I was baffled by what was happening with Robin. I couldn’t understand why she kept feeling so awful and thinking so irrationally. There was no clear explanation. It did not make sense that her depression had been resistant to so many different medications for over a year and seemed to be getting worse and not better. I still couldn’t believe she was unable to tell me how hopeless she had felt before her suicide attempt several years earlier because she was afraid I would “ditch” her. How did that happen? There was no question my tendency to keep my boundaries very rigid had probably contributed. Although I was reassured about Robin’s new willingness to be open with me and to eat more, I was confused about why she wasn’t getting much better. In an attempt to figure it out, I went back and re-read her whole clinical chart…all the progress notes I had written over the previous decade.
I first met Robin in 1993, a few days after her roommate had found her sitting under a sheet, dissociating and cutting her arm with a knife. Her roommate convinced Robin to come to the agency’s emergency department where Robin insisted she was not suicidal and promised to attend outpatient therapy. She had never had treatment of any kind. I was a bit nervous about seeing her since I did not have much experience treating self-mutilation. After I met Robin, though, I instantly liked her. And it was clear she needed my help. I consulted with my supervisor a lot, began to gradually dig into the details of her history, and worked to help her verbalize her experiences and her emotions.
In addition to her obvious depression, Robin revealed a trauma history including sexual abuse as a child by someone outside her immediate family. She had significant social anxiety and described herself as a person who had always been very timid and shy. Despite this, she worked in the mental health field and knew a lot about mental illness. She was able to talk intelligently and insightfully about her issues. But, she had never talked openly with anyone about the extent of her painful symptoms or her sexual abuse.
As Robin and I began to work together, she showed symptoms consistent with her trauma history. She met the criteria for a diagnosis of Posttraumatic Stress Disorder (PTSD) including nightmares, intrusive memories of past trauma, significant anxiety accompanying those memories, avoiding reminders of the trauma, dissociation, insomnia, a negative self-image, detachment from others and self-destructive behavior. The depression she experienced was very common among trauma survivors. The anxiety she felt seemed to be genetic, life-long and magnified by the trauma.
We spent much time during the first two years of treatment processing her sexual abuse experiences and helping her tolerate painful emotions without needing to dissociate or self-mutilate. Self-mutilation is a common behavior pattern for trauma survivors. It is not about wanting to commit suicide. It serves different purposes for different people, but is generally described by those who do it as a method of coping with emotional pain. For Robin, cutting herself usually accompanied dissociating and drinking too much alcohol, which she readily admitted she did to numb herself when she was depressed. When we began treatment she immediately agreed to try antidepressant medication, which significantly helped to decrease both her depression and her PTSD symptoms and allowed her to tolerate the painful emotions evoked by talking about her issues.
Robin quickly made progress. I really liked working with her, as her sarcastic sense of humor always made me laugh and was balanced by an overwhelming sense of kindness toward others. These qualities combined with her intelligence, knowledge and insight made our sessions especially rewarding for me. As we worked together, Robin became more able to feel and express her emotions. She felt better about herself. Her tendency to dissociate and cut herself virtually stopped. Sometimes she would stop taking her medication, usually to test whether she still needed it…a very common pattern for people coming to terms with chronic mental health issues. For Robin, going off the medication would always lead to more depression. Getting back on it or adjusting it when appropriate always helped, and she was able to get back on track quickly.
As I was re-reading Robin’s chart I came across the incident in which she had set a deadline for herself to move out of her parents’ house in 1995, and then felt compelled to kill herself if she didn’t meet the deadline. I remembered feeling so scared after she revealed this to me. I had always remembered Dr. Rios’ comment about her high suicide risk. In reading about this incident in her chart, though, I was reminded about what I did in response, which made sense to me at the time.
I had learned a lot about cognitive techniques as a therapist-in-training during graduate school. Back then cognitive therapy was starting to become widely used to treat many different issues. In order to help people feel better, cognitive therapy focuses on irrational or self-defeating thought patterns and helping people shift their thinking to be more realistic and healthy. After I learned about her suicidal crisis, I suggested Robin try implementing a specific cognitive strategy.
I figured, as long as Robin was always seeing suicide as an “out,” she was not putting as much energy as possible into healing and moving on with her life. I was still focused on trauma being her main issue and assumed if she could just focus her energy on processing her emotions more effectively, she would eventually heal. I suggested she work on shifting her thinking to incorporate the belief that suicide is just not an option. In hindsight, I imagine this intervention was partly unconsciously motivated by my own fear. I was scared at the time by what had just happened surrounding her deadline, and by what Dr. Rios had said. Whether Robin was ready to do this or not, I desperately wanted her to stop believing suicide was an option.
This cognitive intervention did make a significant difference for Robin. Shortly after we had this discussion I felt very gratified to hear her say she was going to try harder to focus on living and not dying. She began to talk more openly about her significant OCD symptoms and the rigid routines she felt compelled to follow. Robin was able to move out of her parents’ house and in with some friends. She returned to a previous job which worked well for her, because she was surrounded by other people her age and had a built-in social network. This job eventually became too stressful for her, which is what prompted the suicide attempt by carbon monoxide I never knew about. Instead of killing herself at that time she ended up quitting this job, finding a new one and fairly quickly getting back to a place of stability.
Robin’s severe OCD symptoms primarily revolved around sun tanning. She had an irrational need to be as tan as possible and would lay in the sun for many hours at a time without sunscreen. If it was sunny and warm outside and she was not able to lay in the sun, she would become anxious and obsessively preoccupied with the need to do so. She enjoyed tanning, but mostly Robin did not choose to tan because she enjoyed it. She felt compelled to lay in the sun to avoid feeling unbearably anxious. She spent much time and energy obsessing about the weather and focusing on getting “fresh color.” Because she knew how irrational this pattern was and did not want to “lose my respect,” Robin did not reveal to me that tanning was an obsessive-compulsive symptom until we had been working together for several years. I obviously noticed her deep tan, but she would just say she enjoyed laying in the sun. She eventually revealed the truth about these symptoms and we tried to address them in treatment.
Robin remained mostly stable for many years. She socialized with friends, generally enjoyed her work, and continued to feel better about herself. She was proud to move into her own apartment and to finally feel completely independent. We stopped meeting as regularly. Robin continued to see a psychiatrist for medication management and expressed a desire to check-in with me periodically because I represented “accountability” to her. Meeting with me helped her stay on track. We made attempts to work on decreasing her severe OCD symptoms with both medication and therapy, consistent with the latest research. Medication did not decrease these symptoms at all. With therapy, Robin was able to decrease her tanning time slightly, but this was the one issue she remained unable to overcome. Her life continued to revolve around laying in the sun during “tanning season” from May to September.
Robin and I started meeting more regularly again in 2002 when her depression worsened, and Dr. Greene and I worked closely to try to find the right medication combination to alleviate these symptoms. Her depression had always responded to antidepressant medications in the past. We kept trying different antidepressant medications, alone and in combination…right up to the time of her meltdown.
In March 2003, after I had re-read Robin’s whole chart and reviewed her history for myself without any light bulb answers coming forward, I decided to tell her about it when she came for her next session. I wanted to help her look at the big picture of her treatment, to recognize how much progress she had made, and to know I had a better understanding about how isolated she had been. At that point, the only explanation for her continuing severe depression that made sense to me was her complete disconnection from people. I wanted her to know this was something we could work on. I wanted to try to instill some hope that things were going to improve.
“I want you to know I read your chart from the beginning,” I explained to Robin. “I wanted to see if I missed something that might explain why you are having so much trouble. Basically the notes show we talked about your sexual abuse for the first couple of years, and then there was a turning point in 1995.” I reminded her about the episode with the deadline (minus Dr. Rios’ statement about her suicide risk, of course). I reminded her about my cognitive intervention and that she said she was going to focus more on living. We talked about her progress after that. I was not expecting to hear her response.
“That’s why I thought you would ditch me if I was too suicidal,” she said.
“What? Really? Why?” I asked.
“I don’t know,” she said. “I don’t remember. I just know that was the conversation that made me think it.”
Wow! The surprises just kept coming. All of a sudden, though, it made complete sense. Later in our treatment when we had tried to address her OCD symptoms I became painfully aware of the degree to which Robin’s severe cognitive rigidity made it very difficult for her to shift her thinking. She never was able to impact these symptoms significantly. In hindsight, I realized that to tell Robin she should try to eliminate suicide as an option in her mind had been ridiculous. To suggest she could somehow stop her brain from focusing on suicidal thoughts when she was depressed was a terrible thing to say. I was, in essence, unknowingly suggesting she should be able to control her severe OCD symptoms.
I realized that if I had talked to Dr. Rios in more detail about his statement that Robin was “at significant risk for suicide,” I might have gained a better understanding of her cognitive rigidity at that time. He seemed to understand what I did not. Had I talked to him I might have understood that I could not just suggest Robin change her thinking, and have it work that quickly. I would have talked much more about my cognitive intervention with her over time, to make sure we were on the same page. But, I did not. She had said at the time she was going to focus on living, and she then started to make significant progress. I didn’t question it. I had no idea she was actually motivated by the fear that I would ditch her, and that this fear kept her from being able to tell me when she was seriously suicidal. I realized my lack of experience in 1995 had caused a big misunderstanding over many years and had contributed to her feeling completely alone. Obviously there were many reasons she felt alone, but I felt bad about having contributed to it in any way.
Robin and I talked at length about the misunderstanding. I explained what I had been trying to say at the time, and why I said it. We talked about how easy it was for her to misinterpret it, given the impossibility of what I was asking her to do. I admitted I did not fully understand at that time how hard it was for her to shift her thinking, and I apologized for putting her in an impossible position. Robin was very forgiving, and we talked about how good it was that we “cleared that up.”
At the time of this discussion in March 2003, Robin was staying at her brother’s house and caring for her nephew. She said she did not think about suicide when she was with him, but when she was alone after putting him to bed she would get very depressed. She was sleeping, but not well, and said she was exhausted. She was continuing to spend time with friends and family to help decrease her sense of isolation. In our twice a week sessions we were talking about ways to prepare herself to return to work. And, we started to talk more about our relationship, which had clearly been affected by the misunderstanding about me ditching her.
“Robin, you have been much more open with me since you were hospitalized. How are you feeling about that?” I asked her one day.
“I feel more vulnerable,” she said. “It makes me anxious sometimes. I am afraid I’ll become too dependent.” She was not able to say what it meant to be too dependent, just that she would know it if she felt it.
“I know it makes you nervous to be vulnerable,” I said. “But I would never do anything intentionally to hurt you. Please tell me if you ever feel hurt by something I say or do, or if you feel too dependent and we will talk through it.” We talked about the need to have consistent contact as she transitioned back to work, which would be a stressful time for her. “I want you to know I think it is not only fine, but also a good idea for us to stay connected until you are feeling better. We will figure out the right balance in terms of contact once that happens.” We made plans to continue meeting twice a week, and to touch base by phone as needed. Because of the enormous anxiety she felt about calling me, we scheduled times to talk briefly on the phone in between our sessions.
As we talked about her impending return to her job, Robin seemed to be starting to think more rationally. She made contact with her boss to talk about returning to work as soon as her brother and sister-in-law got home. Although she seemed better, she continued to say she had thoughts of suicide when she wasn’t distracted by something else. When I asked if she would commit to staying alive beyond the time she was responsible for her nephew, she was not ready to make any promises but said she thought it would take “something bad happening” to cause her to become unable to manage her ongoing suicidal thoughts.
I was encouraged. I began to relax slightly and to think maybe, just maybe, we were on the right track. This was, however, short lived.
“I’m exhausted,” Robin said in a session during the time she was watching her nephew. I asked questions, as usual.
“Why do you think you are so exhausted?” I asked. “I know taking care of a toddler is tiring, but how are you sleeping?” Robin had told me earlier in the week that she skipped her nighttime dose of the antipsychotic medication one night because she had been afraid she wouldn’t wake up if her nephew needed her. She had slept so badly without it she immediately began to take it again.
“I skipped Geodon again last night,” Robin reluctantly confessed. “And I didn’t take any of my meds this morning. My friend from Chicago is visiting tonight and I don’t want to be on too many meds in case we drink.”
In case you drink? What? Just when I thought we were getting somewhere. “Robin, you can’t do this! You are just starting to feel better. If you start sabotaging treatment it will just get worse and you won’t be able to function when you go back to work. What are you doing?”
“It isn’t going to hurt to miss one day of my meds,” Robin rationalized.
“But you skipped Geodon earlier this week, and last night and this morning. It isn’t just one dose.” She could tell I was upset. “You need to get back on your meds as prescribed and for God’s sake, don’t drink!”
Robin’s affect was still flat. Her knee was bouncing. She knew I was not happy about what I was hearing. “I don’t think I’ll kill myself any time soon,” she said, trying to reassure me. “I just don’t want to keep living the way I’ve been living.”
“I know you feel awful,” I replied. “And I know how alone and isolated you’ve been for a long time. But we can work on that, and your life will get better. You need to be open with all the friends who have been so helpful over the last month. You need to keep working on being more open with your family. It would help if you can let all your people know how hard it is for you to keep reaching out to them. They’ll understand.”
I had been feeling the relief of knowing Robin’s support network had been mobilized and were continuing to regularly spend time with her. It helped me to not feel so alone with Robin in her pain. I guess I just assumed (or maybe hoped) she was also at least letting them know she was still depressed. I was wrong. With my new awareness of the degree to which being open with people caused severe anxiety for Robin, I should have expected her response.
“Now that the crisis has passed, I’ve told everyone I’m fine,” Robin said. “They believe me.”