The story begins with a phone call one day from Robin. She and I had been working together in therapy for almost ten years at that point. She had almost never called me between sessions during that ten year period, partly because she was very aware of and careful about “boundaries,” but also because severe anxiety about making phone calls was one of her symptoms. If she had ever called it was only to reschedule an appointment, which was a rare occurrence. Needless to say, I was quite surprised to hear from her when she called and said “I’m not doing well,” and asked if she could see me that day or the next day. In retrospect I should have canceled other clients and squeezed her in that day, knowing how significant it was for her to make this request. What I did was to tell her we could meet the next day. She assured me she would be okay until then.
Robin came in the next day and I immediately knew something was very wrong. She was sitting with her head in her hands in the waiting room, and looked exhausted. When she got into my office and started talking, her speech was noticeably slurred. She looked very anxious, with her leg vigorously bouncing, which was a clear sign of her significant anxiety that I had seen many times before. I asked what had happened that led to her call the previous day. “I went to work Monday morning and got a voice mail from my boss,” she said. “She had left it on Friday after work. She was saying what a good job I do and how valuable a team member I am, and how important my contributions are. It made me cry and I couldn’t stop.” I went on to gather more information, and she explained that she had told a co-worker she wasn’t feeling well that day and then just went home.
I knew Robin had been depressed for the previous year. I knew she had not been sleeping well. I knew she had been having some suicidal thoughts. Her psychiatrist and I had been working together to try different medication options to get her significant depression under control, without much success. I knew she was struggling at work, but her boss’ voice mail confirmed my belief that she had been faking it well, as was her tendency. It didn’t surprise me that she had been able to hide her significant symptoms and continue to do well at her job. The voice mail from her boss, however, which caused Robin to suddenly acknowledge how bad she actually felt in comparison to what others perceived, was the last straw for her already fragile defenses. “So what did you do next?” I asked. “What have you been doing since Monday? What did you do after we talked yesterday?”
“I went home on Monday and started drinking.” Robin reluctantly said. She did not usually drink at all, but when her depression got worse she would drink to numb herself. It had been a frequent pattern for her in the past, but she had made significant progress in treatment and had not been self-destructive in years (to my knowledge at the time). She went on to say, “I’ve been thinking more about suicide. I’ve been researching methods. I have Tylenol, but I don’t want to take too little and ruin my liver or go into a coma and just make things worse. I went to Barnes and Noble to try to find a book that would tell me how much I need to take.”
Thankfully, Robin said she was not able to find any resources that would definitively tell her the amount of Tylenol that would be lethal. I kept questioning, to try to figure out why her speech was slurred that day. “I guess I’ve been taking too much medication along with the alcohol. This morning, I went to Eddie’s grave,” she said. Eddie was her older brother, who had died of cancer when he was four years old. Robin and her twin brother had been younger, so she did not remember Eddie. But, he had been a significant topic of discussion in her family and she frequently connected his memory to her suicidal thoughts. I was distressed already about what I had heard, but her report of visiting Eddie’s grave that morning was a particularly bad sign in terms of her level of suicidal risk.
It obviously did not take long for me to determine that Robin needed to be in the hospital. She had never been hospitalized before, and would have never previously considered it as an option. She had been working in the mental health field for years, part of the time treating adults with chronic mental illness, and had always been horrified to imagine herself being on the other side of the treatment relationship any more than she already was. (Not to mention being locked in a hospital, completely out of her familiar routine, surrounded by other people she didn’t know). On this day, however, when I suggested the hospital she did not argue at all. I had hospitalized many clients over the years and they often asked lots of questions about what it was like there before they agreed to go. They usually wanted to go home and pack clothes and personal items, or to talk to someone else about doing so. Robin was so depressed and so unable to think clearly that she did not do any of these things. She agreed to follow me over to the agency’s inpatient unit which, thankfully, was attached to the outpatient building where we were.
Before we made the trip over to the hospital I asked if she had any concerns about being there. She said, “I don’t want my parents or my brother to know.” This was not surprising to me since I was aware that Robin’s pattern was to hide the extent of her symptoms from everyone, including her family. But I also knew her family was very supportive to her and she would benefit from having them know. I tried to convince her. “No. I won’t go if they have to know,” she said.
“Obviously, Robin, you know I can’t tell anyone without your permission,” I replied. “But, they would want to know, and I think it would help for you to have their support.” She was adamant, and maintained that she would only go to the hospital if her family didn’t know she was there. I was not about to argue at that point, figuring she would change her mind. I just needed her to be safe.
We were waiting together in the waiting room of the hospital for her insurance to approve the admission. I will never forget the big fish tank sitting next to us…I guess it was there to help people in the waiting room of the psychiatric hospital feel more calm. There were not enough fish in the world to make either of us feel calm at that point. I was worried about what I had just heard from this person I had known for so long. I was concerned that she did not want her family to know what was happening. It was there, with us both looking at the fish, where Robin asked me a simple question that rocked me to the core.
“Are you older than I am?” she sheepishly asked. I was stunned! In that one small moment I became acutely aware of the degree to which I had kept myself detached from Robin for almost ten years.
In typical therapist fashion, I answered her question with a question. “Why do you ask?” I said.
“Because I’ve always wondered, but never wanted to ask,” she replied. I don’t know if it was the intensity of the moment or more likely the fact that her impulse control was impaired that made her finally ask me the question she had apparently most wanted to ask me.
“Yes, I am four years older than you,” I said.
“I’m glad,” she said. “I didn’t like the idea that you would be younger than me.”
Self-disclosure is a topic of some debate among therapists. Those who follow more of a psychoanalytic or psychodynamic model tend to shy away from all self-disclosure. They believe we therapists are supposed to be a “blank slate” by not revealing anything about ourselves as people, keeping our offices free of personal items, etc. The theory is that if a client has feelings about us, being a blank slate means those feelings must be “projected” onto us and are actually feelings about people from the client’s past. I disagree with this theory, as do many therapists these days.
My personal approach to self-disclosure was to limit it to only those times when it was beneficial to the client. I did not talk about myself during sessions very often. I did so only if it was completely relevant to what we were discussing and was relatively benign. I would answer questions that my clients asked about me as long as they were not inappropriate or too personal. Clients would often ask me about my age, marital status, whether I have children, etc. I thought it was important for them to know a little about who I was, and very willingly answered these questions…but only if they were asked.
The problem for Robin, as I realized all at once sitting in the waiting room of the hospital in 2003, was that she never felt comfortable asking me anything. My policy about only answering questions when asked, and her policy about never asking, had led to the incredible situation in which, after ten years Robin “had always wanted to know” how old I was. I certainly understood that clients would not usually ask their therapist about their age. But, Robin and I had known each other for a decade. She had shared so much with me. I had just assumed, for years, she was completely comfortable. What shocked me was the sudden realization that she had never felt comfortable asking anything about me, even though she wanted to know. What did that say about how distant I had been? The reality of this and what else she might have wondered through the years without asking, as I said, stunned me. But, I had to stay focused in the moment. I needed to make sure she got to the inpatient unit safely.
I encouraged Robin again to contact her family members, but she remained adamant that she did not want them to know she was being hospitalized. Instead she called the one friend she was willing to be open with about what was happening, Christi, and asked her to take care of her cat and bring her some clothes and personal items. I stayed with Robin until the admission process was done and she was being taken up to the inpatient unit. I promised to visit her the next day.
Early the next day, I received a phone call from her psychiatrist, Dr. Greene. He had been treating Robin on an outpatient basis for about seven years at that point. Although we had a good working relationship, it was fairly uncommon for him to call me directly about a client.
“It has been a long time since I have seen someone this depressed,” he said. “I have talked to her about ECTs but she will not agree to them without talking to you first. Can you go and talk to her?” Coming from an experienced psychiatrist who treats many, many people, I knew what a significant statement this was. I also knew Dr. Greene did not rush to recommend electroconvulsive therapy (“shock treatments”), and, in fact, used it very sparingly. Therefore, I knew how significant it was that he was ready to have Robin undergo a course of ECTs immediately. I would never have imagined Robin would need them, but from what I had seen the previous day I did not disagree with his recommendation.
Most people are scared by the idea of shock therapy. Of course, the images from the well known movie One Flew Over the Cuckoo’s Nest come to mind for many people. But, the reality is that the latest techniques for performing ECTs are completely different from the portrayal in that movie. They do tend to cause some memory loss for the time period before and during the treatments. Otherwise, they are a safe and very effective way to alleviate depression symptoms, especially when they are severe and medications have not been effective. I went to see Robin, talked with her about all of this, and convinced her to give ECTs a try. She was desperate to feel better and ready to try anything.
Later that day I received a panicked phone call. I had never heard Robin so upset. She was crying, which she had never previously allowed herself to do in front of me. “I can’t do it,” Robin cried. “I’m not ready to have ECTs.” She explained that Dr. Greene had set her up with one of his colleagues who would be performing the ECTs, to do a consultation about whether she would be an appropriate candidate for this treatment. Robin explained that he had asked her many detailed questions about her childhood sexual abuse history, and that this had triggered painful memories and emotions for her. He had planned to start the treatments the next morning. “He told me I can’t take any medication for anxiety or sleep tonight,” Robin anxiously explained to me. “I can’t do this!”
I calmed her down, and assured her I would call Dr. Greene and let him know she needed some time to prepare herself to start the ECTs, and that she was not ready for them to begin the next day. I called him and explained this. I was surprised by his response.
“It doesn’t matter anyway. I just got off the phone after talking to her insurance company. They won’t approve the ECTs,” he said, very angrily. “Tell Robin she can take her meds for sleep tonight, and we will talk tomorrow about the next step.” We talked briefly about the insensitivity of his colleague who had done the consultation. We also commiserated about the complete short-sightedness of her managed care insurance company in not approving the ECTs. We hung up, both feeling frustrated. I called Robin and reassured her that she did not need to start the ECTs the next day (Friday) and that I would visit her before leaving for the weekend.