After six weeks of medical leave, Robin had been back to work for only two half-days following her meltdown and was stressed about getting through a weekend with no social plans. When I got the voice mail at 4:00 pm that Friday saying she was upset about her Jeep and was going to get drunk, I was deeply concerned. She continued to demonstrate behavior that was so unlike the person I had known for so long.
At that time in my career I don’t think I had ever talked to a client from home and, if so, never on a weekend. The agency where I worked had 24 hour emergency coverage which allowed outpatient therapists to maintain strict limits in terms of client contact. I had never heard any of my colleagues say they had talked to a client from home. Work time was work time. After work, we let the emergency services department cover for us. These boundaries allowed for re-energizing between long, stressful days of seeing five or six therapy clients per day, and served as a way to help clients keep from becoming overly dependent on us. When Robin was clearly worried about getting through the weekend on that Friday in March 2003, it never crossed my mind to suggest we talk while I was at home…despite me saying earlier in the week I would be much more available to her.
When I got the voice mail from Robin saying “I’m going to drink until I pass out,” I immediately called her.
“I’ve already started drinking,” she said. I asked her to stop and she refused.
“Robin, you are depressed and suicidal,” I said firmly. “Drinking decreases your impulse control. I’m worried about what you’ll do once you are drunk.” She was alone in her apartment and everyone in her life, other than me, thought the crisis had passed and she was doing fine. Knowing she would not tell her people she needed support from them, I was very concerned.
“If I feel too suicidal I’ll call the emergency services,” Robin said, obviously humoring me. We both knew there was no chance she would do this. I confronted her.
“You’re right,” she said, already feeling the effects of the vodka she was drinking. “That’s unlikely.”
“Do you need to be back in the hospital?” I asked. It was actually the last thing I wanted to have happen, as I did not want to have to deal with the hospital staff again about Robin being difficult. But, I was genuinely worried for her safety…more than I had been since the day of her meltdown two months earlier. Robin was adamant that she did not want to go back to the hospital.
“I’m just going to drink and go to sleep,” she said, trying to reassure me. “I’m sure I’ll wake up tomorrow feeling better.” Not likely, I thought.
I was in a horrible position. I did not want to hospitalize Robin against her will. That would require having the police go to her apartment and forcibly bring her to the hospital. I did not think she actually met the criteria for being “detained” anyway, as she was denying any plans of hurting herself in the immediate future. Robin had signed Release of Information forms for me to talk to family and friends. I could have called one of them and asked them to go check on her, but I was concerned this would destroy the new level of trust we were developing. I knew I could not just leave things the way they were and go home for the weekend. I was too worried, knowing Robin was so depressed, isolated, suicidal and drinking. Judgment calls about suicidal clients were a routine part of being a full-time therapist at a big mental health agency. I knew I needed to do something, but I wasn’t clear what that was.
I was happy to discover my supervisor was still at work late on that Friday afternoon. I needed to consult with someone I trusted. We had worked together for a number of years, and Judith had been a mentor to me. She had lots of experience and was highly regarded by clinicians within the agency and throughout the community. She knew about Robin’s meltdown, as I had been consulting with her from the beginning.
“Judith, I need your help,” I said, and explained the situation. “I’m really concerned about her safety.” Judith was one of the people I had consulted about the issue of whether to extend the boundaries with Robin. We had talked through my belief that she did not have borderline personality disorder despite the hospital staff’s opinion. Like my friend Giselle had earlier in the week, Judith helped me immensely on that Friday afternoon by making a simple, obvious statement.
“Sharon,” said Judith. “Why don’t you just plan to check in with Robin by phone over the weekend?”
Of course. What a wake-up call! It is unbelievable to me now that I felt so unable to make this decision for myself. But, it was as if I needed Judith’s permission to violate what felt like an absolute rule of therapy, at least at that agency at that time. My own obsessive-compulsiveness kept me from being able to be more flexible. I had told Robin earlier in the week I was going to be more available, and then when she was vulnerably saying she was worried about getting through the weekend I had stayed within my usual rigid boundaries. The people who believed Robin had borderline personality disorder might have thought I was reinforcing self-destructive behavior by doing what I did next. I will forever be grateful to Judith for trusting my judgment enough to know this was not the case. I called Robin back.
“Robin, it’s me. I didn’t like the way we left things when we talked earlier.” She was still drinking and sounded slightly intoxicated, but was still relatively coherent.
“After we hung up I called a friend of mine from college who lives in Nebraska and told her what’s going on,” she said. “She’s going to call me later tonight.” Wow! This surprised me. I never imagined she would be open with any of her friends.
“I thought you were mad at me,” she said. Apparently her fear of making me angry motivated her to actually reach out to one of her friends and be honest. Granted, it was a friend from another state with whom she rarely had contact, but this was significant and was a good sign.
“No Robin, I’m not mad at you. I’m worried. I’m concerned about you doing something while you are drunk that you wouldn’t do when you’re sober. You’re depressed and having suicidal thoughts. I just want you to be safe.”
“I’m horrified by how fast I crashed,” she said. “I know I’ll have trouble facing you on Monday after behaving so badly.”
Okay, there was a moment of clarity about the destructiveness of what she was doing. I tried again to get her to agree to stop drinking and pour out her alcohol. After some negotiation she did agree to stop drinking for the evening. I promised to touch base with her by phone in the morning.
Since Robin had called a friend and had agreed to stop drinking, I felt like I was reinforcing positive behavior by planning to talk on Saturday. I very was glad I had consulted with Judith and realized I needed to be more flexible. Making the significant shift, to feeling able to talk to Robin on the phone after work hours, would become crucial to keeping her alive over the subsequent months. In the case of that particular weekend it was instrumental in helping me realize that Robin had been misdiagnosed…for a decade.
The next morning I called Robin as planned and asked her how she was doing. “I screwed up,” she said sheepishly. “I’m completely hung over. I know drinking was a huge mistake.”
“Do you need to be in the hospital, Robin?”
“I’ve been wondering that myself,” she said. “I’m horrified about how I acted yesterday. I’m not stable. It scares me how fast I crashed and how stupid I was.” She seemed genuinely frightened by her own behavior.
We talked about the pros and cons of having her go to the hospital and mutually decided the only benefit would be keeping her safe, which seemed like less of an issue than it had the previous day. “It would just cause more problems,” Robin said. “I’d have to take more time off work, when I just went back.” She was also worried about the financial obligation of returning to the hospital, since she did not know yet what she would owe from her previous three week hospital stay.
We talked about her plans for the weekend. “I was throwing up all night after drinking so much,” she said. “I don’t think I could kill myself now even if I wanted to, because I would just throw up whatever pills I take.” We discussed that she had no other viable methods for killing herself available.
Robin then said yet another surprising thing. “I’m wondering if I subconsciously got drunk to make you mad enough to ditch me. It would be easier to kill myself if you would just ditch me.”
Wow! There was the insightful Robin I knew. Not only were we having a rational discussion about whether she should be hospitalized, but she was thinking about and openly discussing her feelings about our relationship. I had gotten through to her! It was impacting her to know she would hurt me if she killed herself. Thank God.
At the same time, I was just beginning to grasp the degree to which Robin felt unable to control herself, and the fear this caused for her. She seemed to be trying to make sense of her own behavior. Robin felt bad enough about drinking the night before, and guilty enough about me calling her on the weekend, that she assured me she felt she would be okay until our scheduled session on Monday. I believed her. She was sounding more rational than she had in a long time.
In our Monday session, Robin continued to be more open with me than ever before. “I feel out of control,” she said. “I’m worried about what’ll happen if I get any more bad news. I’m not planning to kill myself at this point, but I still hate myself, hate my life, and wish I were dead.”
Robin went on to openly talk about how her obsessive brain was continuing to focus on suicide. She was able to verbalize the internal battle being waged in her mind. She said she had gotten online over the weekend to research more specifics about ways to kill herself. At the same time, she said “It makes me uncomfortable to get more attached to you because it will only make it harder to kill myself. But I keep coming to therapy and taking my meds. And, I called you last Friday even though I usually would never do that. Part of me clearly wants help and wants to live.”
What a relief it was to hear Robin say this. Thank God! It was her willingness to finally be completely open about what she was really experiencing that allowed me to begin to think about her situation and symptoms differently. Her very sudden mood shift, followed by impulsive self-destructive behavior and then genuine fear about feeling so completely unable to control herself, made me start thinking she might benefit from a mood stabilizing medication. Robin was scheduled to meet with Dr. Greene two days later, and I planned to talk to him about this option.
The next evening I was at home, thinking about Robin and what had happened. Mood stabilizing medications are usually used for people with Bipolar Disorder. Wait a minute! Bipolar Disorder? All of a sudden my brain was reeling. It felt like I couldn’t keep up with my thoughts as I was instantly processing many things all at the same time.
Bipolar Disorder comes in several forms. Most people are familiar with the typical bipolar pattern of depression alternating with mania. During an episode of mania people feel very happy, energetic, don’t need sleep and often do impulsive things they later regret. In its more severe form, bipolar mania often causes psychotic symptoms including hallucinations (hearing or seeing things that are not there) or delusions (believing things that are not real). A milder version, hypomania, causes all the typical symptoms of mania but not psychosis.
Robin had never shown signs of typical mania or even hypomania. She never had periods of elevated mood. The idea of her having bipolar disorder had never before entered my mind. But, there is a version of bipolar disorder less well known to people called “mixed mania,” or “a mixed episode” in which people experience symptoms of both depression and mania at the same time. All of a sudden, as I was thinking about letting Dr. Greene know I thought Robin needed a mood stabilizer, I had an “epiphany.” That word came to my mind, even before I remembered this was the name of Robin’s cat. Maybe Robin was having a mixed bipolar episode!
I had been to the conference in Florida on psychopharmacology two months earlier, right after Robin got out of the hospital. I learned more about mixed bipolar episodes than I had known before. The presenter was making a big deal about it, because it is often difficult to distinguish the difference between a mixed bipolar episode, and an episode of severe depression accompanied by significant anxiety. I remembered him saying it was crucial to be able to make this distinction because, “giving antidepressant medications to someone with bipolar disorder, without a mood stabilizer on board first, can make them worse.”
In the moments of trying to wrap my brain around the epiphany I was having, I ran to get the materials from that conference. I remembered the presenter had talked about how to identify a mixed bipolar episode, but I didn’t remember what he had said.
I found the handouts. There was one slide from his presentation that said it all. I was suddenly clear. The slide had the four distinguishing characteristics of “a mixed state”: “Unrelenting Dysphoria, Marked Irritability, Severe Agitation/Anxiety, Intractable Insomnia.”
Oh my God! It suddenly all made sense. Dysphoria is depressed mood, which certainly fit. This was why Robin had not responded to multiple antidepressant medications for the past year. It explained why her affect had been completely flat for so long and she was so depressed. This was why she was so irritable, which was so unlike her. It was why she was being so impulsively self-destructive and feeling unable to control herself. It was why her leg bounced all the time, a clear sign of psychomotor agitation. She was experiencing a mixed bipolar episode!
As I thought about it more, Robin’s reaction to all the medication changes Dr. Greene and I had collaboratively made in the previous year suddenly made sense. It was just becoming clear in the psychiatric field at that time, and the presenter at the conference had talked about this. The newer antipsychotics, including Geodon, had somewhat of a mood stabilizing effect. Robin was only able to sleep when she took Geodon. She got worse when had gone off of it. But Geodon was not known primarily as a mood stabilizer. That was a whole different category of medications, and Robin clearly needed one!
Thankfully, Robin was scheduled to see Dr. Greene at noon the day after I realized all of this. I called him first thing in the morning.
“Dr. Greene, I had an epiphany about Robin!” I said.”
“Oh good, I love epiphanies,” he replied. We had a good working relationship, and he was eager to hear what I had to say.
“Think about everything that has happened with Robin. Now think about it in a different context. Think mixed bipolar disorder,” I said. I went on to explain my thinking and all the things I had realized. I talked about another symptom of mixed mania, racing thoughts, which in hindsight Robin had seemed to be experiencing when she was in the hospital, before Dr. Greene prescribed the Geodon.
“I think you may be right,” he said. “That would explain a lot of things.” We talked about the fact that he was scheduled to see her at noon that day. I told him I thought I needed to be the one to tell Robin what we were thinking, and I would talk to her on the phone before she saw him. He agreed to prescribe a mood stabilizer and to educate Robin about it.
I hung up, feeling relieved that Dr. Greene and I were on the same page. I had not been happy about him thinking Robin had borderline personality traits, when I did not. Before we talked, I had not been sure he would agree with my opinion about bipolar disorder. I had about a minute to feel relieved after our conversation. I had to make a phone call quickly so I could have a serious conversation with Robin before she saw Dr. Greene at noon that day. I had been so focused on the necessary conversation I needed to have with Dr. Greene, I had not even begun to process the ramifications of telling Robin.
All of a sudden it sunk in. I had to call Robin and tell her I thought she had bipolar disorder!