Home Health Big Book of Emergency Department Psychiatry
Agitation as a Result of Confinement
Agitation is a cause of psychiatric emergencies. Agitation sometimes occurs as a result of psychiatric decompensation. However, it can also be the result of confinement or a combination of the two problems. Inmates with mental illness often struggle with confinement, especially in a segregation or isolation setting. This can lead to psychosis including paranoia and hallucinations as well as aggression and suicidality (Scharff Smith 2006). Other acting out behaviors can be seen in extreme cases, such as ingestion of dangerous objects (forks, spoons, batteries, etc.) or feces smearing. In cases where the agitation is a result of confinement, part of the treatment may be a medical order to temporarily remove the inmate from the setting they are in to a safer setting for that individual.
Cell Extractions and Use of Force
There are numerous reasons for an inmate to refuse to leave their cell. Examples include not wanting to go to court, not wanting the cell to be searched, or acute psychiatric decompensation. Generally, when an inmate needs to be extracted from a cell, these events are governed by correctional policies and procedures even if dealing with mentally ill inmates. It is common for these procedures to call for mental health intervention prior to the use of force or extraction of a mentally ill patient. This involves the treatment provider going to the patient and attempting to convince them to voluntarily comply with the correctional officer’s request. This is a setting where the psychiatrist can use their de-escalation skills to get the inmate to comply. In many situations, the inmate wants to make their needs known or needs to feel they have some control of the situation, and with some coaxing, risk of harm to the inmate and corrections staff can be avoided. Part of the evaluation is to determine if the inmate is refusing to leave due to psychiatric decompensation. If that is determined to be the case, then the psychiatrist will then advise corrections on the best way to treat the inmate. If the cause is not due to mental illness and attempts to get the inmate to comply fail, then rather than authorize the use of force to extract the inmate, the psychiatrist will let the corrections officer know mental illness is not the cause of the inmate’s refusal to leave the cell.
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