“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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Robin Discusses ECT and Suicide

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

Electroconvulsive Therapy (ECT) is a treatment method that comes with huge stigma, because of the way it was originally used and because of its dramatization in movies such as One Flew Over the Cuckoo’s Nest. The prospect of having ECT was very scary for me, but nothing else was working to decrease my deep depression and control my obsessive suicidal thoughts. I was ready to try just about anything.

My psychiatrist wanted to use ECT treatments as soon as he saw me during the Meltdown (first hospital stay) because I was so deeply depressed. I was too out of it to really make a decision, but that became a moot point when my insurance refused to cover the treatments. It was determined that therapy and medications should be tried instead. I was frightened when ECTs were revisited as the best option for treating my intractable depression during my third hospital stay. I had researched it on the internet to get a more reliable impression than what I knew was misleading on TV and in movies. I trusted Sharon and Dr. Greene, so I agreed to do ECT in April 2003.

I don’t remember every detail about having ECT, partly because I was in such a crazy place emotionally and partly because the most common side effect is short-term memory loss. I remember enough to give the highlights though. I was still in the hospital for my first treatment. Early in the morning a man came to my room to escort me to the ECT suite on the third floor. I remember he was in charge of the ECT process and he always wore Hawaiian print shirts. In the ECT suite I put on a hospital gown and signed a form (probably a consent for treatment. I don’t remember). While a nurse inserted an IV line into me another person asked me several questions. The only question I recall is whether or not I had any loose teeth, which seemed like a strange question (in hindsight it makes sense, since they were planning to induce a grand mal seizure).

Then, electrodes were put on my head. If you have unilateral ECT they are placed only on one side of your head; they are placed on both sides if you have bilateral ECT. I don’t know whether I had unilateral or bilateral, I just remember the electrode was cold. I was also hooked up to monitoring devices, which monitored heart activity (EKG) and brain activity (EEG), and measured the electrical discharges of the muscles. I was given muscle relaxants through the IV, and I was given anesthesia which quickly made me unconscious. I didn’t feel any of the seizure that was stimulated in my brain by the electrical current passing through it. Soon after the ECT was completed, I woke up in the recovery area and the nurse helped me change back into my clothes. I felt no pain, but I was a little fuzzy headed and disoriented afterward for a while. I was tired, whether from the ECT or the anesthesia I don’t know.

After the first treatment, the rest of the ECTs I had on an outpatient basis, and my dad transported me to them. At that time I was still not being very open with my parents about what was going on. I don’t think my dad knew what to say to me, and neither of my parents asked a lot of questions. I think taking me to my ECT appointments was my dad’s way of being helpful. He picked me up faithfully despite having to be there really early in the morning, like at five or six a.m. He sat around in the waiting room for the duration of the ECT procedure, and took me home afterward. I was grateful that my dad did this for me, as I would’ve had to do the ECT on an inpatient basis otherwise. None of my other friends or family would’ve been able to take this much time off from work.

I was given a sheet of Discharge Instructions after each outpatient ECT. It included things like “don’t drive until cleared by your doctor, avoid extremes of activity, refrain from making important decisions, and avoid emotional subjects in conversations or on TV.” My favorite instruction, though, was “avoid crowded public places, such as the grocery store or the mall. However, car rides with a family member, away from heavy traffic, are recommended as pleasurable relaxation.” This struck me as funny. Seriously, who does that? Car rides with family as “pleasurable relaxation?” The only pleasurable car rides I took back then were the ones I took while I was drinking and listening to depressing music, which I’m pretty sure they’d discourage.

During the first round of treatments, before I returned to work, I had a total of seven ECTs. I went every other day during the week for two weeks (Monday, Wednesday, Friday). After I lost my job, I had three more treatments. About a month later I had another one to reinforce the previous ones, for a total of eleven ECTs.

I suffered no ill effects from having ECT. It didn’t kill my brain cells, making me suddenly stupid. The only long term effects are the hazy memory I have of that time, which I might have experienced without ECT because it was such a freaked out time for me. It didn’t cause brain damage, or ongoing seizures, or any of the other things people fear when they hear the word ECT. There was no pain involved, other than a slight headache after each treatment for a couple of hours. The best part about ECT is that it worked. Not immediately, obviously, but I have no doubt that it sped up my recovery. It didn’t eliminate further hospitalizations, partly because I wasn’t on the right combination of medications yet. I think it shortened the length of my fourth hospitalization, though, and made it possible for me to get over the hump.

The fact that I had ECT is probably what I would’ve kept secret in my story, if that were possible, because of the enormous stigma about it. The image of ECT in the movies and on TV is very negative and misleading. Let’s face it, people believe something is SERIOUSLY wrong with you if you have to have ECTs, right? It is not used lightly. It’s often the treatment used when nothing else works. I’m hoping that by revealing that I’ve had ECT, I can help to normalize it a little bit. I don’t regret having this treatment. I believe that it played a large role in helping me get my life back. It’s not used casually, or to control behavior as some might think. It’s a safe, effective treatment modality for medication resistant depression like I had. I was not instantly cured, because it doesn’t work like that. However, without ECTs I may not have survived.

***************

One of the hardest things when dealing with a chronic mental illness is the urge to give up. Giving up can mean many different things–it could mean stopping your medications, or starting to drink alcohol or use illicit drugs, or stopping therapy, etc. However, the most dangerous way one can give up is through suicide attempts.

For some people, for religious reasons or whatever, suicide never even becomes an option. They just don’t go there. Unfortunately, for too many people, killing themselves feels like the only option. It’s difficult to explain to someone who has never been suicidal how it feels to want to stop living in this world. It takes a great deal of desperation and pain to get to that point. I have also been suicidal when my depression was so bad that I felt total apathy regarding life.

As previously mentioned, I’ve suffered from depressive symptoms on and off since childhood. I’ve had suicidal thoughts for almost as long. When I was young, of course, I had no idea how I could kill myself and had little means to actually do it. It was mainly wishing I was dead at that young age. The first time I can remember feeling depression was in the fourth grade. We moved to a different school system half way through the year, and it was terrible for me. I had to face a new home with new neighborhood kids, as well as a new school with all that entails. My mom has said she thought I hated her at this time. I spent a lot of time alone in my room, crying and hating life. My brother adjusted well, making new friends easily. I remember looking out my bedroom window at him playing with the neighborhood kids, and feeling depressed. It took most of the rest of the school year for me to adjust to this change.

As I grew older, I ruminated about death but never had any real intention of trying suicide. I took a psychology class in high school, which gave me a better understanding of depression. I felt validated after this class, as it reinforced that there were others like me. Also, I read The Bell Jar by Sylvia Plath in high school and was further reassured that the way I sometimes felt was not uncommon. I have reread this novel countless times, as Sylvia Plath does an excellent job of describing how depression feels.

It was during my freshman year of college that suicidal thinking became an obsessive-compulsive issue for me. I think this is when my mixed bipolar symptoms really kicked in, and I started to self-medicate with alcohol. I started listening to depressing mix tapes, got really drunk and usually self-mutilated by cutting on my arms or hitting walls when things got especially bad. It was an out of control time for me, and thoughts of killing myself were rampant. I never consciously tried to kill myself, but it’s amazing that I never killed myself while drinking and driving. Over the years after college, suicidal ideation became a frequent companion to my depressive episodes, and there were several aborted suicide attempts.

I still struggle with suicidal thoughts when I become depressed, or worse, experience a mixed bipolar episode. Unfortunately I am very obsessive-compulsive, so my brain gets stuck on suicide when I’m depressed. At times I get to the point where I cannot possibly distract myself from these thoughts, no matter what I try to do. I ruminate about how, when, and by what method I would do it. I think about every detail. Even if I consciously know I don’t want to kill myself, my brain takes over and will not let me think about anything else. I can’t shift my thinking, my anxiety increases. I am completely unable to sleep and I feel so anxious I can’t even sit still. This makes suicide a real danger for me anytime I get very depressed. At times I will just pace around in my house, or sit and watch television with the sound off in an attempt to distract myself. Alcohol has been a coping skill in the past when I feel this way because all I want is to feel nothing.

Usually when I’m suicidal, there is something that keeps me from giving up. For a long time it was my cat, Epiphany. I knew that if I killed myself, Epiphany would have to go to the Humane Society where she’d probably live in a cage or be euthanized. It’s a sign of how my thinking was not normal that I didn’t worry about my family’s reaction if I killed myself. Many people who are depressed believe people would be better off if they were dead. I’ve actually never felt that way. Instead, I think if I kill myself at a certain time, or in a certain way, it will somehow minimize their grief. My distorted reasoning at those times is usually that, because they got through the death of my older brother to cancer, they’d get through my death okay too. The reality, which I know when I’m thinking clearly, is that they’d be devastated if I committed suicide. As I’ve gotten better and learned to manage my illness, I’ve become more able to let my family and friends help me when I’m having a hard time, so I don’t give up.

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Robin’s Thoughts on Rock Bottom

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 a horrible six months for me at the start of 2003. I had a major psychiatric Meltdown, was hospitalized in a psychiatric hospital for the first time, went on short-term disability, was diagnosed with a severe and chronic mental illness, was prescribed anti-psychotic and mood stabilizing medications, and had a course of ECT. All of these events were completely contrary to my previous identity as a person who had depression magnified by childhood trauma, who just needed to take antidepressant medication (like, it seemed, most people I know). I was reeling from all of these developments, while at the same time I remained deeply depressed. It was unimaginable that things could get much worse for me, but it wasn’t over yet.

Going back to work was a consistent goal for me throughout 2003. I’ve never done well with life changes, even minor ones. I certainly wasn’t ready for all the changes that were happening to me at that time. I wanted my old life back, and latched onto my career as the only way I could achieve this. However, the timing of my return to work six months after the Meltdown was terrible. I had only finished my first few ECT treatments, when I was informed that I needed to return to my job or lose my position. My employer had been very accommodating to that point, holding my position past the length of my FMLA time period. I couldn’t complain much, therefore, when I was told my time was up. I was grateful to Dr. Sanchez for understanding my need to stop the ECTs soon enough for me to return to work, and to Sharon for arranging it all with my supervisor. I did feel better after the seven ECT treatments I received, and was hoping it was enough for me to get back to work successfully.

Unfortunately, I didn’t return to the best situation. The day I returned to work, my supervisor told me I’d need to address my team of coworkers. Apparently I’d made comments during my leave from work which made some of them uncomfortable. I had fairly regular contact with my team while I was off of work, usually meeting some of them for lunch on Fridays. I have a sarcastic, self-deprecating sense of humor, and I was trying to break the tension with my co-workers by joking about what I was going through. I have no memory of anything I said, but I guess some of them did not find my attempts to make light of my situation funny. I was never told exactly what I said which made them uncomfortable. Not knowing what I was apologizing for made it even more anxiety provoking.

Talk about a nightmare during my first week back! I was anxious enough about returning to work. Being open with people under the best of circumstances made me very nervous and uncomfortable. It was okay to make jokes about myself in small groups of people, but to be forced to discuss my very painful issues seriously in front of the whole team at once was terrifying for me. It magnified my already overwhelming anxiety. Somehow I was able to do it, and to say what I needed to say. I survived it, and was relieved.

Another factor which made returning to work at this time difficult was that I had to start over with a totally new case load. I had been gone so long, my clients had to be transferred to other case managers so they could get the help they needed. While I understood and expected this, it was hard for me to begin with all new families. My social anxiety issues made working with new clients hard even when I wasn’t depressed. Taking on new clients in the state I was in at that time was extremely stressful.

To make matters worse, one of the new families was very resistant to working with my program. It was a case that had been referred by the probation department, so they were court-ordered to comply. Court-ordered clients were frequently resistant, but these people were very angry about it and very vocal about their anger. I don’t do confrontation well. I’d been really stressed by resistant clients prior to my Meltdown, and being depressed and anxious one week after finishing a course of ECT certainly didn’t put me in the best possible place to deal with them.

I lasted about a month before the stress became too much and I had to give up my job. Sharon wrote about all the ways I was being self-destructive during that time, seemingly sabotaging myself in my efforts to get my life back to normal and succeed at work. I really don’t remember all of that. The ECTs I had before and after that time make all of it a blur. But it doesn’t surprise me when I read Sharon’s recounting of my out of control behavior of drinking and skipping medications during the time I was working. This is what I did back then when I was depressed, or too anxious, or in hindsight, experiencing mixed mania. I suspect it was probably clear to me, deep down, shortly after I started back at my job that I wasn’t going to be able to manage it. I couldn’t face that reality, and escaped by drinking. I wasn’t thinking clearly, obviously, when I made the decision to skip my meds. Probably I skipped them because to take them and drink meant bad side effects. The bottom line is that I was overwhelmed, still depressed, unable to process the reality of what was happening to my life, and just trying to go to work every day and survive. It finally caught up. I’m surprised I was able to avoid going to the hospital when I lost my job, since it felt like the end of the world to me. But, Sharon quickly convinced me to resume the ECTs, and my brain got refocused on my anxiety about that.

Losing my job was obviously very difficult.  I remember cleaning out my desk and carrying my belongings out to Chuck (my Jeep) on my last day. I was crying quietly, and couldn’t look at my coworkers as I packed. I was close to my team, and was devastated to leave them. My supervisor, Jennifer, said she’d hire me back if I got to a place where I could return, but I think deep down I knew I wasn’t going back.

*************

Around this time, Sharon and I had been discussing the possibility of filing for bankruptcy to alleviate some of my financial pressure. I was lucky I had short-term disability benefits through my employer, so I still had some income while I was off of work. However, I only received seventy percent of my regular income, which was causing greater financial stress. Aside from my usual debt, I now had medical bills for my time in the psychiatric hospital, ECTs, and increases in medication and therapy.

I made decent money as a case manager (I was at the highest salary for the position at my place of employment) and I didn’t have children, so I should’ve been in a tolerable financial position at the time of my Meltdown. Unfortunately, though, I had quite a bit of credit card debt and I didn’t have any savings or extra money to pay for these additional expenses. Partly due to impulsive spending habits on my part, and partly due to the fact that I had to live on my credit cards for periods of unemployment because of mini-meltdowns, I had a large amount of credit card debt. I’m not making excuses, I never should’ve had as many credit cards as I had.  I had a VISA, Mastercard, Discover, and several department store credit cards.  I made payments on time, but usually only made the minimum payments.

I was able to get by when I was earning my whole salary, but once I went on short-term disability and started to receive my bills for treatment from the Meltdown, it became really tight.  I already owed my brother a ton of money for the repair bill for Chuck earlier in the year, so I wasn’t about to ask to borrow any money from family.  As I was beginning to be more open with Sharon, I started talking to her about how stressed I was about money.  This had never been a topic we had talked about before.  Filing for bankruptcy was not an option I had ever considered.

When Sharon suggested it as a way to alleviate some of my stress, I resisted the idea of filing for bankruptcy for quite a while.  I think this is because of my family values and the attitude toward finances I learned from my parents.  I come from a working class family, in which there was never a ton of extra money.  We weren’t poor, and I always had what I needed, but it wasn’t always the expensive name brands like other kids had.

My parents married young.  My dad worked in a factory and was taking night college classes, while my mom stayed home with us three kids.  My brother, Eddie, was diagnosed with cancer when I was a toddler, which put a huge financial burden on my parents.  My dad had to quit college (only 17 credit hours short of finishing), which then limited his occupational options from then on.  My parents had many medical bills for Eddie, some of which were paid for by insurance, but not all.  They also had to make a couple of trips to New York to see a specialist for the type of cancer Eddie had.

In spite of this financial crisis, my parents managed to pay their bills on time.  My mom had to go to work after Eddie died, to help financially.  As I was growing up, there were periods in which my dad was laid off from work, and money became very tight.  However, my parents always managed to pay the bills without assistance from others. They never considered bankruptcy as an option.

This is the environment in which I grew up, so the thought of filing for bankruptcy was against everything I had been taught.  I felt embarrassment and shame at the thought of it.  But, I was reaching the level of financial crisis, and after Sharon and I talked about it, bankruptcy was the only option I could see to repair my financial situation.  I hated to do it, but I couldn’t see any other way out. I finally agreed to talk to an attorney, and borrowed the money from my brother to file for bankruptcy.

At that time, filing for bankruptcy meant easily being totally relieved of all debt, unlike today when the rules are stricter.  So, I was basically given a blank slate financially.  My bankruptcy decision absolved me of all of my medical bills related to the Meltdown, as well as my credit card debt (except for one Visa card, which my dad had co-signed on.  I didn’t want to affect his credit by including it).  I should’ve felt enormously relieved by this sudden financial freedom, but I didn’t.  I felt even more like a failure.

Coming Soon:  Robin’s Thoughts on ECT and Suicide

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“I Know I’m Not Thinking Very Clearly.”

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 doing some investigating, I had a difficult conversation with Robin about options for continuing to cover the costs of her mental health treatment without insurance.

“Robin, I’ve learned you would probably be eligible for Medicaid if you aren’t working.  And, you would qualify for a state funded program which enables you to have a 95% discount for all the services provided here (at the agency).  Without income, you’d also probably be able to get your medications free through the drug companies that manufacture them.  They have what are called patient assistance programs,” I explained some of the details of these options, which could theoretically allow her to give up the expensive insurance through her former employer and still be able to live in her apartment.  Thank God she was physically healthy and had no health costs other than mental health treatment.

Robin was silent for a few moments as she took in the information I was telling her.  “It will take me a while to accept being on the other side,” she said.  “I’m used to being the one helping people get government assistance, not the one receiving it.”

She was silent for a while longer.  She seemed to be processing the reality she was facing.  Then she said, “When do you think I’ll be ready to go back to work again?  Do you think it’ll be six weeks?  Or do you think it’ll be more like six months or even longer?”

I knew I had to be honest with her.  I was afraid of upsetting her, but I knew she needed to hear the truth.  I shifted in my seat.  “I don’t think it will be six weeks,” I said tentatively.

“I agree,” said Robin, staring at the floor.

We both acknowledged her sadness about this, and how hard it was for her to admit the degree to which her stress tolerance had been affected by the previous eight months.  I wanted her to feel some hope, however, as she tried to accept that she would be unlikely to return to her previous job in the near future.

“I think you’ll get approved for long-term disability, Robin.  And, you should probably apply for Social Security disability at some point too.  If you got approved for that, and I think you would, you could work part-time in addition.  This might be a good option for a while so we can focus more in therapy on helping you really heal.”

“What do you mean?”  Robin was finally, as a result of the ECT treatments, thinking clearly enough for me to explain some of what I had been thinking in terms her treatment plan, and what we needed to focus on in therapy in the future so she would keep getting better.

“Well, first of all, in the past you’ve never been willing to actively work on decreasing your OCD symptoms.  If you weren’t putting all your energy into managing the stress of a full-time job, we could work on this,” I explained.

I reminded Robin that I thought her illness was partly biological and partly psychological, as are most mental illnesses.  “I think the biology part includes primarily bipolar disorder and OCD.  Taking the right medication and managing stress helps keep the bipolar symptoms stable.  There are specific cognitive and behavioral strategies for decreasing OCD.  But, I also think there are specific psychological issues that perpetuate and magnify your depression and always have,” I said.  “I wasn’t completely aware of these before your meltdown.  It’s been so helpful that you are finally being completely open with me. We now have an opportunity to help you really heal.”

Robin seemed interested in hearing more, so I kept going.  “Until your meltdown, when you finally let me know what you’d been thinking and how out of control you had felt at times, I was not aware of how alone you were or how negative your view of the world is.  I think those two issues…lack of social support and the absence of a world view that includes any sense of meaning in life, have always made you more prone to depression.  Those are issues we can work on in therapy.”  Robin agreed that these issues had always contributed to her feeling of hating her life.  We talked about how much anxiety it had always caused for her to be open with people, and that she had already made significant progress by being open with me.  We talked briefly about spirituality and the degree to which her existential belief system had reinforced and magnified her depression.

“I just think, Robin, you should allow yourself some time to heal.  Not just heal enough to get back to a full-time job, but really heal.  So you are happier with yourself and your life.”

“That seems impossible,” she said.

I assured Robin we would talk much more about all of these issues.  I just wanted her to have a sense that there was a life beyond disability, and that it could actually be an improvement over her life prior to her meltdown.  I knew she couldn’t possibly imagine it at that time.  But I hoped she would stick around to let us work on helping her get there.

It was August 2003.  Robin still had a few more weeks of short-term disability income she could count on, and was waiting to hear about whether she was approved for long-term disability benefits through her former employer.   She met with her attorney and learned it would likely be the end of September before the hearing would be scheduled to finalize the bankruptcy process.

Robin continued to report ongoing, daily suicidal thoughts.  She focused on trying to keep herself busy while she waited for the events that would finally allow her to relax a bit and feel more settled.   She managed to mostly avoid alcohol, and spent lots of time with her family and friends to distract herself.

One day, completely unexpectedly, I received a voice mail from Robin’s mother asking me to call her back.  I was shocked.  She never called me!   I, of course, was immediately worried it was bad news.  I quickly called Robin, keeping my voice calm when she answered the phone so I didn’t alarm her.

“I just wanted you to know your mom left me a voice mail and wants me to call her back,” I said.  “You’ve signed a release of information form, but I wanted to find out what you are comfortable with me telling her.  Or, if there is anything you don’t want me to tell her.”

Robin took a few minutes to think about what to say.  “You can answer any questions she has.  Just don’t tell her I’ve been having suicidal thoughts,” she said.  “I don’t want people hovering over me.”  Robin insisted I call her back to tell her about the conversation with her mother after I finished it.

“I just wanted to check how Robin is doing,” said her mother on the phone.  “I’m concerned that she’s been acting like things are too okay, and when I ask her how things are going she’s very vague.”  I knew Robin had returned to her instinctive pattern of minimizing her symptoms with everyone other than me.  She still experienced enormous anxiety related to being too open or vulnerable with people, including her family members.  Now that her mother was aware of that pattern, she was picking up on the signs that something was wrong.  I was very relieved.  This was, in my mind, an enormous positive change.

I explained to Robin’s mom that although Robin continued to do much better, her job situation was still a big issue.  We talked about the stress she was experiencing as she waited to hear about disability and about the financial ramifications she was facing.

“Robin is thinking much more clearly than she was for a long time,” I explained.  “But this means she is now processing appropriate emotions of grief about everything that has happened over the last seven months.  And she is in huge limbo about what comes next.”

Robin’s mother was very understanding and supportive, as always.  She expressed her intention of talking to Robin about it, and I encouraged her to do so.  When I called Robin and told her about the conversation, though, I did not expect her reaction.

“I don’t want my mom to know everything that’s going on,” she said.  “I only agreed to have you talk to her because I didn’t want to hurt her feelings.  And I wanted to know why she called.”

“Robin, obviously your mom loves you and is concerned.  And, I think she’s trying to make changes in your relationship so you are more comfortable being open with her.”

At first, Robin’s anxiety about her mother being let in to her world through me, caused her to say “I don’t want it to change.”  After we talked a bit, however, she admitted she and her mother were very connected, and very similar in many ways.  We talked about how healing it could be for them both to work on becoming closer, and that this was an example of what we had discussed in our previous session about increasing her social support.  In typical Robin fashion, however, she said.  “That’s fine, but I just don’t want her calling me all the time to check on me.”  Baby steps, I found myself thinking.

As the days went on and Robin continued to experience the ambiguity associated with not knowing whether long-term disability would be approved in time for her to avoid a gap in her income when the short-term benefits ended, she began to become more anxious and depressed.  Her suicidal thoughts, as usual, intensified.  When we talked about them, Robin made it clear she had no intention of killing herself before the bankruptcy was finalized.  Despite the increase in suicidal thinking, she was still sleeping okay and drinking only an occasional social drink.

Things changed, however, dramatically and quickly.  We talked in a planned phone call on a Monday in late August.

“I’m more depressed,” Robin said.  “I drank three beers on Saturday night and then I couldn’t sleep all night.  I was thinking about what I would write in a suicide note.”

She went on to say she had gone to dinner with her friend the previous evening, and brought up the topic of her cat.  “I asked Christi if she would take care of Epiphany if anything ever happened to me.  She told me she would,” Robin said matter-of-factly.

I knew Christi knew Robin well enough that she probably knew the reason for this question, and was likely uncomfortable.  She was put in the impossible position of disappointing Robin, or making it easier for her to kill herself.  I felt bad that she had to make that decision, but inside I was thinking “No, Christi!  Removing a suicide barrier for Robin is not helpful!”  I kept asking Robin questions, as I got a sinking feeling in the pit of my stomach that we were going down a familiar and dangerous road.

“How much sleep did you get last night?” I asked.

“Very little,” Robin said.  “I didn’t take Trazodone because I don’t want to be on any more medication.  I know I’m not thinking very clearly.”

All of a sudden I had a horrifying thought.  I wasn’t sure at all, because her situation could easily be causing her to have increased depression.  But, I remembered that Dr. Greene had increased Robin’s Celexa dose in mid-July, and added Trazodone for sleep in mid-August.  Both of these were anti-depressant medications, and in the absence of enough mood stabilizing medication, could cause someone who has bipolar disorder to experience symptoms of mania.  Dr. Greene and I had discussed this possibility, but he believed the Depakote and Geodon she was taking would prevent this from happening.  I didn’t want to alarm Robin, partly because I was not at all sure that mania was part of the issue.  But, it came to my mind.

I focused with Robin on the most important issue which was that she needed sleep.  I confronted her about about needing to take her medication as prescribed.  We had been down this road so many times before, that all I had to do was sound mildly irritated and Robin’s need to avoid making me angry led her to agree.

The next morning, however, my suspicion from the previous day was confirmed.  Robin was clearly experiencing a mixed bipolar episode.

“I slept better with the Trazodone,” she said.  “But I’m still having trouble thinking clearly.  I feel crazy and out of control.”  Thank God, Robin and I had gotten to a point where she felt comfortable telling me this was how she was feeling.

“Robin, I’m concerned that the Celexa increase a few weeks ago, coupled with the Trazodone, is destabilizing you,” I said.  She acknowledged she was experiencing all the symptoms of mixed mania including irritability, increased anxiety, racing thoughts, and difficulty controlling her impulses.  Robin admitted she had cut on her arm the previous night, for the first time in many months.

“All I want to do is go buy some vodka and get drunk,” she said.

After some discussion about options for keeping her safe while we stabilized her symptoms, and Robin refusing to consider staying with a family member, she agreed to re-enter the hospital.  It was her fourth hospitalization in eight months.

 

Coming Next:   Robin’s  Thoughts on Rock Bottom

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