“Sticks and stones may break my bones, but words will never hurt me.”
This childhood rhyme aims to teach children to be resilient, that not all words have to hold power. As psychiatrists, we know this is a lofty goal. So much damage and hurt can come from a simple word. Here is an example of how the word “behavioral” has hurt me.
I work at a large statewide nonprofit organization as an outpatient child psychiatrist. During my work week, each day, there is a 60-minute time slot open for hospital discharges, where I do an in-person or Zoom assessment of children who have left an inpatient setting within the past seven days. There are case managers assigned for each patient, and they collaborate care with therapists and me. In other words, I work in the most ideal outpatient setting imaginable.
Last week, in one of these time slots, I interviewed a 14-year-old female suffering from significant depression and had made a severe suicide attempt: Overdosing on over-the-counter pain meds. She had the usual suspects to aggravate a suicide attempt: a history of sexual abuse, underachievement in school, pressure from parents, disconnection from peer support due to COVID and the classic themes of feeling unwanted, unloved, and lonely.
The inpatient team had started her on a combo of Wellbutrin and Lexapro. I worked hard with this patient and family to build an understanding and compassionate safety plan. The patient was still suffering but more open to survival. The parent was willing and ready to work with me and appreciated how depression, particularly in a teenage brain, can dangerously alter good decision-making. In other words, I felt like we were playing on the same team.
I scheduled a follow-up in one week. I referred her for individual therapy. We considered IOP. A case manager checked in with them during the week. And despite this, she ended up back in the ER for another suicide attempt on alcohol, a few of her prescription pills and some marijuana. In the morning, she was in the ER; by 2 p.m., she was discharged and on my telehealth follow-up visit.
While in the ER, the patient had seen an ER physician and several members of a suicide team assessment via telehealth. The mom was frustrated. She had done all the right things — she called the crisis hotline, poison control and had been directed to go to the ER. She had followed through. She was a good, attentive parent. While narrating the visit, however, the mom seemed much more frustrated about her child and the situation. “They said to go home. They said that it was behavioral.”
I was livid. I wasn’t mad that she attempted again. I wasn’t mad that despite working my hardest, she still ended up in the ER. I wasn’t mad that the ER discharged her back to my care and decided not to admit her. I was mad at what damage the ER had done to the rapport I built.
With this single word, mom had now completely altered her willingness to see the deep suffering of her child. This single word watered all of this child’s five years of depression, crippling anxiety, history full of ACEs, and very significant struggle down to a simple, selfish, flippant choice.
Furthermore, mom said that the nursing staff asked her about the medications. Mom informed me that: “The nurse said maybe it’s the Wellbutrin making her this way. Maybe she is suicidal because of this?” If the team had spent five minutes doing a real assessment of suicidal thinking, they would have learned her suicidal thoughts started years prior to her being on medications and have actually decreased in frequency since starting these meds in the hospital.
I could see in mom’s eyes. She now did not trust me when I spoke about the importance and urgency of treatment. Her child was now an inconvenience, my medication recommendations could be damaging, and our work together was now a waste of their time. Mom declined my recommendation to titrate up meds because of her concern about them now brought on by the nurse.
This family went to the ER for help, as was instructed by the crisis team. Yet while in the ER, so much damage was done. The label “behavioral” alone, is used as a derisive term both inside and outside of psychiatry. It is time for us to find a more helpful term to reclaim the legitimacy of patients who express their suffering and pain through suicide attempts and self-injurious means.
Let’s take a page out of DSM-5, when good old pseudoseizures were relabeled as functional behavior. Isn’t this a more useful term?
Think of how differently mom might have thought about her child’s suicide attempt if the ER doctor said it was functional or even dysfunctional?”
We know her attempt served a purpose. What if the ER team called this attempt “purposeful”? Mom would have approached my visit very differently if the ER team had labeled this failed attempt purposeful.
Despite having a utopian outpatient team, our efforts have still failed this child. The system of care spans beyond us and washes up on the shores of medical staff who are more tired, more strained, and more frustrated than we are with our patients every time they land there. Yet we must still find a way to educate our ER staff counterparts. They and their language are so powerful and have a tremendous impact on the progress of our patients.
Words are surgical tools — they pierce the brain, slice through the mind and sever our foundational understanding if misused. They can exercise knowledge and trust. They can embed themselves within and cause cancerous misinformation to grow.
“Behavioral?” I responded to mom, “Everything we do is behavioral. Every choice we make is behavioral. What we need to work on is to help empower this child to make better choices. Working on her depression and anxiety will help her to be stronger, more confident and reduce the urge to end her life. This is the ultimate poor choice. We need her to choose wiser, to function better.”
I will see this patient again next week until she can get into an IOP. I will continue to drill into her mind the power of her choices, the strength of her journey, and the value of her life. I will continue to use my words to suture her sense of self and pray that they aren’t severed too soon.
Shivana Naidoo is a child psychiatrist.
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