I returned from the conference in Florida feeling rested and re-energized. The conference had been about new developments in psychopharmacology and research on new treatments for various mental illnesses, presented by a leading expert in the field. I had learned a lot of helpful information that I could immediately apply to many of the various clients with whom I was working. Because I was away and distracted, I felt like I had gotten some emotional distance from the intensity of the previous few weeks with Robin.
As a therapist, returning to work after a week away was always a challenge. Many clients needed to be seen with some regularity and would get squeezed into my schedule before and after my time away. Those weeks were always busier than usual. On my way to work the day of my return, I was trying to prepare myself for the week ahead. I thought about Robin and had no idea what I was going to hear when we met later that day. I tried to prepare myself for anything.
I worked in a renovated old factory building in the middle of a big campus of many buildings at the mental health agency. I loved my office, which was large and had two windows, built-in cupboards and lots of character. The wall with two windows was brick, painted off-white to match the rest of the walls. The office contained a desk, my chair, a bookcase and three light green, relatively uncomfortable old chairs (provided by the agency) in which my clients sat. One of the green chairs was next to a table with a lamp on it, along with various items I provided for anxious, fidgety people to play with while they talked (a Slinky, a Koosh ball, etc.).
It was almost universal that people would come into my office, session after session, and always sit in the same chair. Whichever chair they picked during their first session with me was the chair they would sit in every session for the rest of our time together. Any therapist or client can confirm that this is what usually happens. There are few exceptions. Robin happened to pick one of the chairs away from the table. She didn’t have easy access to the Koosh ball or other items to distract her fidgety hands. If she needed something to play with, she would bring her own “sculpie.”
Before I left for Florida my gut had been telling me Robin’s inability to be open with anyone, including me, had been contributing to her severe depression. I had realized how disconnected she felt from everyone. Deep down I was hoping Robin had been more open with her family and friends while I was gone and was feeling more comfortable about this. But knowing her, I doubted it.
Robin arrived at our scheduled appointment on time as always, and looked about the same as when I had last seen her. Her affect was still flat, her leg was still bouncing up and down rapidly, and she immediately started to play with the sculpie she had brought with her.
“So, how did it go while I was gone?” I asked.
“At the beginning of last week it got worse,” Robin said. “When I saw Dr. Greene on Wednesday he put me back on the same meds I was on in the hospital.” Before being discharged from the hospital, Robin had gotten stuck on not wanting to take an antipsychotic medication, mostly because of the stigma involved, but also because it was causing the side effect of dry mouth and could possibly cause weight gain over time. Robin had been willing to try it when she was in the hospital, but not to stay on it long term. Because Dr. Greene knew her rigidity would lead her to just stop taking it anyway, he had discontinued it. Apparently while I was gone he insisted on restarting it since she was clearly doing worse without it. Robin did admit she was feeling a bit better since restarting it, and was sleeping better with the addition of anti-anxiety medication at night.
“How are the suicidal thoughts?” I asked, somewhat afraid of what I was going to hear.
“I still think about it,” Robin said. “Whenever I’m not busy, that’s what I think about. I’ve been trying to stay busy. I’ve been hanging out with my friends, going shopping with my mom and going to the library.”
“So, how much are you eating?” I asked. Robin said she had begun to eat a small amount. Thank God. It was clear she was still focused on food as one of her internal rules. But I was encouraged that she was at least eating something. Compared to where she was when I had left for Florida this was an improvement.
“Are you talking to your people about how you are really doing?” I guessed what she was going to say.
“No, I don’t want people worrying about me. I don’t want to freak them out or cause them to feel like they have to tiptoe around me,” she said. Apparently, Robin was doing just better enough to be able to get back into her lifelong pattern of minimizing her symptoms with people. “Bob and his wife are going on a cruise together next week. I’m supposed to watch my nephew while they’re gone and if I tell them how I’m really doing, I’m afraid they won’t go. I’m sure they won’t be able to find anyone else to watch him at the last minute. I’d feel terrible if they have to stay home because of me.”
This was somewhat reassuring to me, because this was more typical of the Robin I knew. She was always thinking about other people’s feelings, not wanting to bother anyone, and worrying about what other people thought of her. It was actually a sign of improvement that she was back to being able to fake it with her friends and family. Before the hospital, she wasn’t able to do this. I figured watching her nephew would give her something positive and distracting to focus on, although we talked about having her mom or her friends help if it got too stressful.
I wanted to focus on her plans for the future. We talked some about her return to work. She said Dr. Greene had extended her medical leave until the week her brother and sister-in-law returned from vacation. We discussed the fact that it would make sense for her to go back half time at first. Robin felt good about this plan, as she said, “barring further decompensation.” We scheduled to meet again later that week.
The day after our appointment I received a voice mail message from Robin saying she was going to Chicago to visit a friend for the day. “I wanted you to know where I am in case anybody is looking for me, gets worried, and calls you,” she explained. I was happy to hear she was getting out of town and doing something fun and distracting. But, it was completely out of character for her to leave me a voice mail. I was well aware that she had only promised to stay alive until after I returned from my conference. I still didn’t completely trust her after learning about how much she had hidden from me for so long. Part of me was afraid she was using the story about going to Chicago in order to buy herself time for a suicide attempt. It made me uneasy. I was relieved to get a phone call from her the next day…until I heard why she was calling.
“On my way back from Chicago yesterday, I started having car problems. I took Chuck (her name for her Jeep) to the shop this morning and just found out the engine needs to be replaced,” Robin said. “I got a call when I was waiting to see Dr. Greene this morning saying it will be around $2,500. I started crying in the waiting room and couldn’t stop. I sobbed through my appointment with him. It was humiliating.” She hated to cry in front of other people. She was clearly very upset and went on to say, “I know this is just depression, but it just seems like a sign that things aren’t ever going to get any better.”
I was somewhat relieved to hear her acknowledge that it was depression causing her to feel this way. This made me think she was starting to think more rationally than she had been prior to my week off. But then she said something that made it clear she was not rational.
“I am done eating,” she declared emphatically. She talked about Dr. Greene clarifying that he wanted her taking the antipsychotic medication twice a day and she had only been taking it once. She said she did plan to keep taking her medications, but then said, “It will be a race to see if the medications work before I starve to death.” I immediately suggested she come in for appointment that day. I needed to determine how suicidal she was.
I learned that Robin was still not doing well at all. Her new willingness to be open with me following her meltdown was helpful, but I continued to be mortified by what I was hearing. “The whole thing with Chuck just makes me feel more sure I’m supposed to kill myself,” she said. “I was on the Internet last week and learned that if you die from overdosing on Tylenol it’s painful. I’ve been thinking about buying a gun, but I know there’s a waiting period. Besides, I don’t have the money.” What? What the hell? Robin is thinking about buying a gun? Oh my God! I stayed calm on the outside, as we therapists tend to do. Inside, I was back to feeling exactly how I felt when she was in the hospital. What happened to the Robin I knew? And, more importantly, did I ever really know Robin?
After some discussion, she admitted that her rule about not eating had become both punishment for herself and a way to kill herself slowly. Wow! I started thinking, “Does she need to be back in the hospital?” But, two weeks after feeling like we needed to get Robin out of the hospital because it was making things worse, and knowing how the staff had treated her, I did not want to go that route unless absolutely necessary. What a nightmare. Whatever rest and relaxation I had felt earlier that week was gone. We were right back to the same place we had been before I left. I remember thinking, “Now what the hell am I going to do?”
I wish I could say I was a brilliant therapist who came back from Florida with a well thought out new treatment plan, knowing exactly what I needed to do for Robin. That was hardly the case. I was a human being who knew another human being was in enormous pain and looking to me for help. I didn’t have a step-by-step guidebook on how to help a smart, insightful but very depressed client get past her anxiety about being open with people, and I didn’t really know why she was still so depressed. I just knew I was still reeling from everything I had learned while she was in the hospital, and that we had had a big misunderstanding in which she worried for years that I would “ditch” her if she got too suicidal.
When I learned that day how suicidal and irrational she continued to be, and I knew that having her go right back to the hospital was not going to solve anything, all I knew to do was trust my gut. In that moment, with Robin sitting across from me in the crappy green chair, leg bouncing, playing with her sculpie, and telling me about her suicidal thoughts, I knew she was in enormous pain. And I knew there was no one else who she could possibly be open with about the thoughts she was stuck on within her own brain. Her friends and family would freak out if they knew Robin was thinking about buying a gun!
In that moment I knew, on the same deep level I had known before I went to Florida…if I didn’t do something different, Robin was going to die. My gut made a decision. If I was going to expect honesty from Robin, I needed to be honest back. I knew what my gut was telling me to do was risky. But, I decided I needed to trust that Robin was strong enough and our ten year connection was solid enough for me to take this risk.
I told her, more openly than ever before, how I felt.
“Robin, I know you are really depressed and most of you just wants to die,” I said. “But to not eat anything just sabotages everything we are doing to try to get your brain chemistry back to normal. If you don’t start eating more, everything is going to get worse.” I was familiar with the literature on the effects of starvation on the brain. I had learned a lot about treating eating disorders when I was in graduate school. I knew if she was not getting enough basic nutrition it would counteract all of our efforts. I took my honesty with Robin a step further.
“I care about you and have no intention of ditching you. But, I need you to know that when you act self-destructively it puts me in a huge bind as your therapist,” I explained, not knowing how she would react to me saying it. “I understand that you have been unable to tell anyone, including me, how you really feel and have been disconnected from everyone. I think I need to continue to be more available to you than in the past. We need to stay connected until you feel better. But at the same time I cannot, as your therapist, in any way support or reinforce self-destructive behavior like not eating. I don’t know what to do about the bind you are putting me in. I want to keep being supportive to you. But, it won’t work very well if we are battling about your eating.”
Robin did not have much to say in response. I asked her to take her medication as prescribed, to eat two meals a day, and to continue to be open with me about how she was feeling. She said she would think about it and we planned to meet two days later. She walked out the door, and I had no idea what would happen. I had to trust that my gut had been right in telling me to be honest with Robin.
Robin and I met again later in the week. Thank God my risky intervention seemed to work. She revealed that she had begun to eat in order to keep from making me mad. “I feel like a hypocrite, though. Eating and coming to treatment are inconsistent with just wanting to die, which is how I feel.”
“Robin, it’s okay to be inconsistent. I know you are battling with yourself. I know there must be part of you that doesn’t want to kill yourself, and that your brain is stuck. It’s okay to be inconsistent when you are having this battle.”
“I know part of me must want to live or I wouldn’t worry about you being mad. But whenever I’m not busy, I still think about nothing but killing myself.” She was able to acknowledge that the increase in the antipsychotic medication, along with the other meds she was taking, was helping her to feel a little less depressed. She said she would keep taking her medications as prescribed.
Robin told me she was pleased with herself that she was able to have lunch with some of her coworkers and “act normal.” She said she was sleeping fairly well but did not expect to sleep well while staying at her brother’s house to watch her nephew, since she never slept well anywhere other than her own apartment. We talked about the fact that she had lined up people to help her with her nephew if she started to feel too stressed.
When I asked her to promise to stay alive and keep working with me, I was relieved when Robin said, “I am not going to kill myself before my brother and sister-in-law come back from their cruise on March 12. I promised I would watch my nephew.” This promise, I believed completely. I knew she would never kill herself when being charged with responsibility of taking care of her nephew, who she loved deeply. It bought me some time during which I hopefully would not have to hospitalize her, and I could figure out what on earth to do to help Robin get to a better place.