Tales from the Couch

Seeing the patient from psychiatry’s perspective

A Judgment Call

Assessing the unknown

Grace R. had been in treatment for six months. She and her husband, Jack, were on the verge of breaking up. She’d dealt with this situation in a maladaptive way. Each time things came to a head, she threatened suicide. Her self-destructive threats managed to keep him from closing the door on the prospect of reconciliation. Despite my pointing out the counter-productive nature of her behavior, the situation continued.

Their arguments grew more frequent, as did her threats. When I suggested a conjoint session—with the three of us meeting—her husband refused. There was simply no way I could trust her with anti-depressant medication. My options were limited.

I assessed Grace’s suicide potential. If her husband left, she had no family nearby; they lived in another state. Her job would allow her to only marginally pay the bills. She’d thought about a specific method to end her life: she would tape up the apartment windows and door, and turn on the oven’s gas jets. She fantasized about her husband’s remorse if she ended her life. She knew her threats had prevented her husband from leaving—thus far.

At the next scheduled session, she was distraught. Jack had walked out, saying he wasn’t certain he’d return. It occurred to me he too might be posturing to gain an advantage in this malicious jousting match.

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Grace threatened to enact her suicidal plan when she returned home. Alarmed, I again assessed her potential for self-destruction. It seemed clear: I couldn’t trust Grace to leave the office. Even a suicidal gesture might be unintentionally successful.

I told Grace the most important thing was to save her from her own impulses.

“I wouldn’t really do it,” she said with a semi-smile.

“But Jack’s never left you before. This time it’s different. You have to go to the hospital.”

“I’m not going.”

“I can’t take a chance on your doing something to yourself.”

“You know me better than that…”

Yes, I was aware she might be dragging me into the fantasized role of her husband. But my judgment was that while in a temporary frame of mind, she might do something with permanent consequences. I simply could not take that chance.

“You have to go to the hospital,” I said.

She refused and started for the door.

I blocked her way, took out my cell phone and dialed 911.

She grew increasingly agitated; began stomping around the consultation room, crying and cursed at me vehemently.

An ambulance soon arrived. We sat in the rear compartment with an attendant.

“You’re violating my civil rights,” she yelled through her tears.

“Not if you’re so upset and depressed you could kill yourself.”

She was seen in the emergency room and admitted to the psychiatric ward.

When I visited her the next day, she smiled weakly and said, “Thank you.”

Two weeks later she was discharged on medication. Over the next few months, she began adjusting to life without Jack.

A judgment call is always open to question. But as the old cliché goes: Better safe than sorry.

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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