The inpatient unit where Robin was staying consisted of ten rooms with two beds per room, in a long hallway with a nurses’ station in the middle of the unit. The nurses’ station was a room enclosed in shatterproof glass which extended from the top of the encircling counter to the ceiling, serving to protect the staff from people on the ward who might become violent. A half door (which could quickly become a full door and could be closed in a dangerous situation) allowed staff to enter the hallway and clients to talk to the staff without the separation of the glass.
Shatterproof glass was a common phenomenon among inpatient units built several decades ago, but there is no question it contributed to perpetuating the stigma felt by people with mental illness. The separation that the glass engendered, built with the intention of creating a safe environment, contributed to a dynamic of “us” and “them” between clients and staff. As an outpatient therapist I did not often spend time in the inpatient units. It did not take long for me to sense that there was a dynamic of separation during my visits to see Robin. Staff spent much time sitting behind the shatterproof glass talking about the clients rather than on the unit talking to them. At the time of Robin’s meltdown, the physical layout of this inpatient unit and the palpable distancing and stigmatizing dynamic between staff and clients, I believe, contributed to Robin’s social isolation and difficulty being open.
Because Robin was so suicidal, she was moved to the room directly across from the nurse’s station so they could keep closer track of her. This did not help, however, because Robin was still not coming out of her room. The staff needed to physically go into her room every fifteen minutes to check on her. Robin continued to be very depressed, suicidal, irritable, anxious and obsessive, and continued to refuse to interact with other clients or staff members other than minimal superficial contact. She was alone and isolated other than brief visits from me and Dr. Greene or short visits during very sporadic visiting hours from two trusted friends.
After a number of days of not telling her family members she was in the hospital, Robin finally reached out to her twin brother. “I called Bob,” she told me. “He was supportive, but he was asking me so many questions. It was overwhelming. I didn’t know what to say.”
I had met Bob once when Robin had first started treatment. She had always described their relationship as close and I was very relieved to hear she had finally told him what was happening. I immediately offered, if she was willing, to call him and answer his questions to the best of my ability. It had only been a few days since Robin’s meltdown, but part of me was already feeling isolated and overwhelmed, as the only person she trusted within her world of crushing despair.
Confidentiality is crucial to the therapy experience. Clients depend on it. It is sacrosanct. But when you are on the other side as a therapist and are being very affected by what is happening in the therapy process, confidentiality can make things difficult. I was already talking to my supervisor about Robin and I routinely attended a weekly meeting with my “treatment team,” a group of five other therapists who discussed difficult case situations and gave each other feedback. Dr. Greene and I were regularly collaborating. But, despite my professional support network I was still the only person in Robin’s life who even remotely knew what she was experiencing. Her friends and family had absolutely no idea what she had been through. I desperately wanted Robin’s brother to understand, and to have him join me in the stressful process of being there for Robin.
Robin agreed to let me call Bob mostly so she did not have to discuss with him how poorly she was doing. She was still very adamant about not telling her parents she was in the hospital. I called and got a very concerned Bob on the phone.
“I want to explain what is going on with Robin,” I said. “She has been depressed for about the last year and her psychiatrist and I have been trying to get her on the right medications. But her depression has gotten worse and she is suicidal.”
“I think her job has a lot to do with it,” Bob replied. “I’ve always thought it’s too stressful for her to be working with all those people who have so many problems.” I didn’t disagree with him, but I tried to help him understand that her choice of careers was not the most immediate problem.
“Robin has two separate issues going on that interact with each other. She’s very depressed, which causes her to feel hopeless and bad about herself and to not think rationally. And, she has severe obsessive-compulsive symptoms which cause her thoughts to get very stuck. I’ve been working with Robin a long time, as you know, and I’ve seen a consistent pattern where she gets very stuck in self-destructive thinking whenever she gets depressed. But right now she is so depressed her thinking is stuck on killing herself. I have never seen her like this. We are working desperately to adjust her medications so her depression gets better.”
“We are twins,” Bob said. “We had mostly the same experiences growing up. I’ve never been able to understand why Robin has so much more difficulty coping with things than I do.”
I tried to explain to him my belief that Robin’s obsessive-compulsive symptoms, in addition to a clear biological tendency toward depression, were a big part of the reason she had such trouble at times. But, on some level I knew Bob didn’t really need all the explanations. He was just trying to integrate the same reality I was….that Robin, his twin sister, was not okay. She was a smart, funny, competent and kind person who had many people who deeply loved her. And, she wanted to die. I did not know how to help Bob understand this reality in the way a brother who just wanted his sister to be okay needed to understand. I knew it was unfathomable to him. After all my experience with many other people who had been depressed, it was also unfathomable to me that Robin had gotten to such a bad place, seemingly so quickly.
Bob and I talked about Robin’s refusal to tell her parents where she was. He said he had promised her he would honor this. He told me he understood. I was glad he did, because fully understanding this was hard for me under the circumstances. After the startling disclosures I had heard from Robin in the previous few days, I was just beginning to understand the degree to which she had never felt comfortable telling anyone about her internal torture. Her incredible ability to mask her symptoms and present herself to the world as “normal” had extended to her family. I knew she did not want her parents to be upset by knowing her reality. Intellectually I understood that being vulnerable in any way caused anxiety for Robin. But I was also beginning to understand that her complete sense of aloneness had to be contributing to her depression. I just wanted her to be able to allow the people who loved her, to also support her. I already knew that needed to happen if she was going to get better and stay alive.
It took almost two weeks for Robin to finally feel compelled to let her parents know where she was. I walked onto the unit one day and found her pacing back and forth in the hall, wringing her hands and looking very distressed.
“Christi can’t take care of Epiphany (her cat) any longer,” Robin anxiously said. “The only other person I can ask to do it is my mom. Bob is too busy. I have to call my mom to let her know where I am.” I was simultaneously relieved she was finally ready to talk to her parents and also aware of how anxious this caused her to feel. I offered to sit with her while she made the phone call to her mom. We went to the small office off of the main hallway so she could make the call in privacy.
“Hi Mom. It’s just me. I have something big to tell you,” Robin said to her mother. “I am sorry I haven’t been honest with you and Dad about what’s going on, but I am in the hospital. Sharon and Dr. Greene are trying to get my medication adjusted. I am sure it will be okay, but I need you to take care of Epiphany for me while I am here.”
I was not able to hear Robin’s mother’s reaction on the phone. I had never met her mom. I had always heard from Robin that her mom was supportive, but also that she did not ever want her mom to know how much she struggled. Robin was tearful on the phone as she painfully revealed that she had been dishonest about how long she had been there. “I didn’t want to worry you,” she said. “I’m so sorry.” She repeated this over and over during the conversation.
Robin went on to talk to her mom about her job and the fact that she was on a medical leave, and about the hospital policy of her mom needing to provide a code number if she called (a way to protect clients’ confidentiality). Robin was quiet and tearful for a while as she listened to her mom on the other end, saying supportive things to her. When she hung up she was obviously relieved and said, “That went better than I expected.”
Even after this conversation, Robin did not want her parents to visit (wanting to protect them from the reality of where she was and what it was like). But she eventually allowed her mother to come to the hospital to bring clothes and other items. Once her mom was allowed to see her, she started to visit Robin regularly. I was so relieved to have her family involved, even though Robin was rallying all of her energy during their phone calls and visits, and still presenting herself as if she was much better than she really was.
What was becoming clearer and clearer to me as I was beginning to integrate the reality of Robin’s meltdown and the magnitude of the information nobody had ever known about her, was that her life-long pattern of trying to appear normal despite her enormous symptoms, was not something Robin had ever done consciously or purposely. I was beginning to understand her on a whole new level. It made her extremely anxious to be open with people…with anyone. Whether those people cared about her, would judge her, or were trustworthy was irrelevant. I finally got it. Robin’s incredible ability to mask her symptoms was all about avoiding anxiety! Avoiding anxiety was a driving force in her life. I knew that about her. But, in January 2003 I finally, finally understood that one of the things that made Robin most anxious, was being open about herself and the reality of her mental illness.
Two weeks into what would become the year long process of helping Robin get back to some semblance of stability, I was already beginning to think about drastic changes I needed to make in my approach to her treatment. I needed to help her to get past the anxiety she felt about being open with people. She needed to stop feeling so completely alone!
It was partly Bob’s suggestion and partly my encouraging it, but Robin finally agreed have a family session with her parents and her brother so I could explain to them firsthand what was going on. I was thrilled to be able to finally meet her parents who I had been hearing about for ten years, and to be able to help them understand Robin’s reality. Robin, as expected, had enormous anxiety leading up to this session, which she readily verbalized. When the session finally happened, she had gotten herself so worked up that she actually dissociated through most of it.
All I need to say is that Robin’s parents could not have been more caring, understanding and kind to her. I was thrilled to meet them and I felt honored and touched to witness them genuinely loving and supporting her. I explained the same things to them that I had explained to her brother previously on the phone. We talked about how they could be helpful to Robin. We talked about how hard it was for Robin to be open with them and why. I assured them I was going to keep doing whatever I could to help. I was so relieved, again, to feel less alone in the reality of Robin’s pain. But Robin was not relieved.
“I feel more depressed and suicidal,” Robin said the day after the meeting. She had, on a new level, given up her familiar, unconscious defense of keeping everything inside. It made her feel vulnerable on a level way beyond her comfort zone to be open with her family. She was so worried about their reactions and the extent to which they would view her differently after knowing some of the truth about her symptoms. It was not surprising that being more open with her family, after a lifetime of keeping so much inside, increased her level of stress. I felt very clear, though, that it needed to happen. I hoped that eventually Robin would feel relieved to not have to fake it anymore.
Overall, Robin was still not improving. She remained obsessed about the insurance coverage for her hospital stay. Robin’s insurance company was monitoring things closely and only approving a few days at a time. They required detailed updates about what was happening in treatment so they could decide whether they would continue to cover the costs. One day I went to visit her and was surprised by a new development.
“My insurance won’t cover my treatment unless I go to groups,” said Robin.