Wednesday, June 8, 2011

To Be or Not To Be

Mr. Rowley was brought to the ER by his son for a drinking problem. Drink was no stranger to Mr. Rowley, nor Mr. Rowley to the bottle. He had been in a detox program in 2003 that had kept him sober for two years, and afterwards had been able to limit his drinking to a glass or so a day. But in the last few weeks he had lost his job, and the drinking returned in force, to the count of a couple pints each day.

I tend to think that alcohol brings out the real person under the everyday veneer, albeit it in an exaggerated form. That’s why every intoxicated person is different. Some are nasty and mean with a few shots in them; some get deep and philosophical, while others are funny and raucous. Some turn out to be just decent people, polite, respectful, who just seem to be drinking to numb the pain of the day. Mr. Rowley was one of those.

Mr. Rowley recognized his drinking was a problem, but he was not interested in detox; he figured he could do that on his own. What he wanted help with was the depression that led to the drinking. Not only had he lost his job, but also his means of support for the three children he loved dearly, as well as the ability to maintain his obligations to his ex-wife and to care for his pets. He felt he had nothing left, that everything meaningful to him as a man as caretaker and provider were being taken from him, and the only way out was suicide. He knew exactly how he was going to do it as well, at home in the backyard with his shotgun. (And being a man who’s been in similar circumstances in the past, I’ve known exactly how he felt.)

When someone states they have thoughts of suicide, and especially when they have a well-thought plan, they inadvertently trigger a set of clinical and legal interventions. Clinically, we make sure there are no medical problems which might be responsible for these dangerous thoughts. Legally, we are obliged to hold the patient in the ER for their own safety until evaluated by a mental health professional. If the psychiatric screener feels the patient represents a clear danger to himself, we are then obliged to continue to hold the patient for formal psychiatric evaluation. While larger communities often have a local set of mental health services, at the rural facility where I work that means transfer to the State Psychiatric Hospital an hour and a half down the road.

Mr. Rowley had made it clear that while he wanted help with his depression, he didn’t want to be admitted to the State Hospital. He wanted to get some therapy, maybe get on some medicine for his depression, then go out tomorrow and look for a job. But he couldn’t have realized that once the process is set in motion, it can’t be stopped. His statements to me meant that he needed psychiatric screening. His statements to the mental health worker mandated further evaluation at the State Hospital. The fact that he was under an involuntary hold meant that he would need secure transport by law enforcement. And knowing that he didn’t want to go meant that we couldn’t tell him what was going to happen, as if he knew he would leave and short of using force there would be no way to stop him.

So we ended up playing this game of buying time with sandwiches and sodas, telling him we wanted to make sure he was sleeping off his alcohol before letting him go, until all the arrangements had been made and the police were here for transport. It’s my job to tell him what’s going to happen, and I did so as softly as I could, for I felt for this man. Polite, reserved, dealt a bad hand in life, and about to be dealt an even worse one by policies and procedures far beyond his control or mine. He tried to negotiate, but there was nothing more to do. The die was cast.

So here’s this proud man, who is a likeable and decent citizen, getting escorted to the State Hospital by police, and not even with the last piece of cake we’d gotten for him out of the hospital kitchen. Short of going in handcuffs, it had to be the most humiliating thing we could have done to him. All of it was legal, and all of it was exactly by the book. And while I really hope we’ve done something good here, and gotten him some care that can help him find a reason to go on, I can’t shake this feeling that all we’ve really done is let him know that the next time he feels this way, asking for help only makes it worse. I wonder if we’ve made suicide a more inviting option, because at least you go out on your own terms. And I wonder if, as noted by Albert Camus, “There is but one truly serious philosophical problem, and that is suicide,” we’ve just helped him answer the question.

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