A danger to herself or a free spirit?

On the coldest night of the year I sat wrapped in a hospital blanket, finishing paperwork in the psychiatric emergency room of a New England city. Maybe things would be quiet and I could get some sleep.

Then a call came in. They were sending us a patient. I heard the door to the unit bang open. I peeked out of my cell-like room and saw two police officers escorting a gaunt, middle-aged woman with long gray hair.

As a nurse took the woman’s vital signs, I spoke to a social worker and minister, who had come with the patient. The social worker told me the patient was a homeless woman who she had been trying to help for a long time. The woman sometimes slept in the minister’s church.

But not this night; not for several nights. They had been worried. And tonight, when the thermometer dipped below zero, they went looking for her, finally finding her lying outside the train station.

When they begged her to let them bring her to a shelter, she refused. So they called the police.

The social worker wondered if the woman was mentally ill. She looked at me with kind eyes and asked, “Do you think you can do anything?”

“I’ll try,” I said.

The patient wouldn’t tell me her name or age, where she came from or any history. Glaring at me, she said she didn’t have to answer my questions. “I have rights,” she said.

I told her I respected her rights, but needed to figure out what was going on to help her. She challenged me to ask her any questions that would test her sanity; she would answer only those.

So I launched into the questions of the standard screening for cognition: Where are we? What is the date? Repeat three words, name the president, subtract 7 from 100 and keep going down by 7, and so on. She answered them all with a defiant stare. With the same feigned distraction I’d used on the cognitive screen, I asked, “Where is it that you live?” But she had me figured out. I already told you I wouldn’t answer those questions, she said.

I was rattled. But how was she staying warm? What about food? Did she know how cold it was?

She had answered all my questions correctly, she replied, so she was sane enough to do what she wanted.

I said I had no proof she could take care of herself if she left.

She demanded a lawyer, asked to be released. I left the room and returned to the cell-like room where earlier I’d hoped to nap.

It just wasn’t rational. You don’t sleep in the street if there is a place where you can stay. Not on a night like this. I thought, how many street people have mental illnesses -- a lot of them. Perhaps most of them.

But not all. And maybe not her. Was there proof? Was she rambling, disorganized, obviously hallucinating? What was going on inside her head? I had no idea. I only knew she was angry.

And I was angry too, for different reasons. Angry that she’d interrupted my attempt at sleep, angry that she wouldn’t open up to me, angry that she’d let herself freeze to death. And angry that she made me feel like a bully for trying to help.

I filled out the commitment form and classified her as “gravely disabled.” She was livid, and told me I had no right to do this to her. “We’ll just have to agree to disagree,” I said. Then I left the room again.

The social worker and minister smiled with relief when I told them the plan.

When the ER was finally empty I lay in the call-room cot but still couldn’t sleep. My anger subsided and I wondered if I’d done something horribly wrong. Though the law allows doctors to detain someone who is suicidal, homicidal or too mentally ill to provide for her basic needs, did I really have proof she was any of those things? Is it possible someone might choose to live out among the elements, tied down to nothing, and still be sane? And wasn’t there some part of me that admired her spunk and independence?

My choice in life was to work in a clinic all day, then do a 15-hour night shift in a miserable, windowless ER. Hers was to sleep under the stars. Maybe neither made sense.

I might have saved her life that night. But if I ever meet her again, perhaps on another frigid winter night, I think I’ll let her go.

*

Dr. Margriet van Achterberg is completing a fellowship in child psychiatry at Brown University in Providence, R.I.