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