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My protocol for dealing with an acute change in a client's mental status during therapy

Stanley Efrem

Oct 18, 2025

Emergency departments see altered mental status in roughly 5% to 10% of adult patients, with older adults particularly affected [8]. These patients face a significantly higher risk of death within seven days compared to those presenting with chest pain [3]. The statistics alone underscore why therapists need a clear action plan.

Routine therapy sessions rarely involve medical emergencies. Yet when acute mental status changes (AMS) occur, they require immediate response. These situations can present as focal changes like aphasia or visual hallucinations, or diffuse changes such as delirium or stupor [3]. Each type demands its own response strategy.

This protocol comes from years of clinical practice and supervision. You'll find a step-by-step approach to recognizing, assessing, and managing these critical moments. Risk management strategies protect both client safety and your practice.

Your role remains clear: assess, stabilize, and facilitate transfer to appropriate medical care. You're not treating the underlying medical or psychiatric condition.

Important note: This protocol reflects clinical experience and serves educational purposes only. It doesn't replace formal emergency medical training or your licensing board's specific guidelines. Stay within your scope of practice and follow local regulations.

Defining Acute Change in Mental Status in Therapy

Acute change in mental status (AMS) presents a critical medical scenario that can emerge unexpectedly during therapy sessions. Recognizing and responding appropriately to these changes could save a client's life.

Altered mental status means a nonspecific change in a person's baseline level of awareness, cognition, attention, or consciousness [8]. These changes occur suddenly and may signal serious underlying medical conditions. Clinical settings show AMS affects approximately 5% to 10% of adults presenting to emergency departments [3], with higher rates in older adults and very young children [8].

Differentiating AMS from Emotional Dysregulation

Mental status changes differ fundamentally from emotional dysregulation. Emotional dysregulation involves trouble controlling emotions and reactions to feelings [1]. Both conditions may show behavioral changes, but key differences exist:

Emotional dysregulation:

Appears proportionate to triggers within the person's life context
Follows patterns consistent with the client's mental health history
Primarily affects mood and emotional expression
Maintains basic orientation and cognition

AMS:

Appears abruptly, disconnected from immediate psychological stressors
Represents a departure from the client's typical presentation
Affects orientation, cognition, and awareness
Often includes physiological changes like fever or abnormal vital signs

This distinction matters because emotional dysregulation requires psychological intervention, while AMS demands immediate medical attention.

Common Synonyms: Confusion, Disorientation, Delirium

Medical literature uses various terms interchangeably with AMS. Common synonyms include "acute confusional state," "confusion," "acute brain failure," "encephalopathy," and "disorientation" [8].

Delirium deserves special attention. Though often used as a synonym, delirium describes a specific type of acute, fluctuating altered mental status characterized by decline in attention and additional cognitive deficits or altered arousal levels [8]. Delirium affects approximately 10% to 23% of patients admitted to general medical services and up to 85% of patients in intensive care units [8].

Delirium characteristics:

Rapid onset (hours to days)
Fluctuating course throughout the day
Inattention as a primary feature
Disorganized thinking and perceptual disturbances

Why AMS is a Clinical Emergency in Therapy

AMS constitutes a genuine medical emergency for several reasons. The conditions causing AMS can be life-threatening yet potentially reversible if identified quickly. Recent studies found that patients with AMS had significantly higher risk of death within 7 days compared to patients presenting with chest pain [3].

AMS associates with poor outcomes, including mortality in approximately 10% of cases [8]. The economic burden reaches USD 38 billion to USD 152 billion annually in the United States alone [8].

Your role as a therapist: assess, stabilize, and facilitate transfer to higher-level care. You don't treat the medical condition itself. Timely recognition prevents devastating outcomes, as many underlying causes require urgent medical intervention. Studies show delirium goes unrecognized by healthcare providers in 57% to 83% of cases [7], highlighting the need for therapist vigilance.

An acute mental status change shifts the standard of care from therapeutic intervention to medical triage. This protocol guides that crucial transition safely and effectively.

Red Flag Checklist for Acute Mental Status Changes

Early recognition saves lives. When these warning signs appear during therapy, immediate identification determines whether you provide appropriate intervention or face potentially dangerous delays in care.

Cognitive Signs: Disorientation, Incoherence, Memory Loss

Cognitive disruptions signal the most common mental status changes. Watch for:

Sudden disorientation: Your client becomes confused about time, place, or person—especially if previously oriented [10]. Simple questions reveal this quickly: "Where are we meeting today?" or "What day is it?"
Incoherent or disorganized thinking: Listen for rambling speech, irrelevant statements, or illogical thought flow [7]. Clients jump between topics without finishing thoughts or give lengthy, detailed answers to simple questions [8].
New memory impairments: Notice trouble recalling recent events, forgetting just-given instructions, or repeatedly asking identical questions [10]. These deficits develop over hours to days, distinguishing them from chronic memory issues [6].

These cognitive changes fluctuate throughout the day, often worsening in the evening—known as "sundowning" [9]. This fluctuation differentiates delirium from other conditions.

Perceptual Signs: Hallucinations, Delusions

Perceptual disturbances accompany altered mental status and require immediate attention:

Hallucinations: Your client perceives something not present. Visual hallucinations appear particularly common in delirium [9]. Clients might pick at clothing as if removing insects or dirt that isn't there. Auditory hallucinations may also occur [8].
Delusions: Fixed false beliefs persist despite contrary evidence [8]. Clients might suddenly believe you or others intend harm, that they're being followed, or that ordinary events carry special personal meaning [9].

These perceptual disturbances emerge rapidly, unlike gradually developing symptoms of primary psychotic disorders. Recognize these as potential medical emergencies, not conditions you treat directly.

Behavioral Signs: Agitation, Retardation, Paranoia

Behavioral changes fall into two categories—hyperactive and hypoactive:

Hyperactive behaviors: Restlessness, agitation, combativeness, and increased motor activity [7]. Clients may pace, fidget excessively, or show uncharacteristic aggression or anxiety [9].
Hypoactive behaviors: Often overlooked but equally serious. Notice unusual drowsiness, lethargy, slowed responses, withdrawal, or appearing "out of it" [1]. This presentation especially affects elderly clients [7].
Paranoid behaviors: Clients may refuse care, hide objects, or become suspicious without rational basis [9].

Many clients alternate between hyperactive and hypoactive states, with periods of normal lucidity between—called mixed delirium [9].

Somatic Signs: Fever, Tremors, Slurred Speech

Physical signs provide crucial diagnostic clues:

Vital sign abnormalities: Fever suggests infection; abnormal heart rate indicates various medical conditions [8]. Abnormal breathing patterns sometimes accompany mental status changes [3].
Tremors or abnormal movements: Look for asterixis (flapping tremors), unexplained twitching, or unusual reflexes [3]. These may indicate metabolic disorders, withdrawal states, or neurological conditions.
Speech changes: Slurred speech, word-finding difficulty, or newly incoherent language patterns warrant immediate attention [1].
Visual changes: Abnormal pupillary response, eye movements, or visual field defects may signal serious neurological issues [10].

Recognizing these red flags starts your protocol. Next comes structured assessment—remembering your role is to assess, stabilize, and facilitate transfer to appropriate medical care.

Note: This protocol reflects clinical experience and serves educational purposes. It doesn't replace formal emergency medical training or your licensing board's guidelines. Practice within your scope and local regulations.

The Step-by-Step Protocol for Managing AMS in Session

Mental status changes during therapy demand structured response. Once you recognize red flags, shift immediately from therapeutic mode to crisis management. This protocol can make the difference between appropriate intervention and dangerous delays.

Step 1: Ensure Immediate Safety of Client and Therapist

Safety comes first. I position myself closer to the door, ensuring quick exit if needed [11]. This matters especially when clients show agitation or aggression. Remove potential weapons from reach—letter openers, paperweights, or heavy objects [11].

Keep your demeanor calm. Speak in clear, simple sentences. If the client becomes agitated, make an excuse to step out momentarily: "I need to use the bathroom" or "I forgot to give a staff member a message" [11].

Step 2: Perform a 2-Minute Differential: Delirium vs Psychosis

Quickly distinguishing between delirium and psychosis shapes your next actions. Assess these key areas:

Orientation: Delirium typically shows confusion about time, date, place, or identity. Psychosis usually maintains orientation [12].

Attention: Delirium severely impairs attention. Psychosis generally does not [12].

Memory: Recent memory loss suggests delirium. Memory retention points toward psychosis [12].

Hallucination type: Visual hallucinations more commonly indicate delirium. Auditory hallucinations suggest psychosis [12].

Check for medical clues. Fever, abnormal vital signs, or tremors often accompany delirium [6].

Step 3: Determine Acuity: 911 vs Psychiatric Crisis Team

Decide whether this requires immediate emergency services or psychiatric crisis intervention. Call 911 immediately for:

Unresponsiveness or rapidly declining orientation [6]
Suspected delirium or drug overdose [13]
Inability to care for self [5]
Seizure activity or loss of consciousness [6]

For psychiatric crisis without immediate danger, contact the local crisis team instead [4]. Tell 911 operators this is a "mental health emergency" and request responders with Crisis Intervention Team training [13].

Step 4: Activate Support System: Family, PCP, Crisis Line

Activate the client's support network. Obtain consent to contact family during crisis situations beforehand [5]. When calling family members, provide only essential information needed for immediate care.

Consider contacting the client's primary care provider. They often play crucial roles in mental health emergencies. For clients without adequate support systems, utilize crisis lines for additional guidance [13].

Step 5: Manage Session Termination and Handoff

Proper session termination ensures continuity of care. Document objectively what occurred using clinical descriptors rather than interpretations [5]. Write "The client endorsed active suicidality but denied intent to act on his thoughts" rather than vague statements [5].

Include what actions were taken and the safety plan established. During handoff to emergency personnel, provide concise, relevant clinical information while maintaining appropriate confidentiality [5].

Your role remains clear: assess, stabilize, and facilitate transfer to higher-level care. You're not treating the medical or acute psychiatric condition yourself.

This protocol reflects clinical experience and serves educational purposes only. It doesn't replace formal emergency medical training or your licensing board's specific guidelines. Clinicians must operate within their scope of practice and local regulations.

When to Call 911: Medical Emergency Indicators

The decision between calling 911 and activating other crisis resources can save your client's life. Clear indicators help you make this critical choice quickly and accurately.

Unresponsiveness or Rapid Decline in Orientation

Rapid disorientation requires immediate emergency response. Call 911 when a client suddenly becomes confused about person, place, or time after being previously oriented [14]. This rapid decline often signals neurological deterioration requiring urgent medical intervention.

Watch for significant decreases in orientation performance—especially a drop of 5 or more points on orientation assessment. These consecutive decreases may indicate ongoing neurological deterioration [14]. Any client who becomes unresponsive during your session needs emergency services immediately.

Tell the 911 dispatcher that your client is experiencing a "mental health crisis" and share their mental health history or diagnosis [15]. This information ensures appropriate response personnel are dispatched.

Suspected Delirium or Drug Overdose

Delirium is a medical emergency requiring immediate intervention. Call 911 if you observe confusion, disorientation, incoherence, memory loss, perceptual disturbances, or fluctuating consciousness [16]. Untreated delirium carries a 10% fatality rate and demands urgent medical attention [16].

Drug-induced mental status changes present particular risks. Excited delirium syndrome (ExDS), especially from stimulants or opioids, has fatality rates up to 10% [17]. Deaths from excited delirium occur at the scene or during transport 75% of the time, making immediate medical response critical [17].

Key delirium indicators include agitation, paranoia, unexpected physical strength, and hyperthermia [18]. These symptoms together signal a potentially life-threatening condition.

Inability to Care for Self or Others

Call 911 when mental status changes prevent basic self-care. This includes clients who cannot make safety decisions or might endanger themselves through neglect rather than intent [2].

Mental status changes that impair basic needs—staying hydrated, taking vital medications, or caring for dependents—constitute medical emergencies [2]. Children, elderly parents, or other dependents under their care create additional urgency for intervention.

Seizure Activity or Loss of Consciousness

Seizure activity during therapy requires immediate 911 activation. Consciousness is often lost during seizures, preventing the person from responding [19]. Status epilepticus—seizures lasting more than five minutes or multiple seizures without recovery—is life-threatening and can cause brain damage or death [20].

Provide 911 dispatchers with seizure duration, characteristics, and any known seizure disorder history. Remember that 30-50% of patients don't report seizures due to impaired consciousness during episodes [21].

Stay with your client until emergency responders arrive. Ensure safety without restraining them unless absolutely necessary to prevent imminent harm.

Your role is to assess, stabilize, and facilitate transfer to higher-level care—not to treat the medical or psychiatric condition. This protocol reflects clinical experience and serves educational purposes only. It doesn't replace formal emergency medical training or your licensing board's specific guidelines. Operate within your scope of practice and local regulations.

Coordinating with Family and Medical Providers

Effective coordination makes the difference between smooth crisis management and chaotic emergency response. Building these relationships before emergencies occur creates a safety net that protects your clients when mental status changes strike.

Obtaining Consent to Contact Family During Crisis

Get family contact consent during intake sessions. Document this permission clearly in your client's record. Many hospitals require patients to sign a privacy release allowing family contact during hospitalization [22]. Without proper authorization, facilities cannot even confirm admission status, let alone share treatment details.

HIPAA Privacy Rule provides important flexibility during crisis situations. Healthcare providers may communicate with family members or others involved in care, provided the patient doesn't object [23]. When a patient is incapacitated or experiencing an emergency, providers may share relevant information with family if professional judgment indicates it serves the patient's best interest [23].

Client resistance to family involvement presents a common challenge. Patients often worry about losing control or burdening relatives [24]. Address these concerns directly. Explain how family involvement typically improves outcomes and reduces anxiety for everyone involved.

What to Communicate to EMTs and Physicians

Share concise, relevant information while maintaining appropriate confidentiality. Essential details include:

Complete medication history, including over-the-counter and herbal supplements
History of illicit substance use, noting frequency, typical dose, and last use [6]
Recent stressors or precipitating factors
Timeline of the mental status change
Current symptoms and their progression

You serve as the bridge between your therapeutic knowledge of the client and the medical expertise needed in this emergency. Integration between mental health professionals and emergency services produces better outcomes [25].

Role of Primary Care in Mental Health Emergencies

Primary care providers serve as the gateway to the healthcare system, especially for patients with mental health disorders [26]. Primary care services play a crucial first-contact role and offer early diagnosis, intervention, assessment, and treatment planning [26].

Contact the client's primary care provider immediately following an acute mental status change. PCPs contribute vital medical context that may explain mental status changes and coordinate follow-up care after emergency interventions.

Maintain close communication with all healthcare professionals involved to ensure no serious causes of mental status changes are missed [6]. Your role remains clear: assess, stabilize, and facilitate transfer to a higher level of care, not to treat the medical or acute psychiatric condition yourself.

This protocol reflects clinical experience and serves educational purposes. It doesn't replace formal emergency medical training or your licensing board's specific guidelines. Stay within your scope of practice and follow local regulations.

How to Document a Mental Status Change Incident

Proper documentation protects both you and your client while providing essential information for continuing care providers. Your records may become the foundation for medical decisions and legal proceedings.

Using Objective Language and Clinical Descriptors

Document what you observe, not what you interpret. Record specific behaviors, responses, and statements rather than conclusions. Write "client was unable to state today's date or his current location" instead of "client was confused." This creates a factual record that stands up under scrutiny [27].

Objective documentation serves as crucial evidence if your care decisions are ever questioned. Focus on measurable, observable details that another professional could understand without your interpretation.

Sample Phrases for Describing AMS Events

Effective documentation requires specific clinical language. Use these descriptors:

Appearance: "Disheveled, wearing paper hospital scrubs deliberately cut to expose abdomen"

Behavior: "Difficult to redirect for interviewing, inappropriately laughing"

Speech: "Hyperverbal, pressured rate, happy tone"

Thought Process: "Flight of ideas evident throughout session"

Cognition: "Unable to spell WORLD forward and backward" [28]

These phrases paint a clear picture of the client's presentation without subjective interpretation.

Legal Considerations and Risk Management

Never alter records after a claim has been made—this can jeopardize insurance coverage [29]. Your documentation should demonstrate the clinical judgment and skills you applied during the emergency.

Include the specific actions you took and the reasoning behind your decisions. Document any safety measures implemented and the client's response to interventions.

Your role remains to assess, stabilize, and facilitate transfer to higher-level care. Document this process thoroughly to protect both your practice and your client's continuity of care.

This protocol reflects clinical experience and serves educational purposes only.

Conclusion

Acute mental status changes require swift action and clear thinking. Preparation makes the difference between effective intervention and dangerous delays. These situations demand medical attention, not therapeutic intervention.

This protocol provides your roadmap. Recognize the warning signs. Ensure safety first. Make rapid assessments. Call for appropriate help. Activate support networks. Document everything. Your timely response can save lives.

Medical emergencies rarely occur during routine sessions. When they do, you become the crucial first responder. You're not expected to treat the underlying condition—that's not your role. Your job is recognition, safety, and coordination.

Debrief after any emergency situation. Process the emotional impact with colleagues or supervisors. Identify what went well and areas for improvement. Follow up appropriately once your client receives medical care.

Stay prepared. Keep emergency contacts readily available. Review this protocol regularly. Trust your clinical instincts when something seems wrong.

Your role remains clear: assess, stabilize, and facilitate transfer to appropriate medical care. You're not treating the medical or psychiatric condition itself.

Key Takeaways

When acute mental status changes occur during therapy, therapists must shift from therapeutic intervention to medical triage, as these situations can be life-threatening emergencies requiring immediate action.

• Recognize red flags immediately: Disorientation, incoherence, hallucinations, and rapid behavioral changes signal medical emergencies, not emotional dysregulation requiring therapy.

• Follow the 5-step protocol: Ensure safety, differentiate delirium from psychosis, determine 911 vs crisis team need, activate support systems, and manage proper handoff.

• Call 911 for medical indicators: Unresponsiveness, suspected delirium, inability to self-care, seizures, or loss of consciousness require immediate emergency response.

• Document objectively with clinical descriptors: Use specific behavioral observations rather than interpretations to protect both client and clinician legally.

• Obtain family contact consent proactively: Establish emergency contact permissions during intake to enable crucial coordination during crisis situations.

Remember, your role is to assess, stabilize, and facilitate transfer to higher-level medical care—not to treat the underlying condition. Proper preparation and protocol adherence can literally save lives when these rare but critical situations arise.

FAQs

How can therapists effectively manage clients who present with constant crises?

Therapists can set boundaries around crisis discussions, allocate specific time for addressing immediate concerns, and focus on teaching coping skills and emotional regulation techniques. It's important to balance validating the client's distress while also working towards deeper therapeutic goals.

What are some signs that a client's mental status has changed acutely during therapy?

Key signs include sudden disorientation, incoherent speech, memory loss, hallucinations, extreme agitation or lethargy, and physical symptoms like fever or tremors. Any abrupt change from the client's baseline mental state should be taken seriously.

When should a therapist call emergency services for a client experiencing mental status changes?

Emergency services should be called if the client becomes unresponsive, shows signs of delirium, is unable to care for themselves, experiences seizures, or loses consciousness. Any situation where the client's safety is at immediate risk warrants calling 911.

How can therapists document mental status changes appropriately?

Therapists should use objective language and clinical descriptors, focusing on specific observed behaviors and statements rather than interpretations. It's important to document the incident thoroughly, including any actions taken and safety plans established.

What role does a client's primary care provider play in mental health emergencies?

Primary care providers play a crucial role in mental health emergencies by offering early diagnosis, intervention, and treatment planning. They can provide important medical context that may explain mental status changes and coordinate follow-up care after emergency interventions.