Decision making in psychiatric emergencies: A phenomenological analysis of gatekeeping

Abstract

Repeated examination of the patient-evaluative process in emergency room settings over the past 20 years has yielded diffuse and contradictory findings, leaving the decision whether to hospitalize the indigent person with a psychiatric emergency a poorly understood process. In this study of crisis stabilization unit workers' interviewing and decision making, we examined four categories of factors as influences in the treatment decision: organizational factors, community expectations, family influence, and interviewer subjectivity. Factors most important in shaping interviewers' interpretation of interview data and their goals in the interview situation were community expectations that the CSU worker would (1) diagnose and predict levels of dangerousness and (2) deny admission in any cases where outpatient care would serve. The CSU consisted of social workers with 2 to 14 years' experience, whose motivation for occupying the minimally paid position of gatekeeper was determined to be the unusual degree of authority attached to the role.