Tuesday, June 11, 2013

A Chilling Encounter

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

Late one afternoon, I got a page from the emergency room about a 14-year-old male who was in for a suicide attempt, who was medically stable and ready to be interviewed by a psychiatrist. When I arrived at the tiny conference room adjacent to the ER, I was expecting the typical morose teenager, full of emotional turmoil. Instead, this young man looked at me calmly and nonchalantly, smiled, and said hello. He was thin and looked like he could be 12 or 13, dressed in a polo shirt and khaki shorts. He would not have seemed out of place in a Boy Scout uniform.

I started with the obvious. How did you end up in the ER today? He told me that he had tried to end his life earlier in the day by hanging himself, only to be discovered when his father got home early from work. Has there been anything stressful going on in your life? Yes, he said. Several weeks ago, a little boy had reported him for molesting him. When the police investigated, they eventually discovered several other young boys in the neighborhood with similar stories. Somehow, a judge had allowed the teen to remain in the custody of his parents while he awaited his sex offender psychological evaluation.

He seemed at peace, and neither the crowded space nor the noisy environment fazed him in the least. I tried my best to keep a poker face as I continued asking the standard questions. Have you been sad or depressed? No, he said. He'd been in a good mood all summer, even after the accusations surfaced. He has not lost any interest in enjoyable activities. How's your sleep? He slept very well, at least 8 hours a night. Appetite? Good. Any guilty feelings or negative thoughts? Nope. So how did you decide that today was the day to die? He had just finished the last book of a popular young adult series. "I finally got to see how that story ended, and it was very satisfying. Then I decided, I might as well kill myself so I don't have to go to jail."

I kept searching his face for any sign of tension, doubt, or guilt. There was none; he might as well have been chatting with a friend about his favorite video game. In the back of my mind, I wondered if he could detect that I was more uncomfortable than he was.

He told me that he had a normal childhood, that he got along with his parents, and that he was never mistreated or abused in any way. Do you have any friends your age? Instead of answering the question, he mentioned that he was on the golf team for his school and he got along fine with his peers. Are you attracted to males or females your age? "No, I only go for the younger ones." Any reason you targeted those particular children? He looked straight at me and said, "I take whatever I can get," sending shivers down my spine.

Later, I interviewed his mother and father, who seemed like nice, normal suburban parents. They both appeared stunned, uncomprehending. I felt sad for them, yet I was also glad that their son was caught when he was 14, rather than when he was 40 or 75. I could not decide whether it was a good thing or a horrendous thing that he made no effort to deny what he did. Or perhaps he just wanted to appear honest to hide even greater atrocities.

Did I end up admitting this "patient" to the psychiatric unit? I would have preferred to send him straight to juvenile detention, but the hospital had a protocol: A serious suicide attempt like his had to be admitted if there were beds available. As a service to the community, of course. Even better, I had to admit him under a diagnosis of "depression not otherwise specified," since the hospital could not get reimbursement for an admission diagnosis of pedophilia. Walking out of the hospital that evening, I was glad to see the sun still visible low on the horizon, and that the darkness had not quite set in yet.