“Robin, I’m No Longer Going to be Working Here.”

In 2008, when Robin first brought up the idea of writing a book about her life I had to decide whether to tell her I had the same thought.  During the five years following her meltdown year, I had given her some information about the positive changes that had occurred for me as a result of being so closely involved with her throughout the crisis.   I wanted her to know that what still felt to her like a terrible experience, ultimately had a positive impact.  I wanted her to know she had actually helped me by letting me in.

I decided I also wanted her to know I had thought about writing a book about it.  At that time, I wasn’t yet ready to tell her I could envision a time when I would not be a therapist any more.  I wanted to support her in writing her own book.   But, I think I jokingly said something without thinking first, about the idea of us writing a book together “someday.”  Robin jumped right on it, and we talked about what a unique idea it was to have the story told by both the therapist and the client.  Neither of us could remember reading a similar kind of book…probably for the same reason we could not have written the book at that time.  I was still Robin’s therapist.  Boundary issues and all, it wasn’t appropriate.

So we went on, and at times would joke with each other every once in a while about “that book we will write someday.”  Robin, I think, actually did spend some time writing her version of it but ended up abandoning the idea eventually.  She was not a natural writer.

Meanwhile, my job was starting to get very stressful.  I was in a top leadership position within the large mental health agency where I had worked throughout my entire career.  In 2008, after a large sum of money had been borrowed in the form of a bond issue to build several new buildings on campus…and shortly afterward the state government had made cuts to funding for mental health services, it all caught up and the agency lost a lot of money in a year.

The bondholders were not happy with the turn the agency had taken financially and, in 2009 sent in a group of consultants to turn the business around.  I was in the wrong position at the time they arrived.  While I was one of the last of the executive management team to go, I knew my days were numbered.  I still had the same fifteen clients I was continuing to treat, Robin included, when I was asked to pack my office and resign.

I’ll never forget having to call Robin and the others to let them know I would no longer be working there.  I was devastated, and had to pace myself in terms of making the phone calls so as to not start crying on the phone.  I was traumatized to have lost my job, especially after working so hard to try to turn the agency around, and dedicating so many years of my life to the place.

In order to be able to transition things appropriately and not feel like I was just abandoning my long-term clients, I rented a “virtual office” in a downtown office building and was able to see people within a couple of weeks.  I did not ultimately stay in private practice, though, as that had never been my goal.  I was able to help people get connected with new therapists and psychiatrists (Dr. Greene also ended up leaving the agency along with several other psychiatrists), and then I ended up taking a new administrative job.  My days as a therapist were over.  And, after almost twenty years I was ready for them to be.

Robin was able to get connected with a good psychiatrist and therapist, although it was a difficult transition for her.  I stayed connected with her by phone for a period of time, and after I began my new job in middle management at another agency, we began to transition our relationship, gradually, to becoming friends.  I did not end up staying connected to many of my clients…just a handful who I especially liked, and who I felt were healthy enough to not need me as their therapist any longer.

It was 2011 and Robin was doing much, much better than ever before.  By then she had not needed to be hospitalized for several years, had a stable job, and was content with her life.  We began to spend time together here and there, and continued to joke about “writing that book” someday.

My new job lasted two years.  I was commuting an hour each way, while also caring for my then 89 year old mother-in-law who had moved in with my husband and I in 2003, right in the middle of Robin’s meltdown year.  Peaches, as my mother-in-law was called, was beginning to show signs of dementia and decreased mobility and balance.  My husband traveled for business and we were feeling uncomfortable leaving her alone for long periods of time.  I quit my stressful administrative job in 2012 and opened another office, this time to do disability evaluations in order to make some income flexibly while spending more of my time caring for Peaches.  Eventually I added working in nursing homes, primarily doing testing and evaluations.  It was all flexible, low stress work for me, allowing me to use my skills and experience without the stress of being in charge of anything.

Once I was settled into my low-stress job situation and Peaches was in a stable place, the winter of 2014 was the time when it made sense to finally write that book I had been feeling so compelled to write.  Robin was ready too, as she had even more time of stability under her belt.  We made a plan to get started.  We had no idea what a journey it would become.

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Robin Decides to Write a Book

It was 2008, and I had long ago given up on the idea of writing a book about the extraordinary year Robin and I experienced together in 2003, since I couldn’t figure out how to tell the story without violating her confidentiality.  A lot had happened for Robin during the five years after her meltdown, as she attempted to come to terms with the dramatic and devastating turn her life had taken.  A lot had happened for me as well.

In 2003, I was settled into my career as a psychologist.  It had been eleven years since I had started my first job following the completion of my Ph.D. and I was still working at that job.  I loved my work as a therapist.  It was very rewarding to help my clients.  I used to tell people my job was never boring, and that after spending my days immersed in the worst of people’s pain I would usually go home to my relatively calm life feeling grateful.  I had no regrets about my choice of careers.  The problem was, being a full-time therapist was exhausting.  I started to get to the point where something had to change, or I was going to completely burn out before I even reached the age of 40!

The administrators of the agency identified me as a leader and had tried several times through the years to promote me to various management positions.  But, as I said I was an anxious person by nature.  Although doing administrative work would allow me to do less therapy, it would add different stress.  Part of me was intrigued by what it would be like to take on more responsibility, but my fear of change and my desire to keep my life as stress free as possible won out.

As I said, 2003 changed me.  I became less stressed by lots of things.  My perspective about what to worry about shifted.  The other change that happened was that I became more confident in my ability to trust my own gut feelings.  Working with Robin through that terrible year, I had to extend the boundaries of our relationship in ways I had never done with a client before.  My gut kept telling me I needed to do so.

In July 2003, I was summoned to a meeting with the President and CEO of the agency where I worked.  In the eleven years I had worked there, I had never had a conversation with him before.  I wasn’t even sure he knew who I was, since the agency had over a thousand employees.  I had no idea why he would want to talk to me!

To make a long story short, this conversation was the beginning of what would become my new career path.  I don’t know if I would have said yes if I had not already experienced some of the changes that happened as a result of helping Robin through her nightmare, but my gut told me that if the CEO of the agency suddenly asked to talk, it was important to listen.

I was asked to lead the professional staff organization, and was then promoted several times over the next few years to increasing levels of responsibility.  I fairly quickly became a member of the senior management team, and was involved in the decision making of running the agency.  In 2008, I was in the role of Senior Vice President of Clinical Services.  In this position I was the administrator over all clinical programming for the agency including three psychiatric hospitals, residential programs for all ages, and many outpatient and day treatment programs.  The agency was serving 18,000 clients per year.  Needless to say, this was a stressful role.  But, in the years following Robin’s meltdown my increased stress tolerance and ability to keep perspective continued.  I enjoyed being able to use my skills as a leader.

As I took on more management responsibility, I decreased my caseload of clients.  I went from an active caseload of over 100 when I was a full-time therapist, to a caseload of fifteen clients who I felt I either wanted to or needed to continue to see.  Robin was obviously one of those people.  She was aware I was seeing fewer clients and had become a big administrator.  I had reassured her I had no plan to stop our work together.  We had spread out our sessions and were not meeting as frequently.  I think we were probably meeting a couple times a month, but I honestly don’t remember.

Robin, in 2008, was still trying to come to terms with her new identity as a person with a severe mental illness, and was reading various memoirs of people with bipolar disorder or severe depression.  Given everything that had happened in terms of my career, writing a book was the last thing on my mind.

So, imagine my surprise when one day, Robin came into my office and said, “I was reading a book by someone who has bipolar disorder.  I think my story is as interesting as hers.  I’ve been thinking about writing a book about my life.”

Wait.  What?  I was shocked to hear these words come out of Robin’s mouth.  It is important to understand that in the fifteen years I had known Robin, I had probably suggested about a million times that she journal as a way to process her emotions.  She had, not once, made an attempt.  It had become a kind of inside joke between us.  I would say “Gee, journaling might help,” and she would say, “yeah, I’ll get right on that.”  And we would laugh.

So, I was well aware that Robin was not a writer.  But, she was serious about writing a book.  It didn’t make sense.  I asked her to explain her thinking….while inside I was already debating with myself about whether I should tell her I had also thought about writing a book.

“I have lots of time.  I need more to do.  I just thought it would be a good way for me to do something productive,” said Robin.  She said she had gotten a new computer, and thought writing a book would be a good way to use it.  I couldn’t believe she was serious.  Was this a test?  She had no idea how compelled I had felt to tell her story and how she impacted me, or that I had actually started trying to write about it.

There was something else Robin did not know.  As I was continuing to expand my management role at the agency, I was starting to imagine a time when I would stop being her therapist.  Not just her therapist, everyone’s therapist.  I was beginning to realize that many of the clients I was seeing, who were people I had worked with for a long time, were stable enough that they no longer needed me as their therapist.  There would be benefits for many of them to work with other therapists, and some probably did not need to be in therapy at all.  I was starting to imagine a point in time when I would end that role.  But Robin was not aware of any of this.

So, I was faced with the dilemma of whether to tell Robin that I had also thought about writing “the book.”  I trusted my gut.  I told her.

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Feeling Compelled to Write a Book

As I have said, the experiences I had as Robin’s therapist in 2003 changed my life.  I never expected Robin to have such a dramatic meltdown.  I certainly never expected it to take a year for her psychiatrist and I to get her back to being stabilized.   The blog we have written documents in detail the nightmare Robin and I both experienced.  Obviously her nightmare was MUCH worse than mine.  But it is difficult to verbalize how being a witness to her pain, and knowing I was the only person on the planet who she could be honest with about her experiences, affected me.

The best way I can explain it is that I went from being a somewhat anxious (it’s genetic) person who tended to be stressed easily by change or ambiguity, to being able to maintain a much more healthy perspective.  Before 2003 I used to worry about many issues related to my own security…finances, job security, my husband’s job security, issues related to our house whenever repairs were needed (because it added stress both financially and in terms of throwing me out of my routine), and other things like that.  I need to be clear…I was needlessly worried.  We were doing okay financially, and our jobs were not in jeopardy.  I was excessively and irrationally anxious and easily stressed, somewhat like Robin.  There is a reason I could relate to some of Robin’s issues.  Anxiety clearly runs in my family, going back at least several generations, and I got a healthy dose of it.

There was something significant for me about being so completely immersed in Robin’s reality for such a long period of time.  The stakes were high.  Her life was on the line.  I knew, deep in my gut, that I needed to be there for her.  When I try to explain how it changed me to be so involved with Robin’s care for almost a year, I can only say that I gained a completely new perspective about what was important for me to worry about.  Suddenly all the issues I had always previously worried about…finances, job security, my house being okay, etc., were not important.  My focus just automatically shifted.  I had much more important things to be anxious about, like whether Robin was going to survive.

I realized about halfway through the year that this shift seemed to be taking place.  I recognized that I was worrying much less about things I did not need to be worried about.  In fact, I wasn’t worrying much at all about these things.  What I didn’t realize or expect, was that this change would be permanent.  It never occurred to me that I would never again worry the way I had before.  The experience with Robin caused a shift within me that has changed my life.  I am a much more relaxed person.  I am not stressed by change or ambiguity like I used to be.  I am not nearly as worried about security issues.  If my current experience is not involving a life or death struggle, everything else still seems minor.  I am much more able to “go with the flow.”

I began to write in a journal when I was ten years old.  I remember reading a book in which the main character kept a journal (“Harriet the Spy”) and I thought it was a cool idea.  Journaling became a regular part of my life, and still is to this day.  It is more than a hobby.  It is a need.  I have to write, or I don’t feel okay.  I have over forty years of my life documented in detail.  I have joked with my nieces and nephews (I have never had children) that they will have interesting reading some day when I am gone.  There has been much laughing about me “highlighting the good parts.”

After 2003, as I began to realize how I had been transformed by the experience with Robin, I began to think it was significant enough that it warranted writing a book about it.  Of course, at that time I was still Robin’s therapist.  I was still very focused on helping her to recover from the devastation that had happened to her as a result of her meltdown.

But, being a writer, I kept feeling compelled to try to write a book about the significant experience Robin and I had gone through.  At some point, several years after things stabilized for Robin, I actually began to try to write the book on my own.  I wrote probably twenty pages, which are similar to the beginning of this blog.  But I was trying to disguise Robin’s identity and write the book from my own perspective without Robin being aware of it.  It wasn’t appropriate for me, as her therapist, to talk to her about writing a book about her.  At that time I was more focused on how the experience had impacted me, and I wanted to tell that story.

The problem was, it was mostly Robin’s story.  And, as I wrote I became completely clear that it would be impossible to tell the story in enough detail for people to truly understand what happened, without violating Robin’s confidentiality.  Her issues are very significant and very specific.  I couldn’t reconcile a way to tell the story and honor Robin’s privacy at the same time.  I quickly abandoned the whole idea of writing a book about it.

The last thing I expected, at that point, was for Robin to later bring up the idea of writing a book…..

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Preview of Things to Come

Our loyal readers who have followed our story know that Robin and I are working on finishing up our book, and will be self-publishing it as soon as possible.  It will tell the rest of the story of how Robin got from “Despair to Deliverance.”  We are grateful to those who have given us feedback that they are looking forward to reading the book.

An important part of the book writing and publishing process is editing.  I will have more to say about this, and about how our book is currently being edited.  But it is important to know that editing takes time.  While the editing process for the first five chapters is happening and Robin is working on writing the last part of our book, I have decided to tell a new story here on our blog for those who are interested….the behind the scenes story of writing our blog and our book.

Robin and I are newbie book writers, but I have to say it has been quite a process for us.  From the time we first talked about it until now, it has been many years.  I imagine anyone who has ever written a book understands that the entire process can take many twists and turns.  Ours certainly has.

So, loyal readers, stay tuned for more about Robin and I, and how we have gotten from an initial conversation years ago about the idea of telling her story in a book, to where we are now…getting close to actually finishing it!

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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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