During the time Robin was experiencing the aftermath of her meltdown in 2003 I had been a psychologist for a little over ten years. I had been working at the same agency from the time I had begun my career in 1992. It was a large agency which was the community mental health center (CMHC) for the small Midwestern city in which we lived. Being a CMHC meant the agency had the mission of treating anyone from the county who needed mental health treatment, regardless of their ability to pay for those services. Insurance was accepted, a sliding fee based on income was in place, and some state funds were awarded to the CMHC in order to defray the costs of providing a continuum of care ranging from outpatient treatment to inpatient or residential care for all ages. It was a large, rapidly growing agency which, at its height, served 18,000 clients per year.
Working at this agency meant I saw a large variety of adult outpatient clients. In order to make the budget work, the administrators of the agency expected full-time clinicians to see a certain number of clients per week. This expectation helped ensure enough billing was done to help keep the agency financially stable.
I have a version of obsessive-compulsive personality traits similar to Robin’s, only a bit milder. This means I have always been a responsible, reliable, detail-oriented person and employee. I always made sure I met the expectations placed on me by the agency, including seeing the appropriate number of clients and completing my paperwork in a timely fashion. To not meet those expectations created anxiety for me, as I always worried about job security and about the approval of those for whom I worked.
The administrators of the agency kept trying to promote me to a management position, most likely because I was meeting the high expectations of the job, and they wanted me to help make sure others did as well. Like Robin, though, my obsessive-compulsive personality traits meant I was easily stressed by change. I liked being a therapist and was very nervous about doing anything else. I didn’t want to take on responsibility for other people, as I was afraid it would be too stressful for me. The agency was financially stable, and I knew as long as I met my expectations I didn’t have to worry about job security. I felt comfortable with the predictable routine of seeing my clients and doing my paperwork.
Unfortunately, the expectations of the job were unsustainable for me over the long haul without a certain amount of burnout. I found myself, over time, beginning to become very tired and stressed by the volume of people I was expected to treat. It was rewarding for me to be a therapist, and I was receiving good feedback from clients, colleagues and referral sources about my work. But, I was burning out because of the sheer number of hours I was spending every day, day after day and year after year, immersed in the depths of other people’s pain. I came home from work every evening exhausted. It was hard for me to find the energy to do anything other than my job. I began to feel unable to be as emotionally present in my work or in my personal relationships as I needed to be. It didn’t feel right, either for me or for the clients I was responsible for treating.
In 1998, I made the decision to take a twenty percent pay cut in exchange for decreasing the number of clients I was supposed to see per day. I continued to work full-time hours, but was expected to see twenty percent fewer clients. The pay cut was well worth it, as the decrease in volume allowed me to regain my balance in terms of feeling able to manage the stress of the job and my sense of being emotionally present. In January 2003, when Robin was first hospitalized, I was comfortably settled into this routine and was generally happy with my career. I was confident in my abilities as a therapist and had no reason to change what I was doing.
After growing up in a relatively religious family, I had stopped attending church regularly during my twenties. But, I was drawn to reading spiritual books partly, I think, because I needed to make sense out of the enormous pain I witnessed during my work as a therapist. It was not completely conscious, but I think I felt a need to believe that people endured the unfathomable suffering they were experiencing for some ultimately good reason. It made it easier for me to be helpful and to keep from becoming cynical and disillusioned with life. As I kept reading spiritual material, it began to increasingly inform my work.
By the time Robin had her meltdown in 2003, I was firmly entrenched in a spiritual framework that came from years of reading various spiritual books and listening to the CDs of many spiritual teachers. I summarized my personal spiritual perspective in my journal around that time:
“We are all on this earth living a physical existence, evolving as souls. The goal is to learn to love ourselves and others and to connect with other souls (we are all one). We are here to set a good example for others in terms of being kind, compassionate and loving. The more we are able to do this consciously and purposefully, the more of a positive impact we can have. Because we are all connected, each person who sets this example has an impact, energetically, on the global consciousness.
All the negative, painful things that happen both globally and within our individual lives, are serving the ultimate purpose of helping us to experience ourselves as souls. In the absence of pain, we cannot fully appreciate joy and love.
Life is a process of change, offering many opportunities to grow and learn and evolve. The key to being at peace is to welcome change and ‘go with the flow.’ We are constantly being spiritually guided through our emotions…our ‘gut’ feelings. Part of the key to going with the flow is to trust this guidance and follow it.”
Although my many years of spiritual studying led me to intellectually believe all of the above, it remained a struggle for me to actually live these beliefs. As an anxious “worrier” by nature, maintaining this perspective was a consistent challenge. I had to frequently re-read the books that were most helpful and to consciously remind myself of my spiritual beliefs. I mostly did not talk about any of this with my professional colleagues or my clients. I did not want to risk being too vulnerable with my colleagues, not knowing how I would be judged as a proclaimed “spiritual person.” And, it was generally not appropriate to share my spiritual beliefs with clients. I would frequently tell clients to “trust their gut,” without saying this was a way to tune into their spiritual guidance. At times my gut told me to talk to various clients about spirituality, and I did so carefully and selectively. Mostly though, I kept my spiritual beliefs to myself and shared them only with a few trusted, like minded friends.
Living through the few months in the winter and spring following Robin’s meltdown in 2003 caused me to feel overwhelmed on many levels. My spiritual beliefs were being seriously challenged. And, the balance I had found in terms of seeing the right number of clients so I could manage my stress level was completely gone. I was spending an enormous amount of time and energy thinking about Robin, talking to her, and documenting our conversations in obsessive detail, while at the same time seeing all of my other clients.
My obsessive-compulsive personality traits had always caused me to worry and experience anxiety whenever I had a client who was seriously suicidal. Robin was seriously suicidal for many months. Her situation felt like a significant challenge to my ability to cope with stress in general. I found myself constantly worrying about Robin’s safety. It felt clear to me, spiritually, that I was supposed to be in the role I was for Robin and that I needed to extend the boundaries in order to help her connect with someone. But I was exhausted and stressed and scared about Robin’s survival. I was worried about how her family and I would be impacted if she actually killed herself.
On the Monday after I listened to Robin’s CD entitled Sorrow in early April 2003, we had our scheduled phone call. We were still meeting in therapy once a week on Wednesdays and talking on the phone on Mondays and Fridays. I asked her how her weekend had gone.
“I almost killed myself,” she replied. “I got really depressed on Saturday. I had the Tylenol all lined up and drank three wine coolers to prepare myself.”
What? I did not expect this. I knew Robin had been feeling more depressed and was stressed about her job. But in our phone conversation the previous Friday she had assured me if she felt worse over the weekend she would call me. Obviously that didn’t happen. Inside, I was frightened by how close she had come to attempting suicide and worried that she had not honored our agreement. Outwardly, I remained calm as usual. “What stopped you from going through with it?” I asked, completely unsure of what I would hear.
“I was worried about Epiphany,” said Robin. “I actually started thinking seriously about taking her to the Humane Society so I wouldn’t have to worry about her anymore. But then I couldn’t do that either.”
Okay, now I was really scared. Robin had talked several times about her cat being a barrier for her in terms of killing herself. But she had never talked about removing that barrier by taking Epiphany to the Humane Society. Her obsessive suicidal thoughts appeared to be getting more severe. “So Robin, on the 1-10 scale where are your suicidal thoughts today?” I asked, worried that we were going to have to battle about her going back to the hospital.
“I’d say they’re at an eight today, compared to Saturday when they were at a ten. I feel a little better,” she said. “Obviously there must be part of me that doesn’t want to kill myself since something keeps stopping me. But I’m not consciously aware of it.”
Robin went on to tell me she drank three wine coolers again on Sunday. She said she was just tired of feeling depressed and hopeless. I was somewhat confrontive with her about sabotaging her treatment by drinking, but did not want to be too confrontive and push her away. She was insightful and able to admit she was fighting an internal battle between wanting to live, allowing herself to get closer to me and other people, and fearing being vulnerable. Mostly, she said, she still just wanted to die.
I was relieved to hear that Robin’s internal battle was partly about wanting to live and experience feeling connected to people. This helped confirm my gut feeling about extending the boundaries in our relationship and encouraging Robin to connect to me. Her willingness to admit part of her wanted to live and connect helped me to know I was on the right track.
In our therapy session that week Robin and I talked more about her internal battle and the fact that she was struggling more with constant suicidal thoughts. “I had a terrible day at work yesterday,” Robin said. “One of my coworkers told me she had a dream that I killed myself. It completely freaked me out. It just seems like another sign I’m supposed to kill myself or will end up doing it eventually.”
Okay, I was not happy with her co-worker. Everyone at her job knew about Robin’s recent difficulties. Why would someone say that to her, for God’s sake? Robin went on to say she had been very depressed that night and ended up drinking and going to bed early. “I’m just so tired of being suicidal,” she said.
As we talked, Robin acknowledged that her medications were helping many of her symptoms. She said she was sleeping well, functioning adequately at work, feeling more able to think clearly and was experiencing less anxiety and more energy. She was feeling more able to control her impulses. This was all good news. But she remained severely depressed, felt completely hopeless about her life getting any better, and could not stop her obsessive brain from focusing on suicide.
Unlike when she was in the midst of a mixed bipolar episode and had impaired impulse control, Robin now seemed to be choosing to sabotage her treatment by drinking. This was typical of her past self-destructive behavior while severely depressed. She stopped caring about getting better overall, and just wanted to numb herself to feel better in the moment. I knew she could not continue this pattern, especially when her suicidal thoughts were so constant and so intense. She could easily end up killing herself impulsively if she drank too much.
It was not an infrequent situation as a therapist for me to need to make a decision in the moment during a session about what to do next. Therapists develop the skill of listening to the client talking in front of us, while simultaneously processing what we need to say and do next in the session. It is one of those automatic skills that must be learned for someone to be a good therapist. We certainly can’t say, “Okay, what you just said to me is freaking me out. Give me a minute to think about what to do about it.” If the situation was not urgent, and I was unsure what to do, I would wait and consult with my supervisor or colleagues after the session. But Robin was in danger at that time. With her increasing alcohol use it would not take long for her to destabilize her bipolar symptoms and become an even bigger suicide risk. What a nightmare! She was communicating that she needed me to do something.
“Robin, I want to talk to you about the CD you gave me,” I said. I had promised when she had given it to me the previous week that I would listen and we would discuss it in our session that day. “I want you to know it touched me, very much. Thank you for sharing with me more about what you are feeling. It helped me understand more fully how much pain you are experiencing.”
When I had been listening to Robin’s CD that previous weekend I had thought about the possibility of making her a CD in return. I had thought about it as a way to continue to help Robin feel more connected to someone and to give her something positive to listen to when we were not in communication. But this is not something I would ever have done for a client before. I was unsure about it, since I didn’t want to foster too much dependence or make Robin too anxious by increasing the emotional intimacy between us. I had been planning to consult with my colleagues about it and hadn’t made a final decision.
In that moment, though, when I needed to make a quick decision about how to help Robin stop sabotaging treatment, I decided I couldn’t wait to get reassurance or opinions from other people. I knew what I was thinking about doing would be a risk in terms of how Robin would respond. It could have gone either way in terms of causing her to work harder in treatment, or causing her to get too anxious, to distance from me and become more isolated, and to be more at risk of acting on her obsessive suicidal thoughts.
In making my decision, it didn’t matter that I was anxious and overwhelmed or whether I had no idea when my life would ever feel balanced again. My feelings and needs felt irrelevant to me. My spiritual guidance felt clear. I was completely driven to do what Robin needed me to do in order to help her stay alive. In that moment, it felt clear I needed to take the risk of trusting my gut and extending the therapeutic boundaries yet again.
“Robin,” I said. “I am working on a CD for you.”
“What?” she seemed very surprised. “I didn’t know you listened to music or made CDs.”
“I love listening to music too, and do it as a way of connecting to my own emotions just like you,” I said. “I want very much to give you a CD. I have a problem though. I can’t reinforce self-destructive behavior, and I can’t do anything that is unhealthy. You are drinking and sabotaging treatment. I can’t give you a CD when you’re doing this or I will feel like I’m reinforcing self-destructive behavior.”
“I’ll make a deal with you,” I went on. “First, if you are willing, I want you to write a short note about each of the songs on your CD explaining what about the song affected you. I’ll do the same about the songs on the CD I give you. Second, I want to get that session with your parents scheduled so I’m not the only person you are working to be more open with. And third, I need you to get rid of your alcohol, stop drinking, and work harder to stay busy and distracted when you aren’t at work. If you do all of that, I will give you the CD I am making.”
I told Robin I was completely aware that I was asking her to change life-long patterns, and that this would cause significant anxiety for her. I told her I knew she needed more support from me in order to make these changes, and that I was prepared to offer that support as long as she agreed to the conditions I had laid out. Robin agreed to the deal. I went home to start working on my CD.