A person is drunk or angry or momentarily distraught. Or all three. He or she takes an overdose or cuts a wrist, then reconsiders — or never intended to die in the first place — and either calls 911 or tells someone else who calls 911. The police come and transport the person to a psychiatric emergency service where a three-day legal hold is placed. Despite expressing regret for the suicide attempt, the person is admitted for observation and safekeeping.
I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts. Not that it’s always wrong, of course, but sometimes it seems to result from sloppy thinking. The usual rationale is that it’s better to be on the safe side. I.e., if the person’s recent words or actions cast doubt on his or her wish to be alive, it’s better not to take chances. This has merit in cases where there’s some honest doubt: Since our statistical success in predicting dangerousness to others and to oneself is quite limited, “false positives” are the price we pay (well, they pay) to keep the “true positives” safe.
But another reason seems even more pervasive though less often stated: Hospitalization is a predictable and presumably undesired consequence of expressing suicidal feelings. At one level, legal holds and involuntary hospitalization “train” patients not to express suicidal feelings, lest they spend three or more days in an expensive inpatient unit with its attendant shame, stigma, and many inconvenient rules and expectations. It may also serve a related function of taking the patient seriously. Big consequences follow big actions, real or contemplated, and in this way discourage the patient from “upping the ante” with a more serious suicide attempt.
The other side of the coin is that legal holds and hospitalization make us feel better. We’re taking action, not just sitting there. Clinical management is clear-cut for a change. We have an interesting little story with heroic overtones to tell our colleagues. The treatment plan is easy to justify to third-party payors, unlike more subtle interpersonal interventions. (A few days ago I was on the phone with a managed care reviewer who demanded a “5-axis diagnosis” and behavioral treatment plan for my dynamic psychotherapy patient. A more pointless exercise I cannot imagine, except that my patient won’t receive insurance reimbursement without it. This level of skeptical scrutiny rarely arises in hospitalizing the suicidal, even though the cost to the payor is far greater and the benefits sometimes less apparent.) We’re hardly ever faulted for choosing to hospitalize.
Of course, this propensity to “hospitalize first and ask questions later” can backfire. I recall several times in my residency when homeless veterans came to the VA emergency room with bags packed, seeking psychiatric admission. Their claims of suicidal feelings — or even command hallucinations to commit suicide — were hard to argue with, even though it seemed obvious that the real goal was room and board, not psychiatric care. Their complaints quickly disappeared once admission was assured. At the time I noted that civil commitment laws exist to protect the unwilling and undeserving from being hospitalized; none address those who strive to be hospitalized without a valid reason.
A great many suicide attempts and gestures are communicative in nature. Far from being unambivalent decisions to die, they are cries for help, expressions of rage, tests of whether anyone really cares. Our responses as mental health professionals are communicative too. Hospitalization can say, “I’m not playing your game of manipulative suicide threats — I’m calling your bluff.” It can say, “I hear you, and I take your suicide threat very seriously. It’s my job to keep you safe.” It can say, “I blindly follow the rules. You say suicide, I call 911.” Conversely, choosing not to hospitalize can say, “I’m not playing into your drama of getting me to overreact,” or “I’m not taking you seriously, not hearing your pain,” or “I defy the conventions of my profession, you cannot count on me to hospitalize you.”
It’s important to pay attention to the message in one’s clinical actions, and also to realize that one’s message can be communicated in different ways. Hospitalization is not the only way to convey serious concern, even if at times it may be the only way to assure physical safety. If calling the police is an angry reaction to the patient’s misbehavior, it should be re-thought. Nor should it be an unthinking, reflexive response. The converse is true as well: If inaction is an expression of angry avoidance, denial of the severity of the patient’s risk, or a reflexive expression of the practitioner’s bold, iconoclastic nature, that too should be re-thought.
Failure to consider the risks and benefits (pros and cons) of hospitalization on a case-by-case basis would be evidence of sloppy thinking in psychiatric practice. While it may be less common than other forms of sloppy thinking I’ve posted about, it still happens disappointingly often. I also wanted to post about it to give readers a place to comment and ask questions about legal holds, as there is ongoing interest and concern on this topic.
Photo courtesy of Petr Kratochvil.