by Robert J. Lanz, LCSW
When they brought Sarah in she couldn’t talk. She stopped speaking abruptly the night before. I’m not sure why her family waited to bring her in, unless they thought she would get better over night and just start talking again in the morning. I’m not even sure why they brought her to an emergency room just because she stopped talking but without showing any other abnormal symptoms. Then again, where else would you bring a young woman who had just stopped talking? In the big picture, it certainly qualified as more of an emergency than a lot of what came through our doors.
I knew her silence had to be related to an emotional problem, because there aren’t any medical conditions that cause a person to just stop talking, absent any other symptoms. The family knew what had happened. Sarah knew what had happened. I was the only one in my office who didn’t, and it was my job to get her to talk about it even though I didn’t know what “it” was yet. I expected the family to tell me what “it” was at any moment, and I was willing to wait a while to see if they would do just that. I was willing to let them tell me when they were ready, and I was hoping to get Sarah to do that, too.
I started with some really broad questions like, “Did something bad happen to you yesterday?” and “Can you tell me about last night?” This led nowhere, even though I waited silently for almost three minutes to give Sarah a chance to respond. I could sense that everyone else in the room was ready to tell me what happened to Sarah, but they were waiting for her to do it. Maybe they inherently knew it would have been better for her to talk about it. Maybe they were afraid of something or had already given it their best try and had given up. Whatever had happened, I knew that it must have been terrible, because no one else wanted to discuss it.
Hoping to make some progress, I continued with some simple observations like, “It must be hard to talk about what happened,” and, “I see everyone is upset about what happened.” I got nowhere with that, either.
There isn’t a significant body of medical literature to explain what to do when a person suddenly stops talking. I certainly didn’t have a significant body of experience with cases like this, and for the moment, I wasn’t sure what to do. These types of presentation, called a conversion reaction, are not uncommon, and I sometimes saw patients with symptoms that mimicked paralysis when I was doing this kind of work at an army hospital during the Vietnam war. The patients showed up with some abrupt physical manifestation that didn’t conform to any known medical diagnosis. The symptoms had an obvious emotional component and could usually be traced to some specific event with a symbolic meaning that presented in an obvious way.
If the person was partially paralyzed and dragging a leg, it could be deduced that the individual needed to run from something, but couldn’t. A person with a paralyzed arm inevitably wanted to strike someone else but couldn’t. If they couldn’t hear, they had already heard more than they could tolerate. If they had been struck blind spontaneously, they had seen too much. The books all say these things tend to resolve themselves in a few days. They also say that a patient with a conversion reaction frequently talks about their symptoms with little or no emotion. Imagine being struck blind and then talking about it with the same level of intensity as you would when talking about catching a cold. That’s one of the ways mental health professionals recognize that a conversion reaction is present, by the patient’s indifference to that which would cause terror in someone else.
Speechlessness had a slightly different twist to it, and it was difficult to understand the deeper symbolism. On the surface, I surmised that the patient had something important to say, something that was too difficult to verbalize. My problem was, I couldn’t recall what to do about it. I knew that if the patient was insured, that a consulting psychiatrist would want to hospitalize her for a few days, at eight hundred dollars per day, just to see what would happen. Another doctor might want to try some mind-altering drug to bring the patient out of her state. None of the doctors in the ER knew what to do about Sarah’s condition. She didn’t have insurance, but she was in our care and needed to be treated immediately.
I finally took Sarah’s cousin into another room and asked her what happened. She hesitated before speaking
“Her husband is a junkie,” she said, her voice barely louder than a whisper. “Always messing up. Yesterday he died. But he didn’t OD or nothing.”
She paused as if considering her next words. “He hung himself.”
“He hung himself?” I repeated. Hanging was a rarely used method of committing suicide. It usually worked, but certainly was not quick like a gun would be, and it wasn’t painless or dreamy like taking pills. Hanging was brutal, and it brutalized the survivors. That was frequently the intent, a final “screw you” to someone, an exit that left a messy stain of guilt behind. Hanging was an angry act, an evil act, and a punishing act. It was a way to leave the world in anger, and to hurt those left behind. In this case, it worked. Sarah was struck speechless by her husband’s suicide.
“Yeah, he hung himself from the rafter by the front door,” the cousin continued. “When Sarah came in and felt for the light switch, she felt his feet first. When she finally found the switch and turned it on, there he was, looking down at her.”
More symbolism. Maximum effect. And now he had gone to some void and she was stuck in a quiet one of her own, afraid to speak because of the feelings that might erupt. She had been propelled into the emotionally neutral zone, probably the zone her junkie husband had been trying to find for most of his life, a painless place to drift. But he was gone now, of no consequence to me, but Sarah was. She couldn’t spend too much time in the speechless, painless zone, or she would get too used to it, and might not easily come back. The time to take care of Sarah was right then. I wasn’t sure what to do and there was no one to ask. For the moment I too was speechless.
I went back to the room where Sarah sat mute. I looked at her. I looked at her family. They looked at me. They thought I knew what I was doing and that I would soon have the answer. That kind of confidence, when expressed by strangers, is both inspiring and intimidating. There had already been enough intimidation, so I chose to go with inspiration. It was a good call and in a moment, inspiration came, and I knew what to do. I grabbed a pen and notebook off my desk and handed it to Sarah.
“Sarah, I want you to write down what happened.”
There were a few agonizing moments when she did nothing, launching my stomach into its own conversion reaction. I was failing in front of her family, and because of it, my patient wasn’t going to get better. The notebook and pen was the only trick I had, and it looked as if it wasn’t going to work.
The silence made sitting there difficult, and I began to get a sense of the helplessness that Sarah must have been feeling. I contemplated going home that night, having to live only with my small failure in front of a small crowd, failing only in the privacy of my office. I would have failed at something that most anyone would probably have failed at, given the restrictions of time and treatment options in the ER. But Sarah would go home alone with a hundred reminders of her failure, the reminders her husband had purposely planted to put the blame on her instead of on himself.
It was agonizing for both of us. And then, her hand moved, and she started writing. Slowly at first, printing like a child would do. MY HUSBAND HUNG, and that was as far as she got.
She looked up at me with tears in her eyes and said, “My husband hung himself last night,” and the tears continued to come. Then the sobbing came, and the wailing and hysteria and the power of speech came back to her. She told me again how she had found him hanging there by the light switch, and soon she was telling me how she felt when she found him. I didn’t have to do much, just pay attention. Sarah started to talk more and more about her feelings of being angry with herself and then angry with her husband. Then she talked about her feelings of loss, then about being lost and finally about the loser who hung himself. When she started to tell me what bad things her husband had done to himself and to others, that he was better off dead, and that she was better off with him dead too, I knew she would recover. Maybe not as dramatically as her return from muteness, but at least she was no longer silent and no longer helpless.
Neither was I. It was a good save. But it was a close call, and I’d been lucky. If I ever have to do it again and it works then it will go down as experience. This time, it was just a good guess.
Later, in one the ER’s rare quiet moments, Sarah’s doctor asked what happened to the lady who couldn’t talk. He had only seen her briefly and, not knowing what to do, had sent her to me.
“She went home,” I said. “She told me to tell you thanks.”