Robin’s “meltdown” led to a three week hospitalization. I continued to be involved in her treatment even though this was not standard protocol at the agency. Outpatient therapists usually turned the treatment over to the inpatient staff, while the psychiatrists continued to follow their patients in both arenas. Dr. Greene knew Robin would be more open with me than anyone else (including him) and he needed to know what she was really thinking in order to make appropriate treatment decisions. He not only encouraged me to keep seeing her but we consulted each other frequently in order to make sure we were on the same page.
Robin continued to be open with me once she was reassured I would not “ditch” her. Depression causes people to think less rationally than usual. Severe depression causes people to completely lose perspective. Robin was so depressed that she became someone I barely recognized. “I hate myself, I hate my life and I want to die,” was her automatic declaration when I asked how she was feeling. I felt completely helpless as I continued to visit and to hear the details of what was going through her mind. It was like she was suddenly feeling driven to share all of her feelings and thoughts with me, almost like she was making up for all the years when she kept those painful feelings, thoughts and symptoms to herself. I felt honored that she was finally willing to really let me in, but also horrified about what I was hearing.
The inpatient rooms all had a window with an alcove large enough to sit in, and the hospital building sat next to a large river. It was a beautiful setting, with a peaceful view. It was late January and the view was often filled with falling snow. If Robin had a roommate who was in the room I would take her to a small, sterile office off of the main hallway that was used for consultations so we could talk privately. If not, we would talk in her room. Sometimes I stood leaning against the wall and sometimes I sat on the bed across from her, depending on the intensity of the conversation. Often I would walk into the room to find Robin sitting in the window alcove, staring out the window at the river. Early in the hospital stay she rarely came out of her room. Robin remained very agitated, reported that she could not sleep, and presented with “flat affect” which is a physical sign of severe depression where people do not smile or laugh at all and actually show no virtually no emotional expression. She continued to play with her “sculpie” whenever we talked.
During the first few days in the hospital Robin remained very angry that she was being pushed to attend groups and other hospital programming activities. Her anger, however, was mostly directed at herself. “I’m mad at myself for drinking so much last week. If I had not been so out of it when I came to see you I would never have agreed to come to the hospital,” she said. “I never planned to come in that day. I must have dissociated and just ended up in your office. I don’t know why I did that when I just wanted to die.”
“I don’t know why either, Robin, but I am so thankful you did. We’ll figure out what you need and you’ll feel better now that you are finally letting me know what’s going on,” I said. Even though I was shocked by some of the things she was saying to me, I needed to try to provide some sense hope.
Dissociation means to numb oneself emotionally, sometimes to the point of being consciously unaware of what is going on in the moment. This was a defense that Robin had apparently developed as a result of the trauma she experienced as a child. It is quite common for people who have been traumatized at a young age to develop this unconscious defense mechanism to protect themselves from feeling pain. Robin had dissociated frequently before she began therapy, but this had not been an issue for many years. It clearly became an issue again surrounding the severe depression she was experiencing during her “meltdown.” The fact that she was dissociating on the day I had hospitalized her explained why she did not argue at all about going there. It also seemed to explain her sudden lack of impulse control about saying things she would not normally say. This pattern continued.
“Adults should be able to make the decision to kill themselves. It seems like natural selection to me. The people who are weak and unable to cope get weeded out of the population that way. Killing myself just makes sense.” She revealed that before coming to the hospital she had actually chosen the specific date when she was planning to commit suicide. “I know my family will be upset if I kill myself. That’s why I picked February 9th to do it. That is the day Eddie (her brother) died,” she said. “I figure that’s a good day, because my family will already be sad about Eddie and it’ll make it easier for them to just grieve all at once.”
What? I couldn’t believe how little sense she was making and how irrational she was. Obviously she was not thinking clearly enough to understand that committing suicide would devastate her family members, no matter what day she picked. I remained calm and reassuring on the outside, as experienced therapists somehow manage to do no matter what we hear. I don’t even know how I developed that skill. I suppose it just happens automatically to us therapists as we listen day after day, hour after hour and sometimes minute after minute to the horrific pain people reveal. If we don’t become desensitized, we can’t continue to be helpful. All I knew then was that Robin, who is normally extremely sensitive to the feelings and needs of other people, somehow believed her family would grieve less if she killed herself on the day her brother died! Wow.
Not only did Robin continue to refuse groups, but she also refused to eat. She did not have a good explanation for this but said “I guess I feel like punishing myself. I don’t deserve to eat.” Later she revealed that not eating had become “a rule” in her mind that she felt unable to break. This was consistent with her previous pattern of becoming obsessed with self-destructive behavior when depressed. I knew if she stopped eating completely things would just get worse, and I was very firm with her about the need to eat something, preferably protein. She was afraid to make me angry even though I had never expressed anger directed at her before. Robin decided it was okay for her to eat peanut butter and apples. She got her friend to bring them to her. This became her new “rule” about eating. She lived on these two items, refusing all hospital prepared meals, throughout most of her hospital stay.
Severe depression can cause psychotic symptoms including hallucinations and delusions, in which people lose complete touch with reality. Although Robin never lost touch with reality, her thinking just seemed so illogical. Dr. Greene and I were grasping in terms of what to do to help her feel better. We had been collaborating closely about Robin for over a year at that point, talking about and trying different medication options, attempting to get her intractable depression stabilized. I decided to suggest we try an antipsychotic medication, partly to help her think more clearly and partly because it was something different in terms of augmenting the antidepressants she was already taking. Before talking to Dr. Greene, however, I needed to get Robin to agree to take it. This was not a conversation I welcomed, knowing the reaction I would get. She was already very focused on the stigma of being in the hospital for the first time. Taking an antipsychotic medication meant one more step down the path of being on the other side of the treatment process.
“Robin, I need to talk to you about something you are not going to want to hear,” I said. “I want you to know I do not think you are psychotic. You don’t need to worry about that. But I want to talk to Dr. Greene about trying an antipsychotic medication. I am concerned that your thinking is so irrational and I am hoping it will help you shift. What we are doing isn’t working. We need to try something different.”
As I expected, Robin hated that I had even suggested it. But, she was thinking clearly enough to understand we had been doing everything we could think of for a long time, and she was just getting worse. “Will it cause me to gain weight?” she asked, well aware of the side effects of various medications from her work in the mental health field.
“Honestly, Robin, I don’t know. I don’t even think you will need to take it long enough to worry about that. We just need to get you feeling better.” She reluctantly agreed, and when I suggested it Dr. Greene promptly agreed as well.
I had never seen someone so depressed. Day after day she was verbalizing consistent suicidal thoughts. Even though she hated being in the hospital she was able to verbalize that she knew she was “a danger” to herself. She would talk, over and over, about her fear about what her co-workers would think about her being in the hospital, her fear that her brother and sister-in-law would not trust her to babysit her young nephew anymore, and other fears related to her new status of being someone who had been psychiatrically hospitalized.
Her three week hospitalization was much longer than most hospital stays, especially for people with “managed care” insurance companies who closely monitor the care being provided and whether it is “medically necessary.” She obsessed about whether her insurance company would cover the stay and how much she would have to pay for the hospital bill. Our conversations revolved around me trying to help her regain perspective…that the first priority was to get her feeling better and all of these other issues could be sorted out after that. My efforts to help her regain perspective were unsuccessful. She remained very obsessive and unable to shift her thinking but thankfully, willing to share her thoughts with me.
“Do you know how I could get life insurance?” she asked me one day. “I wonder if I have life insurance through my job?” She was willing to admit she had a lot of debt and was worried about her family members having to deal with a “financial mess” if she killed herself. I talked with her about what I knew about life insurance, not wanting to dismiss her concerns. I told her (whether it was true or not) I thought most life insurance policies would not pay if someone died by suicide.
Another frequent discussion topic was her cat, Epiphany, who she worried about abandoning. It was becoming clear to me as I continued to learn more and more about the degree to which Robin had been isolated in her severe depression, that her attachment to her cat had probably been keeping her alive. “I want to find someone who will take Epiphany if something happens to me,” she said. “It’s the only thing that keeps me from doing it. I know everyone else will grieve and move on. But I need to know Epiphany will be okay.” Again, Robin seemed to have no awareness of the degree to which her death would devastate all the people who loved her. This was a reflection of her depression, not her personality. She was simply just not herself. I continued, day after day, to try to integrate the reality of how ill she was and how hopeless she felt.
Robin had revealed to two of her friends that she was in the hospital. One of them was caring for Epiphany and bringing items to her from her apartment. The other was a co-worker who rallied and began to visit her in the hospital regularly. Robin had still not told her family she was there. Finally, one day I went to see her and she told me she had informed her twin brother about what had happened.