 2007). Because the study provides a detailed narrative of LPC’s working with suicidal patients in the ER, CSDT can be applied to the experience of these participants. It is anticipated that this theoretical application supports the psychological trauma experienced. Suicide is a serious public health problem, taking more lives worldwide than war and homicide combines (Stolberg, 2002). The U. S. Department of Health and Human Services (2001, p. 2) has also said that suicides account for twice as many deaths than HIV/AIDS. In the United States, suicide is the 11th leading cause of death, resulting in over 32,000 deaths per year (Centre for Disease Control and Prevention, 2007).

Client suicide is thought to be one of the most stressful crisis situations faced by counselors and other mental health professionals (Alexander, 2007; Coverdale, Roberts & Louie, 2007; Fang, et al., 2007; Jacobson, Ting, Sanders & Harrington, 2004; Knox, Burkard, Jackson, Schaack & Hess, 2006; McAdams III & Foster, 2002; Misch, 2003; Sudak, 2007). Strom-Gottfried and Mowbray (2006) report significant consequences in terms of professional and personal reactions to a client suicide, including feeling negligent, alone, and confused. Other commonly reported reactions include shock, guilt, anger, betrayal, shame, feelings of inadequacy and embarrassment (Alexander, 2007; Lafayette & Stern, 2004; McAdams & Foster, 2000; Pilkinton & Etkin, 2003; Ting et al., 2006). Of all the things that counselors are exposed to and have to take action on, the suicide of a patient is the trauma to them, both interpersonally and legally (Sudak, 2007, p. 333). Few counselors escape experiencing the suicide of a patient during their careers. After effects of a client suicide often becomes common knowledge in workplaces such as a community mental health clinic or hospital ER, which may lead to such vulnerability and scrutiny. Many mental health professionals fear being targeted for blame at risk management meetings and fear lawsuits (Tillman, 2006).

Stolberg (2002) suggests there is no single event in psychotherapy that carries more emotional impact on the part of the counsellor as a suicidal crisis (p. 415). In order to be competent and protect themselves and their clients, skills, knowledge, sensitivity, ability, and fortitude on the part of the counsellor are critical. The role of the counsellor can have frightening and have traumatic consequences leading to compassion fatigue. According to McAdams and Keener (2008), the rate of frequency of severe client crises confronting human service professionals has escalated to such proportions that crises have been referred to as an ‘occupational hazard‘ in the professional literature.

This brings to light the importance of being prepared for a client suicide, because the likelihood of experiencing a client suicide is high for mental health professionals Currie, 2009). Licensed professional counselors have the professional responsibility to become prepared to assess and intervene with patients with suicidal ideation in an ER: A review of the literature on this aspect of mental health counselling will broaden our knowledge about crisis by promoting an understanding of how LPC’s understand and experience these events.

The Need for Training Regarding Suicidal Assessments and Interventions

Those concerned with the training of licensed professional counselors have discussed the need for counselors to be able to form clinical judgments based on personal and professional awareness, but this may not necessarily be a part of their training (Stoltenberg et al., 2008). Foster and McAdams (2002) note that education and preparation for client suicide (threats, risks, assessments, interventions) attenuates the impact of the suicide on the mental health counselor, and that weekly supervision is a healthy place to provide preparation and education.

The Need for Supervision Regarding Suicidal Assessments and Interventions

A review of the literature reveals that good supervision can protect LPC’s from the deleterious effects of crisis work such as reducing the incidence of secondary trauma, and enhance the LPC‘s resolve when providing care for suicidal patients and self-efficacy (Dupre, 2011; Salston & Figley, 2003). However, crisis supervision is frequently not provided and has not been adequately addressed in the literature. Traditional models of supervision do not meet the specific needs of LPC’s working with clients in crisis. The standard practice of providing one hour of scheduled weekly supervision following a client and LPC interaction is both inappropriate and insufficient during crisis events. Nevertheless, virtually all of the supervision literature is based on that assumption (Hipple & Beamish, 2007). Moreover, very little published supervision research has been conducted that focuses exclusively on the crises that LPC’s encounter working in the field. Studies are typically conducted by university-based counsellor educators, utilizing graduate students as research participants (Crockett, Byrd, Erford & Hayes, 2010). Finally, although accreditation boards, such as the Council for Accreditation of Counselling and Relate Educational Programs, require training in crisis services and supervision, they offer no clear guidelines about supervisory responsibilities or protocols during mental health emergencies.

From a review of the literature on crisis intervention, two conclusions become clear. First, most intervention models are protocol driven. The primary focus of crisis response is seen as taking action rather than – being with survivors. Few scholars emphasize the relational aspects of the work (Sandler, 2011. Second, there is virtually no discussion in the crisis intervention literature about the supervision experiences or needs of LPC’s working with suicidal patients in ER setting.

Those concerned with the training LPC’s and their development have discussed the need for counselors to be able to form clinical judgments based on personal and professional awareness, but this may not necessarily be a part of their training (Stoltenberg et al., 2008). Foster and McAdams (2002) note that education and preparation for client suicide decreases the impact of the suicide, and that weekly supervision is a healthy enviormanet to provide preparation and education.

McAdams and Foster (2002, p. 234) conducted a study involving 241 professional counselors and surveyed that almost one fourth of the respondents experienced the suicide of a client they were treating. The impact of client suicide on counselors can result in severe and long-term consequences. From a review of the literature McAdams and Foster (1999) concluded that client suicide could induce acute reactions in therapists (depression, intrusive thoughts and memories, shock, self-blame, and guilt), anniversary stress reactions to the event and pathological grief reactions. Further, the subjects in their study said supervisory support system was the most useful to them in their recovery process, followed by personal support systems, contact with the surviving family, and education and training. While supervision was reported as the most beneficial intervention after a suicide crisis, subjects said it was the least accessible to them.

From a review of the literature on crisis intervention, two conclusions become clear. First, most intervention models are protocol driven. The primary focus of crisis response is seen as taking action rather than ―being with survivors. Few scholars emphasize the relational aspects of the work. Second, there is virtually no discussion in the crisis intervention literature about the supervision experiences or needs of LPC’s working with suicidal patients in ER setting.

Statistical Increase in Mental Health-related Emergency Department Visits

Dawe (2004) presents evidence that the number of mentally ill patients presenting at emergency departments is on the rise internationally. Larkin et al. (2005) cite data that confirms that in the U.S. alone from 1992 to 2004, mental health-related visits to emergency departments increased from 4.9% to 6.3%. Several years later, Larkin, Smith, and Beautrais (2008) cite their nation-wide study of 974 million visits to emergency departments in the United States. They found that of these visits, 52.8 million or 5.4% were primarily for mental health problems:

While the annual number of overall ED visits rose 20% over the decade, or an average of 2% per year, the per-person trend for mental health-related visits increased almost 40%, from 17.1 ED visits per 1000 persons in 1992 to 23.6 visits per 1000 persons in 2001…; the corresponding proportion of ED visits due to mental illness increased 28% during the decade, from 48.7 per 1000 ED visits in 1992 to 62.5 in 2001. (p. 74)

Larkin et al. (2009) also conclude that mental-health patients are the fastest growing component of emergency department visits. They suggest that emergency departments are rich sites for training professionals who are entering the mental-health field. Furthermore, these sites can become important for establishing databases to capture data regarding mental health frequent users, substance abusing and substance seeking patients. Models exist for cancer and cardiovascular disease; these can be adapted for suicide-attempt patients as well as substance abuse patients.

Owens et al. (2010) indicate that of the 95 million emergency department (ED) visits by adults in the United States, 12.0 million (or 13%) were mental health and/or substance abuse-related (MHSA, 2010). Their data indicates that of these 12 million patient visits, over 7.6 million visits (or 63% of mental health-related visits or 8% of all visits) are related to mental health disorders alone, 3.0 million visits (or 25% of mental health-related visits or 3% of all visits) are related to substance abuse disorders, and over 1.4 million visits (or 12% of mental health-related visits or 1.5% of all visits) are related to co-occurring MHSA disorders (p. 2). The most common MHSA- related ED visits are for mood disorders (42.7%), followed by anxiety disorders (26.1%), alcohol disorders (22.9%), drug disorders (17.6%), schizophrenia and other psychoses (9.9%), and intentional self-harm (6.6%). Of all MHSA-related ED visits, nearly 41% (4.8 million) “resulted in hospital admission- an admission rate that is over two and a half times that for ED visits related to other [non-MHSA] conditions” (p. 2). This increase in emergency department visits makes preparation for treating these disorders for a student preparing for a career in psychology a must if the profession is to meet the needs of emergency departments in the U.S.

Causes of Statistical Increase in Use of Emergency Departments

Dawe (2004) credits the increase in the use of emergency departments by patients in need of mental-health treatment to “The deinstitutionalization movements of the recent past, along with growing concerns over inappropriate costly hospitalizations” are an area for concern for the ER. “Between 1960 and 1994, the number of U.S. psychiatric beds per capita decreased by about two-thirds; from 4 per 1,000 to 1.3 per 1,000” (Currier, 2009, p. 311). He notes in addition, that the closure of state psychiatric beds was not accompanied by a transfer of funding to community mental health centers.

McPherson (1984) analyzes the problem from a sociological perspective. He states that the changes in urban demographics, psychiatric manpower shortages for the disadvantaged and those in the city, the increase in suicide attempts, and overall budgetary constraints have combined to pressure emergency department mental-health services. Pasic, Russo, and Roy-Bryne (2005) also indicate that demand for emergency department services increased due to deinstitutionalization, limited outpatient resources and an increase in substance abuse. These mental-health related patients also consume more treatment time in the emergency department. Slaby (1981) cites increased use of emergency department services due to “psychosocial and economic factors, including a greater number of older people in the population, lack of physicians availability in the community, patient education, economics and convenience” (p. 306).

Bryne (2005) reports that while mental-health related visits account for about 10% of all emergency department visits, these patients take up about 30% of the provider’s time in emergency departments. Furthermore, he indicates that due to the unpredictability of visits as well as the lack of emergency-skilled counselors, it is difficult to adequately staff an emergency department with skilled staff. Many times an underlying organic illness may not be recognized and the patient may be incorrectly hospitalized on a psychiatric service, thus delaying treatment of the organic disorder.

Therefore, public policy decisions, coupled with increases in the availability of drugs, for which already mentally ill patients are easy targets, increases the amount of pressure on emergency departments. Currier (2009) claims that as a result of this confusion, few descriptive studies of Psychiatric Emergency Services (PES) protocols and procedures and virtually no quantifiable studies of efficacy of various treatment models exist. He notes that the President’s New Freedom Commission on Mental Health (2003) and the Institute of Medicine report on U.S. Departments in the U.S. (2006) do not mention PESs.

Few studies in the United States have been found examining the effects of suicide assessments and interventions on counselors. Counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma. At times, professional counselors take time to recognize the burnout and with the patient, thus making the help accorded less meaningful. A problem is present when there is inadequate counseling for suicidal patients. According to Bore and McCann (1999), suicidal patients in the ERs do not get the full counseling that is required because of lack of expertise in the ER. This situation may create a repeat occurrence among suicidal patients. Suicidal cases in the dynamic world are on the increase and with continuous efforts, more and more about suicide is being learned and emphasis should be placed on the prevention of repeated suicide cases. It is for this reason that a study is needed to examine the experiences of licensed professional counselors who work in ERs in the United States.

Larkin et al. (2005) indicate that while the number of emergency department visits between 1992 and 2001 increased by 20%, the number of emergency facilities nationwide declined by 15%. Since statistics indicate that “record-breaking numbers of patients are seeking emergency services nationwide,” Larkin et al. designed a study to capture the recent trends in mental health visits to emergency departments in the U.S. by using a national probability sample (p. 672). They employed a four-stage sample of visits to non-institutional general and short-stay hospitals, excluding U.S. military, Federal and Veterans hospitals. They collected data over a four-week period and based their collection on three criteria: DSM-IV-TR based major mental health problems; National Center for Health Statistics (NCHS) assigned reason-for-visit classification codes; and injury E codes related to suicide. Based on this four-week study, absolute numbers of emergency department visits were generated by using census-based, NCHS-assigned patient weights rounded to the nearest thousand. Visits were further analyzed by ethnicity, gender, age, and urgency at triage. They conclude that:

At the patient level, a lack of insurance, social support, and alternatives to care, coupled with the convenience of 24-hour accessibility to the emergency department, are major incentives for both the worried well and the acutely psychotic patient to rely on emergency-based care. (p. 675)

Larkin et al. (2005) also indicate that a subset of reasons for the increase in mental-health related visits is due to a number of return visits by the same patient.

A study conducted by Stroul (1993) through the National Institute of Mental Health (NIMH) and subsequently by the Center for Mental Health Services (CMHS) defines the goals of crisis services as well as a description of the various modes of treatment for severe mentally ill patients developed by profiling 69 different communities across the U.S. The three major goals defined by this study are:

Stabilizing clients in crisis in order to assist them to return to their pre-crisis level of functioning,
Assisting clients and members of their natural support systems to resolve situations that may have precipitated or contributed to the crises, and
Linking clients with services and supports in the community in order to meet their ongoing community support needs. (p. 1)

The study finds five major components of service delivery for patients with severe mental illness. The first is crisis telephone service that provides 24-hour intervention and screening. Next is a walk-in crisis service that provides face-to-face assessment and crisis intervention; third is a mobile crisis team that provides intervention on an outreach basis. Fourth is a residential, non-hospital service that allows the client to re-stabilize and return to the community. Finally, the fifth component is a psychiatric crisis unit that provides inpatient assessment and treatment. The study indicates that these five components should not be provided in isolation but should be coordinated in order to provide the most appropriate care for a patient in the least restrictive setting.

Of the 69 communities responding, 68% represent mental health centers and 84% provide emergency services through a separate unit. The type of crises represented, several of which overlap, are: long-term mental illness (36%); depression suicide (29%); situational (17%) substance abuse (19%); and other (17%). The results of the study conclude that the qualifications of staff for these programs included prior experience on a crisis staff and significant work with substance abuse, children and/or adolescents, and suicidal clients. The staff should be highly credentialed and must be willing to work nights, weekends, and in situations that may bring them into “unpredictable and sometimes unsavory environments” (p. 20). The training of the staff is also an important component; the 69 communities reflect a highly structured training program where new staff is paired with one or more experienced staff. This pairing may continue for a matter of weeks to a period of months. Given the demanding nature of the work, the centers responding to the survey indicate that they consciously provide significant support to their staff in order to retain them. Examples include using flexible scheduling, providing developmental opportunities, ensuring that staff have sufficient time off, utilizing a team approach to provide camaraderie and peer consultation, as well as good compensation and benefits.

Seventy-four percent of the centers responding to the study indicate that they provide linkages to colleges and universities, most commonly offering practical or internships for medical students, interns and residents, as well as social workers, counselors, and psychologists. While most of the centers responding indicate that there is a spirit of cooperation and mutual respect among the various agencies, however, problems between agencies are also noted. Problems such as inappropriate referrals of those who are in need of a nursing home placement or who are in situational crises, but are not mentally ill are often “dumped” on a crisis center inappropriately. Also, lack of clarity as to the role of the crisis center or expectations that long-standing problems could be quickly resolved by the crisis center are frequent responses to the subject of failed linkages. Crisis care is expensive and is often not reimbursable by third-party providers, if the patient even has private insurance. Crisis services are typically funded by state mental health funding, a source that is somewhat precarious.

The most frequently cited problems in providing crisis services include: staffing problems, gaps in service which force patients to use a crisis service when a lesser level of service might have been more appropriate, lack of resources due to insufficient funding, miscommunication and mistrust among agencies, unrealistic expectations, and ensuring safety of the staff. The hope in conducting this study is that the experience shared by the LPC’s can shed insight and catapult the needed training and supervision for professional counselors in the future

Frequent Use of Emergency Department by Patients with Mental Health-Related Illness

To get a snapshot of patients treated in emergency departments, Pasic, et al. (2005) conducted a study that examined socioeconomic and clinical characteristics of frequent users of psychiatric emergency services at a hospital’s triage center in Seattle. Data were collected over four years for 17,481 individuals, who made 31,731 visits to the triage unit from July 1999 to July 2003. Of these patients, 761 mental-health related patients are identified as high utilizes of emergency department services compared with 15,851 mental-health related, non-frequent users (the control group). The two groups are compared using analysis of variance and logistic regression models. The frequent user group is further divided by three criteria: those who have two standard deviations above the mean number of visits (557 patients), those who have six or more visits in a single year (419 patients), and those who have four or more visits in a quarter (520 patients). Of the 761 frequent users, there is some overlap; for example, some have six or more visits in a single year and also four or more visits within a quarter. The authors note, however, that these statistics are at best an estimate because not all health care systems collect data using the same definition. In the study they try to determine the answers to three related questions: (1) what is the prevalence and overlap of patients defined by the three criteria they identified and what are the associated patient characteristics? (2) What patient characteristics distinguish the frequency user group from the control group and how do they differ from the control group? And (3) is there any benefit to using the criteria that was applied in their study?

Pasic et al. (2005) divide the population of frequent users into those who are younger males, non-white, unmarried, unemployed, having a psychotic disorder or schizophrenia, substance abuse, a personality disorder, a history of previous hospitalization, a need for medications, and a lack of social support or homelessness, based both on self reporting as well as on administrative records. Then, logistic regressions are performed to determine the most independently significant variables that characterized the user groups. The final models used for the analysis contain only terms significant at p<.001. Comparing the seven most comparable variables as determined by regression analyses, the frequent user groups are 6.1 times more likely to be homeless; 4.3 times more likely to be developmentally disabled; 2.5 times more likely to have a history of psychiatric hospitalization or involuntary hospitalization and to be enrolled in the county public mental health system; and 1.5 times more likely to be rated as being uncooperative and having unreliable social support.

Pasic et al. (2005) conclude that even though frequent users make up a small percentage of individuals, they use a disproportionate amount of resources. They account for almost 25% of all mental-health visits. For future interventions in order to reduce the rate of return trips to the emergency department, the authors suggest that treatment should “focus on resolving the acute episode and providing links to outpatient services to prevent them from becoming more ill” (p. 684). They also suggest that for those who are already being seen by outpatient services, the services should be reviewed to insure that they are appropriate. This review may discover “whether more intensive or different kinds of outpatient services would reduce their use” (p. 684). The study is “limited by its retrospective study design, inter-rater variability, use of information not verified by hospital records or laboratory findings, and use of an automated hospital database” (p. 684). By using the data collected on characteristics of frequent users, a medical professional, especially an inexperienced practitioner, may be able to better identify patients likely to return for repeat visits and to intervene in individual cases.

As utilization rates increase, Gerson and Bassuk (1980) indicate that the emergency department has become the “chief entry point into the network of mental health services for people in need of help for their problems in living” (p. 1). Arfken, Zeman, Yeager, Mischel, and Amirsadri (2002) study the attitudes of 48 members (75%) of the clinical staff in a Detroit Crisis Center to determine if their attitudes toward frequent visitors (characterized as having six or more admissions) reflect this non-psychiatric need and if a psychosocial solution should be recommended. The staff cites difficulty accessing alternative services (94%), substance abuse (92%), basic needs (92%), wanting inpatient admission (86%), noncompliance with treatment plan (81%) and psychosocial problems (81%) as reasons for frequent visitors accessing the emergency department. The authors correlate frequent visitors using a regression model to variables, such as weather, the lunar cycle, day of the week, and time of the year. The answers provided by the staff correlate with higher minimum temperatures, time of the year, and greater amounts of precipitation, suggesting the data confirm the use of psychiatric services for shelter. The staff surmises that people tend to get into more conflicts as the temperature rises and have more options for shelter in colder weather when they are less likely to be pushed out of a house. No differences by season, amount of sunlight, or lunar cycle are found. Awareness of these motivations should assist psychologists in treating patients and in referring them to social programs that provide shelter, as opposed to an inpatient hospitalization. Breslow (2002) also indicates that the reason that emergency departments have become the default option for those seeking a solution to a quasi social problem is the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires that all emergency departments that receive Medicare funding must provide a medical screening and treatment for anyone who presents him/herself for care.

Evolution of Emergency Departments

Gerson and Bassuk (1980) ascribe the history of the development of emergency department services as described by a need for speed and rush to judgment. Emergency departments, they argue, were originally designed to handle “medical” emergencies. When they were designed, patients used their general practitioner for treatment of more routine matters and relied on the emergency department for true life-or-death emergencies. In this era, speed was often a necessity in order to save a life or to prevent deterioration of an already sensitive problem. This service changed when managed care became the norm in the United States and when psychiatric hospitals were closed without adequate planning for supportive community mental health. When psychiatric emergencies became the norm in ERs, the element of speed continued to be important despite the changes caused by managed care. Gerson and Bassuk indicate that this evolution was very unhealthy for patients in need of psychiatric emergency care.

McDonough et al. (2004) indicate that delayed access to psychiatric care may only exacerbate the patient’s already stressed condition. Breslow (2002) argues that timely rendering of treatment to a patient in psychiatric distress is the first goal of emergency care and like McDonough et al. (2004), believes that delays can only worsen a patient’s distress. As a result, a disposition, typically a hospitalization, may result when the clinician is merely treating the symptoms, and not addressing the root cause of the patient’s behavior. Currier, Allen, Serper, Trenton and Copersino (2002) argue that the staffing in emergency departments has evolved from a practice that was composed mostly of “moonlighters” whose main professional duties were elsewhere in the hospital or in another setting to one which is composed of physicians who see their role as isolating a particular condition and curing it.

The literature indicates that the evolution of the emergency department from one that treats medical emergencies to one that includes the treatment of behavioral disorders specifically suicide was accelerated by the deinstitutionalization of psychiatric hospitals in the 1960s without appropriate community planning. As a result, the sometimes chaotic atmosphere and the speed required to make diagnosis and begin intervention may compromise appropriate treatment. This treatment is detailed in the next section of this review.

Evaluation and Management of Patients with Risk of Suicide

According to the National Vital Statistics Reports referencing data by Xu, Kochanek, Murphy and Tejada-Vera (2010), more than 34,598 people in the United States kill themselves every year. According to Xu et al. (2010), every day approximately 98 Americans take their own life and 2,370 make suicide attempts. A study by Beck, Steer, Kovacs, and Garrison (1985) finds that 7% of patients hospitalized for suicide ideation committed suicide within five or ten years. Also having studied 207 patients for a period of five to ten years, they are researching a tool that would be a reliable predictor of likely future suicide attempts in patients with suicide ideation. The authors use the Beck Depression Inventory, the Hopelessness Scale, developed by Beck, Kovacs and Weissman (1979), and The Scale for Suicide Ideation, developed by Beck, Schuyler and Herman (1974). The only instrument that proves useful in making predictions of future suicide attempts is The Hopelessness Scale (Reeves, 2010).

Wetzel (1976) conducts a similar study and also discovers that in a sample of 94 patients out of a total of 154 patients who returned to complete the test battery, that while hopelessness and depression do not correlate with suicide intent at the time of the attempt, they do correlate at the time of the testing (which occurred subsequent to the suicide attempt). They also discover that the correlation of hopelessness with a suicide attempt is slightly higher than that of depression. In those who threatened suicide, when hopelessness is controlled statistically, depression no longer correlates with suicide intent. Also, when depression is statistically controlled, hopelessness is significantly correlated with suicidal intent.

Beck et al. (1979) focus on suicidal ideation “in order to assess current suicidal intention and potentially to predict later suicidal risk” (p. 344). Suicidal intent is defined as a strong, pervasive wish to die which outweighs the wish to live (Kovacs and Beck, 1977), whereas suicidal intent is a “psychological statement of the probability of the occurrence of a fatal suicide attempt” and involves factors such as “lethality of the method…his or her knowledge of lethal dosages of drugs…access to the contemplated lethal method…and likelihood of) intervention by another individual” (p. 344-345). The authors construct a 19-item scale, which they term the Scale for Suicide Ideation (SSI), and which is designed to predict the probability of a future suicide attempt. They describe the items as:

The extent of suicidal thoughts and their characteristics as well as the patient’s attitude towards them; the extent of the wish to die, the desire to make an actual suicide attempt, and details of plans, if any; internal deterrents to an active attempt; and subjective feelings of control and/or ‘courage’ regarding a proposed attempt. (p. 345)

Beck et al. (1979) administer the items to 90 hospitalized suicidal ideators; through an independent researcher, they also administer the Hopelessness Scale (HS) and the Beck Depression Inventory (BDI). The major hypothesis is that while most patients are initially diagnosed as “depressed,” the correlation to hopelessness, as measured by the HS is much higher than levels of depression, as measured by the BDI. Using the SSI, they find that “both hopelessness and depression positively correlated with the extent of current suicide ideation” (p. 348). When BDI scores are removed, “the correlation between hopelessness and suicide ideation was still significant” and when “the HS scores were removed statistically, the correlation between the BDI and ideation scores was no significant” (p. 348).

Kovacs and Beck (1977) conducted a study of 64 women and 42 men, all of whom were hospitalized for suicide attempts at two large metropolitan hospitals. They assess the seriousness of suicidal ideation using the Suicide Intent scale (SIS). Two clinical psychologists evaluate the patients within 48 hours of admission. The authors hypothesize that the seriousness of suicidal intent can be determined by the outcome of the debate between the Wish to Live and the Wish to Die. They present a cardboard sliding scale to each patient and asked each one to how they felt about living or dying at the time of the suicide attempt. They find that 53 patients (or 50%) want to both live and to die, 12 of whom are truly ambivalent; 40% indicate a strong wish to die; and 9% indicate a wish to live. Kovacs and Beck conclude that the “actual subjective magnitudes of death and life wishes are not as crucial in suicidal intent as the congruence or absence of conflict between them” (p. 363). Therefore, an individual who expresses a strong wish to die, with no ambivalent expression, is more likely to act upon the ideation.

According to Kessler, Borges, and Walters (1999), in the National Co morbidity Survey, about 14% of the American population has thoughts of suicide, 4% have a plan, and 4.6% have made an attempt. Since the survey reports about “90 percent of all unplanned attempts and 60 percent of planned first attempts occur within the first year of the onset of ideation,” thoughts about suicide represent a significant risk factor for suicide attempts, especially after the onset of suicidal ideation (Forster and Wu, 2002). Identifying those at risk for completing a suicide remains one of the most provoking.

Forster and Wu (2002) indicate that recent studies suggest that identifying those who have made suicide attempts is important in order to get more information about those who seem to be at highest risk of committing suicide. Trying to determine those who have made suicide attempts on impulse as opposed to those whose suicide attempts reflect more lethality is of critical importance. The authors believe that those who are about to commit suicide are reluctant to share that ideation with a therapist and so relying on self-report is not a reliable way to provide intensive treatment to those at highest risk. But the task is daunting. Between 1974 and 1985, Allgulander and Fisher (1990) designed a study of 8,895 individuals with high suicidal risk as determined by a battery of assessment tools, and found no clinical predictors that could successfully identify future completers. Similarly, Pokorny (1983) finds that in a sample of 4,800 patients, no set of data measures both the many at-risk cases and erroneously identifies too many individuals as being at risk. He concludes that almost 85% of the suicides that occurred in the five-year period of the study had a diagnosis of an affective disorder, schizophrenia, or alcoholism. They use a variety of rating scales to predict those likely to commit suicide, but none of them prove reliable. Forest and Wu (2002) conclude that no attempt to identify a simple scale to find those at risk of committing suicide has succeeded.

Certainly hospitalizing those who appear at serious risk has been a success, but since many then subsequently commit suicide the treatment plan is a failure. Forster and Wu suggest that hospitalizing those at risk is not always the best plan, but finding a treatment plan that will prevent further attempts is preferable. However, a temporary hospitalization, to prevent an immediate attempt is the decision that must predominate since patient safety must take precedence. Forster and Wu note that there are factors that are “fixed” and those that are “variable.” Fixed factors cannot be expected to change. The task of the clinician is to distinguish between those patients for whom suicide is an “obsession” and those for whom suicide is a result of frustration. This group is described as having made suicidal “gestures,” as opposed to true suicidal attempts.

Forster and Wu (2002) offer suggestions to therapists: first, do no harm—do not prescribe medications that could be used in an overdose; second, remove access to a means of committing suicide—ask if there are firearms in the home or if the person has access to firearms; and third, offer the patient hope—propose an aftercare solution that a therapist can help to reduce the anxiety and relieve the tension that initiated the suicidal thoughts. Such assessment by a clinician will likely result in hospitalization due to the risks associated with sending the patient to an outpatient treatment program. Forster and Wu (2002) conclude that in the case where suicidal ideation involves a firearm, hanging, or jumping, then hospitalization may be the only sensible choice; however, they suggest tempering this rule with clinical judgment. If the clinical relationship established in the emergency department can continue afterward and if reliable phone contact is available should symptoms worsen, then an outpatient referral may be more appropriate. If the patient’s ideation or gesture appears only to be designed to secure hospitalization then an outpatient referral may be more appropriate.

Prescribing medication for a patient with suicidal ideation is fraught with peril because of the risk of overdose. Forster and Wu (2002) indicate the high association of depression with suicide wishes, and therefore suggest that certain drugs that may alleviate depression, but which do not carry the risk of overdose, be used selectively. They indicate that drugs such as maprotiline and trazodone have low risk and SSRIs have virtually no risk, may be appropriate or combining an SSRI with clonazepam may also provide relief from suicidal thoughts, although some medications take weeks to become effective. Lithium may also reduce the risk of suicide.

Sullivan and Bongar (2009) believe that the job for a clinician is not to predict suicide, but rather to assess the risk of suicide. They point out that the courts and the public expect that mental health practitioners have a duty to predict the risk of suicide, but there is no demonstrated process a clinician should follow. Further, as Bongar and Harmatz (1991) suggest one of the reasons that there is little agreement as to the effectiveness of these procedures is the lack of formal training in assessing suicide risk at the graduate level. They conclude: “Suicide risk assessment integrates a careful clinical history, mental status examination, ongoing clinical evaluation, consultations, information from significant others, and data from psychological assessment” (p. 61). They suggest that the clinician must consider factors such as prior suicide attempts, a family history of suicide, substance use, social isolation, to name a few.

Sullivan and Bongar (2009) encourage clinicians to use these risk factors as an entryway into assessing the likelihood of suicide. They emphasize that these factors do not represent a list that a clinician can simply check off. Obviously characteristics like previous suicide attempts and the seriousness of those are important, as is family history, withdrawn or socially isolating behaviors, and the presence of a firearm in the home. With these factors in mind, then Sullivan and Bongar recommend that the clinician needs to apply clinical judgment; he/she cannot rely on the answers provided by the patient. “He should remember that the absence of reported suicidal thoughts or behaviors do not rule out the presence of suicide risk” (p. 70). In addition, psychological testing is an additional tool that is available to the clinician, but the authors warn the clinician about relying on this tool exclusively.

The risk categorization is dynamic, not static and should have a reasonable explicit expiration date. Sullivan and Bongar indicate that a clinician conducting this inquiry should never put down “none” or “nonexistent” describing the suicide risk since “the suicide risk of most patients seeking mental health care is elevated above the population mean” (p. 74). Also, they note that suicide risk assessments should be fully documented so that record is available in the case of an unexpected outcome and the survivors press a legal case. As the risk of suicide increases, so should the amount of consultation sought by the clinician, especially a trainee or inexperienced clinician. In the case of a high risk of suicide, the clinician must decide on an appropriate treatment plan, including hospitalization, psychiatric testing, evaluation of psychiatry medications, and/or electroconvulsive shock therapy. Supportive family members should be included in the eventual treatment plan. Sullivan and Bongar believe a “no harm” contract is virtually useless and may give the clinician a false sense of security.

A study by Appleby et al. (1999) of 105 health authority districts in England and Wales correlates the number of suicides that occurred within 12 months with the patient having contact with a mental health service. They discover in a two-year period, from April 1996 to March 1998, that 24% of those who committed suicide (N = 2,177) had been in contact with mental health services in the past year. Fifty percent had been in contact with mental health services in the week before the patient committed suicide and 20% had been in contact within the previous 24 hours. Three hundred fifty-eight suicides (or 16%) of these suicides occurred when the patients were inpatients in a psychiatric hospital. They ascribe poor ward design and nursing shortages as the main reasons for these inpatient suicides occurring. Of those clinicians who discharged patients, they conclude that most of the suicides were not expected by the clinicians treating the patients, and so they were discharged or sent to a community-based mental health service.

Kleespies et al. (1999) indicate that the first duty of a clinician faced with a patient at risk of suicide is to attempt to establish a rapport with the patient. They offer specific suggestions to a therapist when faced with a potentially suicidal patient. An emergency department can appear chaotic and patients are often frightened by their perceptions. First, the clinician should be sure that the environment is safe for the patient so that no object could be used for self-injury. A clinician using verbal and nonverbal interventions can acknowledge the patient’s distress. Using supportive family members to calm the patient may also be helpful. A clinician must be aware of how to handle a wide variety of psychopathologies, including patients who are “agitated, hostile, intoxicated, psychotic, paranoid, and resistant” (p. 456). Each of these situations requires a slightly different approach; for example, a clinician must use a structured interviewing technique to question an agitated or hospital patient, whereas a paranoid patient may require less intrusive questioning. If the patient becomes increasingly agitated, and demonstrates threatening behavior, the clinician may need to use security guards or possibly restraints, which may serve to calm him. Kleespies et al. (1999) point out that the problem is exacerbated for a clinician who encounters a potentially suicidal patient in an emergency department since he/she likely has no prior relationship with him/her. The decision comes down to whether to hospitalize or not and the authors conclude that there is no absolute rule:

“An important consideration is that the patient fails to respond to crisis intervention…when it is not possible to establish a reasonable treatment alliance and the patient continues to voice an overwhelming immediate intent to commit suicide. Typically 1-2 hr with a patient who maintains an immediate suicidal intent is sufficient to encourage clinicians to hospitalize.” (p. 460)

Procedures Used for Medical Clearance

A major issue in the literature about emergency department protocols is the procedures used for “medical clearance.” Allen (1999) proposes the usefulness of quantitative serum drug assays to prevent a clinician from assuming that behaviors are due to non-compliance, whereas they may be due to medicines that are ineffective or intolerable to the patient. Allen also recommends an ECG before administration of a medicine because an ECG, he believes, is the best measure of tricyclic intoxication in cases of an overdose. Currier (2009) recommends a series of tests, but not a “wasteful and lengthy battery of laboratory tests” that may forestall access to psychiatric services. Rather he recommends a “[complete blood count, basic metabolic panel, urinalysis, and toxicology] and pertinent medication blood levels, radiological studies, electrocardiograms…” (p. 315) that is required for admission to a psychiatric unit, and which may be critical to a diagnosis. Currier et al. (2002) indicate that the busyness in emergency departments may result in clinicians only focusing on the presenting complaint, whereas there may be exacerbating physical problems. A particular group, the elderly, is at risk for a misdiagnosis due to the oversight of a physical problem, the most notable being a urinary tract infection (UTI) condition. Currier et al. (2002) believe that it is uncertain if PES psychiatrists are adequately trained in recognizing the severity of a medical problem that may be the cause of or be exacerbating the psychiatric condition. Furthermore, they argue that often the task of assessing the patient medically falls to a psychiatric social worker who, although they are given some background on biomedical issues, may fail to recognize the organic causes of psychiatric disorders, with catastrophic consequences.

Currier et al. (2002) indicate the importance of performing adequate laboratory testing rather than just relying on the history provided by the patient; however, this practice may lead to unnecessary delays in determining treatment. The most useful laboratory tools in assessing individuals are the urine or serum toxicology tests, but based on studies that suggest that at least 75% of patients were truthful about alcohol or substance abuse, a qualitative test may be sufficient. Other diagnostic procedures that have proven useful are CT scans, liver function tests, thyroid function tests, and electrocardiographic screening. In addition, sometimes a physical examination may be recommended. For example, the head may be examined for trauma or evidence of prior surgery. An ocular examination may determine the use of an illicit drug. Range of motion in the neck may indicate a thyroid problem. A chest examination may reveal the presence of cardiovascular or pulmonary conditions. An abdominal examination may reveal perforation, hemorrhage, or infection. As a result of this examination, more detailed laboratory tests may be needed before the patient can be medically cleared.

Williams and Shepherd (2000) conclude that medical clearance may be “complete” and a patient can be safely passed on for psychiatric assessment and treatment, when a patient’s condition is physically stable, no physical illness is thought to be present, and when a known co morbid condition is not thought to be the primary cause of the psychiatric symptom(s). Green (2002) also believes that distinguishing between psychiatric and organic complaints is key to making an appropriate diagnosis. A psychiatric complaint that is organic has an identifiable pathology or is caused by a physical abnormality, whereas a psychiatric complaint that is functional in nature has no organic basis. In discussing acute psychosis, Green indicates that the first approach should be to make the patient feel safe and gain his cooperation. He suggests verbal intervention strategies, such as maintaining eye contact, speaking simply in a louder-than-normal voice, and using the patient’s name. Once safety and cooperation are assured, the staff in an emergency department should conduct medical examinations and neurological assessments primarily in order to eliminate other causes of the psychosis. Should a medical or neurological basis be found, then treatment of that issue may in fact relieve the psychosis. Thus, he concludes, “it is essential to differentiate between a medical and a psychiatric emergency and to diagnose or rule out various medical conditions” (p. 5).

However, he indicates that the examining specialists should first suspect an organic etiology unless the patient has a history of psychiatric illness. Trying to conduct medical clearance at the same time a psychiatric profile is undertaken is considered by Cameron (2006) to be the best model; however, he admits it is difficult because it often involves different qualifications of staff. He indicates that many triage nurses without a psychiatric specialty are ill prepared to diagnose and/or care for patients with a psychiatric complaint.

Korn, Currier and Henderson (2000) conducted a study to determine the most efficient way to provide medical clearance in an emergency department, so as to separate those with psychiatric complaints from those with medical and/or medical and psychiatric complaints. Then further to determine which complaint should take precedence in the treatment plan. They studied 212 patients, 80 of who presented with psychiatric complaints and 132 of who presented with medically based chief complaints or part medical history in addition to their psychiatric complaints. Medical clearance models in emergency departments have medically evaluated patients as rapidly and accurately as possible so as to avoid referring medically unstable patients to a psychiatric treatment program. The study by Korn et al. (2000) revealed an examination of routine vital signs, an abbreviated mental status evaluation, routine laboratory and radiology results, as well as a medical history including drug and alcohol use, produced 80 patients who could have been medically cleared sooner and referred away from the medical treatment unit to a psychiatric treatment program. The other 132 patients presented to the emergency department with medically based chief complaints, and they received further medical and psychiatric evaluations before admission or discharge.

Korn et al. (2000) argue that medical clearance should really be “medical screening” so that those whose chief complaint is psychiatric can be referred away from many of these tests (laboratory analysis and CXR) that are routinely performed. They believe that the 80 patients who were subjected to extensive treatment could have been medically cleared much sooner, which would have reduced stress on them as well as created a more efficient delivery of service in the emergency department. Korn et al. (2000) do admit “that routine screening is warranted in high-risk patient populations such as substance abusers, the homeless, elderly, and those exhibiting new onset of psychiatric symptoms” (p. 173).

Olshaker, Browne, Jerrard, Prendergast and Stair (1997) conducted a study of 352 patients with psychiatric complaints over a two-month period in a 40,000 visit per year urban university teaching hospital that serves primarily an inner-city population. The study reveals that 214 patients (or 62%) were found to have used illicit drugs or ethanol in the preceding 24 hours and 70 patients (or 21%) had used both illicit drugs and ethanol in the past 24 hours. The researchers find that 65 (or 19%) had acute medical conditions. Most (61/65) of these conditions are identified by the triage nurse at the outset by asking the patient about his/her medical condition. While laboratory screening can be helpful and because the use of illicit drugs is a frequent issue with visitors to the emergency department, they conclude “routine toxicology screening was unlikely to produce information that was not available on history alone” (p. 127).

Zun, Leikin, Stotland, Blade and Marks (1996), on the other hand, argue, “The medical clearance process in the ED frequently misses acute medical conditions because of process deficiencies” (p. 330). An Illinois Department of Mental Health Task Force created a tool that can be used to ensure that patients are adequately medically cleared before they are referred to psychiatric care. The authors believe that “this tool will reduce the number of patients inappropriately transferred to a state-operated psychiatric facility and minimize the time necessary to initiate a patient transfer” (p. 331). They indicate that a physician, social worker, or psychologist will evaluate a patient who presents to the ER with a psychiatric complaint. It is then the job of the physician to determine which psychiatric patients are in need of medical care, detoxification from drugs or alcohol, or whose psychiatric condition has a medical etiology. The characteristics that must be evaluated include: psychiatric signs and symptoms, a medical history and a physical examination (such as blood alcohol level, vital signs, mental status, and drug ingestion), findings that indicate the patient may not be safely transferred to a psychiatric unit, and a 6-item-orientation memory-concentration test. They believe that administering “this tool will reduce the number of patients inappropriately transferred to state-operate psychiatric facilities and minimize the time necessary to initiate a patient transfer” (p. 331). This basic screen is recommended by Cameron (2006) for use in successfully and accurately processing a patient through medical clearance.

Riba and Hale (1990) conclude that psychiatrists should review medical records to be sure they are complete before deciding on disposition of patients. They argue that laboratory testing as well as neurological exams are extremely important and are often incomplete. They realize that patients may be uncooperative, thus leading to an incomplete medical examination. Also, medical-house staff may be eager to move difficult patients along to psychiatry to handle since they are uncomfortable with patients with emotional difficulties. As previously discussed, McIntyre and Romano (1977) pointed out that psychiatrists may feel incompetent to provide a physical examination, and so they rely on the examining physician’s report.

Assessment and Evaluation Tools for Evaluating Risk for Suicidal Patients

Gerson and Bassuk (1980) as well as Allen (1999) also outline plans for effective assessment and evaluations of suicidal patients in and ER setting. First, Gerson and Bassuk note that speed has become of utmost importance in triaging a patient. Clinicians are looking for the “quickest clue,” which they argue may in fact increase the chance of hospitalization (pp. 45-56). If a long period of time elapses between the time the triage nurse first “tracks” the patient until he/she is seen by a therapist, the patient and possibly the anxious family may become even more agitated. Then the need for urgency may cause the therapist to use symptoms to form a diagnosis rather than to spend more time and elicit the cause of the problem from the patient. Allen (1999) agrees that “rapid evaluation, containment, and referral” became the goals for emergency department treatment, which minimized diagnostic considerations, as emergency departments became magnets for free care. Due to poor planning, no standard for emergency assessment exists.

Baxter et al. (1968) conducted a study between February and April 1966 in which they ask 17 psychiatric residents on duty in the ER at the Detroit Psychiatric Institute Hospital to answer a 66-item questionnaire involving 162 patients. One of their conclusions is that making a decision to hospitalize or not characterizes most of the work of the emergency department. In their study, residents made that decision in five to 15 minutes. Since so much of the decision involves that ultimate disposition, Bengelsdorf, Levy, Emerson and Barile (1984) developed the Crisis Triage Rating Scale (CTRS). Allen (1999) finds this scale has little validity and is not in wide use; however Currier (2009) states that the CTRS is one of the oldest, best established, and most clinically useful scale. Bengelsdorf et al. (1984) developed the CTRS for use at the Westchester County Medical Center, a major psychiatric receiving hospital in New York in order to make “the disposition decision as rapidly as possible” (p. 425). The three factors influencing the disposition decision included (1) the dangerousness of the patient, (2) the support available to the patient from his/her family or others, and (3) the motivation of the patient to cooperate with an outpatient treatment plan. The CTR scale itself includes 5 statements for each of these factors the response to which are then rated by a clinician. Under dangerousness, the statements range from the patient having made a serious attempt at violence, hallucinating suicidal/homicidal behavior, coupled with impulsive or violent behavior by an individual who has no history of such behavior. Under “support system” the statements range from a patient with no family or friends to a patient with interested family, friends and others who can provide support. Under “Ability to cooperate” the statements range from a patient who is unable to cooperate to one whom actively seeks outpatient treatment.

Using a Likert-type rating scale to determine the score achieved by the patient, the team at the hospital assigns a patient to likely admission if he/she scores below 9 and assigns a patient to outpatient treatment if the patient scores above 9. Based on the CTRS results, the disposition decisions for 291 of 300 patients evaluated (97%) were in concordance with independent clinical judgment and were decided as follows:

Of the 132 scoring 8 or less, 128 were sent for admission and four were not. Of the 140 scoring 10 or higher, 135 were started in, or referred for, outpatient treatment and five were sent for admission. Half of the 28 patients who scored 9 were sent for admission and half for crisis intervention. (p. 426)

Nine is the score that was the “tipping point” for a disposition of admission. In a subsequent study of 160 patients who were referred to the crisis intervention service and followed for 6 months, the authors were able to remain in contact with 122. Of these, “35 scored from 3 to 8. Of these, three were never hospitalized and 27 were admitted on the first day they were seen (Bengelsdorf, et al., 1984, p. 427). Thus, the authors feel that the CTRS is a reliable tool to use to screen patients and to make more rapid decisions, thus providing more efficiency to an emergency department and creating less stress for the patient. As a result, Bengelsdorf et al. conclude that the CTRS is a useful tool; however, the authors caution that the CTRS is not useful with intoxicated patients.

Larkin et al. (2009) argue that “No mental health screening tool is currently widely accepted or recommended for ER use” (p. 1112). They recognize such a tool for alcohol use and recommend that “a brief, feasible, acceptable, and cost-effective screening/case-finding program” and examine these for use with young, old, and special populations (p. 1112). They argue that this tool can be adapted for use with other mental health problems, including depression, anxiety, and suicide.

Brooker, Ricketts, Bennett and Lemme (2007) use the CTRS scale in the United Kingdom as well as the Health of the Nation Outcome Scale (HoNOS) to determine appropriate referrals to a mental health treatment program. A total of 375 patients were referred, all of whom were evaluated using the CTRS and the HoNOS, and 48 (12.8%) were admitted, most of which were related to suicide risk. The mean crisis rating score using the CTRS was 11.0 and the mean crisis rating score using the HoNOS was 10.5. The relation between the CTRS and the HoNOS are negatively correlated: those with lower CTRS scores have higher HoNOS scores. Between September 2000 and March 2001, all patients referred to the “Out of Hours Team” at the Sheffield Hospital in the UK would interact with a member of the team for at most for a 24-hour period. Those who were admitted are then analyzed as to location of their home.

Brooker et al. (2007) determine that those living in more deprived areas are admitted more often than those living in affluent areas. “Indeed, just under 19% of people referred from the most deprived third of wards were admitted, compared with just over 5% of people referred from the most affluent third of wards” (p. 1317). Brooker et al. (2007) also discover that those with a high level of risk, but with a level of support that allow them to remain at home, are referred to outpatient care more often. Whereas those without sufficient support, even with a lower risk profile, are more often hospitalized. The researchers conclude that there is a significant relationship between risk-to-self and social support. Based on their study, Brooker et al. (2007) also believe that the CTRS is a better predictor of need to hospitalize than the HNOS principally because it contains a rating item for social support. They conclude that the city of Sheffield needs to develop more social support for individuals at risk for injury to self in deprived areas, support that did not exist at the time of the study.

Another scale, the Mental Health Triage Scale (MHTS) developed by Smart, Pollard, and Walpole (1999), provides a four-tiered system designed in accordance with the 90

National Triage Scale (NTS) which is used for triage of patients with physical symptoms. The MHTS adapted the NTS for use in Australia and New Zealand for treatment of patients with mental health problems presenting in an emergency department. As displayed in Table 13, The MHTS is divided into four triage categories (numbers two through five). If the patient is “violent, aggressive, or suicidal, or is a danger to self or others,” he/she should be triaged as an “emergency” and should be seen within 10 minutes. If, on the other hand, the patient is “very distressed or acutely psychotic, (and) likely to become aggressive” or a “danger to self and others,” then he/she should be triaged as “urgent” and seen within 30 minutes. A patient who has a “long-standing or semi-urgent” mental health disorder should be triaged as “semi-urgent” and seen within an hour. Finally, the MHTS describes a patient with a “long-standing or non-acute mental disorder/problem” who may “require a referral to an appropriate community resource” should be triaged as “non-urgent” and seen within two hours (Smart, et al., 1999, p. 59).

Although Smart et al. (1999) do not have an explicit category one; it is reserved for patients who require immediate medical treatment. The first six factors to be used in assigning triage categories two or three to patients depend on the level of distress, and the last six factors are used for patients assigned to triage categories four and five. Factors, such as manifestation of behavioral disturbance, threat of deliberate self-harm, the presence of suicidal ideation, the patient’s current level of distress, a perceived level of danger to self or others, or a need for physical restraint or require accompaniment by the police, should be used in assigning patients to category two or three (p. 60). Factors such as “disturbances of perception, manifest evidence of psychosis, level of situational crisis, descriptions of behavior disturbance in community, current level of community support, [and/or] presence of care giver/supportive adult,” should be used in assigning a patient to triage categories four and five (Smart, et al., 1999, p. 60).

The control group for the study by Smart et al. (1999), which included 261 individuals, was analyzed from December 1, 1993 through February 28, 1994 at the Royal Hobart Hospital (RHH) in Australia, and the MHTS was implemented there on March 1, 2004 and was completed on May 31, 1994, using 306 individuals. Then a post-trial group of 322 was followed to see if familiarity with the tool would cause transit times to decline further. These triage categories are applied to patients by trained nurses in triage and then the application is tested against mean emergency waiting times and mean transit times. The objective of the study is to (1) develop a triage scale consistent with the National Triage Scale (NTS) and to (2) reduce waiting times, transit times, and provide better assessments of mental health patients.

Interventions a counselor may use for a suicidal patient.

Currier (2009) indicates that separating medical from psychiatric issues is difficult in an emergency department given the need for speed of assessment. Carlson, Nayar, and Suh (1981) indicate that about 7% of PES patients seen should have been treated for medical conditions; Olshaker et al. (1997) suggest that in the mid-1990s, serious medical issues are present in 19% of patients who had been categorized as psychiatric patients. More recently, McEvoy et al. (2005) point out that metabolic syndrome is present in 36% of male and 52% of female patients and about 30% of patients with diabetes who are not receiving treatment. These studies indicate that appropriate assessment was not made at initial intake. Currier (2009) suggests that many patients are “gray zone” patients (p. 315) whereby both medical and psychiatric treatment is needed—in various order depending on the symptoms of the presenting patient.

Hall, Gardner, Popkin, LeCann and Stickney (1981) in studying 100 psychiatric patients in a state hospital find that “Forty-six percent of the patients were found to have a previously unrecognized and undiagnosed medical illness that was specifically related to their psychiatric symptoms and either caused these symptoms or exacerbated them substantially” (p. 630). They indicate that the types of diseases most frequently judged to be causative of psychiatric symptoms are: endocrine disorders (36%), polysystem diseases (18%), hematological disorders (15%), and cardiovascular disorders (8%). If a psychologist is unfamiliar with these medical issues that complicate a psychiatric diagnosis, a disposition would be incorrectly determined. The authors indicate that the practicing clinician must be trained in recognizing medical conditions, but indicate that the psychiatrist’s role was weakened by the elimination of the medical training requirement for completing the psychiatric residency program. Reasons cited by the authors for mistaken dispositions include the presence of neurological dysfunction, somatic conditions, as well as personal and systematic barriers to adequate health care. Hall et al. (1981) also discuss the legal implications of a clinician missing a physical ailment under the Rouse v. Cameron case in 1966. In this case, a patient is found to have a right to adequate treatment, and “psychiatric treatment offered without adequate assurance of the absence of underlying medical disease would constitute” (p. 632) a violation of this adequate treatment argument. Several suits have been filed against practicing psychiatrists for failing to evaluate their patients.

Carlson, Nayar and Suh (1981) conducted a study in the Psychiatric Emergency Service department of the Royal Ottawa Hospital, a public psychiatric hospital. The study separates the patients into two groups, those who are non-physically ill and those who are physically ill, and both groups are analyzed for age, gender, marital status, time of visit, physical diagnosis, psychiatric diagnosis, as well as the relationship between the physical illness and the psychiatric disorder. They find that 75% of the 2,000 visits presenting have both a physical illness that is related in some way to the psychiatric illness. The most common physical diagnoses in this group are extra pyramidal symptoms (19%), drug overdoses (16%), delirium tremens (11%), seizures (5%), and gastro-intestinal bleeding (5%). The most common psychiatric diagnoses are: schizophrenia (26%), alcoholism (24%), personality disorders (12%), and chronic organic brain syndromes (11%). Sixteen percent of this group are over 60 years (compared to 8% of the general hospital population) and 24% are diagnosed with organic brain syndrome (compared to 6% of the residents, internists, and fourth-year medical students in various Rochester NY-area hospitals, find that only 13% routinely perform an initial physical examination on their patients and 8% perform an initial psychical examination on their outpatients. Ninety-four percent find the results of a physical examination useful, but cite the fact that usually the results of the physical examination are sent by other physicians with their referral. However, 32% of those surveyed indicate a lack of competence as one of their reasons for not performing a physical examination. In a separate question well over 90% of those surveyed feel that a physical examination is important when the patient is using psychotropic medication(s).

Williams and Shepherd (2000) then present details of the physical examination. They suggest as a resolution to the debate as to the necessity of laboratory testing that it definitely be conducted on patients presenting with new-onset psychiatric complaints and on those over 40 years of age, since “these patients are much more likely to have a medical illness as the primary cause or contributing factor, for their psychiatric symptoms” (p. 191). They conclude: “Laboratory evaluation on most patients being medically cleared should be ordered based on clinical suspicion. Some would suggest that a minimal panel, including complete blood count, glucose, electrolytes and alcohol and qualitative toxicological screens be performed” (pp. 191-192).

A hurried examination may miss organic symptoms that may result in inappropriate treatment for the patient. For example, Williams and Shepherd point out that “Many medical diseases can cause behavioral symptoms. Electrolyte imbalances, infections, endocrine disorders, and cardiopulmonary disease are among the commoner causes…in the elderly population, medications are often responsible for acute changes in mental status” (p. 197). In making a diagnosis, the emergency department staff must determine whether the complaint is primarily functional (psychiatric) in nature or organic (physical) in nature. Williams and Shepherd (2000) provide the following table (see Table 10) to guide the staff in making this determination. Once the psychiatric diagnosis has been made, then the issue of disposition arises. If there is a risk of suicide, suicidal ideation or a risk of harm to others, that patient requires particular attention. Ultimately the decision comes down to whether to hospitalize or not. William and Shepherd warn physicians and psychiatrists that the responsibility for the safety of the patient rests with one of them, not with the psychosocial consultant.

Claassen and Larkin (2005) believe that many patients presenting in an emergency department with a medical complaint, may have suicidal ideation, but this condition goes undetected. They studied 1,590 patients who came to the Parkland Memorial Hospital in Dallas, Texas over a 45-day period whose chief complaint is unrelated to mental health. They exclude any patient who had attempted suicide, or who complained of suicidal ideation, psychosis, depression, anxiety, or other mental health related-condition. The patients were administered the Quick Psycho Diagnostics (QPD) panel to determine its efficacy in detecting suicidal ideation or previous suicide attempts. They find that 185 (or 11.6%) acknowledged suicidal ideation and 31 (or 2%) were planning to kill themselves. Of the 31 planning suicide, 6 had been documented on previous hospital records, but the suicide ideation of the other 25 had gone undetected in the past by emergency department staff. They conclude that “Compared with the general population, those attending emergency departments may be at significant risk of suicide” (p. 353).

Disposition Decisions Determined by Qualification of Personnel

Currier et al. (2002) argue that the qualification of the personnel performing the evaluations is critical in determining an appropriate outcome. The standards differ widely from state to state and from institution to institution. Psychiatrists, especially in emergency departments that do not have a psychiatrist providing continuous coverage, may be at a disadvantage in providing assessments. Currier et al. recommend that in the absence of a psychiatrist on staff, psychiatric nurses, social workers, and less frequently, psychologists, can intervene and provide crisis intervention and brief psychotherapy until a psychiatrist can be called in. In addition, they recommend the use of a performance based cognitive screening process, such as the Mini-Mental State Exam (MMSE) or the Trial making Test (TMT) or the TMT used in combination with the Wechsler Memory Scale (WMS), since this screen may pick up disorders that are commonly missed during the initial psychiatric intake interview. Other cognitive screens suggested are the California Verbal Learning Test (CVLT), the Rey Auditory-Verbal Learning Test (RAVLT), and the Clock Drawing Test (CDT); however, they are time-consuming and probably not effective in a busy, fast moving emergency department.

Gerson and Bassuk (1980) investigate the variability affecting therapists. First they distinguish between the decisions made by psychiatrists versus those made by psychologists. Although there are few studies on this matter, they cite Strainer, Goodman, and Woodward (1975) and Cameron and Walters (1965) whose work shows that psychiatrists hospitalize patients at a much higher rate than do psychologists or social workers. Cameron and Walters, in particular, cite a study in Pinellas County Florida in which a program to treat the mentally ill was established in order to reduce the amount of time these patients were detained in jails and treated like felons. The administration and treatment in the program cost much less than the alternative of hospitalizing these patients, unless that option is necessary. In their study, they received 1,215 calls from mentally disorganized persons, primarily aged 24 to 44 years of age. Since the establishment of the program, about 47% of the patients remained in their homes with access to community-based mental health services, while 44% were detained for further psychiatric evaluation. The remaining were either jailed or sent to state institutions. The point of the article is that providing appropriate emergency services reduces the inappropriate placements in jails and/or in state institutions.

Streiner et al. (1975) conduct a study of 897 patients in the emergency department at St. Joseph’s Hospital in Hamilton, Ontario, from which 309 or 34.5% are admitted for psychiatric hospitalization and 588 (or 65.6%) are not. They find that “the decision for hospitalization is strongly influenced by: (a) the clinician’s discipline and (b) experience; and (c) the patient’s social support system” (p. 415). Specifically they find that family practice physicians hospitalize 49% of the patients they see; psychiatric residents hospitalize 40%; psychiatrists, 39%; nurses, 30%; counseling psychologists, 26%; and social workers 25%. Furthermore, based on years of experience, those with one to three years hospitalize 35%, but those with 16 to 20 years, hospitalize 20%. They also discover that the presence of some support—from the family or others- is another determinant. Clinicians hospitalize 52% of those with no supportive resources available, but only 29% of those with three or more supportive resources available

Baxter et al. (1968) also discover in their study that experience plays a major role in the decisions to hospitalize or not. In their study first-year residents “considered themselves as having greater insight into their patients’ problems than did the advanced resident” (p. 1544). Their study also suggests that first-year residents’ academic interest and his/her like/dislike for the patient are also significantly statistic determinants of the decision to hospitalize. A study by Gauron and Dickinson (1966) indicates that first-year psychiatric residents are quicker to jump to judgment than their more experienced colleagues. Gerson and Bassuk offer an opinion that the personality traits of the therapists themselves may also be a factor in the decision to hospitalize or not. They argue that a greater empathic relationship with the patient may cause the therapist to take more time and in their view, make a more appropriate diagnosis.

Rusk and Gerner (1972) provide a preliminary study that finds that the level of patients’ discomfort decreases most in sessions in which the therapist talks less in the first third of the session and talks more in the last third. The study involves 45 patients who are randomly selected from the ER at the University of Oklahoma Medical Center, where they are evaluated by a psychiatric resident. They are ranked according to their scores on the Multiple Affect Adjective Check List (MAACL). Based on the change in their scores on the MAACL before and after a one-hour session, those whose scores decline are deemed successful, and those whose scores remain stable or increase are deemed unsuccessful. Their research shows that “in the first third of an interview an empathetic, understanding stance on the part of the therapist with a patient capable of responding will tend to result in a distress-relieving session” (p. 885). This study is the only one cited by Gerson and Bassuk that provides empirical evidence that specific intervention techniques can improve patient outcomes. They encourage more quantitative research in this area.

Mendel and Rapport (1969) conducted a similar study at the Psychiatric Division of the University of Southern California Medical Center that analyzed the qualifications of the professionals making the decision to hospitalize or not. They used an eight-day period in August 1967 and reviewed 269 decisions made by 33 social workers, counseling psychologists, and both resident and staff psychiatrists. About 41% of these decisions resulted in hospitalization and 59% of the patients were referred to non-hospital-based services.

After the eight-day period the decision makers completed a survey that described their attitudes about the reason(s) to hospitalize and then three months later they were again asked the same questions about this decision. Social workers tended to hospitalize least, whereas less experienced counseling psychologists and psychiatrists hospitalized more often. The authors speculate that the reason that social workers hospitalized least may have to do with their having more familiarity with community-based resources and also they tend to work only on daytime shifts, when a lower number of hospitalizations occurred.

By then looking at clinical factors describing the severity of symptoms, the group of patients who are hospitalized could not be distinguished from those who are not, yet the decision makers report that severity of symptoms is a deciding factor. The authors conclude that the only distinguishing feature that the authors found is the patient’s history of prior hospitalization. Those who have been previously hospitalized are far more likely to be hospitalized again, yet none of the decision makers think the patient’s history to be a factor when they made the decision.

Also the time and type of day seem to be another distinguishing factor: more hospitalizations occur after 5:00 p.m. on weekends and all day Saturday and Sunday. Mendel and Rapport (1969) conclude that less community-based resources are available in the evening or on weekends. Also, judgments to hospitalize are made on family support as well, which typically is also not as readily available in the evening or on weekends. Based on the inputs from the decision-makers, they discover that of the 110 patients hospitalized over this eight-day period, 84% (or 92 patients) would not have been hospitalized had the emergency occurred during weekday daytime hours. As a result of this study, Mendel and Rapport (1969) conclude that experience of the decision maker, prior hospitalizations as well as time of day of the emergency, are three predictors of the disposition of the patient.

Wood and Khuri (1985) compare dispositions ordered by psychiatrists with those ordered by psychologists and indicate that counseling psychologists have excellent critical skills. The authors compare the disposition decisions for 258 patients made by psychologists as opposed to those made by psychiatrists, a psychiatric team, and psychiatric residents at City of Memphis Hospital, an inner-city hospital servicing an indigent population. These patients are evaluated either by a psychiatrist or psychiatric team alone or by a counseling psychologist alone. In the case of the psychologist, the approval of an attending physician is required and in all cases he/she approves the recommendation of the psychologist. The only statistically significant data are that the psychologist began interviewing the patients sooner than the psychiatrists and also that psychiatric hospitalization is recommended less often by psychologists than by psychiatrists, even though evaluation patterns of patients seen over time are found to be similar

Telemedicine

Telemedicine is defined as “the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care” (Beavan & Frederick, 2000, p. 400). Telemedicine uses electronic information and communication technologies “to provide and support health care when distance separates the participants” (University of North Dakota, 1998, p. 1). In general, telemedicine is a form of medical practice over distance through the uses of computers and telecommunications (American Telemedicine Association [ATA], 2009; Farmer et al., 2005; Beavan & Frederick, 2000).

Telepsychiatry

Telepsychiatry is under the broad umbrella of telehealth. In a 1997 report to Congress, National Telecommunications and Information Administration defined telemedicine as “the use of electronic communication and information technologies to provide or support psychiatric care at a distance” (U.S. Department Of Commerce, 1997, para. 4); conversely, telehealth was defined as “a broader concept” that uses “electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” (Department of Health and Human Services [DHHS], 2001, p. 1). Telehealth implies a broader sense of societal objectives (Wainwright & Wootton, 2003, p. 558), whereas telemedicine is limited to a narrower view of medicine (ATA, 2009; Wainwright & Wootton, 2003).

The terms health information technology (HIT), telehealth, and e-health have been used interchangeably in research studies and reviews. HIT and telehealth refer to the use of diverse technologies to support transmission and management of health information for a wide range of healthcare stakeholders (Blumenthal & Glaser, 2007); with the first focusing on information technology and the second concentrating on healthcare, while e-health emphasizing the role of the Internet in healthcare. Overall, the essential concept is using information technologies in healthcare.

In past decades, information and communication technology has become an integral part in lives all over the world. This fact is especially witnessed in common business operations. Although the uptake of IT in healthcare organizations has been extremely slow compared to the rest of the businesses, research studies indicate that the use of e-health is becoming crucial to the entire healthcare industry. Health information technology facilitates health data exchange and communications, supports healthcare management and delivery, and promotes patient awareness and treatment effectiveness. More importantly, the potential of electronic processing with the wealth of knowledge gained from the massive health data will forever impact human lives and the understanding of healthcare.

The critical role of IT in healthcare extends from patient care to administration and medical records (Merrifield, 2006). IT creates enormous resources in healthcare informatics and unlimited options with computing technologies. IT Internet tools have become important to the early detection of diseases and post-treatment care as well as real time illness treatments. In the 21st century, medical science and technology must adapt to address the growing complexity of modern healthcare. Moreover, the healthcare providing organizations and healthcare providers must collaborate with and benefit from technology developers (Goldsmith, 2004).

In the past half century, the information technology revolution has swept through every aspect of society. Although many research studies have exhorted IT’s potential in transporting healthcare to greater quality and efficiency (Merrifield, 2006; Blumenthal & Glaser, 2007), healthcare providers have been reluctant to change. In considering future healthcare information technology, Scott (2001) held that the CAD-CAM (computer-assisted diagnosis and computer-assisted medicine) system should be applied to healthcare the same way CAD-CAM (computer-assisted design and computer-assisted manufacturing) has been used in engineering and manufacturing.

Beyond greater effectiveness and efficiency, using computerized medical devices can help decrease the need for healthcare professionals, lower healthcare costs, and reduce preventable medical errors. CAD-CAM has been associated with engineering productions; in the new HIT era, CAD-CAM will become essential to healthcare. Among IT explorations in medical practices, telemedicine is one of the most prevalent and current HIT practices. The mainstream attention of telemedicine results from many sources, such as the ever-increasing cost of healthcare, the shortage of healthcare professionals, and the increasing amount of preventable errors in the medical industry (Snyder, 2007). In addition to current healthcare issues, recent research and statistics have warned about the increasingly obese adult population, the increasing rate of cancer, and the higher percentage of aging adults (Sittig, 2006). These future estimates indicate a potential crisis in the amounts of required and necessary healthcare, providers, and costs. With a fundamental change in healthcare delivery concept, telemedicine offers a promising option to help address the uncertain future of healthcare.

Relative Advantages of Telemedicine

Telemedicine enables specialists to attend to communities that otherwise could not be served. It eliminates possible traveling time and cost for patients and healthcare providers (Laplante, 1995; Kuszler, 1999). Telemedicine allows quick access to specialized care in rural communities. It reduces “economic strain” as well as alleviates a patient’s “emotional strain of traveling far from home” (Laplante, 1995, p. 48). In rural areas, treating local patients with telemedicine means more than to provide access to otherwise impossible treatments. It also increases the “financial viability of rural medical facilities and strengthens the rural economy” (University of North Dakota, 1998, p. 3). Networked healthcare also brings balance to the distribution of patients and care providers among urban and rural facilities.

Telemonitoring patients inside hospitals may potentially reduce the cost of intensive care and post intervention observation and increase the administration’s effectiveness. Telemonitoring patients at their homes can lead to improved, continuous, and highly effective disease management (Goldsmith, 2004). Telemedicine makes personalized pre- and post-treatment integration possible through continuous consulting and monitoring. To conclude, general agreements on fundamental benefits of telemedicine are as follows:

Increase patients’ accessibility to medical care in their own community.
Effective use of healthcare resources.
Enhanced continuum of patient care.
Access to specialty care when either geographically or physically impossible.
Timely institution of healthcare at emergencies or otherwise.
Increase productivity of practitioners and improve healthcare service quality.
Cost-effectiveness for the entire healthcare system.
Support of healthcare maintenance needs such as education, training, and informatics.

Traditionally, telemedicine is supported for its benefits to the otherwise inaccessible rural populations. Today’s telemedicine also reaches out to the medically underserved urban populations in inner cities, senior facilities, prisons, and so forth. Global availability of the Internet and highly sophisticated computing technologies has propelled the growth of telemedicine. Telemedicine is becoming an integral part of healthcare throughout the world.

Current State of Telemedicine and Challenges

Research studies have long concluded that telemedicine is useful (Beavan & Frederick, 2000). Nevertheless, telemedicine adoption is still in its infancy. Mainstream U.S. healthcare organizations have been hesitant about telemedicine adoption until recently. There had been considerable amount of skepticism from practitioners, due to a lack of face-to-face, reach-and-touch intimacy (Laplante, 1995; Bergeron, 1998). Hence, telemedicine was often limited to rural settings and was applied to patients without critical needs. The return on investment (ROI) was difficult to justify due to often refused reimbursements, huge initial startup costs, and high maintenance costs. In addition to these considerations, legal issues regarding physician licensing, legal liability, and patient confidentiality concerns also deterred telemedicine adoption (University of North Dakota, 1998; Frase-Blunt, 1998).

Patient care favors personal touch. Research studies agree that in certain cases, medicine can only be fully exercised through one-on-one interaction between the physician and the patient (Bergeron, 1998). With higher speed communications and more providers and patients to meet in virtual spaces synchronously in ways that such personal attendance can be achieved. Live communication, aided by audiovisual devices and high speed Internet, has been rendered accessible due to such devices as tele-presence robotics and pervasive telemonitoring used in current telemedicine practices. As computers and telecommunication become increasingly prevalent and familiarity to the technologies grows, pervasive telemedicine has become acceptable from the perspectives of healthcare providers and healthcare recipients.

Telemedicine used in critical patient interventions have been proved successful in the past. In those cases, remote medical specialists were linked to the actual examination or operating room through real-time interactive communications. Telemedicine for use in neonatal intensive care units (NICU) has been proven feasible as early as in the 1990s (Frase-Blunt, 1998; Phillips, 1999). Tele-ICU provides innovative remote care for centrally monitored ICU patients in an effort to improve ICU critical care as well as leverage scarce intensive care doctors. Tele-surgery requires more technical skills and costs, but tele-robotic surgical systems used with laparoscopic techniques have also demonstrated the capability and effectiveness of remote tele-surgery (Anvari, 2005; “Doctors claim”, 2001; Fleming-Michael, 2006).

Regarding fee structures, the ATA (2009) emphasizes that services provided on site are not different than services provided remotely through telemedicine. Nonetheless, the telemedicine reimbursement issue has persistently been identified as a critical obstacle to telemedicine adoption and expansion (Frase-Blunt, 1998; Joint Advisory Committee, 2008; Smolensky, 2003; University of North Dakota, 1998). Healthcare insurers (Medicare, Medicaid, and private insurers) have argued that the access and cost of telemedicine cannot be adequately addressed (Smolensky, 2003). This is possibly due to difficulty to build a chain of traceability for treatment and is vulnerable for fraud and abuse. Moreover, although the costs of high-speed networks and IT devices have decreased in recent years, tele-digital versions of medical devices are certainly more expensive than traditional versions. Costs for telemedicine provision are difficult to recoup since reimbursement policies are nonexistent or limited. The integration of telemedicine is seriously challenged by the lack of consistent and comprehensive reimbursement policies and regulations (Frase-Blunt, 1998).

Legal and licensing issues are also big hurdles to telemedicine adoption (Frase- Blunt, 1998; Beavan & Frederick, 2000; U.S. Department of Commerce, Office of Technology Policy [OTP], 2004). The transmission of medical records across state lines, different state licensure and accreditation requirements, and dispersion of liability in cases of cross-state practices are all pending on Federal regulation. Moreover, by elevating the care provision, telemedicine also affects the standard of healthcare (Kuszler, 1999). With new standards, healthcare providers may have increased liability for failing to implement up-to-date technologies in addition to liability for inadequate maintenance or use of technologies, resulting in patient dissatisfaction (Kuszler, 1999). Efforts have been put forth for interstate compact and licenses for telemedicine practices. Various organizations such as Federation of State Licensing Boards and the Center for Telemedicine Law (CTL) have initiated policies and regulating models on aspects of licensing and litigation (Frase-Blunt, 1998; OTP, 2004). However, state licensure and liability issues continue to be unresolved obstacles to telemedicine marketing and user acceptance (OTP, 2004).

For telemedicine to be successful, patients require confidentiality, reliable and available connectivity, and consistent data transmission. Real-time data transmission can be especially problematic in remote areas, which is a critical concern when human lives are involved. The issues of data security and patient confidentiality raise critical concerns that demand the development of secure, reliable, and capable connectivity and transmission infrastructure. Current infrastructure and patient data systems, such as electronic healthcare records (EHR), require financial and regulatory encouragement from policy setting organizations in order to meet the standards and compatibilities of telemedicine.

Telemedicine is a marriage between IT and healthcare. It thus inherits the complexities of both disciplines. Healthcare is a context and culture specific industry. Unique healthcare needs and individualized approaches often demand special considerations. The decision making process and workflow patterns require adaptation to specific healthcare provisions and providers. Conversely, to keep pace with the constant evolution of new technologies, IT must address usability, connectivity, scalability, maintainability, and so forth. IT practices follow standard development cycle with multiple iterations of prototyping, developing, and testing that are not usually applied in the healthcare. By merging the two disciplines, telemedicine expansion must seriously focus on inter-disciplinary practices, blended expertise and partnership (Jennett & Watanabe, 2006).

Challenges have persisted in telemedicine adoption and expansion despite its evident effectiveness. However, with techno-centric development in almost every business area, the demand for telemedicine applications will drive the market. Using telemedicine is not only critical to the healthcare systems, but also important to the healthcare delivery model and to the entire economy. Conversely, regardless of the tele part of telemedicine, healthcare providers must abide by the rules of quality healthcare practices and patients need to accept the advance of medical technologies while understanding their limits. Furthermore, research asserts that there is an existing wide “digital divide” between those who, including both healthcare providers and recipients, have access and those who do not have access to telemedicine (Sittig, 2006, p. 814). If not properly addressed soon, this differentiation may continuously widen and result in serious problems in healthcare delivery in the future. To sum up, continuing patient education and practitioner training is absolutely critical to telemedicine progress.

Current Applications of Telemedicine

Today’s telemedicine applications may be divided into three tiers based on maturity states: (a) matured applications such as radiology and pathology; (b) developing applications including cardiology, psychiatry, dermatology, and ophthalmology; and (c) anticipated applications such as surgery, pediatrics, emergency care, and so forth (Bashshur & Shannon, 2009). The options for today’s telemedicine applications are literally unlimited.

Telemedicine can be extended to any imaginable healthcare activity that is practical and valuable to patient care. Many telemedicine practices have been salient in healthcare such as tele-cardiology, tele-consultation, tele-diabetics, tele-ophthalmology, tele-psychiatry, tele-radiology, and telemonitoring. Recent developments in tele-ICU and tele-surgery have also gained strong support. Summarized from general telemedicine services, current telemedicine is found mostly in the categories of tele-consultation, tele-diagnosis, telemonitoring, tele-treatment, and tele-presence.

Among telemedicine developments, telemonitoring is the fastest growing category. In 2004, research studies reported that the total telemedicine market was about $380 million (OTP, 2004). In 2007, it was predicted that the tele-home care market alone would grow to be in the billions by 2010 (Boric-Lubeke & Lubecke, 2002; “Home ehealth”, 2007). In-home telemonitoring currently focuses on two chronic, high mortality diseases: diabetes and congestive heart failure. However, tele-pulmonary monitoring has also been prevalent. Telemedicine in these cases provides remote consultation and helps manage the episodic needs of high-risk illness, provide education, schedule care, reduce hospital stay, and improve overall patient and clinician satisfaction. Research studies suggest that even though not all patients are willing to be monitored 24/7/365, most homebound patients who have difficulties accessing to medical care are comfortable with the arrangement (Snyder, 2007).

According to research, demographic trends would likely require increasing future home healthcare (“Home e-health”, 2007; OTP, 2004; Sittig, 2006; Snyder, 2007). Research studies assert that an aging population and increasing rates of obesity and cancer indicate a significantly larger population of chronically ill elders that require rehabilitation and long-term care management (Stanford, 2002; OTP, 2004; Sittig, 2006; Snyder, 2007). This scenario translates into significantly increasing demands upon the relatively small group of healthcare providers and inevitable cost inflation. Compounded with the increasing shortage of healthcare professionals and facilities, healthcare provision is becoming an acute problem; telemedicine will most likely be the only use of telemedicine allows patients to access to the best clinical providers, despite differences of time and distance, and frees up the small group of highly specialized experts for the most critical cases. From the aspect of a hospital, telemedicine technologies enable the efficient use of resources, improved quality, decreased medical errors, and enhanced medical care experiences. From a patient’s perspective, telemedicine allows the patient to stay at their residence, to cut the cost of long-term healthcare, and to decrease the frequency of hospital visits. Timely data entry and immediate access to patient electronic records help reduce the latency issues of patient care (Scalise, 2004). Moreover, recent wireless technology further promotes the mobility of both healthcare professionals and patients. Researchers predict that “the future of inpatient care is digital, wireless, and interactive” (Scalise, 2004, p. 40). With the help of telemedicine, patient care can be achieved in the patient’s room at hospital or at home with the CAD-CAM assurance of safety and quality.

Chapter 3: Methodology

Purpose of the Study

It is recognized that the majority of suicidal patients suffer emotionally which contributes to the reason as to why they would end their lives (James, 2005). Such situations where patients are emotionally unbalanced call for professional care to deal with the cause of their suicidal sentiments (Reeves, 2010). The crucial role played by professional counselors in averting future suicidal attempts cannot be understated, and this forms the basis for this study. The study explores the input of experiences by professional counselors in the treatment of suicidal patients in the ER setting The purpose of this study is to explore the experiences of licensed professional counselors working with suicidal patients in the ER setting. This study provides insight into the experiences of counselors in ER settings. Information shall be obtained from narratives provided by the counselor. The use of phenomenological questions in this study may help gain insights into the role of counselors in an emergency situation and suicide prevention/interventions in ER settings through narratives of the experiences of counselors. , this study could impact the way LPC educators train mental health professionals to work in the emergency setting. Many other special populations of psychological trauma victims exist in the ER such as rape victims, incest survivors, and domestic violence clients. LPC’s based on their exposure to both critical incident and cumulative stress, also present as a special population of trauma victims. LPC educators and researchers need to begin to understand the effects of cumulative stress within ER workers so that helping sciences can better train its practitioners in valid and reliable techniques for dealing with this phenomenon. The need for supervision, debriefing, and other types of interventions were also investigated.

Research Design

This study utilizes a phenomenological qualitative research design. Phenomenology relates to the self reporting where participants report their individual experiences under a particular phenomena. Therefore, under phenomenological research, emphasis is placed on personal interpretation and perspective. Individuals are in a position to report their subjective experience and the researcher is expected to facilitate individual’s self reporting (Moustakas, 1994).

Phenomenological qualitative research design encompasses a variety of data collection methods. These include focus meeting, interviews, conversations and participant observation and as such, the researcher is expected to ensure that he or she identifies the method most appropriate for his or her research (Langdridge, 2007). Under the above form of research design, the researcher should ensure that there is maximum output and also minimum interference. Therefore, the researcher avoided undue influence that affects the self reporting among the participants.

Data was collected during a semi-structured interview in order to examine the experiences of licensed professional counselors working with suicidal patients in the ER setting.

Target Population and Participant Selection

Licensed Professional Counselors (LPC’s) were solicited to participate in the study from a database of National Certified Counselors (NCC). A sample of convenience from the state of Pennsylvania was used. Licensed Professional Counselors (LPC’s) who have worked in ERs with suicidal patients for over one year were selected from three major cities in Pennsylvania: (four subjects) from Pittsburgh, (four subjects) from Philadelphia, and (four subjects from Harrisburg ).

The sample for this study was the representative of the larger population of licensed LPC’s from the above mentioned cities. Inclusion criteria included LPC’s who have worked with suicidal patients in an ER setting for one year or more. According to the Pennsylvania Counselling Association (2013), there are approximately 21,000 LPC’s practice in the state. Furthermore, of those 21,000 LPC’s, 5,644 reported having experiencing working with suicidal patients in an ER setting. Out of LPC’s from Pennsylvania who responded to the survey, a total of 12 LPC’s were selected for this study on a first come first serve basis. Furthermore, a fifth LPC was selected from each city as a backup if the initial participant(s) are unable to complete the requirements for the research study.

Procedures

An e-mail message were sent to 12 Pennsylvania LPC’s from each of the identified cities, (4) from Pittsburgh, (4) from Philadelphia, and (4) from Harrisburg explaining the study, requesting their participation, and indicating that a $25 Visa gift card would be given to those who were willing to participate and were selected for the study. An informed consent form was attached to the e-mail message.

As counselors responded to the e-mail, agreeing to participate in the study, the researcher contacted the counselor by telephone to complete the screening process. The screening interview asked:

1.) Are you a Licensed Professional Counselor in the state of Pennsylvania?

2.) How long have you been working in the ER setting conducting suicide assessment?

Counselors accepted to participate in the study had a full LPC license in the state of Pennsylvania and at least one year of experience working in the ER. If the participants met the criteria to participate in the study and would have liked to be a participant in the study, the informed consent form was sent to them in the mail. After receipt of the informed consent form, a meeting time and place (e.g. a closed room in a public library) in their community was scheduled for the interview.

Instruments

Three open-ended questions were asked using a sequential approach. Subjects were encouraged to freely express themselves (Giorgi, 1997) and include detailed information.

The researcher then traveled to Philadelphia, Pittsburgh, and Harrisburg to facilitate the interviews at a public library. The researcher used a room in the public library where the interviews were conducted. To ensure that there was transparency, the rooms were closed; however, doors were unlocked to avoid instances of coercion or where participants feeling uncomfortable. Interviews lasted approximately one hour and were audio-recorded. The audio-recording were transcribed into a Word document. The subjects’ identities were coded for preservation of confidentiality. Each interviewee was assigned a number and identified by geographic location thusly (e.g. Pittsburgh1). Transcribed interviews and audio tapes were placed in a lock box in the home office of the researcher for a period of seven years. After seven years, the research transcriptions and audio will be destroyed and documents shredded by the researcher.

Research Questions and Hypothesis

The overarching research question was: What is the lived experience of clinicians during an ER encounter with a patient who are suicidal? The results of this study provided a fundamental understanding of the importance of supervision for LPC’s who evaluate suicidal patients in an ER setting.

The following sub-questions guide data collection and analysis:

What have you experienced when evaluating suicidal patientswithin the ER setting?
Which cases amongst all the cases that you have treated, have stood out and made your perception of how to handle suicidal cases change?
How have these experiences shaped your personal & professional life as a counselor?
What type of training, supervision, and follow-up did you receive when completing suicidal assessments and interventions in the ER setting?

Data Analyses

The data-analysis steps started with the description of the researcher’s experiences with the subject matter (epoche), identifying significant statements in the data, clustering these statements into meaning units and themes, synthesizing the themes into textual and structural descriptions of the participants’ experiences, and constructing a composite description of the meanings and the essences of the experience (Moustakas, 1994).

Step 1: Epoche Phase

The researcher will begin in the Epoche phase. Here, the researcher will provide a rich description of his experiences about the topic in order to avoid any biases. This is the point where the researcher provided the proof that his past experience would not influence the outcome of the research. The researcher relied on the data collected from the interviews in order to achieve the goals of the study.

Step 2: Phenomenological Reduction

The researcher will use horizontalization, in which the interviews will be transcribed and then the researcher will analyze the data, highlighting every expression relevant to the experience that the researcher believe have provided an understanding of how the study participants experienced the phenomenon (Mertens, 2005). The specific reduction analysis method to be used in the study will be bracketing. Bracketing is an inclusive process where preconceived notions about the phenomena under study will be set aside. The process will involve the impartial analysis of the different experiences amongst LPC’s setting aside prior knowledge on the successes and failures of numerous practitioners. This will assist in obtaining helpful information about the different aspects under study. Bracketing will follow three steps that include obtaining the relevant information from respective respondents, analyze the data independently of pre existing knowledge, and draw specific conclusions from the analysed data (Juniper, 2008). This systematic method of analysis will give some sense of purity to the collected data in order to ensure it can build on the existing depth of knowledge.

Step 3: Coding Process

The researcher will identify significant statements in the data. Then the researcher will develop clusters of meaning from these significant statements in order to identify themes (e.g. supervision, debriefing, interventions, training). These significant statements and themes will provide an understanding and description of how participants experienced their interaction with clients who have suicidal ideation in the ER: this is called a textual description (Creswell, 2007).

Step 4: Composite Textual Description

The significant statements and themes will also be used to write a description of the context that influenced how participants experienced working with patients with suicidal ideation in the ER: this is called imaginative variation or structural description. Then the researcher will write about his own experiences and the context and situations that influenced the experiences (Creswell, 2007). The researcher will then write a composite description from the structural and textual descriptions, which is the essential or invariant structure (Creswell, 2007). After engaging in a process of imaginative variation, the researcher will compose individual structural descriptions and then a composite structural description.

Step 5: Synthesizing

Finally, the researcher will synthesize the composites into a rich description of LPC’s lived experiences in evaluating patients with suicidal ideation in the ER. This study is grounded in constructivist self-development theory (CSDT) as described by Lisa McCann and Laurie Pearlman (1990).The proposed research will help provide an understanding the lived experience of LPC’s working with suicidal patient assessments and interventions in the ER (ER) setting and associated cumulative stress.

This study is grounded in constructivist self-development theory (CSDT) as described by Lisa McCann and Laurie Pearlman (1990). The proposed research will provide critical insights into the lived experience of LPC’s working with suicidal patient assessments and interventions in the ER (ER) setting and associated cumulative stress. The general panacea for treating trauma has been focused on treating patients and close relatives experiencing suicide trauma in ER. The overwhelming amount of counseling that LPC’s face in ER blurs their emotional and psychological responses to suicide traumas. Because the study will provide a detailed narrative of LPC’s working with suicidal patients in the ER, CSDT can be applied to the experience of these participants. It is anticipated that this theoretical application will support the psychological trauma experienced

Expected Findings

Counselors like suicide survivors are affected by the death of their clients. This has both personal and professional consequences and yet, professional counselors are expected overcome such obstacles. Due to the nature of the fast-paced environment of an ER setting, professional counselors may not have enough time to recover from traumatic events. This may affect them in many ways (Reeves, 2010).

Counselors are expected identify behavior associated with suicide ideation. However, due to work related factors such fatigue and vicarious trauma, some of the counselors in ER settings might not be in a position to identify signs and symptoms associated with suicide ideation (Baraff, Janowicz & Asarnow, 2006). Counselors, therefore, might experience secondary trauma as a result of suicides in the ERs (Goldstein & Buongiorno, 1984). This may affect a counselors’ productivity and the ability to predict and prevent suicides in ER settings.

This study provides insight into the experiences of counselors in ER settings. Information shall be obtained from narratives provided by counselor. The use of phenomenological questions in this study may help gain insights into the role of counselors in an emergency situation and suicide prevention/interventions in ER settings through narratives of the experiences of counselors.

Some practical implications that may result from this study includes the advancement of the training standards for LPC’s handling suicidal ideation patients in the ER , treatment protocols, and information for professional counselors on how to deal with suicidal patients and other psychological issues. However, the primary issue that is being addressed in this study includes discussion on the “lived experiences” of LPC’s such as the effects of cumulative stress as emergency room workers. By adequately addressing the effects of cumulative stress, LPC’s may better be able to improve job satisfaction, job retention, reduce burn-out, and improve the mental health of LPC’s in ERs.

Mental health workers such as LPC’s, psychologists, and social workers are charged with the task of helping patients deal with psychological trauma experienced on the job. Many formal models of psycho education, crisis intervention and psychological debriefment exists dealing with the impact of critical incidents. However, these treatment strategies do not address the effects of cumulative stress. Typically, counselors use the same intervention strategies for both types of stress. By understanding the lived experience of LPC’s as ER workers and its associated stresses, the counselling sciences may be able to adequately assess and address the mental health needs of emergency workers.

Finally, this study could impact the way LPC educators train mental health professionals to work in the emergency setting. Many other special populations of psychological trauma victims exist in the ER such as rape victims, incest survivors, and domestic violence clients. LPC’s based on their exposure to both critical incident and cumulative stress, also present as a special population of trauma victims. LPC educators and researchers need to begin to understand the effects of cumulative stress within ER workers so that helping sciences can better train its practitioners in valid and reliable techniques for dealing with this phenomenon. The need for supervision, debriefing, and other types of interventions will also be investigated.

Chapter 4: Analysis and Presentation of the Qualitative Data

Introduction: The Study and the Researcher

Qualitative data requires analysis in order to find out whether research questions have been answered or not. According to this dissertation, there is need to find out the experiences of LPC’s who evaluate suicidal patients ER. According to the literature review, it comes out that effect on LPC’s who deal with suicidal clients has never been considered. This dissertation seeks to find out experiences that these LPC’s undergo while discharging their duties. After conducting interviews, it is important to undertake an analysis in order to single out the real experiences at play. This chapter presents the qualitative data that was collected from the interviews in a logical way in order to draw a conclusion from it. In any research work, there must be a problem that needs to be solved. Finding the actual situation demands that the researcher goes to the fields in order to collect data, but the raw data, in itself, may not help achieve the objectives set for this dissertation. This chapter presents the result of the interviews conducted by the researcher on the Licensed Professional Counselors from three different cities.

This chapter has been organized into five sections in order to give a logical sequence on the analysis and presentation of data. The introductory part of this chapter has the background information that gives its importance and place in whole dissertation. This section goes further to describe researcher’s interest in the experiences of Licensed Professional Counselors who work with suicidal clients. The second section of this chapter describes the sample that was collected. This is done by describing Licensed Professional Counselors who participated in the interviews, noting their demographic information as well as the size of final sample. The third section gives the research methodology applied to data analysis. Different models can be used in order to analyze phenomenological approach; the chosen model is described and its application in analyzing raw data is shown. This section ends by noting some of the changes that may have brought deviation from the previous chapter. Data and results of the analysis are presented in the fourth section of the chapter where generic steps used in the analysis are elaborated (Wertz, 2004). The last section of this chapter is the summary of the answers to the research questions, something done to help the reader make a smooth transition to the next chapter.

Note that this dissertation adopts phenomenological research design, something that seeks to give human experiences. Experiences by different Licensed Professional Counselors may be similar or different depending on the specific assignments. This means that collecting data from interviews require an elaborate method that seeks to find the main themes exhibited by different experiences. This is an important part of this dissertation as it gives the logical and systematic result of the research. Phenomenological research design requires that the method of analysis adopted only follows the nature of the data collected (Shaw, Dyson and Peel, 2008). The importance of this topic also comes from the fact that descriptions given by interviewees must be organized and understood by the audience, something that can only be possible through adopting an approach that abstracts themes exhibited. Raw data from interviews contain numerous elements that need consideration in order to come up with the correct conclusion. The importance of this chapter can never be overemphasized since it presents data upon which conclusion can be made. This dissertation would miss to achieve its goals without having a chapter that gives the analysis of the data collected (Groenewald, 2004). Furthermore, conclusion made would be in adequate and without the required support and evidence.

At this point, it is important to note that the research question is: What is the lived experience of clinicians during an ER encounter with a patient who are suicidal? This means that this study seeks to find the need for supervision on LPC’s who evaluate suicidal patients in an ER setting. The following sub questions will guide data collection and analysis:

What have you experienced when evaluating suicidal patientswithin the ER setting?
Which cases amongst all the cases that you have treated, have stood out and made your perception of how to handle suicidal cases change?
How have these experiences shaped your personal & professional life as a counselor?
What type of training, supervision, and follow-up did you receive when completing suicidal assessments and interventions in the ER setting?

The Researcher

Researcher’s interest in this study came from the fact that counseling is a high burnout profession with experiences that may affect counselors in terms of fatigue and trauma. Professional counselors recognize the fact that clients’ last hope rely on them, something that easily bring with it anxiety. The situation becomes more serious with professional counselors who deal with suicidal clients because a small mistake may lead to bigger problems. Every counselor desires that a client be helped from the situation that present a problem. The researcher noted that not all counseling sessions yield positive outcome as some of suicidal clients sometimes injure themselves. Such an occurrence is likely to have a negative impact on the professional counselors, either psychologically or emotionally. Supervision and follow up is rarely done on these counselors to find out their psychological situation in relation to the previous counseling sessions. It is with this understanding that the researcher saw the need to find out lived experiences of professional counselors when dealing with suicidal clients in ERs. Supervision plays an important role into ensuring that LPC’s are helped also helped in case of negative experiences from interaction with clients. Lack of enough literature that addresses the problem presented by this study has also played a major role in the researcher’s decision to conduct this research.

The researcher is a counselor with a ten-year clinical experience, something that has exposed him to the first hand ideal of what LPC’s undergo in emergency counseling rooms. The researcher endeavoured to develop his own intuitive ability and to facilitate conditions for the growth of intuition leading to the creation of this investigation. Experience in conducting research is an essential thing that determines the quality of dissertation produced. On this respect, it is important to note that the researcher is a master’s student at the Capella University and has undergone a thorough study on how to conduct qualitative research. It is important to note that this is not the first research study conducted by the researcher and the previous similar work has played an important role into giving direction to this dissertation. The researcher has immense experience on working with clients with psychological problems, something that puts him in the right position to conduct a proper analysis as required in a dissertation.

Collection of the data was solely done by the researcher. This began by conducting a comprehensive overview of subject matter in order to find out how to structure the interview questions. In order to come with proper interview questions, non-Capella experts were involved in doing a review of the same. The researcher is National Certified Counsellor with full member rights and privileges of looking for participants from National Board of Certified Counselors (NCC) Database available at http://www.nbcc.org/. Four participants were selected from each of Pittsburgh, Philadelphia and Harrisburg cities to help in providing the data. The researcher went ahead to plan for interview venue and time, going further to plan for recording of the process. The researcher used the collected data to do an in-depth analysis in order to find out the themes that described experiences of the LPC’s interviewed. After undertaking the analysis, the researcher employed the services of a peer debriefer in validate the analysis done.

Researcher’s past experience played a major role into directing the whole process. Being a member of the National Board of Certified Counselors, he was vast with the protocol of conducting such a study. Being fully aware of the biases that may arise, the researcher put certain measures to ensure that likely biases were set aside. For this reason, the research analysis was left to be directed by the collected data. Researcher’s past experience as an LPC was also not considered to avoid any kind of bias.

Description of the Sample (Participants)

The primary informants in this research were licensed LPC’s. This research was aimed at finding out the experiences of the LPC’s while dealing with suicidal clients. All the participants came from the three participating cities, which were Pittsburgh, Philadelphia area and Harrisburg. The process started with an announcement that was made from the list of LPC’s from the National Board of Certified Counselors (NCC) Database available at http://www.nbcc.org/. Participants were picked from the first four LPC’s that responded from each of the three cities, bringing the total number to twelve (12). It is important that the promised $25 gift card to the participants was honoured as promised by the researcher. Qualification for participation was that the LPC must have attained LPC license and worked for at least one year of experience with suicidal patients in an ER setting.

To avoid bias, the first four respondents from each of the cities were selected to participate in the interviews. This means that four (4) participants came from Pittsburgh, four (4) from Philadelphia and four (4) from Harrisburg areas. After the selection, a follow-up e-mail was sent to all of them, giving more information on the inclusion criteria. The consent form and the demographic information form were also attached to the e-mail. All the respondents who had been selected participated in the study as planned with none of them dropping from the study. This can be attributed to the fact that all the respondents were informed that participation was voluntary and it required the necessary consent. Therefore, those responded and selected were aware of this fact and did not see the need to drop out of the study. In order to conceal identities of the respondents, certain codes were used. For instance, participants from Pittsburgh were coded as Pittsburgh 1, 2, 3 and 4 respectively. This also applied to the LPC’s from Philadelphia and Harrisburg.

The conducted interviews were the main sources of information for this study; however, the researcher did an extensive literature review in order to find out some of the information that exists from other scholars and previous researches. In this analysis, standard phenomenological models were used in order to come up with LPC’s experiences as well as actions taken over the different cases mentioned by the counselors. Participation by all the selected respondents in this study means that analysis represents the correct situation. Withdrawal or drop-out of respondents is able to influence the outcome of the research, especially on a phenomenological study like this. The interviews had been planned to take place within public utilities like library. Rooms were secured in time for these interviews and no interferences were noted during the interview process of all the respondents. Doors to these rooms were closed and the respondents encouraged giving their express themselves as free as possible in order to give their experiences while dealing with suicidal clients. The electronic digital recorder functioned well and all the information was captured as required and transferred to the secure researcher’s personal computer.

Research Methodology Applied to the Data Analysis

Giorgi and Giorgi’s (2003) phenomenological research model was used in order to analyze the data collected. Analysis must be done in a specific way for a meaningful interpretation to be made on the data available. The raw data cannot, in itself, give information that brings interpretation. The best way forward is to choose an appropriate model that transforms the raw data into logical information that can be interpreted.

Phenomenological reduction was the first significant step that was employed in the data analysis (Smith, Flowers & Larkin, 2009). This stage entailed transcription of interview audio recordings and evaluating them in terms of the experiences of the respondents. The researcher listened to the digital audio recordings repeatedly in order to build familiarization with the wordings used by the respondents, having the intention of building a holistic view of the unique experiences of each of them. Reduction entailed bracketing of the transcript data from the audio files. The second process involved coding in order to find out significant statements from each of the data collected. These significant statements were then clustered to help develop themes. According to Creswell (2007), textual description of significant statements and themes provides the best method to understand the experience of the respondents.

Composite textual description was the next process. This allowed for the description of the context that may have led to the experiences mentioned by the respondents (Cooper, Fleischer and Cotton, 2012). Since working with patients having suicidal ideation in the ER can be affected by different factors, it was important to make an imaginative variation. After this, the researcher made a description of his own experiences while working in such conditions and context that might have influenced his experiences during various interactions with clients. All these information helped to develop the composite textual description during the analysis. The last step in this phenomenological research model entailed conducting synthesis the formed into a description that shows LPC’s lived experiences in evaluating patients with suicidal ideation in the ER (Wright, 2007). It is important to note that the application of the phenomenological research analysis model was made possible by the method used for collecting data. No source material was lost or misplaced before the beginning of this analysis.

Presentation of Data and Results

Meaning Units of Significant Statements

The first step of conducting this analysis entailed determining natural meaning units from the interview transcripts and as expressed by the participants. Transcripts were read and re-read in order to high LPC’s experiences in relation to matters under investigation. These meaning units are separate entities; however, when joined to the rest, they give the complete meaning of LPC’s’ experiences. Below are the meaning units and the related verbal statements from all twelve (12) respondents.

Table 1: Meaning Units and Verbal Statements Derived from the Individual Interview with Pittsburgh 1

Meaning Units	Verbal Statements (Quotes)
Anxiety, fear, racing heart and heightened senses in the ER.	· At times I have experienced anxiety, · Fear of not being able to help this individual through a difficult case. · Will I know the right thing to say? · Racing heart and heightened senses.
Perception that suicide and depression affects all persons.	· Depression and suicide can affect folks for all walks of life regardless of age, gender, race, religions. · Understanding that regardless of who walks through the door we (counselors) must be prepared and understand our own internal responses to the individuals that we may encounter
Awareness of the surrounding.	· I find myself aware of my surroundings—when I am out to dinner and see someone in distress I often times want to help. · As a counselor it has sharpened my ability to recognize the seriousness of suicidal thoughts and when people at are great risk for harming themselves and acting on his or her thoughts
Rare follow-up	· There was rare follow up if any. · The high speed environment in the ER rarely allowed for debriefing and or supervision to review cases.

Table 2: Meaning Units and Verbal Statements Derived from the Individual Interview with Pittsburgh 2

Meaning Units	Verbal Statements (Quotes)
Fast past and uncertain ER environment	· I enjoy the fast past environment of the ER setting. · Every day is not like another day. · You never know who will walk through the door that will need our help.
Hope to Patients	· I hope that I was able to give this patient some hope for the future and that she invest in her treatment.
Very little one on one supervision	· We have monthly staff meetings but very little one on one supervision

Table 3: Meaning Units and Verbal Statements Derived from the Individual Interview with Pittsburgh 3

Meaning Units	Verbal Statements (Quotes)
Lost hope by patients in ER rooms.	· Often when individuals are in crisis and come to the ER they have hit a very low and dark place in their life and this may be their last hope for getting their life back on track
Advocacy	· I continue to advocate for anti-bully programs and education within the community and schools.
Less supervision	· We have quarterly meetings where we can express concerns. · This is not enough. I would like to have at the very minimal bi-weekly supervisions.

Table 4: Meaning Units and Verbal Statements Derived from the Individual Interview with Pittsburgh 4

Meaning Units	Verbal Statements (Quotes)
Cry for help in ER rooms	· These folks are crying out for help and I find fulfillment in my career that I am able to help people in their time of need.
Personal Growth	· It continues to be a challenge but I take pride in my work and have grown both personally and professionally as a counselor
Minimal supervision	· Very minimal supervision and often times felt overworked with the lack of resources in the ER.

Table 5: Meaning Units and Verbal Statements Derived from the Individual Interview with Philadelphia 1

Meaning Units	Verbal Statements (Quotes)
Stressful and chaotic environment	· A very fast past, stressful, and chaotic environment · I feel that I am the last hope for some of the people that come to the ER. · At times I feel myself being overwhelmed because I never know the outcome after a pt. leaves the ER and is placed at a psychiatric facility.
Pain and suffering	· It has made me question my spirituality and faith due to the pain and misery that I encounter on a daily basis. · These people are at their very worst and it breaks my heart to know that there is so much pain and suffering in the world
No supervision in the last 7 months	· My old director would hold monthly supervision but since she is no longer here. I have not had supervision in the last 7 months

Table 6: Meaning Units and Verbal Statements Derived from the Individual Interview with Philadelphia 1

Meaning Units	Verbal Statements (Quotes)
Attentive listening skills in ER.	· Life or death situation that requires attentive listening skills and ability to process what is being relayed by the suicidal pt.
Need for a change	· It is challenging work; I know I do not want to do this for my entire life. I am looking for an outpatient setting to work with clients
Rare processing of cases	· I meet with my supervisor once a week. But we rarely process cases

Table 7: Meaning Units and Verbal Statements Derived from the Individual Interview with Philadelphia 3

Meaning Units	Verbal Statements (Quotes)
Busy or slow schedules	· My days are either extremely busy or at times can be very slow. · On the fast days I can see up to 10 patients in an 8-hour shift.
Learning to deal with situations	· I have learned to deal with the fast paced environment and processing what the stories that I hear
Bi-monthly review by other counselors	· I meet bi-weekly with the other counselors in the ER to review and process cases over the previous two weeks.

Table 8: Meaning Units and Verbal Statements Derived from the Individual Interview with Philadelphia 4

Meaning Units	Verbal Statements (Quotes)
Lost hope in ER	· I have experienced people at that end of their line and have no other options · and that has given up on life and wants to end it all.
Danger of Domestic struggles	· People who have worked their entire life at doing the right things can want to end their life when their marriages or relationships end.
No supervisions	· I have not received any supervision in regards to processing the cases that I have encountered on a daily basis. · I wish I had the opportunity for supervisions but there is never any time.

Table 9: Meaning Units and Verbal Statements Derived from the Individual Interview with Harrisburg 1

Meaning Units	Verbal Statements (Quotes)
Struggles and exhaustion	· It is thankless work however the few folks that has expressed how much that I have helped them really keeps me going and makes my job all worth the struggles and exhaustion.
Thankfulness	· These experiences make me thankful for what I have and helped me become closer to my family and friend and force me to reflect on my personal journey.
Supervisions	· We have weekly supervisions.

Table 10: Meaning Units and Verbal Statements Derived from the Individual Interview with Harrisburg 1

Meaning Units	Verbal Statements (Quotes)
Feelings of stress and pride	· Feelings of stress but also awareness and pride in my clinical skills and abilities to help people in distress.
Global perspective	· It has allowed me to view the story from a global perspective and take into account the information that the family is providing.
Supervision on request	· I only have supervision when I request it. · At times I feel like I don’t request it because I often feel like I am a burden to my manger when I do request it.

Table 11: Meaning Units and Verbal Statements Derived from the Individual Interview with Harrisburg 3

Meaning Units	Verbal Statements (Quotes)
Fear	· Fear that I will not be able to help the people who want to end their life. · I pray daily that I can do my very best and help the people when they need it the most
Nothing for granted	· I am thankful for both my personal and professional life. I never take a day for granted.
Rare supervision	· Very rare to have supervision

Table 12: Meaning Units and Verbal Statements Derived from the Individual Interview with Harrisburg 4

Meaning Units	Verbal Statements (Quotes)
Alertness in ER	· A very fast paced environment that keeps me on my toes and on constant alert.
Personal growth	· It has strengthened my counseling skills and allowed me an opportunity to grow as a person.
Bi-weekly supervision	· We have bi-weekly supervision but we don’t always get to process the cases. · We often use this time to review policies and new changes within the hospital system

Themes Arising from the Interviews

The next step entailed performing an analysis of the meaning units identified in the previous section in order to come with the related themes. In the process of performing analysis on interview statements by all the respondents, it was apparent that similar points came up. Out of the meaning units identified in the previous section, ten themes could be deduced from the process to describe the experience of the LPC’s who took part in this study. It is important to note that a number of similarities were noted in the data collected from the participants. The below table shows the list of themes deduced from statements of the twelve respondents.

Table 13: Themes deduced from meaning units

Themes
1	Anxiety
2	Need for Alertness
3	Fear of failure
4	Fast-past environment
5	Sense of personal growth
6	Need to appreciate life
7	Danger of Domestic struggles
8	Need for supervision
9	Need for case reviews
10	The final hope to clients

Theme Descriptions

After the themes have been enumerated, Giorgi (2005) points out to the need to tie them into descriptive statements. In this research, formulation was made from the description of the identified themes in the previous sub-section and in accordance to the research objectives. It is should be noted that the descriptions given in this study are not universal and can only be applied in certain situations. The themes described in table 14 below are some of the ones identified among the responses by respondents.

Table 14: Description of themes

Theme Descriptions
Anxiety and fear of what to expect.	ER environment is fast-past, something that makes every LPC anxious and fearful of what is expected of them.
ER experiences lead to personal and professional changes in terms growth and alertness	Experiences have made all the LPC’s have a different perspective of life and professional practice.
Supervision and case reviews are necessary.	LPC’s require frequent supervision in order to review cases and establish best practices that help clients.

Composite Textual Descriptions

As seen in the previous sub-sections, it comes out that LPC’s who took part in this research had varied experiences in the ER. This is evident by the response given by the participants on their experiences on the ER environment. Anxiety and fear of not being able to help a client over the suicidal condition is one thing that comes out of the data (Harrisburg 3). Pittsburgh 1 alludes to this fact, going ahead to note that finding the right words to speak to a client in the ER is also a challenge. It is also evident that ER environment is fast-past and all the LPC’s have to put up with it by being alert on what needs to be done. Pittsburgh 2 says that “You never know who will walk through the door that will need our help”. Harrisburg 1 notes that the work is exhaustive and one rarely gets appreciated for the work done. Uncertainty of what to expect in the ER requires that each LPC must be prepared for anything.

On how LPC’s’ experiences have shaped their personal and professional lives as counselors, it comes out that ER experiences have worked to bring changes in personal as well as professional lives. All of the respondents agreed to the fact that their lives and service to the suicidal clients have changed. One important fact is the awareness that comes from the needs of the suicidal clients. Most of the LPC’s allude to the fact that their ER experiences have made them have a different perspective of life and their profession. Pittsburgh 1 notes of awareness to the environment as one of the effects brought about by ER experiences. According to Harrisburg 4, “It has strengthened my counseling skills and allowed me an opportunity to grow as a person”. Harrisburg 3 says “I am thankful for both my personal and professional life. I never take a day for granted”. Most of the respondents alluded to the fact that through ER, they have been able to understand issues that may cause suicidal tendencies, something that has made Pittsburgh 3 embark on advocacy on school bullying. He says, “I continue to advocate for anti-bully programs and education within the community and schools”.

Supervision is another important part of this study. Respondents were asked to mention whether ER supervision programs existed in their work stations. According to many of these respondents, supervision is not a serious aspect of the work done by the LPC’s. All the respondents allude to the fact that the fast-past ER environment makes it difficult for supervision and review of the handled cases. Pittsburgh 1, Pittsburgh 2, Pittsburgh 3, Pittsburgh 4, Harrisburg 3 and Philadelphia 2 say that they rarely have supervision of their work. Philadelphia 4 notes that no supervision exists in his work station by saying that “I have not received any supervision in regards to processing the cases that I have encountered on a daily basis. I wish I had the opportunity for supervisions but there is never any time”.

Summery

Chapter 4 has shown how the analysis has been done, going further to present the qualitative data collected in this study. It comes out that LPC’s’ play an important role in helping suicidal clients. The twelve respondents from Pittsburgh, Philadelphia and Harrisburg all honoured their commitments of participation and were interviewed by the researcher in their respective areas. Analysis of the data collected shows that all the respondents experience first suffering of their clients. Three themes can be described from the statements given by the twelve respondents. To most of them, ER environment is marked by anxiety of what is to be expected from clients. These professionals see themselves as the last hope to the suicidal patients who come for assistance. From their experiences, LPC’s’ personal and professional lives have been impacted as their worldview has changed. To most of them, they no longer take life for granted and continue to appreciate whatever they have. Supervision comes out a necessity; however, Pittsburgh, Philadelphia and Harrisburg areas do not have such programs in order to review and improve service delivery. From the analysis and the presented data, it is now easy to make a discussion and interpretation of the results in the next chapter.

Chapter 5: Discussion of the Results of the Study

Introduction

Chapter 5 discusses the interpretation and implications of the results presented in the previous chapter. Note that this study was designed to find out lived experiences of the LPC’s in ER environment while dealing with suicidal clients. The chosen qualitative, phenomenological study design helped in collection and analysis of the data. At the end, results have produced three main composites, which are: (1) anxiety and fear of what to expect explains ER environment, (2) ER experiences lead to personal and professional changes in terms growth and alertness and (3) supervision and case reviews are necessary. Organization of this chapter entails, first, a summary of the results in order to give the general understanding of the study. Second, a discussion of each of the main composites in relation to the literature review in this study, appropriate theories, recorded and transmitted data from the respondents. Third, a discussion of the conclusion is done, a process that entail discussing the findings of this research in relation to the available literature. The next sub-sections include limitations, recommendations and conclusion of this study.

Counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma (Goldstein, 2007). The purpose of this study was to gain a better understanding of the experiences of LPC’s who evaluate suicidal patients in ERs in order to determine the need for debriefing or other interventions for the counselor and the need to develop a training curriculum in the United States. Literature shows that due to the nature of the fast-paced environment of an ER setting, professional counselors may not have enough time to recover from traumatic events (Malchiodi, 2007). This may affect them in many ways (Reeves, 2010). This study utilized a phenomenological qualitative research design. Phenomenology relates to the self reporting where LPC’s report their individual experiences while dealing with suicidal clients in the ERs. This research found out that LPC’s experience mixed emotional issues ranging from anxiety of what to expect each time a suicidal patient comes into the ER. Anxiety of their ability to provide the hope needed to these hopeless people is another experience noted by respondents. Supervision of the work done by LPC’s comes out as something not emphasized in all the responses.

Discussion of the Results

As noted above, counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma (Goldstein, 2007). This is true, especially if it entails the process of trying to help someone avoid suicidal tendencies. LPC’s are required to be the last hope of the people who exhibit suicidal tendencies. In their workstations, these professionals are expected to be the last source of help to the clients. The sample used in this research represents licensed professional counselors who have practiced for not less than a year. LPC’s are known to be professionals, meaning that they are believed to have the ability to execute their duties efficiently. Just as noted in the literature, results of this study show that these professionals’ experiences have a bearing on their professional and personal lives. Below is the concise discussion of the three composites that have been brought about by results of this study.

Anxiety and fear of what to expect explains ER environment

Majority of suicidal patients suffer emotionally, which contributes to the reason as to why they would end their lives at any time (James, 2005). When these clients are brought into an ER, LPC’s are expected to listen to and offer the correct direction into ways of helping such helpless persons. As indicated by the interview transcripts from the LPC’s who took part in this study, they meet varied suicidal cases within their practice. For instance, Pittsburgh 1acknowledges that “At times I have experienced anxiety” when faced with the task of helping suicidal clients. Transcripts from this interview (see Appendix E); fear comes from the fear of finding the right words that can help overcome his or her predicament, a condition that sometimes made the heart of this interviewee race just before meeting a client in the ER. Most of these people come when they are hopeless and their only option is to injure or end their lives. To the LPC’s, anxiety of what to expect is something that cannot be avoided at all. Some of them are afraid whether they would be able to find out the right words that can help the hopeless client. This is in contrast to the expectation of clients who have faith in these professionals as source of help to them. Such a scenario creates anxiety and uncertainty of what to expect.

According to Owens et al. (2010), 95 million emergency department (ED) visits by adults in the United States, 12.0 million (or 13%) were mental health and/or substance abuse-related. Counselors have to deal with different issues that may include finances, substance abuse, family issues and bullying. Some of these issues are serious to an extent that they leave a huge impact on the counselor after having a whole of handling various cases. According to the findings, it is obvious that ER environment is fast-paced; something that requires the professional is highly alert in preparation for what may arise in the ER. Not knowing what to expect is a serious issue that define experiences by LPC’s in the ER. This describes a challenging fast-paced environment that only focuses on the helping suicidal clients. the findings in this research proves statistics by Larkin et al. (2005) that while the number of emergency department visits between 1992 and 2001 increased by 20%, the number of emergency facilities nationwide declined by 15%.

ER experiences lead to personal and professional changes in terms growth and alertness

LPC’s are expected to deal with a wide variety of psychopathologies, including patients who are agitated, hostile, intoxicated, psychotic, paranoid, and resistant. Data collected from the respondents indicate that each of them have dealt with different cases in the process of executing their duties. Each of these situations requires a slightly different approach; for example, a clinician must use a structured interviewing technique to question an agitated or hospital patient, whereas a paranoid patient may require less intrusive questioning. All of the respondents in this alluded to the fact that their ER experiences have led to led to them having a different perception of things in life. After a whole day session with various suicidal patients, respondents noted of changes in the happenings in the surrounding, especially, on suicidal ideation.

It is important to admit that not all cases handled by LPC’s turn out to be positive. Unfortunate circumstances may lead to injury and even loss of life to the patients. Such unexpected turn of events, in addition to the variety of psychopathologic cases covered by these professionals have positive and negative influences on them (Keogh, Doyle & Morrisey, 2007). Handling these cases has exposed them to some of issues that affect humanity, some of which people take for granted. One of the respondents noted that he preferred changing working stations in order to avoid the fact-paced ER environment. This means that ER experiences are likely to cause negative impact on the LPC’s. However, many of the respondents in this studied noted personal as well as professional growth from the ER experiences. As much as many clinicians may decide to change their working environments as a result of the ER experiences, many have improved their professional skills on ways of dealing with various suicidal ideation cases. Such improvements have gone beyond work environment towards family life and the general public.

Supervision and case reviews are necessary

Research shows that much effort has been in place to help suicidal ideation patients recover from their conditions. However, little attention has been directed towards supervision of what goes on with LPC’s as a result of ER experiences. As noted before, some of the cases attain the intended breakthrough while others end up with tragedies that may include loss of lives. Having an elaborate supervision plan in place is likely to help in following up on what takes place in the ER. Conducting reviews of the handled cases is likely to show the impact of the ER experiences on the LPC’s. According to the findings of this study, supervision and cases reviews are rarely done, something that works against the desires of the counselors. All the counselors who took part in this study mentioned the need to have supervision as part of their work. Many of these respondents noted that their work stations rarely have supervision programs. Counselors are expected to identify behavior associated with suicide ideation. However, due to work related factors such fatigue and vicarious trauma, some of the counselors in ER settings might not be in a position to identify signs and symptoms associated with suicide ideation (Baraff, Janowicz & Asarnow, 2006).

Limitations: Limitations to this study may arise from the fact that the respondents were picked from the first four LPC’s who responded to the communication made by the researcher. There was no specific criteria that was put in place to find out eligible persons other having LPC license and having practiced for a minimum of one year. Other factors like age and specific operation centers did not matter in the selection. Future studies should be able to capture the impact of ER experiences on LPC’s as dependent on certain factors like age and years of practice. Such a research should come with results that are more targeted and inclusive. It also comes out that this research does not attempt to find out from the LPC’s the number of clients who have committed suicide or injured themselves after attending to them and the effects thereafter.

Design flaws: Qualitative research is most of the time criticized for being too subjective. Subjectivity is considered something that researchers should keep out of their research work, something to, at least, control against through a variety of methods to establish validity. This may also have a negative connotation in this particular research.

Discussion of the Conclusion

Comparing and contrasting the study’s findings with the previous research

The work done by LPC’s in helping clients with suicidal ideation is an important one and requires attention from the stakeholders. This study finds out that the fast-paced ER environment has adverse effects on the professional counselor who interacts with a patient suicidal having suicidal ideation. Just as indicated by Reeves (2010), it comes out that the fast-paced environment in ER does not give LPC’s time to recover from certain traumatic events they experience. They are always required to attend to cases as they arrive. One of the respondent alluded to the fact that he could attend to as many as ten cases in an eight-hour shift. Such an environment do not allow for time to overcome effects of experiences that may be negative to their lives. The research done by Echterling and Stewart (2005) shows that, in an attempt to perform their duties, LPC’s may experience a crisis that triggers fears of making a mistake and provoking feelings of helplessness and uncertainty. This is proved by this research as indicated by the findings where all of the respondents agree to experience some sort of fear and anxiety of what to expect while dealing with suicidal ideation (Bongar & Harmatz, 1991).

Preparedness also comes out as an important aspect of dealing with suicidal patients. Literature shows that professional counselors need adequate training in order know how to handle and overcome some of the effects of negative experiences in the ER (Wolf, 2008). Personal and professional awareness are important in making of informed clinical judgements by the LPC’s. Therefore, the need to have a constant follow-up of what they undergo in the ERs is of utmost importance to both patients and counselors. According to the findings of this research, the experiences by the LPC’s who took part in the interviews said that their ER experiences have made them see the need to prepare for any kind of an encounter with the patients (Frances, Miller & Mack (Eds.), 2005).

There is need for supervision with regard to suicidal assessments and the interviews conducted by the LPC’s. Literature notes that less effort has been put in place by various organizations in order to achieve this. Less literature is also available on suicidal ideation supervision. The impact of client suicide on counselors can result in severe and long-term consequences. In this research, respondents were free expressing their desire for supervision and review of cases, something that rarely took place in their work stations (Dawe, 2004). This is in line with the available literature. This study provides insight into the experiences of counselors in ER settings. Information was obtained from narratives provided by the counselor, something that proves findings by other researchers on lack of adequate supervision on the LPC’s. However, literature review indicates that supervision is mostly accorded to the suicidal clients. This is not captured in this research work as none of the LPC’s interviewed noted it. According to the findings of this research, LPC’s desire to have supervision that is directed to their welfare since their profession involves lots of work.

According to Goldstein (2007), counseling is a high burnout profession due to experiences such as compassion fatigue and vicarious trauma. This is verified in this research as indicated by the responses given by all the respondents in this study. It also comes out that most of these professionals do more than they are supposed to cover in a given day, but later going back home fatigued and traumatized by the experiences of the day. Literature shows that appropriate training is required for all professional counselors in order to identify and deal with burnout signs. Note that all respondents in this research are professional counselors with licenses and have practiced for not less than one year. According to the transcript responses, all of them have indicated the anxiety and fear they experience in ER. This means that LPC’s may be affected by the ER experiences irrespective of the professional training attained. Therefore, this research confirms the need for supervision for all professional counselors dealing with client suicidal ideation.

Limitations

Criteria for choosing respondents may not have captured all the aspects of LPC’s. For instance, messages were sent to professionals who were listed in the licensed counselors’ database. Selection was based on the first qualified respondents to these messages. Apparently, this was done to avoid any kind of bias on selection. Such kind of research should be able to cover other important details like practise period and even age of LPC’s. It is important to find out effects of ER experiences on LPC’s in terms of age and other factors. Another limitation arises from the fact that the interviews only limited the respondents to stating one experienced case in this study. More case scenarios could have brought up more information for analysis.

Another serious limitation is evident on the research questions adopted for the research as they fail to capture some of the actual suicidal instances and specific influences on the LPC’s. The framing of these research questions only interrogate one case and the general perception of these professionals on their experiences. These questions should have captured specific instances that affected personal and professional aspects of the LPC’s. The main objective of this research was to investigate effects of client suicidal ideation on counselors, something that could only come out from well-directed study questions. Limitations are evident on lack clear interrogative ability that can allow LPC’s to show how their experiences have positively or negatively affected.

Effects brought about by an experience can be determined by many factors like age and religious beliefs. This research could have brought out more elaborate and convincing if the researcher could have selected respondents through a process that captures the same. Some of the respondents could have been chosen in terms of their ages and definite duration in practice and not just in terms of licences. Moreover, religious beliefs are an important factor that easily influences how professionals perceive and adapt to ER experiences. This research fails to capture influence of religious beliefs by the respondents. However, one of the respondents alludes to the fact that ER experiences have made him respect the purpose for which God has created human being and never to take life for granted.

Recommendations for Further Research or Intervention

The data captured in this study has helped analyze important perceptions help by the LPC’s in terms of ER experiences while dealing with suicidal clients. However, as noted in the previous section, this data fails to capture some of important aspects like age and religious beliefs of different LPC’s. Further study should be conducted in order to have findings that capture such aspects. The current research only captures the general effects of client suicidal ideation of counselors. An elaborate study with data that capture the degree of influences of client suicidal ideation would give the correct perspective of the sampled LPC’s. Few studies in the United States have been found examining the effects of suicide assessments and interventions on counselors. Lack of literature on this issue has worked to conceal sufferings that LPC’s undergo. Other studies should cover other areas that include the effects of suicidal ideation in relation to ages of the counselors.

As much as phenomenological qualitative research design is the ideal method for such a study, there is a need to have more than one method of collecting data. Phenomenological qualitative research design allows for collection of data from respondent experiences as well as observations made by the researcher. This means that other than conducting interviews, the researcher could have made attempts to make observations from certain ER sessions. To get the correct feeling of the effects of suicidal ideation, the researcher could have organized for interviews immediately after ER experience. Making an observation long after an event has occurred may not give the correct effect as that made immediately after an event has occurred. For this reason, it is affirm belief that using more than one mode of interviews could have helped bring out more inclusive data.

It is noted above that this research has failed to capture important aspects of counselling like age and religious influence on ER experience. More studies should be done to capture this. The importance of such inclusion comes from the fact that a young professional with less experience may not be affected by the suicidal ideation as that professional with much experience. In this study, the researcher picked respondents in terms of ‘first come first served’. The main factor was whether the respondent had a license and had served for not less than a year. Further research should ensure that respondents are carefully chosen also in terms of religious beliefs, age and experience.

What comes out in the literature review is lack of deliberate supervision on LPC’s. This research also finds out that all the cities represented in this research do not have deliberate plans to follow and supervise counselors. This research also finds out that all LPC’s desire for a follow up in terms of supervision and discussion of past cases. Reviewing these cases stand to help coming up with best methods of dealing with suicidal ideation as they arise. This is a call to all the institutions and the relevant body to come up with necessary measures to ensure that all LPC’s are supervised to find out what kinds of cases they tackle and how are affected by the same.

Conclusion

In conclusion, it is important to reiterate the importance of LPC’s in dealing with suicidal ideation cases. Literature indicates that good supervision can protect LPC’s from the deleterious effects of crisis work, reduce the incidence of secondary trauma, and enhance the LPC‘s resolve and self-efficacy. This study finds that ER’s fast-paced environment makes LPC’s experience certain difficulties in dealing with their personal and professional assignments (Grella & Stein, 2006). Supervision comes out as non-important in most of the work stations as seen by respondents from different areas. Regular supervision and review of cases handled by the LPC’s is the best method that can determine the effects of these cases on them.

It is clear that suicidal ideation has huge influence on LPC’s. Therefore, efforts should be put in place to follow up on them just like it is done on suicidal clients. LPC’s desire to have forums in which they can share their experiences either with their superiors or fellow professionals. Such forums may help counselors know how to deal with different situations as they arise on a day to day basis. Otherwise, many of negative experiences may end up impacting personal and professional aspects these counselors. Many of respondents in this study noted the influence that ER experiences have brought in their lives. Note that some of these experiences may not be positive as much as others may be so.

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