Articles: Managing intoxicated patients & Early Career Psychologists {Below}

Managing intoxicated patients

By Justin R. Gauthier, Ph.D.
February 5, 2020

While working with populations who use substances, psychologists may encounter patients who are intoxicated. In these situations,  a variety of ethical and legal issues

Doctor Diagnosis

may arise and often take precedence over direct clinical service. The purpose of this brief article is to provide some initial education as well as an overview of several common situations and factors psychologists may wish to prepare for and consider in their professional decision-making when encountering an intoxicated patient.

Understanding risks

Impairments in mental status and physiological changes are common with substance use. Intoxicated patients are particularly vulnerable as a result and special care should be taken. Safety should be paramount. In addition to fatality from overdose or physical injury, the use of some substances in combination may result in a medical emergency due to effects on the body, such as depressing respiration.

Further, withdrawal from alcohol and benzodiazepine use can be fatal. Substance use has also been associated with adverse outcomes, including suicide. Professional decision-making in such situations is complex and requires a well-thought-out rationale that centers around risk management.

Managing of medical risk

Upon indication that a patient is intoxicated, it may be helpful to gather substance-related information to the extent feasible, including the substances used, amount and frequency of use and the date and time of last use. If substance use has the potential to cause acute harm, ideally, the patient may be referred to a detoxification appointment with a medical provider, such as their primary care physician.

Large medical centers may often offer these as same-day appointments. If the patient is using chronically and heavily, presents with or has a history of acute withdrawal symptoms, such as seizures, hallucinations or insomnia, or has a complex medical presentation or history, referrals to an urgent care facility with the proper resources, an emergency room or calling 9-1-1 are likely to be the safest and most appropriate option.

Throughout this process, the patient is likely to benefit from appropriate support and education. To the best of one’s ability and scope of practice, patients should be educated about the risks of use and withdrawal from the substances used. Proper releases of information should be completed if non-emergency referrals are made.

Management of transportation and public safety risks

An intoxicated patient driving presents a danger to self and the public that may potentially prompt mandated reporting. The psychologist should express these safety concerns to the patient and explore reasonable alternatives to reduce the potential for harm.

The psychologist may ask if the patient would be willing to turn over car keys temporarily,

while arrangements are made for alternate transportation via a cab, ride-sharing app,

public transportation or family member/friend. If a patient insists on driving, the

psychologist may consider gathering available information, such as car make, model,

color and license plate number. If a psychologist deems an impaired driver to be within

mandated reporting responsibility, a call to a non-emergency or emergency police line may be appropriate.

Psychologists speaking with patients on the phone, who appear or report being intoxicated and indicate they are going to drive may be assessed to determine if they are an imminent risk. A welfare check or call to the local police where the patient lives may be appropriate or mandated.

Documentation

Psychologists may consider including statements in their informed consent process about what may happen if patients engage in clinical encounters while under the influence of substances. Further, given the potential for complex clinical, ethical and legal consequences after the encounter, thorough documentation may be wise.

Specifically, document mental status, assessment of suicide and homicide risk and any actions taken and justification for such actions, other mandated reporting disclosures, substance use history, reported and observable signs of impairment or withdrawal symptoms, referrals made to medical providers or facilities, the patient’s mode of transportation to and from the appointment and the related transportation risk assessment.

Information provided and patient understanding of the risks of use and withdrawal from the substances used should be documented. Consultation with colleagues may be considered throughout the encounter, whenever appropriate, and possible and careful documentation should be made of these as well as the rationale and steps taken to protect the patient and public.

Recommendations

It is recommended that psychologists who anticipate such clinical encounters review applicable laws in their jurisdictions, as well as general principles and enforceable standards of The Ethical Principles of Psychologists and Code of Conduct that are particularly relevant to these scenarios. Psychologists employed in medical systems, group practices or other settings may already have procedures and policies in place to best utilize available resources and adhere to specific laws and standards of practice in their locations and settings.

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Justin R. Gauthier, Ph.D., is a licensed psychologist and adjunct professor of psychology with specialization in addiction, traumatic stress, psychological assessment and program evaluation. He is available for consultation and can be reached at: JustinGauthierPhD@gmail.com.

Early Career Psychologists: Integrated care requires integrating with treatment team

By Cinnamon Westbrook, Psy.D.
February 5, 2020 

Support Group Session

As scientific literature has increased awareness of the relationship between the biological and psychological aspects of the human condition, and terms such as multidisciplinary and interdisciplinary have become the norm, so has the presence of psychology as an integral component of treatment teams.

From a global perspective, research shows that the presence of a mental health professional embedded within a team greatly contributes to the success of the team and patient outcomes at large. Given the culture and training of different disciplines, however, not every member may appreciate the utility of mental health representation.

As psychologists settle into new roles within teams, some may struggle to find their voice and identity, or find they are largely left out of patient care altogether. In the pursuit of whole-person care, what can we do when we find ourselves working in less inclusive cultures?

Observe

First, take note of the team culture. As a new member, getting the lay of the land and assessing team dynamics will be useful information to assist you in being more effective within the team.
Next, take note of the individual members. What are their goals? How do they approach their work? How do they function within the group? While this step takes time, learning how the team functioned before your arrival will inform you on how to integrate successfully.

Educate

While we are aware of the value of our skillset, psychologists have a responsibility to educate others on the assets we possess and the assistance we can provide.

Increasing your colleague’s awareness of the role of psychology and the importance of mental health support is crucial for survival within the system. Find time to share with colleagues your knowledge and how mental health can be of service to team and patient outcomes. Even today, many disciplines are unaware of how a psychologist functions within healthcare or even what skills we bring to the table.

Demonstrate your worth

Contribute to team outcomes by helping other disciplines achieve their goals. Focus

on problem-solving issues from a team perspective. Be willing to jump in and do the

dirty work. Demonstrate through your actions that the goal is to put the success of the

team above that of the individual in order to reduce a sense of competition and opposition.

Build up the team, set healthy boundaries

Praise others for their accomplishments. Celebrate team and individual achievements. However, avoid landmines such as team splitting and gossip. By gently ignoring the behaviors that create barriers to effective teamwork, you set the precedence that you are a member with integrity, respect, egalitarianism, and collegiality.

Check your ego at the door

Appreciate that being a good member of a team means you must let go of any self-centered positions. Approaching interactions with the attitude that only you and your discipline have the answer to a problem will alienate you and the profession. Share decision-making, and be open to the input, perspective and expertise of others.

Make yourself available

Have an open-door policy, and more importantly, be mentally present when others come to you. It’s important to send the message that you value the input of others and that you are open and willing to work together toward a common goal.

Alternatively, reach out to team members. The more you engage with your teammates, the more people will think of you as part of the team. Use your rapport building skills you developed as a psychologist to your advantage and capitalize on your ability to form relationships with others. Get to know the other team members; not just for what they contribute professionally, but who they are personally.

Recognize your true value

Lastly, in your training as a psychologist, you are often taught to approach interactions with humility and passive support. While those skills have a time and place, learning to be actively engaged with a clear and confident but respectful voice will earn you greater respect from your colleagues as an asset to the team.

Appreciate your skills for what they are. Be mindful of psychology’s value in its ability to diversify and deepen the impact healthcare delivery systems can have on a person’s meaningful recovery and quality of life.

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Cinnamon Westbrook, Psy.D., received her doctorate degree in clinical health psychology from Loma Linda University. Following a medical psychology internship in Dallas, Texas, she received her postdoctoral specialty training in neuro-rehabilitation psychology at the VA Palo Alto Healthcare System Polytrauma System of Care. She is in private practice in the San Francisco Bay Area. Her email address is: cinnamonwestbrook@gmail.com.

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