Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.
Prior to her second hospitalization and prior to my epiphany about her diagnosis, I made a decision to have Robin complete a daily record of various pieces of information. The record sheet, which I constructed myself and photocopied for her to fill out each day and bring to our sessions, asked her to report the number of hours she slept, significant events of the day, what she ate, whether she took her medication as prescribed, positive coping skills she utilized, if she drank any alcohol, and, if so, how much. I also had her rate several factors on a scale from one to ten including depression, anxiety, suicidal thoughts, urges to drink alcohol and urges to self-harm. There were many reasons I decided to ask her to complete these record sheets on a daily basis.
Mostly, I wanted the information. I wanted to know if Robin was getting better or worse. I also hoped that having to actually write down whether she took her meds, what she ate, whether she drank and all the other information would help her to stay honest and accountable to me. I hoped that if she had to write these things down for me to see, it would help motivate her to focus on avoiding self-destructive behavior.
I have to admit, though, that I had an ulterior motive in asking Robin to complete these daily record sheets. Once I realized she had gotten back to “faking it” with her family and friends following her first hospitalization, I was right back to feeling very alone in the stressful situation of being Robin’s only confidant. I was the only person who really knew what she was thinking and feeling and how much pain she was experiencing. And, I felt clear the possibility of Robin eventually killing herself was still high.
As I continued to witness Robin’s never ending excruciating pain, I thought a lot about her family. I had only met her parents once and her brother twice, but I had heard nothing but positive things from Robin about how supportive they were. When I met them I really liked them. I thought about how shocked they would be if Robin committed suicide, given the extent she was minimizing her difficulties. I knew they would be completely devastated and would have many questions. One of the reasons I wanted Robin to complete the daily record sheets, in her own words and handwriting, was to help her family understand, if it came to that, how much she was suffering.
Robin actually asked me at some point during that time if I would promise to help her family understand “if something happened to her.” Needless to say, I did not tell Robin this was one of my motivations when I asked her to fill out the record sheets. But it did make me feel better to know I had something other than my therapy notes to document her ongoing pain and the extent to which she was battling with herself.
After her second hospitalization in March 2003, Robin’s record sheets reflected that she was doing better. This felt miraculous to me after the intense time we had been through for over two months. I assumed the mood stabilizer, Depakote, was starting to take effect. The record sheets, which Robin brought to our first session following her discharge from the hospital, indicated that her depression and suicidal thoughts, as well as her urges to drink and self-mutilate had all decreased.
“I feel more stable,” said Robin. “I feel like I can control myself better. But I’m having a bad day. I found out it’s going to cost about $500 more than I thought to get Chuck fixed. I’m getting really stressed about my finances.”
Robin had never been very open with me about her financial situation. She had made reference to having debt, mostly connected to periods of time when she had been unemployed between jobs. But she had never talked about being particularly stressed about money.
“I don’t really feel like I’m up to going back to work full-time,” Robin went on to explain. “I have to. I can’t afford to go any more time without my full income. But I’m exhausted. I think the Depakote is making me really tired.” This was possible. Dr. Greene had increased her Depakote dose when Robin was in the hospital. Fatigue could certainly be one of the side effects. I knew it might improve as she kept taking the medication, or it might not. We talked about her scheduled appointment to see Dr. Greene the following week. I told her he could certainly make adjustments to her medications if she continued to be too tired.
“Robin, how are you feeling about being more open and vulnerable with me?” I asked before we ended our session that day. I needed to know how much contact she felt she needed, so we could plan whether to schedule a phone call before our next session. “I feel like I’m getting too dependent,” Robin said. “It makes me anxious.” She was unable to verbalize what being too dependent meant, but it didn’t matter. Since she was feeling more stable, I needed to back off and let her get some distance.
I felt like I needed to get distance too. I had been expending significant emotional energy during the time when it was clear Robin was not okay. Worrying about her safety non-stop for over two months had taken a toll on me, and I needed to get back to my normal routine. She was finally doing better. I believed we had gotten her diagnosis right and things would continue to improve with the addition of Depakote. I was just as ready as Robin was to tone down our contact, as long as she was safe.
After some discussion, Robin and I made a plan to return to once a week sessions. We had been meeting twice a week during the previous two months. Since she had enormous anxiety about calling me, I made sure to plan times to touch base by phone. I still felt clear I needed to keep track of how she was doing, and she needed to stay connected enough that she didn’t feel so alone. So we planned to talk briefly on the phone on Mondays and Fridays and to have our therapy sessions on Wednesdays.
Robin called the next Monday after she finished her first full day at work. “I’m feeling worse,” she said. “I felt like I was zoning out all day (dissociating). It was really hard to do what I needed to do. All I want to do is sleep.”
“Oh no! I’m so sorry, Robin,” I said. This was terrible! If she couldn’t work I knew she would start feeling more and more stressed about her finances. I knew she could not tolerate asking her family, who had helped pay for the repairs to her Jeep, for any more money. I knew being unable to work would only compound her anxiety and depression and make it much harder for Dr. Greene and I to get and keep her stabilized. The brief relief and hopefulness I had felt the previous week disappeared instantly.
“Are you having suicidal thoughts?” I asked for what seemed like the millionth time. I felt like I knew the answer, but I needed to find out how severe her thoughts were and her level of immediate risk.
“Yes, but I’m not going to kill myself,” Robin replied. “But, I don’t think I can keep doing this much longer.” I could hear the hopelessness in her voice. I understood it. She had been feeling so bad for such a long time. The reprieve we had both felt the previous week seemed very far away at that moment. I could feel her disappointment about continuing to feel overwhelmed with despair. I felt it too. I wished I could do something to make things better for her.
“I’m scheduled for supervision tomorrow. I don’t know if I’ll be able to go to work, but if I do I’ll have to talk to Jennifer about what’s going on,” Robin said. I had a release of information form signed for Jennifer, her supervisor. I told her to have Jennifer call me if either of them thought that would be helpful.
“Robin, let me talk to Dr. Greene about how bad you are feeling. I don’t know whether it’s Depakote side effects or whether he needs to tweak your meds. But we’ll do something and we’ll get you feeling better.” I tried desperately to help her feel more hopeful. And, I needed Dr. Greene’s help. The Depakote seemed to be helping Robin feel more in control, and she seemed to be thinking more clearly. She was not being self-destructive in any way. But she was exhausted and seemed to be stabilized at such a depressed level.
Before her second hospitalization Robin had been taking two different antidepressant medications, Paxil and Wellbutrin, in addition to the antipsychotic Geodon and an antianxiety medication, Ativan, which helped her sleep. When Dr. Greene agreed she was likely experiencing a bipolar mixed episode he added Depakote and stopped the Wellbutrin, which he feared was exacerbating her mixed mania.
“Dr. Greene, I’m concerned about Robin,” I said when I called him. “Her mania symptoms are gone, but her depression is worse, and she is exhausted.” I loved that we had such a good working relationship that I could just call him and he would trust my report of what was going on.
“Tell Robin to decrease the Depakote from three times a day to two. And tell her to re-start Wellbutrin,” he said. Dr. Greene and I agreed that while taking both Depakote and Geodon, it was more likely that re-starting the Wellbutrin would help Robin’s depression without causing mania. And she was probably more depressed because it had been leaving her system.
I called Robin to let her know Dr. Greene’s instructions. She agreed to follow them and said she was planning to talk to Jennifer, her supervisor, at work that day. “I’ll have her call you if she wants to. You can tell her anything,” Robin said. “I need her to understand what’s going on, and I don’t think I can explain it very well. I’ll be too anxious about talking to her.”
I received a call from Jennifer later that day. “Robin’s psychiatrist and I both believe we are finally on the right track in terms of getting her stabilized,” I said to her. “We believe she has bipolar disorder, and now that we are treating it I think she will be getting better.” I hoped I was right. “Robin is really worried about losing her job,” I said. “Does she need to worry about that?”
“Robin and I talked today about ways to decrease her caseload so her days aren’t so long,” Jennifer said. “We do not want to lose her. She’s a great case manager.”
“I know Robin is really stressed,” I said. “But do you have any concerns about whether she is doing her job adequately? Is she doing what she needs to do with the clients she has?” Jennifer and I agreed that, despite her significant depression, Robin seemed to have good judgment about what she should and should not do with her clients.
“I trust Robin to let me know if she’s feeling unable to manage the responsibilities of her job,” Jennifer said. I was relieved to hear this. I had always found Robin to be very insightful, and her ability to fake it even in the midst of a mixed bipolar episode was astonishing to me. But it was good to have confirmation from Jennifer that Robin was a valued employee, that her judgment was trusted, and that she did not have to worry about losing her job. I looked forward to telling Robin this in our session the next day so I could reassure her.
“I almost feel manic,” Robin said the next day when we met. She had decreased the Depakote and restarted Wellbutrin per Dr. Greene’s instructions. “I have more energy, but I’m worried that it’s too much.” We talked it through and made plans to monitor her symptoms closely following the most recent medication adjustment. Thankfully, Robin said her suicidal thoughts were “a little bit less.”
I felt fairly confident that Dr. Greene’s decision to re-start Wellbutrin would help Robin’s depression and that the combination of Depakote and Geodon would keep the mania under control. I tried to reassure Robin that this was likely. I decided to talk about the big picture of our treatment in order to help her feel more hopeful that her life, overall, could improve now that I believed we were on the right track.
“Robin, I want you to know I think a big part of why you have been so depressed is that you have been completely isolated,” I said. “Now that you have been more open with me, and we are on the right track with the medications, I think you will start to feel better. I know it makes you anxious to be so vulnerable with me, but I do think it will get easier.”
“I want to be closer to people,” Robin bravely admitted. “But it’s really hard for me to trust. And it just makes me uncomfortable. I feel too dependent because I know it isn’t realistic to continue to be close to you. I’m just another one of your crazy patients.”
Wow! I was shocked she was willing to be so vulnerable and so direct. This was great. “Robin, therapy is a process. Right now it’s okay for you to be dependent on me as you get used to feeling close to someone. But you also have to be working on being more open with other people in your life. I can’t be the only one, or then it does become unhealthy. At some point, when you are more comfortable being close to other people, it will feel okay to distance from me.” I suggested we have another session with her parents in order to help her begin to stop faking it with the important people in her life. I was surprised and pleased to hear her agree. She said she would talk to them about scheduling something.
Before Robin left our session that day, she anxiously pulled something from the bag she always carried with her. It was kind of a big purse and kind of a tote bag. I had no idea what was coming. “I made a CD of songs I listen to when I’m really depressed,” Robin said. “I have a hard time explaining how I feel then. If you want to listen, these songs reflect it.”
I was honored. Robin was continuing to make herself more vulnerable even though it made her very anxious. I told her I would be glad to listen to the CD in order to better understand her feelings. I told her I would listen to it over the weekend, and we would talk about it in our session the following week.
We talked on the phone on that Friday, per our agreed upon schedule of contact, but I was not prepared for what I was to hear.
“I feel less manic than I did,” Robin said. “But I feel more sad and depressed.” We talked about the fact that this was actually a good sign since it was too soon for the Wellbutrin to be helping and feeling manic may have meant she wasn’t on enough Depakote.
“I forgot to take my meds last night and woke up at midnight,” she said. “I didn’t realize it until 2:30 am, and I didn’t want to take them then and sleep through my alarm. But then I never got back to sleep.” I believed her. She would have told me if she had purposely skipped her meds.
“It was a really long day at work but I made it through,” she said. Robin sounded exhausted and more depressed than I had heard her sound in a while. She admitted her suicidal thoughts were “about an eight” on the one to ten scale, but assured me she would not hurt herself over the weekend. She agreed to call me if she felt unable to manage and stay safe. I debated about suggesting we talk over the weekend, but I wanted to honor her previous request to decrease our contact so she would not feel too dependent. She was saying she felt more in control of herself, and she was promising she would call if she felt unable to stay safe. To suggest having contact would have been to alleviate my own anxiety, which was inappropriate. I didn’t mention it.
That weekend I listened to Robin’s CD. I was unfamiliar with the majority of the songs she had chosen. Although I was a very avid listener of music and had my own share of melancholy songs in my library, I was not drawn to the kind of music Robin shared with me, and I was not prepared for my reaction when listening to the CD.
It was the beginning of April 2003. As I said, I had devoted much emotional energy to riding the rollercoaster of Robin’s intense despair, self-destructiveness, hopelessness and complete isolation for over two months following her initial hospitalization in January. My gut felt completely clear I had been doing the right thing by serving as a life-line for Robin who was unable to be open with anyone else. I knew intellectually I was the only person in her life who could have tolerated hearing the details of her obsessive self-destructive thinking. But, while listening to Robin’s CD, I suddenly, for the first time, began to fully grasp her reality on an emotional level. I realized she was only just beginning to be able to share with me her real experience. Feeling it was overwhelming to me.
The CD was titled Sorrow. The songs reflected enormous amounts of pain, loneliness, hopelessness and depression. As I sat alone in my house, listening to the CD and grasping on a whole new emotional level the degree of pain she had felt for so long, I sobbed.
I believed we were finally on the right track in terms of her treatment. I felt clear about what needed to happen for her to feel better than she ever had before. She needed to let people in and stop feeling so isolated. But, I also knew that even after her brain chemistry was stabilized it would be a long process, and not an easy one, to help Robin become more open with and feel close to other people. I didn’t know if she was going to be able to hang on long enough or tolerate the anxiety it would cause for her to get there. I honestly didn’t know if she was going to survive.