Once Robin started coming out of her room and attending groups, things worsened for her in terms of the dynamics with the staff on the inpatient unit. She was still not thinking clearly. Her new status as someone who had been psychiatrically hospitalized just made everything worse. She was unable to envision any way to recover her reputation with her colleagues in the mental health field and was having difficulty tolerating the anxiety associated with having revealed so much to me and to her family and friends about how crazy (her word) she was.
Robin’s severe depression and suicidal thinking were not unfamiliar to the inpatient staff. They were used to seeing people ruminate in hopelessness and depressed thinking. They did not understand, however, the impact of Robin’s severe obsessive-compulsive symptoms. Because the names are similar people often confuse OCD and OCPD but they are two different things. Robin actually had both.
Obsessive-compulsive disorder (OCD) is a biological illness that causes people to experience intrusive, unwanted, anxiety-provoking thoughts and often to develop compulsive rituals that serve to decrease the anxiety caused by those intrusive thoughts. People who experience these symptoms are usually completely aware they are irrational, but their significant anxiety compels them to do what they know will help them feel better.
An obsessive-compulsive personality pattern is a tendency toward perfectionism, rigidity, preoccupation with details and anxiety about change or uncertainty. A mild version of this pattern can be very adaptive and can lead to high levels of conscientiousness and achievement at school or work. The pattern becomes a problem when it is severe enough to get in the way of relationships or to impair functioning, which then qualifies the person for an Obsessive-Compulsive Personality Disorder (OCPD) diagnosis. I have obsessive-compulsive personality traits which tend to be genetic and have run in my family for generations. Whether these traits, for me, are severe enough to interfere with my relationships or impair my functioning, thus qualifying me for the diagnosis of OCPD, probably depends on whom within my circle of friends and family is asked.
What had become clear to me over the years as I got to know Robin was that she had specific symptoms of both OCD and OCPD. She had a double dose of anxiety and rigidity in her thinking. When she was biologically depressed her brain would automatically get stuck in self-destructive thinking and she would have extreme difficulty shifting out of those thoughts. Obsessing about suicide was a frequent occurrence for Robin during periods of depression.
I was introduced to the severity and dangerousness Robin’s obsessive-compulsive symptoms relatively early in our work together. It was 1995 and I was a somewhat inexperienced psychologist having earned my Ph.D. three years earlier. Robin had been in therapy for about two and a half years and had made significant progress in terms of resolving trauma issues. But she was living with her parents temporarily after having quit a job impulsively about a year earlier due to overwhelming stress. She had eventually found a new job, but was trying to recover financially from a period of unemployment by living with her parents and saving money.
Robin was experiencing increased depression related to living with her parents and was pushing herself to find an apartment and move out. I knew she was depressed. She admitted she was having some suicidal thoughts but always assured me she did not want to kill herself. Discussions about “passive” suicidal thoughts (no plan or intention of acting on them) are a common occurrence in therapy. Imagine my surprise one day, though, when Robin came into my office and revealed that she had “almost done it.”
“I had set a deadline of December 1st to move out of my parents’ house,” she reluctantly told me. “I figured that would motivate me.” I knew taking the steps to find an apartment was overwhelming to Robin, especially in her depressed state. But she was putting a lot of pressure on herself because having to live with her parents, after previously living on her own, caused her to feel more inadequate. She worried a lot about what other people thought about her and how living with her parents would worsen their opinions.
“I told myself if I didn’t meet my deadline I would have to kill myself,” Robin revealed. “I didn’t want to, but as the deadline got closer I got more and more anxious.”
“So what did you do?” I asked, starting to get anxious myself as I was trying to process what she was telling me. I couldn’t believe she had not told me she was so seriously suicidal!
“I was getting so freaked out I finally decided on the day of the deadline that it would be okay to extend it,” Robin said. “Then I felt guilty not telling you.”
Robin had struggled with self-destructive thinking and behavior in the midst of depression for years. Medication adjustments always seemed to return her to “baseline” where self-destructive thinking and behavior was not as much of an issue. Robin and I had developed a good therapeutic relationship and she frequently referred to me as her “accountability.” If she was ever self-destructive she felt compelled to tell me. As her therapist I had learned to count on this honesty and to feel relieved that this was one of her self-imposed rules. I learned over the years that any hint of increased self-destructive behavior was a signal that her depression required a medication adjustment. It was clearly a biological pattern.
When Robin told me in December 1995, though, that she had gone through the suicidal crisis surrounding her self-imposed deadline without anyone else knowing about it, I was very surprised and very scared. I was young and inexperienced and didn’t really know what to make of what Robin was telling me. I suddenly didn’t know if I could trust her to tell me the truth about her suicidal thoughts. It shook me and made me very nervous. The worst fear of every outpatient therapist is that one of their clients, who they are entrusted to help, will kill themselves. Unlike in 2003, I wasn’t focusing back then on how alone Robin must have felt. I was too busy thinking about myself, my fear, and how it would affect me if she committed suicide.
At that time there was a semi-retired psychiatrist, Dr. Rios, whose office was two doors down from mine. He was helpful to me, as I was very interested in learning about medications, and he seemed to enjoy teaching me about them. When Robin entered treatment I had referred her to see him because of the severity of her symptoms. They had developed a good working relationship, although it always made her anxious to talk to him. After Robin told me about her near miss, in which she felt compelled to kill herself even though she didn’t want to, I immediately scheduled her to see Dr. Rios. I needed help. I didn’t understand. After meeting with her, Dr. Rios said something to me that I never forgot.
“Robin is at extremely high risk for suicide at some point,” he said. I think he probably tried to explain why he said this, but I didn’t really process it. I was too stunned and scared by what he said. At that point in my career I had never seen anyone in therapy with Robin’s level of cognitive rigidity and self-destructiveness. I didn’t understand the dangerousness of this combination. Dr. Rios, with his many years of experience did understand how dangerous it was and was apparently trying to tell me something. I should have asked him to help me understand more clearly. The fact that I did not, would become one of my biggest regrets as Robin’s therapist.
When Robin entered the hospital following her meltdown in 2003 she was very caught up in her long-standing pattern of imposing rules in her own head which she then felt unable to break. Being depressed meant those rules were self-destructive or at least self-defeating. One of her rules at that time was that she would not go to groups. Another was that she could not eat anything other than apples and peanut butter. Robin was not making conscious choices about her rules. Her own intrusive thoughts were driving her. She had very little ability to control it. She was overwhelmed with anxiety in addition to profound despair. Robin was always, on some level, driven by her anxiety. Her internal rules were always about what caused the least anxiety for her.
Unfortunately, because the inpatient staff did not understand Robin and because the unit at that time had such a dynamic of “us” and “them,” they almost immediately began to label her as “manipulative.” They thought she was being difficult. They did not understand why I, as her therapist, was not pushing her to attend the groups they ran. They really didn’t even understand why I was treating her in the hospital, as outpatient therapists usually did not do this. I am sure they probably thought I had fostered too much dependence with Robin over the years, which could not have been more untrue. They didn’t understand Robin’s intense anxiety about being open with anyone or her internal rules. I tried to explain all of this to various staff members. It didn’t matter.
I couldn’t fault the inpatient staff members too much, because Robin’s behavior was difficult to understand. It had taken me years to begin to understand it myself. It was easy for them to mistakenly believe Robin was purposely refusing to participate in programming because as a mental health professional, she felt she did not need what they had to offer. Robin even made statements consistent with this belief, in order to explain herself in a way that made sense.
“I run groups like this,” she would say to the staff. “I know all about them. I am not a group person.”
Robin started to attend groups after almost two weeks in the hospital, only because her managed care insurance company threatened to stop covering the costs of her treatment if she did not start to participate in programming. Her anxiety about the prospect of having a large bill to pay overrode her anxiety about coming out of her room and interacting with people. It was that simple. Her brain changed the rules based on what made her least anxious. That was how Robin’s brain worked.
Once Robin came out of her room and began to go to groups, she began to feel a bit better. The groups served as a distraction from her depressed thinking. But she would only attend some of the groups, depending on how much anxiety she thought each group would cause. She refused medication at times if she was concerned about the side effects. The staff did not understand why she was refusing meals and overall being “uncooperative.”
No staff members behaved rudely to Robin. Nobody did or said anything wrong. But there was that palpable dynamic of separation and distance, made worse by the shatterproof glass of the nurse’s station. Staff members were distant. Robin was hypersensitive. She was able to sense that some of the staff members did not like her, without them doing anything overt to indicate it. It caused an increased level of anxiety for her.
Robin was still not sleeping well and remained quite depressed. She was responding slightly to the antipsychotic medication, though, and had begun to think a bit more clearly and rationally. Her suicidal thoughts had decreased somewhat. Although she was still not stable, when the dynamics with the staff worsened her psychiatrist, Dr. Greene, and I became concerned that being in the hospital was actually making things worse for Robin rather than better. Her depression was better but her anxiety and insomnia were worse. I began to believe she might do better if she could get back to somewhat of a normal routine. After meeting her family and being able to explain to them what was going on, I hoped she would feel more comfortable relying on them a bit for support. I knew they and Robin’s friends would be motivated to support her. For many reasons I finally said to Dr. Greene, almost three weeks after she entered the hospital, “we have got to get her out of here!”