Challenging Situations in High and Intensive Psychiatric Care: Professional Perspectives and Key Characteristics

Background: Managing acute psychiatric crises remains a major challenge, as some situations exceed the capacity of even specialised care. These situations typically arise from a complex interplay of patient, team, ward and organisational factors, leading to prolonged admissions, increased use of coercive measures, and distress for both patients and professionals. Aims: This study aimed to identify the most challenging situations within High and Intensive Care wards, clarify their multifactorial origins, and explore strategies for more effective management. Method: This multi-centre, multi-method sequential qualitative study involved two phases: collecting 40 challenging cases, synthesized into two fictional vignettes, and discussing these in three focus groups with 33 mental health professionals, with data analysed through qualitative content and thematic analysis. Results: Participants recognised the vignettes and emphasised that it is the combination of patient, team, ward and system factors that places teams under sustained pressure, undermining the therapeutic environment and safety. These situations often evoke strong emotional responses and certain team dynamics, such as countertransference and splitting. Key challenges included dilemmas around admission, lack of treatment perspective, and systemic barriers. Suggested strategies focused on reward-based and autonomy-promoting care, requiring improved team communication, decisive clinical decision-making, and shared responsibility with external partners. Conclusions: Addressing challenging situations in High and Intensive Care wards calls for timely recognition, open discussion, structured team reflection, and ongoing staff training. Personalised care, clear protocols, and robust cross-sector collaboration are essential. Ongoing evaluation and further research, including patient and network partner perspectives, are needed to optimize interventions and ensure effective, empathic care.