Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.
I met with Robin’s parents in June 2003, after my return from vacation. They seemed grateful to hear more information about what was going on, given that Robin had returned to her usual pattern of minimizing her difficulties with everyone other than me. I was given permission by Robin to talk about anything her parents wanted to know. I was thrilled to be able to, finally, have a conversation with them with no restrictions in terms of confidentiality. Honestly, my motivation in initiating the meeting was partly that I wanted her parents to fully understand that Robin was still at significant risk for suicide.
Robin’s parents, as I had experienced before, could not have been more supportive. They just wanted to understand why Robin was still having so much trouble and was unable to do the job she had performed successfully for many years. They had no idea Robin had been drinking and skipping her medications prior to losing her job. I tried to help them understand that this was due to the remaining biological depression she was experiencing, combined with her inability to manage the stress of working full-time. We talked about our collective hope that the three additional ECT treatments Robin had received were going to help her brain to continue to normalize.
I was able to educate Robin’s parents about her ongoing difficulty being open with people, and that before her meltdown she had not even been completely open with me. I knew they were not aware of her serious suicide attempt by carbon monoxide four years earlier. I told them about it, not to freak them out but to help them understand how Robin’s severe depression, rigid brain and social isolation could lead her down that path. Robin’s parents asked a few questions but mostly they just listened. They seemed surprised about the seriousness of Robin’s suicide attempt, but not surprised when they heard it was her significant OCD symptoms that saved her life. Without coming right out and saying “I want you to be prepared for the possibility you may lose your daughter,” I tried to help them understand that it could happen. I assured them I would do everything possible to help.
The day after my meeting with her parents, Robin met with her bankruptcy attorney and with Dr. Greene. Later in the day, we had a session.
“I feel okay about filing bankruptcy, but I don’t know how I’m going to come up with the money to pay for it. I’m so afraid I’ll never be able to go back to my job.” Robin said, fighting back tears. “I can’t deal with one more bad thing happening,”
Robin admitted she had continued to obsess about suicide and had been thinking about going back to the hospital. “If I was in the hospital I wouldn’t have to make any decisions. I feel pressured to do the right thing, but I don’t know if I can follow through with it.” She was referring to me repeatedly saying that she needed to take her medications and not drink. She had continued to have trouble being consistent about these things, which remained a source of tension between us.
I suggested Robin consider partial hospitalization, which was an intensive outpatient alternative to being in the hospital. It involved going to treatment five hours a day, five days a week, and meeting in various groups to talk intensively about current and past issues. Even though Robin had not gone to many groups in the hospital, the partial hospital program was likely to have people with whom she had more in common.
“Robin, I think the partial hospital program would be a good next step. It would give you structure, distractions from obsessing about your situation, and input from people other than me…if you could be open.” I needed to throw this out as an option, but I knew Robin was not likely to go along with it.
“I have led groups in a partial program before,” she said defensively. She thought for a minute and then shifted. “You’re right. It’s probably the right option for now, but I don’t know if I can do it. I’ll think about it.”
The next day on the phone Robin was more rational than I had heard her since before the meltdown. I was thrilled to hear she had talked to her mom openly about the partial hospital program. She sheepishly eliminated this as an option because her OCD symptoms continued to compel her to lay in the sun for hours at a time. She didn’t think her brain could shift from obsessing about tanning if she was attending the program, since she saw the partial hospital program as “voluntary.”
When it came to tanning Robin had always been able to make an exception for work, which she did not see as voluntary, but otherwise during the summer she still had to lay in the sun for many hours on any nice day. When she explained why she couldn’t attend the partial hospital program, it actually made sense in the context of her OCD symptoms. Robin went on to say she and her mom had a more open conversation than ever before about her illness, including a discussion about a significant family history of OCD she had never known about.
“I’m starting to realize I was doomed genetically (with OCD and Bipolar Disorder) even before I was sexually abused,” she said. “This changes my whole view of myself.”
“Robin, I am so glad you and your mom had such a good conversation,” I said it calmly, but inside I was cheering. Thank God she was talking more openly to someone other than me. And, thank God her mom seemed to be okay after our session and was being more open with Robin. Yay!
“My mom said I seem to be back to myself. I guess I really am good at faking it,” she said, acknowledging that she still didn’t feel remotely like herself. “I’ve been doing it automatically for as long as I can remember. I think what happened when I had my meltdown is that I just couldn’t fake it anymore.”
“I agree,” I said. “How are you feeling about the bipolar diagnosis?” I wanted to get a sense of where she was in terms of processing her new identity.
“I actually think I’d rather have people know I have bipolar disorder at this point,” Robin said, surprisingly. “It would explain to people why I had such a hard time at work and had to quit.” Wow! Her mom was right. Even though she was still feeling depressed, Robin was thinking so much more clearly. She may not feel like herself, but she was starting to sound like herself. The additional ECTs seemed to have helped, thank God.
I was surprised further to hear Robin say she had investigated the amount of money she would receive in the form of Social Security Disability benefits if it came to this. She actually said she was beginning to accept that she would not likely be ready to return to her job as soon as she had hoped.
“I’ve been thinking about what I could do instead,” she said. “Maybe I could help my brother and sister-in-law by watching my nephew a couple days a week. Or maybe I could volunteer as a court-appointed special advocate at some point to use my skills and stay in touch with people I know through work.”
It was fantastic to hear Robin say these things. Although I knew she wasn’t ready to volunteer anywhere due to the stress this would cause, the fact that her brain was going there at all was miraculous. I couldn’t believe she was actually allowing herself to consider ways in which being on disability could be okay. I took the opportunity, in the moment, to suggest what I knew needed to happen. I had previously been afraid to bring it up.
“Robin, I think it’s time to find out more about your long-term disability benefits,” I said, knowing she was going to exhaust her short-term disability benefits in a couple of months. She agreed and said she would call her employer’s human resources department.
Unfortunately, Robin’s ability to think completely rationally was brief. She called to tell me she had lunch with her co-workers, which she said was awkward and made her feel more depressed. She said she believed the reality of losing her job was beginning to sink in. This reality and its effects on her mood exacerbated her obsessive suicidal thoughts, although she continued to say she didn’t want to kill herself and hurt her family. A few days later, Robin called to say she had learned about her long-term disability benefits.
“I have to go back to work,” she said emphatically. She sounded very upset. “If I go on long-term disability I’d make only 60% of what I made before, but now my $400 health insurance premium would come out of it. I’d never be able to afford to stay in my apartment. And I can’t afford my meds without health insurance. She’s sending the paperwork in case I decide to apply, and she said it usually takes about a month to process it. But I can’t do it. I have to go back to work!”
I was not prepared for this. We had just gotten to the point where Robin was able to begin to consider being on long-term disability. While I didn’t know for sure this was what needed to happen given how much better she was as a result of her latest ECTs, I did know she needed to be okay with this possibility if necessary. As she explained the reality of what she had learned, I knew Robin was not remotely okay with the idea of losing her apartment and her financial independence.
We talked about her plan to talk to Jennifer, her former supervisor, about when a position might open up on her former team. She needed to either apply for long-term disability or return to work within the next two months before her short-term disability benefits lapsed. I immediately took the opportunity to confront her about her ongoing self-destructive behavior.
“Robin, if you want to go back to work in the next two months and succeed, you will absolutely have to stop drinking and start taking your medication completely consistently.” I told her I was very concerned about the amount of time she was spending alone, thinking about how stressed and depressed she felt about her situation. “You need to continue being open with your mom and your other family and friends. You need to let them know you are struggling and ask them to spend time together.”
“I know I need to do all of those things,” Robin replied. “But it’s just so hard for me to change patterns that are so ingrained.” I told her I understood how hard it was especially with her rigid brain, to make these changes, but that I hoped her sudden increased motivation to return to work would make it easier.
It was the beginning of July 2003. Robin had been without a job, trying to wrap her brain around this reality, for several weeks. Over the next month she experienced ups and downs as she dealt with the enormous stress associated with being in complete limbo. The stakes were high. She was thinking more clearly and was therefore able to process things mostly realistically.
Robin, understandably, still wanted to return to her life prior to her meltdown where she was working full-time in a career she enjoyed and was able to support herself. She had embraced the concept of bankruptcy, which meant financial relief. The idea of earning her previous full-time income without the pressure of paying off past debts contributed to her desire to return to work. Obviously this was her strong preference, as this would prevent her from having to accept any significant limitations imposed by her new identity as someone with a severe and chronic mental illness.
During that time, when the possibility of returning to full-time employment in her chosen field seemed realistic, Robin went through periods where she avoided alcohol, took her meds consistently and reached out to her people. Then, inevitably she would be faced with a potential barrier in terms of this goal, or she would have a brief realization that her stress tolerance was not consistent with full-time employment. This would cause her mood to plummet, returning her to the self-destructive patterns that always accompanied depression. I vacillated between being supportive and encouraging when she was not self-destructive, to confrontive and concerned when she was.
Robin’s supervisor, Jennifer, was open to the idea of Robin returning to a position similar to the one she had lost. But, she sent Robin a letter outlining all the responsibilities of this position and said she would need a written statement from her treatment team (i.e., me or Dr. Greene) confirming she was ready to perform all of these responsibilities before she would be hired. It was not clear, though, whether there would actually be an opening during the timeframe Robin needed it. Robin had significant difficulty with all of the uncertainness. But, she tried to set this aside and work on her issues.
Robin and I had many conversations about her long-time patterns of social isolation and self-destructiveness, the big picture of her treatment (that she was improving in many ways despite all the ups and downs), and what she needed to do to continue making progress. Because her biological depression was better, she was able to read and watch television again, which served as distractions. I had her reading books on specific ways to overcome depression. She began to walk for exercise. We worked on cognitive and behavioral techniques, which had always previously been difficult for her, to help shift her ingrained patterns.
Robin had her last ECT procedure at the end of July 2003. Dr. Sanchez believed it would be helpful for her to have one treatment about a month after her previous series, in order to ensure that the biological changes in her brain continued. Because Robin was still struggling with ongoing, obsessive suicidal thoughts, Dr. Greene decided to increase one of her five medications, Celexa, to a higher dose. We were continuing to attack her significant depression from every possible angle.
Robin was trying to process the reality of her meltdown, her job loss, and the ongoing uncertainty about whether she would be able to return to her previous career. I was disappointed to learn she was blaming herself for “not controlling her emotions enough” when she was first hospitalized in January 2003. She then insightfully said, however, “if I don’t blame myself I have to acknowledge the degree to which I lost my defenses and went crazy.” Robin was seemingly, painfully, beginning to come to terms with her illness.
I was relieved by Robin’s progress. Very relieved. But I knew we were not out of the woods yet. I knew, deep down, that until Robin was settled….either back at work in the mental health field or on long-term disability in a situation that felt okay to her, things could get dangerous again very quickly.