Psychiatric emergency services: Evolution, adaptation and proliferation

This paper traces the dramatic rise of psychiatric emergency services (PES) and crisis intervention services over recent decades. It examines three processes--the evolution of such services, their adaptation to diverse settings, and the striking increase both in the number of programs and their utilization. PES first evolved along three disparate lines--makeshift psychiatric emergency care in the emergency room of the general hospital, ad hoc after-care services in the psychiatric hospital, and the community mental health movement. Community mental health legislation of the 1960s not only provided funds for PES but led to the merging of the three lines. PES have adapted to and are found in a great variety of settings. The latter include small general hospitals and huge medical centers; county, state, and private mental hospitals; free clinics; telephone hot-lines, and others. Their adaptability appears due to their flexible requirements and lack of need for an elaborate technology. Although fewer than 160 facilities were known to offer PES in 1963, their number exceeded 2000 by the early 1980s. Available piecemeal data indicate constantly increasing utilization of PES. This is a result of many factors, including deinstitutionalization. Although PES were initially visualized as resources for acute mental health care and continue to serve as such, they have become increasingly chronicized, consequent on the deinstitutionalized abandonment of many chronically ill persons. Changes are also occurring in the social and demographic characteristics of persons utilizing PES and in the ways in which the services are perceived and utilized. The early development of unlabeled and makeshift psychiatric emergency care in the general hospital's emergency room and the psychiatric hospital were instances of 'evolutionary planning'. That is, in the face of mounting environmental demands, internal organizational strains, or other situational pressures, the organization adopted some expedient accommodations--modifying things only enough to maintain the essential system as it was. Currently, in the face of deinstitutionalization, policy shifts, and federal and state cutbacks in funding, new forms of evolutionary planning are emerging among facilities that provide PES.