She looked like a whipped puppy that had had a garden hose turned on it and slunk off to a far corner of the yard to dry out in the sun.

She sat there, wizened but hard, thin and wiry, dressed in standard issue blue emergency room scrubs, thin tanned face, long stringy, wet prematurely gray hair falling limply around her shoulders. She looked down at the floor, but when her head came up and she made eye contact with me, her blue-steel eyes cut through me like a sword.

Like many people I see in the ED, she had tried to kill herself and was damned near successful.

“I don’t want to talk about it.”

She said this not in a defiant way, not in a disrespectful way, but matter-of-factly, like she knew I would understand.

I did.

“I know, but I can’t help you unless you talk to me about whatever part of it you think you can share with me.”

The next thirty minutes were a scripted dance. I’ve partnered with thousands of patients in this jerkily choreographed yet smooth and fluid transition from defiance to half-hearted refusal to longing to reservation to willingness to despair to resignation. The new trainee gives up at “I don’t want to …”, citing respect for the patient’s wishes. The young clinician pushes gently into the land of reservation, thinking that he is doing the patient a favor by not making her express her pain in this setting of codes and glaring lights and empty suicide-proof rooms. The tender-hearted provider, overloaded with his own personal grief or depression or closet alcoholism, over identifies with the despair and leaves it there, sitting raw and bloody like a piece of meat, ugly and untrimmed by the butcher, waiting to be wrapped in white paper and neatly labeled and put away in a deep freeze somewhere. The experienced clinician, having seen this story played out thousands of times, simply waits.

I waited.

“I know where the money’s been going now. I work damn hard all week. I clear almost a thousand dollars a week, doc. He said he was paying the bills.”

I wait, because I know she wants to talk about it.

“Pissing his life away. Pissing my life away. My money up his nose.”

We explore the hurt, the betrayal, the fear, the anger, the loss of control. It’s always about the loss of control.

Killing yourself is the final act of defiance, payback, and ultimate control.

“Yes, at the time I really did want to die.”

I believed her, of course. There was no reason not to.

A sudden infusion of energy, anger, fresh anger, now directed at me, at the system.

“I just don’t believe that somebody can haul me in here and make me sit in an empty room and take my rights away and not do a damn thing for me. I promised to defend the constitution of the United States. I made a vow. This is what I get.”

She spat on the floor. If she could have spat through the camera onto my shoes, she would have.

“Why don’t you must leave me alone? Why don’t just let me make my own decision and let me die? Does it really matter to you? To anybody? Just let me go home. I want to go home.”

Despair.

We discuss the rules of the game in the state of South Carolina. The mandates, the rights and privileges of the citizenry that hold true, always, unless there is a clear and present danger that leads to involuntary commitment and treatment.

Her head hangs, if it’s possible, even lower than before. I do not see her eyes again.

“I’m afraid that you’re not going home today.”

The hose running from the exhaust to the cabin of the truck had decided that even before we talked on camera.

A silent nod.

Resignation.

“Please just let me die.”

The newbie feels a strange mix of pity and fascination and fear.

He responds, “I can’t.”

The old dog knows that the situation, no matter how bleak, will look different once the fog and the darkness have lifted. There is every chance in the world that life will go on, should go on, must go on.

He responds, “I won’t.”

Out of the many he has seen, he will do his very best to help just this one.

Greg Smith is a psychiatrist who blogs at gregsmithmd.