Well, They Are a County Patient: How Interorganizational Relationships Impact Psychiatric Emergency Departments

Background and Purpose People experiencing psychiatric crises cycle through criminal-legal systems and emergency departments (ED) that are often ill-equipped and/or unwilling to provide appropriate care. Specialized psychiatric emergency departments (PED) seek to stabilize people experiencing psychiatric crises and connect them to services and resources. Yet, as entities within broader organizational ecosystems, we know little about the impact of a PED’s relationships with adjacent organizations and institutions, like other healthcare systems and law enforcement agencies. This qualitative case study aims to understand the impact of interorganizational relationships on the daily operations and experiences of staff at Mental Health Services (MHS), a closing county-operated PED in a midwestern city.

Methods Data for this project come from three sources. Thirty-seven participant observation shifts were conducted over a 6-month period. An observer shadowed and assisted MHS staff as they performed daily tasks—paying attention to how they interacted with patients and their loved ones, law enforcement officers, hospital systems, and each other. Twenty-two semi-structured interviews were conducted with a purposive sample of 20 MHS workers and administrators and behavioral health advocates. Participants were asked about patient pathways into MHS, strategies to working with patients, collaboration with external entities, historical events that have shaped daily operations of MHS, and the looming closure of MHS. The sample was mostly female (n=15) and racially heterogenous, ranging from 25 to 69 years of age. Documents concerning MHS, including newspaper articles, press releases, annual reports, and MHS training materials, were collected and analyzed to supplement and contextualize observations and interviews.

Results Findings reveal that MHS serves many functions outside emergency psychiatric care, including being a de facto shelter, respite facility, detoxification facility, and information hub, despite lacking numerous resources. The crisis many MHS patients present with is poverty, and they fall (or are pushed) through the cracks of upstream services— eventually landing at MHS. Participants express mixed feelings about external organizations and institutions. Some view law enforcement officers as helpful partners, but others argue they bring in patients unfit for treatment and behave in ways that communicate disdain for MHS and its staff. MHS personnel express more negative views of other hospital systems, stating that external EDs “dump” patients onto MHS and external inpatient hospitals refuse to accept transfers from MHS. Participants describe external hospital systems as publicly supporting collaboration and increasing access to mental health services, while labeling high-acuity and poor patients as “county patients” in private meetings and relying on MHS to handle populations they do not want to service.

Conclusions and Implications An inability to access healthcare services has positioned EDs as growing avenues for primary care for many, and burden shuffling situates MHS in a liminal space between “safety net” and “dumping ground” for a largely poor and Black clientele that is unable to obtain services elsewhere. Social workers often work with marginalized populations who face the greatest likelihood of visiting a PED and must understand the daily realities of PEDs and the perspectives of those who work in them to best serve their communities.