NOTE TO THE READERS OF DESPAIR TO DELIVERANCE

For those of you who have followed along, Robin and I have now finished telling our story of the very stressful year we both experienced in 2003 after her meltdown.  Our plan is for Robin to write the last chapter of what will become our book.  This chapter, which is currently in the works, includes Robin telling the story of how she got from the place of having her life decimated by her mental illness in 2003, to where she is now.  She remains stable and content.  She continues to experience symptoms of her severe mental illness, but she has learned how to manage these symptoms without the self-destructive behavior that was so prevalent in 2003.  She has not been hospitalized for almost seven years.

It was a long process for Robin to get to a place of acceptance of her illness and “deliverance” from the despair she lived with for so long.  We hope you will buy our book, which is currently being edited and revised.  It will have additional material written by Robin about her history prior to 2003, in addition to the rest of her story leading up to the present time.  Our plan is to self-publish the book within the next few months.  It will be sold on Amazon both in print form and e-book form, and we will include a link and an announcement as soon as the book is ready.  We will include updates as the process of getting the book finished and published progresses.

A disclaimer:  All profits from the sale of our book will go to Robin.  I have no intention of profiting from Robin’s experiences or her willingness to tell her story to the world.  I helped her to write the book because I felt strongly that her story needed to be told, and could help others.

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Robin’s Thoughts About 2003

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

Reflecting back on the Meltdown year is always difficult for me. Most of the time I don’t let myself think about it. After all, it has been twelve years. However, writing this book has forced me to transport myself back to that time. As a result I’ve had to re-experience the grief that I felt. Prior to working on this book, I had managed to tuck away my feelings about everything that happened that year, except for a small grieving period every year around the anniversary of the Meltdown. Aside from this, I haven’t let myself dwell on that period of my life (or I would be in a perpetual state of depression). Since we began working on the book, though, I’ve had to consider the overwhelming losses I suffered in 2003 and the utter hopelessness I felt at that time. The crisis during that year led to emotional, occupational, financial, and social devastation for me. I was suddenly facing a new reality, one which I had never imagined myself living.

I had to attempt to integrate the fact that I had a serious and chronic mental illness, not simply the depression I had suffered at times. In my mind there was a huge difference between depression and chronic mental illness. Depression had become more socially acceptable by 2003. I had several friends who had experienced depression and were taking antidepressants as a result. We could talk openly about seeing therapists, and even joked about it with each other. Being chronically mentally ill was a whole different story, though.
At that time my experience with people who had serious mental illnesses resulted mainly from my work as a group facilitator for adults at a community mental health center. The clients were predominantly diagnosed with schizophrenia and bipolar disorder. Most of them lived in group homes and did not have jobs, instead collecting Social Security Disability benefits due to an inability to sustain employment. I observed the attitude of people in the community toward these clients first hand, when the group met at the library. People stared and moved away from them, as many of the clients had poor hygiene or were overtly responding to auditory hallucinations. Although I was sympathetic to my clients and their experiences, I did not identify myself as one of them. Not in any way. They were the people that others either made fun of or felt sorry for. I was one of the people who helped them. In 2003 my vision of what it meant to be seriously mentally ill was forever changed, as I tried to grasp what it meant to be “one of them.”

I also had to accept taking an antipsychotic medication for the first time. This was an issue because I didn’t want any association with anything that had the word “psychotic” attached to it. In my experience with the clients in group therapy, those who had been prescribed antipsychotic medications for a long time sometimes had side effects such as tardive dyskinesia, which causes involuntary muscle movements. They often gained weight or had other side effects, and I was afraid I would experience these things too. But mostly, taking antipsychotic medication put me too close to that category where I didn’t want to be. That category where people were laughed at or pitied, or both.

Being a patient in a psychiatric hospital, which I never considered as a possibility prior to my Meltdown, and having ECTs with the enormous stigma attached to them, were further blows to my identity as I had known it. It was very difficult to acknowledge these events as part of “me.” I was familiar with being on the other side of the mental illness divide, as a helper and a professional. I wasn’t even remotely ready to accept being on the side of the stigmatized patient. It terrified me.

I had to face the possibility that I might be unable to return to my job as a case manager at the facility where I had worked successfully for over four years. This completely impacted my social network, as much of my social life revolved around my job. There was uncertainty as to whether I could return to work as a case manager at any facility. Although I stayed focused on returning to my previous life, deep down I didn’t know if I would ever again be able to work in mental health in any capacity. Losing my job and being uncertain about my ability to return to work in the mental health field crushed my identity, which centered around my life as a respected mental health professional. My self-esteem and confidence were shot.

Filing for bankruptcy and applying for long-term disability were further blows to my self-image. More importantly, though, my independence was threatened. I had to face the possibility that I would no longer be able to afford to live on my own. I was in my mid-thirties and I certainly did not want to return to living with my parents. I had moved home ten years earlier after quitting a job (soon after the meltdown that led to my first appointment with Sharon). After that, I had lived with roommates or alone in my own apartment. It would have felt like an enormous step backward if I was forced to go back home to live, assuming my parents would have allowed me to move in. I also, obviously, had Epiphany to consider as my parents had a dog. I was still depressed, and having to try to grasp all of the ramifications of my newly diagnosed bipolar illness was completely overwhelming.

When I finally got stabilized and back to “feeling like myself” again, this meant my thoughts weren’t going a million miles a minute, I wasn’t obsessing about suicide, and my depression and anxiety symptoms felt manageable. I wasn’t cured, but I finally felt like I was back to my baseline of stability. However, I was still completely uncertain about my future ability to work, to support myself, and to live independently. That year, 2003, ended with my reality being completely different compared to when it started. I was less depressed and felt more stable, but my life was in ruins.

Aside from grieving the losses that resulted from my Meltdown, as I reflect on that year I’m very surprised I did not actually kill myself. My surprise is due to the fact that I was so focused on suicide most of the time. I was completely obsessed with taking my life and spent hours on the internet, painstakingly researching methods that would allow me to do so successfully. Also, despite Sharon’s efforts to get me to abstain, I drank alcohol frequently during that year. I drank in order to numb myself and get some form of relief from the painful depression I felt. But the combination of obsessive suicidal thoughts and drinking alcohol, when my impulse control was also being affected by my bipolar symptoms, was a potent recipe for disaster. I have no idea why I did not, in a weak moment, just do it. In my more coherent moments I knew I didn’t want to hurt people or put Epiphany in a bad situation. But I had plenty of moments where I wasn’t coherent and wanted very badly to be dead. I guess I was lucky, or something bigger than me was operating. I have no idea why I survived.

When I reflect back I feel enormous gratitude for my treatment team, especially Sharon. Her extraordinary efforts, going way above what is expected of a therapist, are a large part of the reason I am alive. I was very lucky to have treatment providers who worked well together to provide my care. Sharon and Dr. Greene were a cohesive team. If I went into the hospital, Sharon was able work with me and Dr. Greene remained my treating physician. There were no gaps in communication. This is not the case in many communities, especially not now after many changes have taken place in the funding of health care over the past decade.

I have not been hospitalized since 2008. But if I had to be hospitalized today in my community, I would not have anything close to the level of continuity of care I had back in 2003. The large community mental health center where Sharon and Dr. Greene worked, ended up closing in 2011, largely due to financial issues. My current therapist and psychiatrist now work for a different agency than the new local psychiatric hospital. If I had to be hospitalized today, they would not be involved in my care in any way. I would be treated by a psychiatrist and therapist who don’t know me, and who may or may not request information from my treating providers. This reality terrifies me, because there is no guarantee I’ll never be hospitalized again. I’m still on most of the same medications that stabilized me in 2003, and have no idea what would happen if a doctor I don’t know chose to change them. My fear about this possibility helps keep me motivated to do everything I can to keep my bipolar symptoms under control.

When reflecting on my Meltdown and the subsequent nightmare year I also have to consider the changes that happened in my close relationships, namely with my family and with Sharon. The change with my family was very slow and gradual, especially with my parents. I was slightly open with my brother, Bob, at the time of my Meltdown. I was able to tell him about my hospitalization after a few days. However, I wasn’t open with my parents. They had no idea how emotionally unstable I was when I had the Meltdown, and I didn’t inform them that I was in the hospital for quite a while. I was used to faking it with everyone so I wouldn’t have to talk about how depressed or suicidal I was feeling. As the year progressed I was able to be more open with my family, although at the end of this year I still wasn’t comfortable telling them when I was suicidal. I knew that the thought of me killing myself was hard for them to consider, and I didn’t want to freak them out anymore than I already had.

In terms of my relationship with Sharon, the change was more noticeable. I had been faking it with her to an extent for years in therapy. I let her know when I was depressed, but didn’t reveal how suicidal or out of control I felt. It was important to me that she respect me, and I didn’t want to be just another “crazy” client on her case load. I was very rigid in terms of boundaries, which I knew was important in therapy because of my own work in the mental health field. These issues all changed, however, when I had the Meltdown. Suddenly, my filter was gone and I said things I would never have previously said. I began to express my feelings more openly with her, like telling her when I was feeling like drinking or killing myself.

As Sharon stretched the boundaries of our relationship and encouraged me to continue to open up, I was initially very anxious because it was such a change from how I had always been in all of my relationships. I had never told anyone how I really felt. I actually didn’t even know how to articulate it. Gradually, it got easier with Sharon’s encouragement, although I worried about becoming too dependent on her because of the frequent contact. I knew it could not continue to be that way forever, and was afraid to be too open. I was afraid it would be too hard when things had to change back to a more normal pattern of contact. But, I think it was me knowing Sharon was willing to work so hard to help me that made me feel more able to be open with her. It made me anxious to talk about my feelings and thoughts, for many reasons, but Sharon motivated me to try harder and it eventually got easier.

There are obvious lessons to be learned from my experiences during the Meltdown year. For instance, it is crucial to take medications as prescribed and not self-medicate with alcohol or non-prescribed drugs. Also, it is important to become as educated as possible about your mental illness. But, I think the most important take away from my experiences is the need to be open with treatment providers and develop a support system of family and/or friends. Had I been more open about my real issues with Sharon sooner, I could’ve been diagnosed correctly sooner and received the proper treatment earlier in the process. I was lucky to have Sharon as a therapist for as long as I did, and that she put in the extraordinary time and effort that she did to help and support me. However, this is not typical in therapy, and shouldn’t be expected. It’s crucial to have other sources of support. It took time, but I eventually became open with my family and some friends so that they could support me as Sharon gradually decreased her contact with me over the years.

If I could change anything, obviously I would never choose to have bipolar disorder, or obsessive-compulsive disorder, or any of the other symptoms I experience. However, some good came out of that nightmare year. It was not an easy process rebuilding my life, but I am now more connected to other people and feel much more stable than I ever did prior to being correctly diagnosed and treated. In 2003, I could have never imagined myself saying this.

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“I Feel Like Myself Again.”

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

If there was one thing I learned about Robin over the course of our time together in therapy, it was that her brain was very rigid.  If she got stuck on something, she was stuck.  She had very little ability to shift her own thinking.  In November 2003 she had recently come close to making a suicide attempt because she felt hopeless about rebuilding her life following her complete bipolar meltdown, and she could not stop herself from obsessing about planning and preparing for this attempt.   This “near miss” allowed her to finally admit to herself and to me, unequivocally, that she did not want to die.  It motivated me to talk to Dr. Greene about my concern, which prompted him to make medications changes to help continue the ongoing process of stabilizing her significant symptoms.

One of the consistent themes of my many conversations with Robin throughout the course of her very painful year of despair, was that her severe depression and obsessive suicidal thoughts had both biological and psychological components.  The medication changes Dr. Greene made were an effort to continue to stabilize her brain’s biology.

Even though Robin and I had worked together in therapy for a decade prior to her very sudden, devastating meltdown in January 2003, it came out of the blue for me.  There were many factors that caused Dr. Greene and me to misdiagnose her illness for so many years.  But once she could no longer contain her enormous pain and she began to let me know how she really felt, we were able to get much clearer about what was happening and how to treat her severe and intractable symptoms.

The biological factors contributing to her meltdown were her enormous obsessive-compulsive anxiety, and the unfortunate reality that we did not know she had bipolar disorder.  When she became more depressed at the beginning of 2002, Dr. Greene and I collaboratively worked to try various combinations of antidepressant medications for a year with no real success.  It never occurred to either of us that she might have bipolar disorder, and so we were actually making what we subsequently realized was mixed mania worse, by adding more and more antidepressant medication without a mood stabilizer.  The difficulty we had in terms of stabilizing the biology of her brain, I am convinced in hindsight, was partly due to the fact that she went so long without the proper treatment.  I think it was also due to the enormous psychological factors that were contributing to her ongoing, significant depressed mood.

Robin’s brain was stabilized biologically step by step over the course of 2003.  Although Dr. Greene immediately wanted her to have ECTs, it was not an option.  We were grasping when we talked about adding an antipsychotic medication, and he started her on Geodon.  We did not realize it would actually help, not because it was an effective enhancer to the antidepressants she was already taking, but because atypical antipsychotics are beneficial in stabilizing bipolar symptoms.  When we finally figured out the bipolar diagnosis the addition of Depakote, a mood stabilizer, was extremely helpful in terms of helping Robin to sleep better and to decrease her impulsivity.  But, by this time her life was already falling apart and her mood, although stabilized, was stabilized at an extremely depressed level.  She was on Paxil, which got changed to Celexa and increased to a high dose.  She went off and on Wellbutrin, with a clear pattern in which she she did better with it than without it, as long as she also had Depakote and Geodon.  It was during her fourth hospitalization in August 2003 that Dr. Greene discontinued Geodon and started her on Abilify, a relatively new medication at that time.

It was the ECTs, I am convinced, that actually helped Robin turn the corner biologically.  Without them I am not sure we would have been able to get her mood stabilized soon enough to keep her alive.  The ECTs certainly did not solve everything.  They did not change the fact that Robin now had to face her new reality as a severely mentally ill person.  They did not address the enormous grief she felt about the loss of her job and her life as she knew it.  But, the ECTs helped Robin get from a place of overwhelming biological depression (completely flat affect, psychomotor retardation, profound anhedonia, feelings of hopelessness and worthlessness, and obsessive suicidal thoughts), to a place of being able to process reality more rationally.  Her affect brightened, she began to enjoy watching television again, and she began to think more clearly.  The ECTs were an instrumental part of what finally allowed us to stabilize Robin’s brain.  But, there was one more piece of the biological puzzle that needed to happen.

The medication adjustments made by Dr. Greene following her near suicide attempt were to increase her Depakote and Abilify doses.  It quickly became clear that the Depakote increase caused her to feel tired and lethargic, which we realized in hindsight had happened the previous spring when she had been on that dose for a short period of time.  At the same time, though, her mood was improving and her suicidal thoughts virtually disappeared for the first time in over a year.  This happened within the timeframe that would be expected for Abilify to take effect.  So, with a decrease in Depakote and the new, higher dose of Abilify, Robin finally, finally, finally came in to a session with me one day in late November 2003 and said, “I feel like myself again.”  There was no question…it was Abilify that was the final piece of the puzzle.  The dosage increase following her near suicide attempt got her to the place where she finally felt like herself.  It caused her suicidal thoughts, which had been there consistently for over a year, to stop.  Completely.

Robin felt like herself again!  It had been almost two years since she had felt that way.  What an enormous relief for us both.  Four hospitalizations, eleven ECT treatments, Celexa, Wellbutrin, Depakote and Abilify.  And many, many months of despair and angst.  Robin finally felt like herself again.

Regarding the psychological factors contributing to Robin’s enormous symptoms, it was the shock of finding out she had been unable to let anyone really know what she experienced, including me, which helped me recognize that avoidant personality disorder for lack of a better description, was a huge issue.  I knew she was more open with me than anyone else.  Once I found out how much she had not been telling me I began to realize how alone she must have felt.  I was sure this was a major contributing factor in terms of her severe depression.

Learning about her previous suicide attempt by carbon monoxide, and that it was her obsessive-compulsive need to be on time to work that saved her life, helped me to finally understand the extreme rigidity of Robin’s brain.  It helped me understand the extent to which she had no control over her own thoughts, and that when her brain locked onto suicide she had no ability to shift her thinking.  Early in my career and my work with Robin, I was warned about this by her first psychiatrist, Dr. Rios.  But I was too inexperienced to really understand.  When I finally understood this, it helped me know more clearly that I needed to change my whole approach to her treatment.

I became clear Robin needed to connect with people, and at first it needed to be me.  I knew she needed to be able to continue to talk to someone consistently about her persistent suicidal thoughts.  Her family and friends would not have been able to handle this.  I purposely and consciously extended the boundaries, appropriately, within our therapeutic relationship because I knew this was going to be a crucial step for her going forward.  She needed to get past the enormous anxiety it caused her to be open with people.  I assumed once she was able to become comfortable being open and vulnerable with me, it would allow her to do the same with the other people in her life.  Without this happening, I knew Robin would continue to feel alone and would be very prone to significant depression.

Robin and I, throughout the years of our work together, had occasionally talked about her very pessimistic world view.  This was another clear psychological factor contributing to her tendency toward depression.  She had never been willing to be proactive, though, about doing any reading that might challenge her basically agnostic, negative and fatalistic perspective.  Her meltdown allowed me to take a leap of faith that simply having her read some books and listen to some more positive music than she was used to hearing, would not violate the general rule of thumb amongst therapists to not impose our beliefs onto our clients.  I was careful when sharing music and writing notes about my thoughts about the lyrics, to let Robin know these were my own beliefs and did not need to become hers.

When she was feeling like it was impossible for her to adjust to being on long-term disability, I simply focused on my belief that the biggest and most important purpose we all have in our lives is to love other people.  I consistently reminded her that she still had this ability, no matter what her job or financial situation happened to be.  Most importantly, I repeatedly gave her the message that having a severe mental illness did not keep her from fulfilling this purpose, and if we worked together to help her get closer to others she could get much better at fulfilling this purpose and feeling better about herself and her life.

I wish I could say stabilizing the biology of Robin’s brain, as evidenced by her statement “I feel like myself again,” meant that all would be smooth going forward.  But, the other psychological factor that became clear over the course of 2003, was that we still had a lot of work to do in terms of helping Robin access and express her emotions in healthy ways.  It became clear as her brain was stabilizing, that suicidal thoughts were an automatic response whenever she was feeling painful emotions.   She had come so far from when we first met…she never cut herself and she rarely dissociated throughout all of 2003 despite all the pain she felt.  But, we had more work to do in order to help her feel pain without her brain automatically locking onto suicidal thoughts and wanting to use alcohol to numb herself.

I also wish I could say that once Robin’s brain was biologically stabilized she was able to agree that taking some time before attempting to return to work…to grieve, and heal, and work on the psychological factors we identified, was the best next step.  But, instead, the biological progress had caused Robin to think clearly enough to grasp the many painful ramifications of her severe mental illness.  She did not like the prospect of making this transition, to say the least.

Robin stayed stuck in all or nothing thinking.  Despite my repeated attempts to convince her that being on disability was an opportunity to take some time and energy to work on the issues we needed to address in therapy, she remained singularly focused on returning to her previous position as a full-time case manager as soon as an opening became available.  She was not ready to grieve and move forward as a person disabled by chronic mental illness.  She wanted her old life back.

By that time I knew once Robin got stuck on something, she was stuck.  I knew she was going to have to make another attempt to return to her previous life, whether it was likely to work or not.  It concerned me, greatly, that she was going to set herself up for another disappointment and potential meltdown.  I was concerned for her, but also for me.  I had extended myself for many months.  I was so relieved she was finally better.  I wanted and needed a break from the intensity and the stress.  But, Robin was stuck.  I was not going to change her mind.

So, when Robin came to a session in December 2003 and told me there was an opening on the same treatment team with all of her former co-workers at her previous place of employment, working in the same full-time capacity as before, I was concerned.  But, despite my gut feeling that it was not going to go well, I wrote a letter, co-signed by Dr. Greene, saying Robin was ready to return to work.

COMING NEXT:   ROBIN’S THOUGHTS ABOUT 2003

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“I Don’t Want to Kill Myself.”

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

It was October 2003 and Robin had been battling her own brain for over eight months.  After four hospitalizations, eleven ECT treatments, the loss of her job and health insurance, and the finalizing of a bankruptcy, she was trying to piece her life back together.  It was not working for her to have too much unstructured time, during which she was ruminating about the losses she had experienced.  In order to have something to distract herself and feel productive, she began to volunteer for an agency that provided care specifically to patients with AIDs.  On her very first day there, however, she already had to face the realities of her new identity.

“Several people asked me what else I do,” Robin said as she was telling me about her experience in our session after that day.  “It caught me off guard.  I didn’t know what to say, so I just told them I’m on long-term disability.”

It had not occurred to me to try to prepare Robin for this.  Of course, this standard question people ask when they are trying to get to know each other would come up.  Upon meeting Robin, a young women who looked perfectly healthy, of course people would innocently wonder what she does for a living and why she had time in the middle of a Monday afternoon to volunteer.  Robin worried so much about what other people thought.  It would have helped if we had discussed that this question might come up, before she went there the first time.  I told her I agreed being honest was best, since she needed to feel accepted by other people who knew the real her.

“So, how did the volunteering go?” I asked.

“I’m going to start going there four hours every Monday and will be driving clients to appointments,” she said.  “I’m anxious about getting lost when I’m trying to find the offices, but as long as they don’t pack too many appointments into one afternoon I’ll be fine.”

Robin said she felt positive after her first day, and felt “briefly competent” afterward.

The next day, Robin called.  “My brother got a questionnaire from Social Security.  They’re asking him a bunch of questions about me.”  I told her this was standard procedure when someone applied for Social Security Disability benefits, because they want objective information from someone who knows the applicant well.

“I didn’t sleep at all last night,” she said.  “I was obsessing about a lot of different things, but mostly the Social Security paperwork made everything more real.  I would prefer to be in ‘la la land’ where I believe I’ll be going back to work whenever they have an opening.  But I know this isn’t true, which makes me depressed.”

We discussed the possibility of her former supervisor receiving a questionnaire from Social Security as well, and how she should handle this.  As we wrapped up our session, Robin agreed to let me know if her sleep did not improve.

In our session the following week, Robin said she had gone to volunteer, but they had no clients who needed her to drive them anywhere.  She said they had her do some filing, but she only stayed for a couple of hours.

Then, as we kept talking, Robin started saying things I was not expecting or prepared to hear.  Although I shouldn’t have been, I was probably more stunned than I had been during the previous eight months.

“I was feeling okay after volunteering, until I went to bed.  “Then, I couldn’t sleep.  I began to obsess about suicide including what I’d write in a note, what songs I’d want to have played at my memorial service, and who’d need to be contacted after I am dead.”  She said it took her several hours to get to sleep.

“Robin, what happened?  You have been feeling so much better overall!  What caused your mood to shift so suddenly?”

“I was really anxious about going to volunteer on Monday.  Then I felt let down when they didn’t have much for me to do.  I’m trying to accept that I won’t be going back to my job.  But I’m having trouble getting past this.”

We talked again about the big picture of her life and her treatment, and about all the progress she had already made.  We talked about all the progress she could continue to make in the future.

“It feels like it would be too hard to make the changes it would take to make things better enough,” she said, sounding very hopeless.

Robin went on.  It was, as was often the case, as if she felt compelled to confess to me.  “Yesterday I was seriously thinking about overdosing.  I had everything ready.  I even had the CD of songs made, the note written, and the list of people to contact.”

What?  I couldn’t believe what I had just heard.  I thought we were past this!  Throughout the entire time since Robin’s meltdown, she had never carried it this far.  She had never written a note.  She certainly had not made a CD of songs for her memorial service.  It indicated that she had not only been obsessing, she had been meticulously planning to carry out an attempt!  After hearing this, it was one of those moments when I was suddenly not even remotely calm on the inside, but I relied on my ability, honed over many years of practice, to remain calm on the outside and ask the right questions.

“What stopped you?”  I tentatively asked, not sure what I would hear.

“Well, Christi and I had plans to get together.  After I decided to kill myself, I had to call her to cancel our plans so she wouldn’t be worried about me.  I expected to just leave a voice mail, but she picked up the phone.  She was so disappointed about me canceling, I changed my mind and decided to go over there before I killed myself.”

Thank God for Christi!  Although I had never met Robin’s friend, I had heard a lot about her and liked what I had heard.  Inside I was thinking I would give her a big hug if I could.  She had no idea how helpful she was to Robin that night.  I was trying to digest the reality that, again, Robin had planned a suicide attempt without me knowing it and could have easily, in an impulsive moment, carried it out.  It was a painful reminder that no matter how hard I had worked to help her, and no matter how much progress she had made, Robin could still very well end up dead.

“So, I am assuming by the time you got home from Christi’s place you had shifted enough to keep from carrying out your plan?”  I asked.

“Yes.  I guess part of me doesn’t want to kill myself, because I don’t want to hurt people.  Besides, I think there is also part of me that is too chicken.  I’m really afraid I’d just screw it up and make things worse.”

In hindsight, I should not have been surprised by Robin’s near suicide attempt.  It is widely known and discussed among clinicians that people are often at high risk for suicide when they are coming out of a serious depression.  There are many theories about why, and probably lots of different reasons for different people.   I suddenly remembered that Robin had talked about needing to finalize her bankruptcy as a barrier in terms of suicide, so she did not leave a financial mess for her family.  That barrier had recently been removed.  Robin was feeling hopeless about being able to adjust to her new identity and not returning to her previous job.  In hindsight, it made sense that she was having more suicidal thoughts.

I asked the question I had asked so many times before during that year.   “Do you need to be in the hospital, Robin?”

“I really want to avoid that if I can,” she said.  We discussed the fact that she had not been drinking despite her increased depression, and was not showing significant signs of mixed mania.  I told her I would talk to Dr. Greene the next day, and we would go from there.

“Dr. Greene, it’s Sharon,” I said after paging him the next morning.  “Robin has been doing much better since her last hospitalization, but her sleep has started to get disrupted and she has been more depressed in the last week or so.  She is back to ruminating about suicide.”

After some discussion in which I told him about the events of the previous day, Dr. Greene made the decision to increase both Robin’s Abilify and Depakote doses.  I called her to let her know.

“How are you this morning?”  I asked, hoping to hear she was feeling better.

“I didn’t sleep very well.  I still can’t stop thinking about suicide,” she said.  “I feel like I’m waiting for something bad to happen to give me an excuse to do it.”  She agreed to make the medication changes Dr. Greene had suggested.

Robin and I continued to talk through her grief issues as we waited to see what the medication changes would do.  We continued to have some contact on the phone during the week, in addition to meeting in therapy once a week.  She continued to refuse to talk on the weekends, as she did not want to feel “too dependent” on me.

So, when she called me on a Sunday in late October 2003, I knew she must not be doing well.  It remained highly unusual for her to contact me without a planned time to talk, especially on a weekend.

“I still can’t stop thinking about suicide.  I’m having a hard time and need to refocus away from those thoughts.”  Wow!  This was a shift!  Robin had overcome her anxiety about calling me in order to proactively try to avoid being self-destructive.  I was surprised, and thrilled by the change.  Robin described a clear pattern over the previous few days of doing okay during the day when she was busy and distracted, but getting more depressed toward evening and ruminating about suicide at night.  Then, she said something truly remarkable.

“I don’t want to kill myself,” she said.  Clearly, unambiguously, and unqualified.  For the first time since her meltdown, she said it.  Thank God.  “I’m frustrated that my brain keeps going there.  I’m tired of trying to fill time to keep myself distracted.  I just want to stop thinking about it.”

I don’t know what happened that caused Robin to suddenly get clear.  I don’t know whether her near miss the previous week had scared her, or whether she was beginning to benefit from the medication changes.  But, what a relief it was to hear those words.  Robin finally felt clear she did not want to die.

We talked about ways to help her brain shift.  I suggested we think about ways to increase the barriers in terms of acting on her suicidal thoughts.  “What do you think you could do that would make it harder for you to act on those thoughts in a weak moment?” I asked.

Robin was open that she had a stockpile of old medications she was no longer taking, which had been part of her plan for overdosing.  She decided that night to get rid of all of the extra medications she had in her apartment.  She reluctantly agreed to pour out all of her alcohol, even though she had not recently been drinking.  And, after some discussion she agreed to delete her recently written suicide note, in which she gave final instructions, from her computer.  Robin, finally, was clearly serious about wanting to stay alive.

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“I’m Tired of Doing the Suicidal Battle in My Head.”

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

In mid-September 2003, approximately two weeks after her fourth hospitalization, Robin began to display noticeable signs of a further lessening of depression.  Her affect was brighter.  Her thinking continued to become clearer.  She moved more quickly and responded to questions more easily and with more depth (less psychomotor retardation).  She was beginning to look more and more like the Robin I had known before the year of depression that led up to her meltdown, rather than the depressed and slowed down version of Robin I had been seeing for many months.  She had clearly been improving as a result of the ECTs, but this was a new level of “better.”  She even began to say she was feeling considerably less depressed.

“I really think the medication changes Dr. Greene made when you went into the hospital, lowering the Celexa and changing Geodon to Abilify, are helping,” I said to her in a session one day.

“I actually don’t feel out of control like I had been feeling for so long,” she said.  “It’s surprising.”

“Robin, I hate to say it, but if there was any remaining doubt about whether you have bipolar disorder, this probably eliminates it.”  I said.  “Otherwise you wouldn’t be responding so well to these specific medication changes.”  We discussed that having bipolar disorder makes it particularly important to eliminate self-destructive behavior, especially those things that sabotage her brain’s biological stability.  We talked about the enormous grief she continued to feel about losing her job, and the uncertainty her new diagnosis caused.

“I just don’t know what I’m going to do with my life,” Robin said.  “And even though I’m less depressed, I’m still really anxious about whether I’ll be approved for long-term disability.  If I don’t get approved I have no idea what I’ll do.”

“Anxiety has always been a big part of who you are, Robin.  I think you will always struggle some with anxiety, especially surrounding big life changes.  Your anxiety is completely understandable.  It just can’t be the excuse for self-destructive behavior.”  She was still struggling with urges to drink and I was still being firm about avoiding all alcohol.

“I’m trying to do what I need to do,” she replied.  “But it will definitely help to know I can pay my bills.”

Thankfully, the next day I received a phone call from a representative of the company that provided long-term disability insurance benefits for her former employer.  He wanted me to fax copies of my therapy progress notes to them, as they were considering Robin’s application.  I was able to talk to him about her symptoms and the monumental meltdown she had experienced.  While I had him on the phone, I let him know how anxious she was to find out not only whether she’d be approved but when she would receive her first check.

It did not take long for the reviewers at the insurance company to make the right decision.  After reading the details of Robin’s experiences, I think they realized that if anyone deserved long-term disability benefits, she did.  It was the following day when I received a phone call from the same representative, telling me Robin had been approved and her first check would be mailed that day.  I was very happy to call Robin to tell her the news.

“This is the first good thing that’s happened in a long time,” was Robin’s reply.  She was able to relax a bit, knowing she would continue to have income.

Over the next few weeks during our sessions, Robin began to try to integrate all that had happened to her during the previous eight months.

“I don’t know why, but I’m having urges to stop taking all my medications in order to see what happens,” she said one day.  “I don’t understand why I need to be on so many different ones.”  Robin did not remember much of what she had been through, partly due to the ECTs but also because she had been so overwhelmed with emotions that she had been dissociating at times.  I explained to her the reasons each of the five medications she took had been added, and why each of them remained crucial to her ongoing stability.  My hope was that hearing some of the details of how bad things had been and how each medication had helped change things for the better, would help motivate Robin to avoid sabotaging her brain chemistry.

“I hope it doesn’t get really bad again,” she said as she was clearly beginning to understand the reality of how dangerous her illness had become.  “I don’t know how I would survive it.”

Robin readily acknowledged that she was back to her previous pattern of minimizing her symptoms and issues with her friends and family, and presenting herself as doing better than she actually felt.  Although her mood was definitely better, she was sleeping better and her anxiety was decreased, the obsessive suicidal thoughts continued.

“I need to feel like things are getting back to normal,” she said.  “I want everybody to treat me like I’m okay, not like I’m crazy.”

“That’s fine, Robin, for now.  As long as you aren’t minimizing anything with me.  I need you to keep working on getting more comfortable being open with me, even though your defenses are returning and it would be easy for you to fall back to what worked for you for so long.  You have to be open with someone.  Right now that’s me.  As you get more comfortable, we’ll work on having you be more open with your friends and family.

I went on to reiterate a crucial concept she needed to integrate.  “It’s important for you to shift from trying to keep everything inside and under control, which is what you’ve spent your life doing, to being willing to talk about painful feelings.  I think you’re already making this shift, but it has to continue to be a focus in therapy.”  She reluctantly agreed.

Once Robin was able to stop worrying about getting approved for long-term disability, her mood, unfortunately, deteriorated.  As had been happening gradually over the previous few months since completing ECT treatments, she was thinking more clearly and recognizing more completely the implications of her illness.  She was realizing on a new level the degree to which her life and her identity had been forever altered.

Part of the problem was that Robin lived alone and had nothing to do.  She had too much time to think, and not enough contact with people.  She continued to have suicidal thoughts on a regular basis, and her mood fluctuated depending on how much time she spent alone.  It was clear to me that this depression was situational, but it was worsening.  Robin needed something positive in her life that served as a distraction, put her in contact with people and gave her a sense of purpose.

“I just wish things could go back to the way they were before,” she said during a session in late September 2003.

“Robin, I hate to say it, but you really weren’t happy with your life before the meltdown either,” I said, trying to help her shift.  “Your jobs in mental health have always been very stressful.”  I reminded her of some of the specific situations we had talked about through the years that caused her to feel stressed at work.  “I’m not going to dismiss your enormous grief, and I want to help you work through that.  But it may also help to look at being on disability as an opportunity to find a better balance in your life and not feel so stressed.”

I frequently had clients accuse me of being too positive.  I knew, at that moment, Robin probably wanted to throw something at me for suggesting that being on disability could actually be a good thing.  But, I believed what I was saying and I wanted to help her believe it too.  It would become a frequent topic of conversation.  Robin’s stress tolerance was not high.  Working full-time in mental health had always caused anxiety for her.  I believed if she could find the right part-time job or the right volunteer position or both, she would be much happier than if she went back to her previous full-time work in mental health.

“I know you can’t imagine it right now,” I said.  “But if you had the right balance in your life, and could get to a place where neither your work nor your illness defines who you are, you could actually feel better than you probably ever have.  And, you have many people who care about you.  If you could feel more comfortable letting them in and feeling accepted by them for who you really are, this would make all the difference.”

I was trying to paint a picture for Robin of a future that was very possible, and could allow her to be happier than she had ever been.  She couldn’t imagine it.

“I don’t think about the future,” she said.  “I never really have.  I’ve always just assumed I’ll end up killing myself.  It seems unlikely that I’ll ever get to a point where I’m actually happy.”

Although Robin had never been very successful at consciously shifting her rigid brain and changing her thoughts by using cognitive techniques, we talked about specific ways for her to continue to work on this.  And, we talked about how to address the problem of her having too much time alone in her apartment, thinking about how unhappy she was about her life.   She began to think about and explore opportunities to begin volunteering.

In therapy I continued to try to help Robin shift her thinking.  Her bankruptcy hearing, which finalized the process, took place in early October 2003.  This further alleviated anxiety as she no longer needed to worry about the overwhelming debt from the past, and it enabled her to stay in her apartment as long as we got the drug companies to provide her medications.  But, the bankruptcy contributed to Robin’s feelings of failure, and highlighted all the negative life-changing experiences she had endured over a relatively short period of time.  It caused her suicidal thoughts to increase.

“I’m tired of doing the suicidal battle in my head all the time,” she said one day in a session.

“Robin, your depression is now much less biological, and much more tied to situational events,” I said.  “I actually think suicidal thoughts have become your brain’s way of experiencing strong negative emotions.”  We talked about the fact that in the past she had dissociated frequently and self-mutilated, in addition to using alcohol to numb herself when she was feeling particularly depressed.  She was able to acknowledge that she had not self-mutilated at all during the past year and had dissociated relatively little, given what she was experiencing.  She was able to give herself credit for these signs of enormous progress.  We talked about her efforts to continue to avoid numbing herself with alcohol.  Mostly, we talked about the importance of finding the right balance in her life as a way to continue to decrease her depressed mood and the associated suicidal thoughts that always accompanied it.

In order to begin the process of rebuilding her life, Robin decided to start by finding a volunteer position that would work for her…in other words, that would not make her too anxious or stressed.  It did not take long, with her credentials, to find a local agency that wanted her help.  So, it was with enormous trepidation that Robin began a very part-time volunteer position in mid-October 2003, as a way to get out of her apartment and feel useful again.

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“For the First Time I Was Really Angry at You.”

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

After a three day Labor Day weekend, I drove my car into a parking space at work.  Employees were required to leave the parking lot closest to the outpatient building free for clients and visitors, so it was a bit of a walk from the employee lot.  On the beautiful agency campus I walked along a tree lined drive, overlooking a large grassy area with a sculpture garden as I made my way.  As I was walking, I found myself thinking about Robin and wondering how her weekend had gone.  We planned to talk on the phone later that afternoon.  I had been concerned that she had been discharged from the hospital prematurely, so I was trying to prepare myself to hear just about anything.

“I had a bad weekend,” Robin said, not surprisingly, when we talked.  “The weather was crappy and the plans I made fell through.  I went out and bought some vodka yesterday and got drunk.”

What?  I was instantly angry.  It was the first time in my ten years as Robin’s therapist that I was angry at her.  Through all her times of self-destructive behavior during the previous eight months, I had been able to stay patient and focused on Robin’s severe depression and difficulties with impulse control.  I was able to empathize with how awful she must have felt, and to understand she would want to numb herself with alcohol.  I calmly and firmly made it clear that I could not support or enable self-destructive behavior.  I was always able to stay professional and therapeutic.  But on that day in September 2003, I reached my limit.

I had already been irritated the previous Friday, after Robin campaigned with Dr. Greene to get out of the hospital before her mixed bipolar episode was actually stabilized, did not take the Ambien he prescribed for sleep, and then refused to plan to talk with me over the long weekend.  To hear that she not only drank, but purposely went and bought vodka with the plan of getting drunk, scared me.  If she didn’t take her medication and refrain from drinking, things could get very ugly again, very quickly.

I was angry mostly because Robin made a choice to not call me, and to get drunk instead.  After all the ways I had extended the boundaries to help overcome her severe anxiety about reaching out to people, I was hurt that she was still unwilling to call me to avoid being self-destructive.  Underneath anger, I would always tell my clients in therapy, is usually hurt or fear.  That day I was feeling a lot of both.  But what I felt consciously, was just plain anger.

The rational part of me knew Robin wasn’t thinking clearly, because she wasn’t yet stabilized.  The therapist part of me, had it been operating, would have been able to hide my anger from Robin on the phone.  But I was a human being who had extended myself for her, in many ways, over a long period of time.  I was getting tired.  The therapist part of me wasn’t able to override the hurt, scared and angry human part.

“Are you ready to get back on track and stop being self-destructive?”  I asked, with a clearly angry tone in my voice.

“I’m not sure,” Robin said.  “I’m trying.  I went to work today and packed up all my stuff from my desk.  Then I went to lunch with my co-workers.  I had to fight to keep from crying during lunch.”

Of course.  Robin was dealing with the enormous grief associated with losing her job.  I wasn’t surprised she had a hard time while packing her office and seeing her co-workers.  But, she did not have to do this today.  From my angry perspective, I wondered whether she was choosing to immerse herself in the grief, almost as if she wanted an excuse to self-destruct.  I knew I was taking it too personally that Robin drank.  I had temporarily lost any ability to be therapeutic.

Our phone call was supposed to be a brief contact to discuss how things had gone over the weekend.  We were scheduled to meet the next day.  I was thinking clearly enough to know I needed to get off the phone and get myself calmed down, so I could be therapeutic during our session.

“I need you to get rid of the rest of the vodka you bought,” I said, emphatically.

“I’m not ready to do that,” Robin said, just as firmly.

Wow, okay.  This was not going to go well.  I shifted enough to say, less angrily, that we would talk more about all of it when we met the next day.  I asked Robin about her suicidal thoughts.

“They are low,” she said.  “I’m ruminating more about job stuff and what’s happening financially.”  She assured me she would not kill herself before our appointment.  I hung up, knowing I needed to get clear before our session the next day.

I needed to make a decision.  I had made a very conscious judgment call shortly after Robin’s meltdown to make part of the focus in therapy our relationship.  I realized the extent to which she had severe anxiety about being open with anyone.  My decision to extend the boundaries within our relationship and to be open with her about the fact that I cared about her, had gradually allowed her to feel more comfortable being open with me, and then more open with her family.  I knew my gut had steered me in the right direction.

I needed to trust my gut again.  Robin and I had developed a close enough connection that I hoped I could influence her positively by being honest about my anger.  If I knew she was stable, it would have been an easy decision.  I would have trusted the connection and used the situation as a “teaching moment” in the therapy process.  But she wasn’t stable.  She was still not sleeping well, and her behavior over the weekend was evidence of impaired impulse control.  There was a risk that if I talked about how angry I was, and she was not able to process it rationally, she could use it as yet another reason to kill herself.  I had used our close connection, which I had fostered, as a way to keep her alive until she stabilized and could let more of her own people in.  If she felt like our connection was ruptured in any way, I wasn’t sure whether that would push her toward more self-destructiveness.

Surprisingly, I didn’t agonize very long about my decision.  My gut felt clear.  I trusted the connection.  Robin had stayed alive through so much partly, I believed, because she felt good about being able to be completely open and feel accepted by me.  I knew I needed to be honest and direct with her in our session.  I felt clear it was worth the risk, since she was continuing to be self-destructive and I needed to do what I could to stop this.  When she arrived, I was a bit nervous about saying what I needed to say.

“Robin, we have talked a lot about our relationship over the last eight months.  I’ve been more open with you in order to help you feel comfortable in close relationships.  Part of close relationships is the ability to be open and direct about all feelings, both good and bad.  I need you to know that yesterday, for the first time I was really angry at you,” I said.  I went on to explain why.

“I could tell you were angry,” Robin replied.  “I’ve already gotten rid of the vodka.  I’m going to try to stop being self-destructive.  I don’t want you to be mad at me.”

Thank God!  All of a sudden I felt validated.  All my questioning earlier in the year about whether I was doing the right thing by opening up to Robin and extending the boundaries, felt clearly like the right decision.  She cared enough about me and about not making me angry, that she was willing to work harder to stay alive.  I was relieved.  Very relieved.

We went on to have a long discussion about cleaning out her office, and losing her job.  She cried as we talked, which was unusual for her.  I was glad she was beginning to feel more comfortable showing her emotions in front of me.  She was open about how hard it was for her to accept her inability to work.

“Robin, I think it’s going to be important for you to have something productive to do.  It doesn’t work for you to have too much unstructured time and so little social contact.  I know you are grieving many losses.  But maybe volunteer work of some kind would be a good distraction.  I think it will help if you can shift your focus to rebuilding your life, rather than on what you have lost.”

“I agree,” Robin said.  “But first I need to get some things settled.  I need to finalize the bankruptcy and know whether I’ll be getting long-term disability.  I’ve been thinking about it, and probably need to just go ahead and apply for Social Security Disability benefits too.  There’s no point in putting it off.”  She became tearful again, as she talked about how hard it was for her to admit she needed to take this step.

I wanted Robin to feel good about the progress she was making in treatment.  It was enormous that she was being so open about her feelings, and allowing herself to cry with me.  This would have never happened before her meltdown.  I was also relieved to hear that she was thinking clearly, despite her enormous grief.

“Robin, I want you to know how huge I think it is that you are dealing with your strong emotions in a more healthy way.  You drank over the weekend, but the fact that you are here, talking to me about how you feel and allowing yourself to cry, is a sign of all the progress you’ve made in therapy this year.  If you can keep this up and let other people in, I think it will help you keep feeling better.”

Robin revealed that, despite what I was saying, she continued to believe her meltdown in January resulted from her “not doing a good enough job of keeping things under control.”

“I think the complete opposite is true,” I told her.  “I think it was your life-long pattern of trying to keep everything inside that finally caught up.  Learning to express your feelings in healthy ways is the key to healing.  I think you have the ability to do this.  This year has helped me to get much more clear about what we need to work on in therapy going forward.”

I felt much better after this session.  I was no longer angry.  It helped me to know Robin was willing to consider volunteer work, and to apply for Social Security Disability benefits.  This was all progress in terms of her accepting the reality of her situation, despite her enormous grief.  The next day, I was even more encouraged by her progress.

Robin called, unexpectedly.  I was very surprised to hear why she called.

“I need to tell you about something you said in our session yesterday that hurt my feelings,” Robin said, sounding nervous.  Wow!  This was amazing.  For her to be this assertive and direct with me, was unheard of.

“Please, tell me,” I said.

Robin and I had been talking about how bad she felt over the weekend when she chose to go buy vodka and get drunk.  At another time in the conversation she talked about making a mix CD of songs during the weekend.

“When I was telling you about my CD you asked if it was a drunk and depressing CD,” she said.  “I felt hurt because it took a lot for me to share my CDs with you.  I felt like you were dismissing that.”

Oh my God.  What a huge thing!  I was instantly sorry.  She was completely right.  I had obviously still been angry when we talked about her CD.  I had crossed the line, was unprofessional, and said something hurtful.  When therapy focuses on the relationship between client and therapist, the theory is that it provides a safe place for clients to practice these kinds of relationship skills.  I was absolutely thrilled that Robin felt safe enough to say this to me.  This was the person who, eight months earlier, had confessed in the middle of a severe mixed bipolar episode that she had kept many details of how she had felt from me for a decade.  All the work we had done together during the previous eight months was clearly paying off!

“Robin, I’m so sorry.  You’re right.  That was very hurtful,” I said very apologetically.  “I’m so happy you felt like you could tell me this, and that you called to say it rather than waiting.  Good for you.  Please, forgive me.  If I’m ever angry at you in the future I’ll be more careful about what I say.”  I went on to explain that I had been very honored that she shared her very personal CDs with me, and did not mean to discount what a huge step this was for her.

We were scheduled to meet the following week.  Robin was sleeping better and clearly stabilizing following her hospitalization for symptoms of mixed bipolar disorder.  We talked about her plans for the weekend, and she assured me she would not drink.  She stated it clearly and emphatically, “I don’t want to make you mad again.”

It wasn’t the best reason for her to avoid drinking.  I would have preferred her to be internally motivated to stay stable and avoid relapse.  But at that point, I wasn’t going to argue.  Progress was happening!

 

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“I’m Not Sure You Can Keep Your Apartment.”

Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.

It was the end of August, 2003 and Robin was in the hospital.  Unfortunately, between the time we had the conversation about covering the costs of her medical care and the time she was hospitalized, I had learned some bad news.  Really bad news.  I hadn’t told her yet because she had been in crisis.  It made sense to tell her while she was in the hospital and safe, so she could have some time to integrate the new information and make some decisions…hopefully with her family members’ help.

The inpatient unit had a bank of phones on the wall in the hallway.  From my office in the outpatient building I could call the Transitions Unit nursing station in the adjoining hospital building, give the confidentiality number assigned to the patient (which I happened to know was the medical record number I wrote on every progress note), and the staff would find Robin and connect my call to a phone in the hallway.  I hated to have this conversation on the phone where she had no privacy, but my schedule was packed that day and I did not have an opportunity to get over to the hospital to see her.  And, I needed her to know what I had learned as soon as possible so she could rally support from her family.

“Robin, it’s me,” I said when I heard her answer the phone.  It was the day after she had entered the hospital.  Her voice sounded flat and sad.  “How are you doing?”

“I just talked to my brother,” she said.  “He was trying to be supportive.  He was telling me he’s always been concerned that working in mental health is too stressful.  He agrees I should go on disability long-term and do something part-time that doesn’t involve suffering.”  Yay for Bob, I thought.  I actually agreed with him.  But I couldn’t be the one to tell Robin I thought she should stop working in mental health.  She saw it as her identity, and as her only real area of interest.  I was happy to hear Bob was supportive of Robin collecting disability benefits.  His support was crucial to the bad news I was about to share.

“Robin, I’m glad Bob is supportive and you are being open with him.  There’s something I’ve learned that I need to tell you.”  I went on to share with Robin that her previous income would not cause her to be ineligible for Medicaid (government healthcare) benefits, but the amount of money she would earn on long-term disability would result in a “spend down,” the equivalent of a monthly deductible, of around $500 per month.  Also, having Medicaid benefits would disqualify her from receiving free medications through the drug company patient assistance programs, which were available to people whose incomes were low enough and who had no insurance benefits of any kind.

Robin, distressed by being back in the hospital and unable to concentrate well due to mixed bipolar symptoms, was confused by my explanation.  I boiled it down for her.  “What I’m saying, unfortunately, is that giving up your insurance would make it impossible to cover the costs of your medications.  You’d have to cover $500 of the costs every month, and then have Medicaid cover the rest.  You’d still get the 95% discount for your services at the agency, and I’m sure Dr. Greene would provide some samples, but that won’t work as a long term solution.  I’m not sure you can keep your apartment.”

When Dr. Greene admitted Robin to the hospital he had immediately lowered her Celexa dose, as he had agreed with my assumption that increasing it and adding Trazodone for sleep had triggered a mixed episode.  The other change he made to her medications was to stop Geodon, the antipsychotic Robin had been taking since her first hospitalization in January.  He replaced it with Abilify and prescribed Ambien for sleep rather than Trazodone.  Ambien was specifically a sleeping medication, not an antidepressant like Trazodone, and was not likely to exacerbate mania.

I had learned about Abilify, a new antipsychotic medication in 2003, at the psychopharmacology conference I attended in January, immediately after Robin’s first hospitalization.  I didn’t know specifically why Dr. Greene chose to make this change, but I remembered the presenter at the conference saying it was a brand new type of antipsychotic medication, unlike anything else that had ever been on the market.

The problem was, Abilify (or Geodon) and the other medications Robin was taking regularly (Celexa, Wellbutrin, and Depakote) were very expensive.  Without insurance they would cost hundreds and hundreds of dollars per month.   There was no way Robin would be able to afford to pay for them without insurance.

I threw out the only other option I could think of, one which could potentially allow her to continue to live in her apartment.  It was not a good option, but a possibility.

“Robin, I don’t think it’s a good idea but the other option is to go without insurance.  You’d qualify for free medications from the drug companies and for the 95% discount from the agency.  Obviously there would still be some medical costs, but they’d be minimal as long as you only need treatment for mental health issues.  If you had a car accident, or an injury or physical illness, you’d be uncovered.  I’m concerned living on the edge to this extent would be really stressful.”

Robin was silent on the other end of the phone.  This was a lot of information to take in.  I didn’t want to say what I said next, because I figured it was the last thing she wanted to hear.  But I had to say it.  Out of all of the options, in my opinion, it really was the best one.  Robin needed her family.  They needed to feel more involved in her life.  Hell, I needed them to be more involved in her life.  I was still feeling the effects of continuing to be the only person she felt comfortable letting in.  I was sure they’d all be willing to help, if Robin would let them.  But, I didn’t know if she could sustain yet another huge loss, without becoming even more suicidal.

I tentatively asked my question. “Do you think living with your brother or your parents would be an option?”

I expected her to instantly react badly to the idea of losing her independence.  I figured she might be upset with me for even bringing it up.  I had known her a long time and knew how important it was for her to support herself.  After living with roommates for many years, Robin had been very proud to be able to have her own apartment and take care of herself financially.  I never could have imagined her response.

“I wouldn’t be able to keep Epiphany,” Robin said simply.

Wow, okay.  That had never occurred to me.  Robin went on to explain that her parents’ dog was “high strung” and would not likely get along with a cat, and her brother’s wife was allergic.  Damn, I thought.  I knew Epiphany had to be part of the package.  Epiphany had been keeping Robin alive.  It was terrible, in my mind, that she could not accompany Robin to live with her family.

I knew it was time for me to step out of the driver’s seat somewhat.  Robin, overall, was much better.  Her mixed episode, which happened for very explainable reasons, was being treated and she was already improving after being in the hospital one night.  I assumed this was because her family members were rallied, aware of her financial dilemma, and being supportive.  Robin was still anxious and not sleeping well, but she said her mood was a bit better and her suicidal thoughts had dramatically decreased.  It was finally time for both me and Robin to let her family help.

“Why don’t you talk to your family members about the situation and all the options?”  I said.  “Tell them they can call me if they have any questions or concerns.  I’ll stop in and see you tomorrow.”  She reluctantly agreed.

The next day, I was shocked by the changes.  “I saw Dr. Greene this morning,” she said.  “He’s discharging me today.”

What?  I knew I needed to step out of the driver’s seat somewhat in terms of Robin’s care, but I did not expect this.  I had no idea whether she was stable enough to leave the hospital.  If Dr. Greene had told her he would send her home, without calling me first as he usually did, Robin must have been very convincing!

“I feel more stable and ready to go home,” Robin said.  “My parents and Bob and I all talked about what to do.  They want to help me keep my insurance, and my apartment.  Bob is going to pay me to help with the kids and do other stuff around their house.   If it doesn’t work out, we talked about me moving in with him if I need to.”

Really?  Wow, this was great.  I couldn’t have been more relieved to hear the news.  But, we were approaching the Labor Day holiday weekend.  Robin and I had decreased the frequency of our contact, partly because she was doing better overall and partly because she didn’t want to become too dependent on me.  I knew she wouldn’t want to talk during the three day weekend.  I wanted to make sure she was actually safe to go home, and not just minimizing her symptoms with Dr. Greene because she wanted to get out of the hospital.

“Are you concerned that getting out of the hospital will cause your brain to shift back to thinking about suicide?”  She had been experiencing a mixed bipolar episode, and she’d only been in the hospital two days!

“I’m feeling better,” she said.  “I’m hoping this was a wakeup call for me.”  She said she was still having significant trouble sleeping, typical for her during a mixed episode, but she was hoping once she got home this would improve.  She always had trouble sleeping when she was not in her own apartment and bed.  We had one night for her to test her theory before the holiday weekend.  Robin was discharged home that day.

Shortly after she left the hospital, I received a call from her mom.  “I’m just calling to see how Robin is really doing,” she said.  “I was surprised that she needed to go to the hospital and then got discharged so quickly.”

No kidding…me too.  Robin had given me permission to talk to her family members about anything other than her suicidal thoughts.  I explained to her mom that she had been experiencing a mixed episode, and we were now completely clear that bipolar disorder was Robin’s main issue.  We talked about how stressed Robin had been about the financial ramifications of losing her job and applying for disability, and that when she gets too stressed she stops sleeping and is unable to think clearly.

“Dr. Greene made medication changes that will help.  But I also really think it helped that Robin feels supported by you and her dad and Bob,” I said.  “You have no idea how glad I am that she is allowing you to know what’s going on, and to be involved in helping her.  That is all huge progress for her.”

“But is she okay to be out of the hospital?” Robin’s mom was clearly starting to understand the potential dangerousness of the situation.  Thank God.  It was such a relief to me.  Robin was finally letting her family in!

“I think she’s definitely better,” I said, trying to reassure Robin’s worried mom without painting an unrealistically rosy picture.  “But I honestly don’t know how much of the sudden change was Robin faking it well enough to get out of the hospital.  I promise I’ll be talking to her tomorrow before the holiday weekend to make sure she is sleeping.  If not, I can talk to Dr. Greene about options.”

The next day, Robin and I talked by phone.  “I’m feeling more stable.  I’m less depressed than when I went to the hospital, but I’m still really anxious and tired.  I slept last night but I kept waking up,” she said.  As we talked, I learned she had not taken the Ambien Dr. Greene prescribed for sleep.

I was instantly irritated.  Part of the point of us talking that day was to see if the Ambien did what she needed it to do, so I could consult with Dr. Greene about a change before the weekend if necessary.  Robin did not seem to understand that we were trying to stabilize her brain chemistry, and not taking the medication as prescribed could jeopardize that.  I was already frustrated that she had, without talking to me, gotten Dr. Greene to discharge her right before a holiday weekend.

Robin had, at some point after she started feeling better, rigidly decided talking on weekends was no longer necessary.  This was fine, and preferable for me, except when I knew she was still not stabilized following a mixed episode.  Despite letting her family in, I knew she would never call them if she was feeling unstable, suicidal or having urges to be self-destructive.  I knew she had little control over her rigid, unstable brain.  But she was putting me in a difficult position as she had countless times the previous seven months.  My patience was beginning to wear thin.

Trying my best to hide my irritation, I told Robin to take the Ambien.  She agreed, and we talked about what she would do to stay busy over the weekend.  She promised not to kill herself, or drink.  This was hard for me to trust when I knew she was not yet stabilized.

As I drove home from my office that evening I reminded myself, for what felt like the millionth time, that I had done everything I could possibly do.  If Robin chose to die, I could not stop her.

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