I have helped hundreds of ER patients acknowledge the reason for their self-injurious gestures. Typically, someone who has just had a dustup with a parent, a significant other or a spouse will take a number of pills. These pills may be the patient's prescribed medication, someone else's prescribed medication, an over-the-counter medication or a mixture of these drugs. Some patients call 911 themselves. Others tell someone else about what they have done, and that person calls 911 or brings the person to the hospital. Once a patient is in the ER, the poison control center is contacted and given the specifics of the overdose. Experts there on pharmacology make recommendations for treatment based on protocols. After the patient has been medically cleared, someone from the psychiatry service is called in to do an evaluation.
In all but a handful of overdose cases, I have been able to work with the patient to understand what the overdose meant. Most patients reveal their intention quickly and gladly. "I wanted attention" is the most common reason given. Others admit they were trying to punish a family member or significant other who they felt had wronged them. Typically someone, who was not getting their way and was not willing to take an instrumental next step to resolve the underlying conflict, decided to dramatize the point. Countless mothers (and not a few fathers) have told me, weighing in on the situation, that their adolescent son or daughter had just "thrown a pity party." What some patients try to say with pills others express with superficial cuts, usually to the ventral wrist.
Patients love to talk about why they make these gestures. It is as if they have finally been listened to and understood. They are now getting the "attention" they have craved for so long. This success justifies to them the need for having spoken in the code of gestural self-harm. Many feel that the discomfort of the nasogastric tube and the charcoal lavage, or the sight of the bloody wrist was worth it (although most also say they will not try it again). They leave the ER believing they have accomplished something and, in a sense, they have. I try to get them to acknowledge that there are better ways to be heard and to get the kind of attention they should be seeking. When I see patients absorbing this point, I feel that my time with them was well spent.
Some patients come to the ER down on their luck because of their bad behavior. This often involves substance abuse and the betrayal of everyone they know because of it. They have no money and no place to stay. These patients often make a point of not contracting for safety. "I'm suicidal," they will tell the triage nurse. Some add, "I'm also homicidal," presumably hoping to cover all the bases in their bid for a hospital bed. There is that old ER saying: "The patient knows what to say," i.e., what to tell the ER staff to get admitted and receive the proverbial "three hots and a cot."
Clinicians who evaluate psychiatric patients in the ER should be able to determine what the patients who "know what to say" really mean. After interviewing between 200 and 300 ER patients, many of them substance abusers, I began to feel what I can only describe as a new degree of confidence in making a determination about a patient's "safety" (Muller, 2000). Surgeons call this blending of discipline and instinct unconscious competence (Lahr, 2001). Clinicians just honing their skills will wish, as the saying goes, to err on the side of caution. I have had patients who were broke and homeless, whom I knew to be no threat to themselves or to others, say "I'm so suicidal I'll never make it home." One patient told me, "I'm so suicidal I'll never make it out of the ER." We need to learn how not to be manipulated by those who would use mental health care facilities to reduce the consequences of their bad behavior (Muller, 1998).
At times, I do not know in my head and in my gut why a patient took an overdose or chose some other act of self-harm. Sometimes, I sense that a patient may not have exhausted the need to act out a conflict in a harmful way. I hospitalize these patients, regardless of what they "contract" for. Ultimately, I try to determine whether a patient can imagine a future, in spite of the difficulties, and has the will and the capacity to deal with what is ahead. True despair, the kind that drives the real suicidal act, is the lack of this will and capacity.
I did not ask Julia to contract for safety as a condition for discharge from the ER. I have come to see these contracts, made in the heat of crisis with a clinician whom the patient does not know, as intrinsically unreliable and essentially different from the agreement often made in outpatient therapy. Outpatient contracts, struck with a clinician when a therapeutic alliance is already established, have proved effective in containing the self-destructive impulses of suicidal patients.No 'Safety Contract' Is Ironclad
Like those patients who have no other place to go and "know what to say" to be admitted, patients who have already made up their minds to do serious harm to themselves or to others also "know what to say" to be discharged from the ER. One patient's ER contract for safety, apparently accepted at face value, led to a tragedy. I know the story only second-hand, but the source is a reliable one.