​“Sign here. You’re going to inpatient psych.”
 
With that stern, autocratic and controlling statement, I began my interaction with a certain woman in the Emergency Department. Let’s call her Audrey. I was the psychologist and she was my patient. I already knew Audrey from past encounters. And I knew that she was present on this particular evening because of her own actions. Audrey intended to die by means of an overdose of her psychiatric medication. Her life was burdened by an abusive husband, economic hardship, and feelings of worthlessness and hopelessness, all in the context of neurochemically-based mood changes that were out of her control. I knew Audrey from prior encounters on the inpatient psychiatric ward, including a period of three weeks during which her depression was unremitting. The psychiatrist was aggressively trying different pharmacologic treatments with her. I was having limited success with a cognitive-behavioral therapy approach.
 
Audrey’s two sons, one age seventeen and the other two years younger visited her in the hospital. They cried during the visit, barely able to comprehend the purpose of a hospital ward that looked more like a hotel than a medical facility. But unlike a hotel, the front door did not open without a staff member’s badge or through some action by a nurse behind a thick transparent pane. “Mom, please don’t do anything like this again,” they pleaded.
 
I saw Audrey begin to cry again. Was she remorseful for causing her sons such anguish? Or was she again feeling trapped in a life that seemed to be a hopeless wreck, in which she could not live and which she also seemed to be incapable of ending?
 
I’ve met many people whom I judged to be at great risk of suicide. Some had enduring risk factors. Some people were suicidal only under specific circumstances, such as when they were drunk. Most could be safely released the following day when they were sober. They seemed to be different people when intoxicated, certainly not suicidal, and sometimes had no recollection of what they said and did while under the influence of alcohol. Their discharge instructions would include advice to avoid alcohol. They did not outwardly disagree with my recommendation. Nevertheless, months later I sometimes saw a familiar name in the newspaper, with the innocuous phrase “Died suddenly at home” in the obituary. I would think, “I know exactly what happened.” 
 
Suicide risk assessments are best completed in a hospital emergency department. The emergency department is a less than ideal setting for several reasons. But it does have the benefit of being a setting that can control behavior and prevent a person at great danger from leaving. And there are security personnel to maintain safety.
 
However, one of the most imminently dangerous people I ever evaluated came to my attention as a voluntary walk-in to the admissions department of a private psychiatric hospital. His father was with him. It was a Sunday, and I was the only professional in the department. There was no security department. This young man clearly expressed his suicidal intent. He told me that he had a lethal plan and a day picked out on which to end his life. But he would not tell me how or when he would kill himself. He added that he wanted to have his organs harvested for transplant to help other people. I advised him that some methods of suicide make a body’s tissues unsuitable for donation. He assured me that he was taking that issue into consideration.
 
But he refused my offer of voluntary admission. And, not being an emergency department, I could not get a physician’s order from the same hospital to admit him involuntarily. I was being thwarted by some ethical-legal issues. The key to resolving this case satisfactorily, that is, without releasing a person in extreme danger back into the painful world, hinged first on my ability to maintain my own clear thinking. “OH MY GOD,” I thought. “THIS GUY IS IMMINENTLY SUICIDAL!”
 
I had been to a high school reunion some years earlier. One of my former classmates asked me, “Have you seen it all at this point? I mean, does anything surprise you anymore?” I answered him, in all seriousness, “Every day is different.”
 
Now, on this day, I needed to stifle my own horror at the idea of this young man calling the paramedics and then killing himself before they could arrive. It was his intention that the ambulance crew would encounter a body that was beyond resuscitation but was yet suitable for the harvesting of parts. I had to stifle my fear of death and my horror over his plan. I had to keep my own feelings under control.
 
I left the young man in the consultation room with his father. I could not involuntarily admit him to the hospital where we were. But, in my capacity as a psychologist I could have him brought involuntarily to a nearby emergency department. I called 9-1-1 and presented the situation. I then completed the Psychologist’s Request for Examination that would empower the state police to take him into custody. I returned to the consultation room and informed the young man that he would be transferred to the nearby community hospital’s emergency department. “But I don’t agree,” he said. I responded, “I have taken that choice away from you.” If he bolted from the room at that point, I could not have stopped him. But he stayed. And when the state police arrived and I again explained the situation, the young man calmly walked outside with them.
 
Two weeks later, the head of the admissions department informed me of a telephone conversation he had with the father of the young man. “He’s home. He’s better,” I was told. And the father wanted to thank me for remaining cool-headed during this crisis. That was my last contact with that case so I cannot report on the long-term outcome.
 
The case of Audrey is a little different. She was my patient in the outpatient clinic, and she received medication prescribed by our psychiatrist. Then there was a period of weeks when she did not keep appointments. She also stopped taking her medication. Audrey kept an appointment with me, and I was immediately alarmed. She denied suicidal thinking, but I was not convinced of her safety. However, I didn’t have the justification needed to have her admitted involuntarily. The psychiatrist saw her as well. We agreed that Audrey did not seem well. Before I could see Audrey for her third outpatient visit of the week, the psychiatrist came into my office. “We were both right,” she said. “Audrey is in the emergency department now with serious injuries. She’s about to transfer to the inpatient unit.” Audrey had packed an overnight bag and left a note on top of it. The note said “If this works, please give my cat to Kimmy. If it doesn’t work, bring this bag to the hospital.”
 
I entered Audrey’s room on the inpatient psychiatric unit. I found her sitting on her bed, her arms heavily bandaged. The overnight bag was on the floor. I looked at the overnight bag, then at Audrey. “I guess it didn’t work,” I said to her. She smirked and just said “No.” Her suicide attempt had failed, and she was not yet thinking that this was a good thing.
 
Audrey was eventually discharged from inpatient care and attended a therapeutic day program. After some weeks she was again in my office in the outpatient clinic. “Let’s think about this,” I said. “What are we missing? We’ve been treating this as an issue of recurrent major depression. Maybe we need to put more emphasis on your trauma history.”
 
Audrey and I worked together to devise the conditions that would make her life worth living. We worked together, that is, until the time came for my family’s move from Connecticut to Florida. I made certain that a trusted and competent colleague would continue to work with Audrey. And I asked Audrey to please always know that I want her to live and to be happy.
 
In years past I heard people older than me say that time passes more quickly with advancing years. And so, it is hard to conceive that my last conversation with Audrey occurred more than six years ago. I still want her to know that I wish for her to live and to be happy.
 
I wasn’t difficult for Audrey to find, just a few weeks ago. She wanted me to know that she is about to move to another state to be with her new romantic partner, that she is part way through a college degree, that she is on the Dean’s List studying psychology, and that she has, in her words, “Big plans for the future! You’ve seen me at my worst and so I want you to know this.” It’s not often that I get news that makes my heart sing.
 
We defeated death in Audrey’s case. I asked her to keep me informed of her progress. And I gave her my favorite closing:
 
Be well. Stay strong.
 
 
Dr. Wayne Rosenfield is a psychologist who has worked extensively with high risk and impaired populations. He is presently a professor in a graduate program of National Louis University. He performs assessments for a group psychological practice and is a co-investigator in a research addressing combat posttraumatic stress. He is a frequent speaker in the field of rare diseases. His book Great Necessities is available on Amazon.com.
 
07-11-2020