One of my clients, who has OCD, sometimes has intrusive thoughts (i.e., obsessions) about hurting himself or someone else. In the past, he has acted on compulsions to non-suicidal self-injury, but never harmed anyone else, nor attempted suicide. Most of the time, he has the thoughts without acting on them.
Instead, he tends to present to emergency rooms for crisis evaluation and level of care assessment. He went through a period a few years ago, before I met him, of frequent hospitalizations. Then he transitioned to frequent partial hospitalization program admissions. Now, he's usually just referred back to his outpatient providers.
In spite of the steady decrease in his rate of admission to higher levels of care, he's been getting evaluations with increased frequency over the last few months, creating something of a puzzle for me: If these evaluations are not about being admitted to a higher level of care, then what are they about?
I have a few theories on the matter, or course. For one thing, I have been somewhat less available during this time, with holidays and a new full-time job, so the role of his attachment to me (and related transference) in helping him feel safe could be a factor. He declined a referral to a therapist with more availability (again likely due to attachment), but perhaps occasionally needs a "booster" intervention, which he seeks out via crisis evaluation.
Whether or not my own availability has played a role, it seems clear that the crisis evaluation plays some sort of symbolic role for him. It's not a specific crisis service or clinician, since he presents at various local emergency/crisis locations, so it must be the process itself. One possibility is that the crisis evaluation serves as a kind of transitional object representing the treatment relationship with me and his psychopharmacologist.
Another possibility is that the crisis evaluation itself has become part of the compulsion - perhaps a kind of sublimation of the initial compulsion to harm self/others. In other words, the compulsion to harm is diffused by acting on the compulsion to seek crisis services. Alternatively, getting a crisis evaluation may also be a kind of "safety behavior" diffusing the anxiety in another way: he doesn't trust himself to 1) stay safe, and/or 2) know whether or not he can stay safe. Having a clinician and doctor tell him he's safe to go home provides the reassurance he needs to actually go home and be safe.
Normally, the treatment of choice with safety behaviors is exposure and response prevention - however, the risks of that treatment are considerably higher when the compulsion is about risk. While I'm pretty sure someone can not wash their hands and still come out in one piece, interrupting this safety behavior could result in harm to self or others. I'd rather he get the evaluation than act on a dangerous compulsion!
Instead, I'm thinking that harm-reduction may be the way to go. Since he has needed less and less intensive treatment over time, continuing the work will hopefully lead to less need for evaluations as he trusts himself more to stay safe. If anyone has another idea, though, I'm all ears!