I had no idea how Robin would react to the news that I thought she was having a mixed bipolar episode. I was very concerned. If I was right about her diagnosis, this would confirm she was experiencing impaired impulse control and judgment and was actually not able to control herself. It would explain completely why she was not acting like herself. Robin had said repeatedly she did not think she would kill herself unless something bad happened. Would this conversation qualify as the “something bad” which would push her over the edge? I hated to imagine this possibility and how devastated I would feel if this happened.
I nervously made the phone call. Robin was home for the morning, as she was still working half-days following her meltdown.
“Robin, I have something big to tell you,” I said. “I had an epiphany last night. I think the reason you’re feeling so out of control may be because you’re having a mixed bipolar episode.” I went on to tell her about the symptoms and how this would explain why we had been having so much trouble finding the right medication. “Dr. Greene agrees this may be what’s going on, and he will be talking to you about taking a mood stabilizer. If you have bipolar disorder, this could make all the difference. It could be the answer in terms of you getting back to feeling okay again.” I was trying to focus on the positives of the news I was giving her, knowing what a big deal it was for her to have to wrap her brain around it.
She seemed stunned, which was to be expected. “It would be a big adjustment for me to get used to this,” she said. I knew she would need some time to process this news. We made plans to talk on the phone later that day after she got home from work.
“I’m having a lot of anxiety,” Robin said when I called early that evening. “I’m afraid I’m not going to sleep tonight.” She acknowledged that the anxiety was likely related to the idea of having bipolar disorder. “I’m concerned about the side effects of Depakote.”
Depakote was the mood stabilizer Dr. Greene had chosen, as it was especially effective for mixed bipolar symptoms. We talked about her session with him, her concerns about being on Depakote, and her anxiety. She assured me she was not suicidal and said she needed time to process this new development.
I also needed to process this development, which had happened quickly following my sudden epiphany. How did both Dr. Greene and I go so long without either of us thinking about the possibility that Robin might have bipolar disorder? I felt bad about the fact that she had been depressed for over a year, trying medication after medication, and had only gotten worse. This made complete sense in the context of bipolar disorder since taking antidepressants without a mood stabilizer can actually make bipolar symptoms worse. In fact, Dr. Greene and I had decided to increase her antidepressant dose a few weeks prior to her meltdown, trying to get more aggressive about treating her ongoing, significant depression. That medication increase, I assumed, had probably contributed to her getting worse and may even have led to her meltdown.
I felt bad about that possibility, but I was not beating myself up too badly. I knew why we had never considered bipolar disorder. Robin had never had a typical manic or hypomanic episode, with elevated mood. She had never told me she felt unable to control her impulses, which was a hallmark symptom of mania. Both severe depression and mixed bipolar disorder could show depressed mood combined with enormous anxiety and agitation, and persistent insomnia. Robin had a trauma history, obsessive-compulsive disorder, obsessive-compulsive personality disorder and avoidant personality disorder, all of which caused anxiety. Insomnia was common for her and was completely explainable in terms of the severe anxiety that was an ongoing part of her life.
Most importantly, prior to the year before her meltdown, Robin’s depression symptoms had always been easily alleviated with antidepressants alone. These medications had never previously made her worse. Given all the facts, there had been no way for us to know she was experiencing bipolar symptoms until she got worse enough, and felt comfortable enough to tell me how out of control she felt. Her new willingness to be open about her symptoms, in addition to the symptoms worsening to the point where they were more obvious, had finally helped me shift. I was just sorry, for Robin’s sake, that it had taken so long for it to become clear. She had suffered, so much.
I prepared myself to talk to Robin in our session the day after I gave her the news. I was worried about her not being able to deal with this news well, especially given that she was not yet stabilized on the Depakote and was still very depressed.
“If I have bipolar disorder I’d have to accept a whole new identity,” Robin said. “I’m okay with having depression and taking medication for it. Lots of people take antidepressant medication. But having bipolar disorder would mean I’m chronically mentally ill. I’d have to take mood stabilizers and maybe antipsychotic meds for the rest of my life.” We talked in this session and in a phone call the next day after she finished work, about all of the ramifications for her of this identity shift. Having worked in the mental health field for so long, Robin was acutely aware of what it meant to have a severe and chronic mental illness. Her knowledge about the stigma associated with her potential new identity made it hard for her to imagine ever feeling okay about it.
Robin expressed fear about her tendency to feel, at times, compelled by her own brain to skip her medications and about how this would be a bigger problem if she had bipolar disorder. She processed the uncertainty in terms of what having bipolar disorder would mean for her future. Robin openly revealed that since adolescence she had felt “crazy” when she was especially depressed and anxious. This was consistent with the racing thoughts I suspected, in hindsight, she had been having while she was in the hospital. The perception that one’s thoughts are racing is another symptom of mania. Robin acknowledged that racing thoughts had been an issue which she had never before felt able to verbalize, and that this was when she felt especially crazy.
Robin asked me what she would experience if the Depakote started to work. I told her she would feel less crazy, more stable and hopefully would feel less despair.
“That would be a relief,” she said with no emotion.
As the weekend was approaching, I was met with the dilemma of whether to plan to talk to Robin on the phone, as we had done the previous weekend. I was torn. I knew what a big deal it was for her to be trying to integrate her new reality, especially in the context of not thinking clearly due to her likely bipolar symptoms. It seemed to warrant an extra phone call. But at the same time, I didn’t want to push her to have more contact with me than she was comfortable having. I knew her avoidant personality traits caused her to feel very anxious about being more open with me than she had ever been before with anyone. I didn’t want to make things any worse for her. I decided I needed to let Robin make the decision about whether to have contact that weekend. Her response was not surprising.
“I feel like I am getting too dependent,” she said. “It makes me uncomfortable.” She was not interested in scheduling a time to talk. She was getting increasingly anxious as she continued to process the bipolar issue and as she thought about returning to work full-time the following week. She said it would cause too much anxiety for her to plan to talk to me on the weekend. “I probably won’t call. But if I feel too unstable I will try to call you.”
It was the best I could expect. Robin was making herself very vulnerable by being so open. She said she was not used to talking to people about her self-proclaimed craziness. I was very concerned as I went home that weekend, knowing Robin would likely not call me or anyone else if she started feeling worse. I also knew that during a weekend with no plans and too much time to try to wrap her brain around her new reality, the likelihood of her getting worse was high.
These are the situations outpatient therapists dread. I could not hospitalize Robin against her will. She was not psychotic and was insisting she was not planning to kill herself that weekend. Under the circumstances Dr. Greene would certainly have hospitalized her if she would have gone voluntarily, but she didn’t want this.
I spent most of the weekend feeling anxious and worried, knowing Robin needed me to leave her alone in her anxiety and despair. Part of me was surprised, and part of me was not surprised when she called me on Sunday afternoon.
“I drank a couple of wine coolers to get my nerve up to call you,” Robin admitted. “I went to my parents’ house to tan and talked to my brother. I tried calling Christi but she wasn’t home. I’ve been reading on-line about bipolar disorder but I don’t understand mixed episodes. I don’t know whether I have it or not.”
“Robin, we need to take one step at a time,” I replied. “Let’s see if the Depakote helps. We should know in the next few days and that will help us know if bipolar disorder is the issue.”
Robin talked about her anxiety and fear about returning to work full-time the next day. It had only been a week and a half since she had returned part-time following her hospitalization and medical leave, and it had been stressful. She said she was thinking about calling off work, saying she was sick. I asked about whether she felt safe, or whether she needed to be in the hospital.
“I don’t want to go the hospital and I’m not planning to kill myself,” she said. “But I’ll probably keep drinking.” We began to debate about drinking, as we had the previous weekend. I expressed my concern about how this could make her feel worse and impact her already fragile impulse control. She seemed to be trying to get me off the phone. I didn’t want to battle with her and make her more likely to destabilize. I knew how hard it was for her to call me, and I didn’t want this call to end badly. “I will read some magazines and go to bed early,” Robin said.
We hung up. What a nightmare! I knew Robin was not okay, but I had no good options. I battled with myself for a while, trying to figure out whether I should do something and, if so, what. I was still hesitant to involve Robin’s family, who had no idea she was struggling. Robin would feel hurt, angry and betrayed if I involved them without telling her. If I was sure it was a life threatening situation, I wouldn’t have hesitated. But I wasn’t. It didn’t make sense to violate Robin’s trust.
During the time I was a therapist, as an anxious person I would almost always worry when I was in a situation with a depressed client who I knew was having serious suicidal thoughts. But as long as I felt I had done what I could do, and they were telling me they were not planning to kill themselves, it was not up to me to do anything more. Making contact with a client just to relieve my own anxiety would be completely inappropriate. It would send the message that the client was too fragile to make his or her own decisions, and it would just contribute to fostering an unhealthy dependency within the relationship. On that Sunday, part of me was telling myself the right thing to do was to manage my own anxiety and trust Robin to make it through the evening.
But then there was my gut, screaming at me. This was not a typical situation. Robin had just been told she may have bipolar disorder, was aware of and trying to process the ramifications of that, and was facing an enormous stressor of having to go to work full-time the next day. If I was right about the bipolar diagnosis, her impulse control and judgment were impaired anyway and she had already started drinking which would make it worse. And most importantly, Robin had called me. She had almost never called me, in our decade long relationship. It was a big deal. She had to drink wine coolers to “work up the nerve.” There was something she wanted me to know.
An hour or two had passed after our phone conversation when my gut finally won the battle I was having with myself about what to do. I called her back.
“Robin, I am so sorry if it makes you anxious to talk to me again, but something told me to call you and find out if you are okay.”
“I’m in my car driving around,” Robin said. We talked for a while and she sounded even more depressed and hopeless than when we had talked earlier. But the insightful Robin was also still there. “I know I’m making bad decisions. I’m mad at myself. I’m out of control,” she said.
“Robin, I think you need to be in the hospital,” I immediately told her. And, just like the day of her meltdown, she did not argue. She agreed to go home, pack her things and meet me there. I called ahead, talked to the emergency services staff and told them we were coming. I was relieved, knowing Robin would be safe.
We met at the hospital where I again sat with her by the big fish tank in the lobby while the admissions staff worked to get approval from her insurance company. It was two months after the day she was first hospitalized. Robin looked exhausted and anxious at the same time. Her leg was bouncing more vigorously than usual. Her affect, as it had been for the previous two months, was flat.
“I drank more than I told you,” she confessed. It was one of her obsessive-compulsive rules to tell me whenever she engaged in self-destructive behavior. This had been the case throughout our decade long therapy relationship.
“How much?” I asked, horrified that she had driven home and back to the hospital. She had not sounded drunk on the phone when we had talked. She was not looking or acting intoxicated.
“I don’t know,” she replied. “But I’m pretty drunk.”
Wow! Thank God I had trusted my gut and called her back that day. As we sat in the lobby of the hospital, by the fish tank, Robin revealed she had been drinking vodka while she was driving around. She could have killed someone else in addition to herself! I felt clear I had made the right decision by calling her back. I let the admissions counselor at the hospital know Robin had much more to drink than she had previously said. I wanted the staff on the unit to be aware she was intoxicated. I told Robin I would be in touch the next day.
The next morning, Dr. Greene and I talked. I needed to make sure we were on the same page about her diagnosis. There was still the issue of the hospital staff believing Robin had borderline personality disorder. Dr. Greene had agreed bipolar disorder was a strong possibility, but I didn’t know if he would still think it was appropriate for me to treat her while she was in the hospital. If she had borderline personality disorder, this would not have been a good idea. I would have been reinforcing self-destructive behavior, which would not have been therapeutic. I was relieved Dr. Greene agreed that I needed to continue to be involved during Robin’s hospitalization.
Robin’s second hospitalization, in March 2003, lasted three days. She was more open with the staff than she had been in her first hospitalization but did not attend the groups. Dr. Greene increased her dose of Depakote. Within two days, Robin said she wanted to go home.
“I screwed up by drinking,” she said. “I need to work harder to avoid alcohol.” Robin and I set up a safety plan which included getting rid of all the alcohol in her apartment, and making social plans to fill the next weekend so she would not be so isolated.
Robin was discharged from the hospital with the plan of returning to her job half-time the rest of that week and full-time the next week. Her affect actually appeared brighter than it had in a long time, and she said her suicidal thoughts were minimal. She was sleeping well. Her thoughts were no longer racing and her knee was no longer bouncing. I was sure the Depakote was starting to take effect.
For the first time in over a year, I felt hopeful that we were on the right track in terms of Robin’s treatment. I believed the mixed bipolar disorder diagnosis was the answer, and that as the Depakote continued to take effect Robin would soon be feeling and functioning much better than she had in a long time. I wrote in my journal:
“I am feeling much more hopeful about Robin’s situation. Bipolar disorder just makes sense. She is tolerating the Depakote and I think it is going to cause her to feel dramatically better soon. What a relief! I plan to keep in close touch with her until I know she is feeling more stable, and then we will process our relationship and the amount of contact we need to have. It has been a long haul over the past two months. I can’t wait to see her feeling better!”
I had no idea how wrong I would turn out to be.