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Suicide: What will happen to you when you ask for help?

Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

The Triage Process

Whether you end up at the ER or the office of a mental health professional, you can expect to be interviewed in order to establish the acuteness and lethality of your present suicide risk. In a hospital environment this entrance interview is typically known as triage. If your risk of harming yourself is judged to be severe, you will likely be asked to enter the hospital as a psychiatric patient on an inpatient unit. If your suicide risk is judged to be lower than severe, you will likely be given some names of local mental health professionals and sent home.

You can expect a similar introductory interview to be part of your first interactions with any psychiatrists or psychotherapists you may work with on an outpatient basis. Those professionals also must establish your level of suicide risk and the type of care necessary to reasonably ensure your safety. See the section below concerning the Initial Treatment Interview, for a list of some of the questions you may be asked that help professionals to understand your current level of suicide risk. Even if you start off in a clinician's office, if you are judged to be acutely suicidal, you may be asked to enter the hospital for a while. If you are not judged to be an acute risk, you will likely be offered psychiatric and/or psychotherapeutic care consistent with your presenting symptoms, and your suicidality risk will be monitored on an ongoing basis.

Please be as open and honest as you can during this triage process. Try to let go of any shame you may experience at feeling suicidal and focus on describing what you are thinking and feeling as accurately as possible. Suicidality is often a response to overwhelming stress; it does not mean you are "crazy". Many people feel at least vaguely suicidal at some point in their lives, and a substantial minority of them will experience a true suicidal crisis. Most of those people recover, and recovery is a strong possibility for you as well if you allow helpers to know what is happening so that they can respond appropriately.

Inpatient Treatment

If the doctor or therapist performing triage on you determines that you are not safe to return home, he or she will discuss more intensive levels of help that might benefit you, including voluntary and involuntary forms of hospitalization.

Voluntary psychiatric or substance abuse hospitalization (or similar crisis treatment facilities) are often recommended if you are judged to be at high risk for suicide and are willing to be admitted for treatment. If you are judged to be a high risk for suicide and refuse your therapist's recommendation for voluntary hospitalization, or if you are intoxicated, you may be lawfully hospitalized against your will for several days. In many states, involuntary substance abuse and psychiatric systems are separate, so whether you are intoxicated will determine which type of involuntary hospitalization will be used.

Voluntary and involuntary hospitalization processes differ from state to state (sometimes even within states). Someone's need for involuntary hospitalization is usually determined by two court-appointed medical specialists. As a result, you may be interviewed multiple times; first by a triage doctor, and then later by one or more mental health professionals who will determine whether you require commitment (as the process of involuntary hospitalization is commonly known).

Be as open and honest and as accurate as you can be when discussing your condition with such specialist doctors. It may be annoying and irritating to have to repeat yourself multiple times, but this repetition is actually for your benefit so that you are not railroaded into an unnecessary hospitalization. The process is typically designed such that separate doctors must speak with you directly and arrive independently at the same opinion that hospitalization is necessary to keep you safe before you can be restrained against your will.

Many people fear involuntary commitment and are resistant to the idea of seeking help for their suicidal feelings purely on the basis of this fear. In addition to fears of being restrained (in a locked hospital unit), many people fear that they may be hospitalized indefinitely. While you might indeed be admitted to a locked unit for a few days, any fears you have of indefinite hospitalization should be put to rest now. In today's modern world, you probably would not be hospitalized indefinitely even if you really needed it. It's too expensive to keep people in the hospital for long periods of time. Financial and other societal factors work together to minimize the duration of all hospital stays.

A typical involuntary hospitalization scenario in the U.S. works like this. Your initial commitment period lasts at most three days, after which it must be reviewed by two court-appointed mental health specialists (typically psychiatrists) who can re-certify it for perhaps an additional three days. All the while, insurance companies (and the courts) are reviewing your progress closely with an eye to ordering your discharge as soon as possible so that their costs are kept to a minimum. It is the rare and very ill patient who is kept hospitalized on an indefinite basis these days. In fact, in many cases today, patients are discharged before they feel they are ready to go home, while they are still feeling somewhat overwhelmed and suicidal.

If you enter the hospital on a voluntary basis, you are typically free to leave the hospital once your level of suicidality has decreased. However, if it seems to your doctors that you continue to be an acute risk for suicide and you decide to leave the hospital against medical advice, your doctors may be allowed by law to ask for involuntary commitment at that point (i.e., you started off as a voluntary patient, but then become an involuntary one). Involuntary hospitalization may also be extended while your suicide risk remains high, but such extensions require additional assessment procedures and certification by a court or a mental health court, depending on the laws in your area.

Unfortunately, there may not be any available hospital beds in your area at the particular time you need one. In such a case, the mental health professional who is in charge of the triage procedure will work to find another crisis facility that you can go to. If a suitable placement cannot be found for you when you need it, do what you can do to set up a circumstance for yourself that will help keep you safe. Call your psychotherapist (if you have one), local crisis lines and supportive friends and family as necessary. Ask a reliable family member or friend to stay with you until you are feeling safer.

Regardless of the circumstances of your hospitalization, it is okay to ask questions about the nature of your treatment. Questions such as how long you will be hospitalized, and what you can expect to occur while you're hospitalized are very reasonable and should be answered by hospital staff to the best of their abilities.

While in the hospital, you will likely be interviewed at least once by a psychiatrist, who may prescribe various medications. You will also generally be asked to participate in individual and group therapy sessions. The more you cooperate with your treatment recommendations and requirements, the better you are likely to feel.

If you believe that your care plan is not helpful or appropriate, it is okay to say so. Offering alternative treatment ideas may prove more successful than simply expressing dissatisfaction. You can also ask for help from your psychotherapist, a family member, a friend, a legal advocate or an advocacy organization such a local NAMI (National Association for the Mentally Ill) chapter. It is best to discuss your objections and ideas in as calm and rational a manner as possible, so as to best be listened to and taken seriously. Hospital staff members must maintain an orderly environment for all patients under their care, and they may restrain patients who throw fits or temper tantrums in order to keep the general peace. Restraint techniques used by hospital staff members are designed and regulated so as to be as non-harmful as possible for the individuals being restrained, but they still suck. It is always best to avoid the need for restraint in the first place.

 




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