The phone rings and pierces my sleep with the death rattle of a robot banshee.
“Hello! This is Behdad,” I say, springing from my pillow to grab the handset like a leg hit by a reflex hammer.
“We got another: SI and HI,” the nurse says in a weary, casual tone that simultaneously says she’s been doing this job too long and it’s undeniably 3:00 in the goddamn morning.
I reply robotically, my eyes blurry, my mind slow, yet impatient with fatigue.
The computer screen glows like an electric fire casting sterile white light on my hands and face. The note from the triage nurse says “SI/HI” and nothing else, meaning the person told the nurse he has suicidal and homicidal ideations, or thoughts of killing himself and someone else.
The first time I encountered SI/HI, I was anxious, shocked, and intimidated. Who was I, a sputtering intern with bad hair, to assess someone’s motivation for murder and self-annihilation? I remember gently inquiring with hesitant delicateness. Now, if I feel anything hearing those words, it’s annoyance, suspicion, angst, or indifference.
SI and HI, huh? We’ll see about that.
I head to the patient’s room yawning. He’s a lanky black man with puffy eyes and well-trimmed hair. He’s wearing purple paper scrubs and struggling to open an apple juice.
“Hi Richard. I’m Dr. Bozorgnia. How can I help you tonight?” I ask with the enthusiasm of a McDonald’s drive-through clerk.
“SI and HI. Didn’t you read that?” Richard replies with irritation.
Like fire flashing in a pan, anger surges through me. Instead of telling me his story or describing his suffering, he begins with psych buzzwords. He’s trying to lead me down a path to other words like “high risk,” “self-harm,” and “requires hospitalization.”
“How long have you been feeling this way?” I ask.
“Awhile,” he replies, staring at the wall beside him.
“What’s making you feel that way?” I ask.
“Everything,” he says, scowling at the ground.
His answers are vague and evasive. He avoids eye contact and is irritated by my questions. I’m becoming annoyed, suspicious, and angry. He endorses every symptom of major depressive disorder while ravishing a turkey sandwich, not looking depressed at all.
He insists on immediate hospitalization, citing his own safety risk.
When I offer alternatives, he yells, “If I go out there I WILL KILL MYSELF!”
I am unimpressed. His presentation carries the telltale signs of what psychiatrists call “malingering,” a sanitized word for bullshitting to get what you want. His story is so vague and inconsistent I can barely piece it together. He claims to be incapable of feeling pleasure, but seems to find the hospital food so delicious that he cannot stop eating it even for an interview with a doctor who he’s asking to save his life. For someone suicidal, he seems bizarrely concerned with his safety. He’s not just lying, he’s doing it poorly.
I sympathize with most malingerers. If you’re willing to wait in the ER for six hours in the middle of the night just to speak to a budget psychiatrist with bad hair and worse breath on the off chance of ending up in a locked unit of a mental hospital, your life probably sucks. But at 3:00 AM when I haven’t had a good night’s rest or a regular meal in five days, my patience grows thin. I’m not mother Teresa and this ain’t a church.
“What do you think?” the nurse asks when I return, looking at me sideways.
“He’s a malingerer,” I assert without missing a beat.
“Uh-Huh!” the staff resounds in firm agreement.
I often feel preoccupied and conflicted about my feelings towards people who feign suicide. Parsing fact from fiction in the context of human desperation and suffering is completely unrewarding.
Initially, I blamed patients for lying. I thought they met my good will with deception, even though I sympathized with their goals, most often getting a comfortable place to sleep. Yet “malingering” or “suicide for secondary gain” as I speak of here is not an individual, but a systemic achievement, resulting from the ways the medical culture, and by extension society, treats words and ideas related to suicide.
When a person makes a claim about suicide, our world shifts slightly. People’s behavior towards that person changes. Entire algorithms, networks of relationships, and protocols of response are ready to address the statement.
With the state of current social services, a person who makes a claim of suicidality is more likely to be given food, shelter, and human care than a person who makes direct claims of being hungry, cold, and lonely. If a person came to my psychiatric ER saying they needed food and a place to stay, I would quell the desire to roll my bloodshot eyes and politely refer them to a shelter.
Claims regarding basic human needs have low market value and cannot be exchanged for high quality goods and services. A person who claims to be hungry has a very low probability of receiving food.
Imagine the homeless person who stands at an inner city intersection and holds a sign that says “hungry.”How many people will pass him by before someone gives him money? How many of those generous people will it take to gather enough capital for a single serving of food? It is reasonable to imagine that dozens of cars would pass by without making any monetary contribution and dozens more would have to pass by before enough funds are gathered for one meal. Claims of hunger, cold, and fatigue are worth pennies to most people.
Now imagine the same homeless person from the previous paragraph holding up a sign reading, “I want to kill myself!” Do you imagine more or less people stopping to help? A person who claims to be suicidal to another person is much more likely to receive aid than a person who claims to be merely hungry, cold, or tired. It is reasonable to imagine that within a short span of time, the police would be called, who would then escort the person to an emergency room to be evaluated by none other than some jerk like myself. Even if this homeless person is not admitted to the hospital, the process of evaluation entails shelter, food, and human attention.
The disparateness of responses to claims of basic human need and claims of suicidality incentivizes claims of self-harm in order to meet basic human needs. In a strange way, the hungry, cold, and tired person is forced to ransom their own life in exchange for being provided housing, food, and empathy.
“What do you want to do with him?” the nurse asks.
“He can sleep here, then he leaves in the morning,” I reply, and go back to bed.
is a third year psychiatry resident at Penn interested in philosophy and positive psychology who is an Editor-in-Chief of this magazine.