Dr. Greene had told Robin in no uncertain terms that he would not be releasing her from the hospital until after February 9, 2003. This was the day she had originally planned to kill herself. It was the day her brother Eddie died…the brother she never knew because he had died of cancer when she was two years old. Dr. Greene understood Robin’s cognitive rigidity well enough to know how important it was to keep her safe until that date passed. He agreed that being in the hospital seemed to be making things worse for Robin in terms of anxiety and insomnia, and that her depression symptoms had improved enough that we would be able to continue her treatment on an outpatient basis. We discussed the need for a solid safety plan prior to her discharge. We agreed he would not discharge her until I was comfortable with this plan. We talked about the unfortunate timing of a week-long conference I planned to attend the following week, and that he would make sure to see Robin while I was gone.
Robin was tired of being in the hospital and was campaigning to go home. She was insisting she had fewer suicidal thoughts and no intention of acting on whatever thoughts she had. She was showing signs of improvement including better mood and clearer thinking. She was attending more groups. She had been able to relax her rule about food, and was eating about one meal a day.
I went to talk to Robin and found her in her room. I suggested we go to the private office. We needed to have a serious discussion. “Dr. Greene and I have talked about getting you ready to go home,” I said. Robin was relieved about this. “I need to tell you something, though,” I reluctantly explained. “I have a conference out-of-town next week. I know how hard that will be for you and I’m really sorry about the timing.”
Robin could tell how bad I felt. “Of course you need to go,” she said. “I’ll be okay. I won’t kill myself while you’re gone. I promise. I owe you that much.”
“Thank you…I’m really happy to hear that. But before you go home, especially since I will be gone, we need you to put together a safety plan.” I went on to make it clear that some things were not negotiable if she wanted to leave the hospital. “You can’t just go home and sit in your apartment by yourself. It’ll just make you feel more depressed. We need you to rally your friends and family, schedule plans with them ahead of time, and I want to talk to them before I leave town. I want you to stay with your brother for a while. And, I need to talk to one of my therapist colleagues about covering for me while I’m gone. I know you won’t call him, but I need your support network to have someone to call if they have concerns. I’ll need to tell him about what is going on.”
Robin agreed to all of these conditions, although it wasn’t like she had much choice. She wanted to go home and knew, even though Dr. Greene was the one to make the final decision, he would listen to me if I thought she wasn’t ready. She immediately directed her obsessive-compulsive personality characteristics into organizing a very detailed safety plan involving her friends and family, who she referred to as her “angel network.” When I went back the next day I was impressed with her progress.
“I talked to my brother, my parents and three friends,” said Robin. She showed me a written schedule of plans she had made with everyone. She agreed to call one of her angel network members if she felt unable to manage her symptoms. She promised not to drink. We talked about her returning to work part-time two weeks after discharge.
“I think it might help to smooth the transition back to work if you can meet with your boss and maybe have lunch with some of your co-workers before you go back,” I told her. “I am concerned it will be too stressful otherwise in terms of anticipating everyone’s reactions.” She agreed and said she would work on setting up these meetings.
Finally, I had her sign release of information forms to allow me to talk freely with all of her support people about what she needed from them, to answer any questions they had, and to make sure they had the contact information for the colleague who would be covering for me.
I was impressed by Robin’s ability to think clearly enough to organize her safety plan. She was definitely better than when she had entered the hospital. I was thrilled that she was being so open with her friends and family about her need for their support and was finally letting them in to her private world of pain. I was glad I got a chance to talk to each of them to make sure they knew Robin needed them to initiate contact and not just wait for her to contact them. They were all very supportive and reassured me they would “take good care of her.”
Robin’s angel network helped me feel okay about leaving for the week-long conference I had planned to attend on psychopharmacology in Florida. Even though I knew it would be hard for Robin, I also hoped she would be more likely to rely on and continue to be open with her friends and family if I was not there. I still did not want to foster too much dependence. I wanted her to keep working on being honest with people other than me, as I knew this would be crucial to her recovery.
I also knew it would help me to get some distance from Robin and her difficult situation, as I had been putting a lot of time and energy into being there for her for three weeks. I knew I desperately needed some time to process what we had been through, to regroup emotionally, to think about what I needed to do differently in terms of her treatment and to prepare myself for whatever was going to happen with Robin when I returned. To ensure she made a smooth transition after leaving the hospital we made plans to meet in my outpatient office two days after she was discharged…the day before I was scheduled to leave town.
Robin was discharged on Wednesday morning, exactly three weeks after her admission to the hospital. By late afternoon that day, she called me. She was not okay.
“I’m freaking out,” she said. “I don’t know why. I thought I was ready to come home, but I am just really anxious.” She was at her apartment, alone, and not at her brother’s house as we had discussed. She said she planned to go there that evening. We talked about what she needed to do for the rest of the day and, given the circumstances, I told her to call me the next day if she wanted to talk. She did.
“I only slept three hours last night. I’m exhausted. I know I’m not thinking clearly.” Robin admitted she was feeling more depressed since leaving the hospital. We talked about her plans for that day, including the plan to get together with one of her friends.
“I don’t want to sleep at Bob’s house,” Robin said. “I don’t sleep well there or anywhere else other than my own place. I just want to be at home.” I was not surprised. She had protested about this part of her safety plan when she was still in the hospital. I did not want to argue with her, knowing that if she believed she would not sleep well she probably wouldn’t. I told her I was less concerned about where she slept than I was about minimizing her isolation. After some discussion about what she would do if she was having insomnia by herself in her apartment, we agreed that if she spent time with other people throughout the day and evening, sleeping at her apartment would be okay. She promised to pour out all of her alcohol.
The next day Robin arrived at my office, on time as always. She showed her usual indication of severe anxiety…her leg was bouncing up and down rapidly. She looked exhausted.
“I’m not as depressed as I was before the hospital,” Robin said. “But I’m still depressed and I only slept five hours last night. And I know I’m not always rational.” She went on to say she had scheduled an appointment with her boss for the following Monday to discuss returning to work, but said she was not feeling ready to go back.
“Are you eating?” I asked, trying to get a sense of how bad things were. I had been surprised that not eating had become one of her self-imposed rules, as this had never been an issue in the past. Robin had occasionally talked about obesity being a problem for people in her extended family, but she had never been significantly overweight or underweight during the years I had known her. Her sudden focus on refusing food during her hospitalization was one of many things that had surprised and confused me about the previous few weeks.
“I’m not hungry,” Robin replied.
“Robin, if you don’t start eating, you will sabotage all of our efforts to help you feel better,” I said, trying to confront this issue somewhat gently. “Are you trying to kill yourself slowly? What’s the whole issue about eating? Help me understand.”
“No. It has nothing to do with killing myself,” she explained. “Eating is the only thing I have control over.” Wow! This was unexpected. It was a statement people with eating disorders often make to explain their need to restrict calories. This was not the Robin I knew. We debated a bit about it, but I did not want to get into a power struggle with her. The last thing I wanted to do was leave for a week with her worrying about whether I was angry. Any sense of distance on my part might make it easier for her to go against her promise to stay alive until I got back. It worried me that Robin was still thinking so irrationally.
Two days earlier when she was still in the hospital I had been okay about leaving Robin in the hands of her angel network. But suddenly, with Robin feeling so overwhelmed and still thinking so irrationally, I was no longer okay about it. I knew at a deep level that Robin was still not remotely herself. I also knew, though, that I had done everything I could to try to ensure her safety and I needed to let go for the time being. As a therapist it was not unusual to feel uneasy about someone’s safety. In fact, this was a common occurrence for me as a full-time outpatient therapist with many severely mentally ill clients. Judgment calls about safety issues were a routine part of being a therapist to people who frequently had suicidal thoughts. I often had to remind myself that there is always a limit to what anyone can do if someone is determined to commit suicide.
Before ending our session Robin and I reviewed the details of her safety plan. We confirmed her promise that she wouldn’t kill herself while I was gone. I mostly trusted that promise. Robin had always had a policy of never promising anything if she didn’t feel able to honor it. But, knowing how much she wasn’t herself, it left a bit of doubt. I tried to instill some hope by talking to her about how huge it was that she had finally been open with me and that she no longer had to worry about me “ditching” her. I told her my new understanding about how things had been for her would help us to approach treatment differently, which would help her to make more progress. I wasn’t very clear yet myself about what this meant, but I tried to be positive for her sake.
I had never given a client my contact information when going out of town before. The agency where I worked had 24 hour crisis services, which enabled the outpatient staff to avoid ever being on call. But I did not feel okay that day leaving Robin without any ability to contact me. In 2003 I had not yet begun to carry a cell phone, so I gave her the number to the hotel where I would be staying.
“I’m not going to call you when you’re out of town, for God’s sake,” Robin said. “I don’t even usually call you when you’re in town, remember?” Okay, there was a hint of the Robin I knew. I told her I knew she wouldn’t call, but I would feel better knowing she could if she changed her mind. We scheduled another appointment for the Monday after I returned to the office.
Robin walked out of my office that day and I was suddenly overwhelmed with emotions. I sat in my office, at my desk, looking out the window and crying. I felt so many different things. I think it was partly just the intensity of the emotions of the previous three weeks catching up. It was partly the realization of the implications of everything Robin had never told me before, the severity of her symptoms, and the suddenness with which she had become so dangerously unstable. I felt very bad about leaving so soon after her discharge from the hospital, knowing how unlikely it was that she would be open with anyone about what she was feeling…no matter how bad it got.
I had a new understanding of the enormous anxiety it caused for Robin to be open with people. I had a new awareness of how much pain she must have been hiding from me for many years, partly out of her fear that I would ditch her. That day, knowing how irrational and depressed she was, I felt like I was abandoning her. Whether I had done my job as a therapist to cover all the bases with her safety plan was not the issue. I knew I had. I knew I needed to go to the conference and trust that she would honor her promise to stay alive. But, at the same time I was finally beginning to understand the words of Dr. Rios so many years earlier…Robin was “at extremely high risk for suicide at some point.”
In those private moments in my office that day, I was beginning to get a sense of how much Robin would need me to be the one person she could continue to be open with about the depth of her pain. I had been reading many spiritual books in the years leading up to Robin’s meltdown. I sensed that what was happening was bigger than me, and bigger than my job. My gut told me…Robin needed to stop feeling so alone or she was going to end up dead. And, I needed to help her get there.
I gathered myself together and went home to pack. I wrote in my journal that night:
“I don’t know why, but I have a strange feeling that this whole experience is as significant for me in some way as it is for Robin. I think I’m supposed to be learning something, but I’m not sure what it is. All I know is that I want to be able to get a chance to work with Robin when she is thinking clearly again. I would love to be able to talk to her about this whole experience and what we’ve both learned from it. Right now she can’t think clearly enough to discuss any of this, obviously. I just hope and pray that at some point we can talk about it all.”
I had no idea how right I would become about the significance for me of continuing to be there for Robin. I had no idea how much worse it would get, and how powerfully I would be affected.