I made a CD of music for Robin in April 2003 partly because I was moved by the painful emotions she shared with me through her music. It helped me relate emotionally to the depth of her pain. I gave her some of my hopefully uplifting and comforting music to distract her from her suicidal thoughts. I also figured listening to a CD from me would help her feel connected when we were not in contact, which would hopefully help her feel less compelled to kill herself. I wanted her to remember that someone would be affected by her death, specifically, me.
There was another reason, however, to make Robin a CD. While I had developed a spiritual belief system that provided perspective and guidance for me, Robin had a horrible world view. We had talked around the issue for years prior to her meltdown. She had described reading existential literature as early as high school and defined herself as agnostic. She had acknowledged for years that her pessimistic view of the world, and her uncertainty about spirituality likely contributed to her depression. I had encouraged her to read about spirituality, hoping it would help shift her thinking in this area and provide material for us to discuss in therapy. But I purposely hadn’t recommended specific books, because I didn’t want to impose my beliefs on her. Despite my repeated suggestion that she do so, Robin had never started to read about spirituality on her own.
Cognitive techniques, a usually helpful therapeutic strategy, had never worked well for Robin. Her very rigid brain did not shift easily. In April 2003 when Robin’s manic symptoms were stabilized, but her depression was worsening and getting more dangerous, I got a new sense of how negative her world view was by listening to her CD. Because it felt so impossible to impact Robin’s thinking by using cognitive techniques, my CD was a new way to try shifting her thinking by accessing her emotions. Robin had tremendous difficulty identifying and talking about her emotions. I asked her to make notes about the songs on her CD and what affected her about each song because I wanted to know more about what was going on in her head. Then, I could begin to try helping her reconsider her negative world view.
Desperate times called for desperate measures. With Robin’s life on the line, I suddenly didn’t worry as much about suggesting a specific new way for her to view the world and the purpose of life. Because I had many songs with subtle spiritual messages (if they were too blatant I knew Robin would not relate to them), I chose some of them for my CD, and I wrote my notes about the messages within the lyrics.
At the time of the CD exchange Robin had just confessed to me she would have attempted suicide if it were not for her worries about her cat, Epiphany. She continued to be very isolated. She was still not letting her family or friends know how depressed she was, which is why I asked her to allow me to bring her parents into a session with her. They needed to know she was not okay. Although she was still somehow managing to do her job during the week, she was spending way too much time alone on the weekends obsessing about suicide.
On weekends at that time, I was spending several hours on either Saturday or Sunday in my office working on paperwork. I couldn’t do therapy notes from home due to confidentiality issues, and I was usually unable to complete them all during the week. I actually enjoyed the quiet time in my office, and I liked being able to work on my paperwork without time pressure. Not feeling the pressure to get it all done during the week helped me to retain the balance I needed by working shorter days and not being too exhausted in the evenings.
Because Robin agreed to work harder to avoid being self-destructive as part of our CD exchange, I decided to reinforce these efforts by planning to briefly talk on the phone sometime during the weekend, which was clearly her most dangerous time. Robin was adamant that she would not be comfortable talking to me from my home. Somehow it was just more acceptable for her to have a phone conversation on the weekend if it happened from my office. I was there anyway, so we made plans for me to call during that time.
Robin took our agreement very seriously. She worked harder at staying busy the following weekend and was able to stop drinking. She reported a corresponding decrease in the intensity of her suicidal thoughts, from an eight or ten on the 1-10 scale down to a five. However, the improvement was short-lived. In our next session, it became clear that Robin working really hard and me making her a CD were not enough to overcome the severe depression and obsessive suicidal thinking that were consistently torturing her.
“I feel like I’m having a mini-meltdown,” Robin said. She continued to show completely flat affect and her leg was back to bouncing up and down. “I feel very sad, and I don’t feel like I’m in control of myself as much as I was before. I’m not planning to kill myself, and I don’t think I need to go to the hospital, but I don’t feel like I can go to work and not act crazy.” She said she planned to call off sick from work the next day. I was instantly concerned that my extending the therapeutic boundaries further had made her too anxious and was contributing to her feeling worse. I asked her about it.
“Actually, I feel more comfortable about opening up to you,” she said. “It’s helping, and I’m starting to get more used to it. The fact that you’d make me a CD helps me trust it.” She hadn’t even listened to the CD yet, but I was glad to hear she was feeling okay about me making it. Based on the fact that she had been working so hard to not be self-destructive, I was assuming my intervention had helped. But I was baffled about why Robin was still so severely depressed and getting worse. I was grasping.
“Are you feeling stressed about the planned session with your parents next week?” I asked, trying to figure out what was causing her to feel worse. “Because if you are not feeling up to it we can always reschedule or put it off until you feel better.”
“I haven’t even thought that far ahead,” said Robin. “I’m just trying to stop thinking about killing myself.” She was more able to acknowledge the part of her that “doesn’t want to do it,” but she could not stop herself from obsessing about it. Her severe OCD was completely taking over her thoughts.
Robin had seen Dr. Greene earlier that day, and he had raised her dose of the antidepressant medication Wellbutrin. She was happy about this and said she hoped it helped. She expressed her intention of trying to return to work the next dayafter taking a day off. I hoped the Wellbutrin helped too, although I knew it would take several weeks. It didn’t seem like Robin could wait that long to feel better.
The next day I received a voice mail from her. She had called on a day when we had not planned to talk, which was highly unusual. Her voice mail was very disturbing.
“Hi Sharon, it’s just me, Robin. I think one of the reasons I’m more depressed is because when I saw Dr. Greene yesterday he told me he’s assuming I’m bipolar. I’m having trouble with the idea of being chronically mentally ill. I don’t think I’m hallucinating, I think I’m just talking to myself in my head and I’m just thinking about suicide too much. You don’t need to call me back. I’ll just plan to talk to you tomorrow like we planned.”
Oh no! There was not a chance I was going to wait until the next day to talk to her. Robin never left voice mails. She hated making phone calls. And she had absolutely never referred to having hallucinations, ever. I was very concerned and immediately called her back to see how she was. It was early evening. She sounded very drowsy.
“Robin, I got your message. What’s going on? Are you okay?” I asked. “Why do you sound so tired?”
“I already took my night meds,” Robin said. “I just want to go to bed.”
“Why were you talking about hallucinating?” I asked nervously.
“I don’t think I’m hallucinating,” she replied. “I just can’t get the suicidal thoughts out of my head. I’ve decided to change my method of suicide to drowning. Something I was reading about it made me decide that it wouldn’t be too bad.”
What? In what universe would drowning oneself not be bad? I couldn’t believe what I was hearing! Then, she kept talking and it kept getting worse. “I’ve been thinking about going through my stuff and getting rid of some things,” she said. “I don’t want my family to have to deal with as much stuff if something happens to me.”
Okay, now she had a new plan and was thinking about getting rid of things, which was a clear sign of preparing for suicide. But, why on earth was she telling me this? Robin was smart enough to know she couldn’t say these things to me without alarming me. She was clearly not herself. The relentless depression just continued. I felt completely helpless in terms of trying to impact it.
We talked about Dr. Greene’s comment about his assumption that she had bipolar disorder. I realized we hadn’t talked enough about this. When we initially brought it up the previous month, Dr. Greene and I both told Robin we weren’t completely sure about the bipolar diagnosis. But, her positive response to Depakote in terms of stabilizing her manic symptoms had pretty much confirmed we were right. I guess I had been assuming Robin knew this, but in hindsight I’m not sure how I thought she would have come to this conclusion. I had been too busy focusing on her being disconnected from people, her return to work and on her suicidal thoughts. I hadn’t been processing her feelings about her diagnosis. Apparently she was hanging on to the hope that we were wrong, and Dr. Greene’s comment had caused her to have to again try to integrate the reality of the severity of her illness, and its implications. It made sense why this was causing her to feel worse.
As we talked on the phone that evening, Robin started sounding a bit more rational. We talked, again, about whether she needed to be in the hospital. She assured me she wasn’t going to kill herself that night and said she was going to try to go to work the next morning. She was able to convince me she would be safe.
“I went to work today,” Robin said when we talked the next afternoon. “I stayed only long enough to count the day, and then I left and went home. I spent some time this afternoon at work cleaning out my desk. I have too much stuff.”
“What? Robin, you are focusing on getting rid of things? Last night you said you were thinking about getting rid of things in your apartment. Now at work? It sounds to me like you are planning to kill yourself. Do you have a date picked?”
“What do you mean our conversation last night?” Robin asked, sounding surprised. She had no memory of our long phone call. I told her about the voice mail message she left and our talk afterward.
“Oh my God! I can’t believe I called you and said that stuff,” Robin said. “I’m horrified.” She insisted she had not been drinking when we talked, and we discussed the fact that she was likely dissociating.
I asked the question that was becoming a routine part of every conversation. “Do you think you need to be in the hospital?”
“No, I’ll be okay. I have lots of plans this weekend,” said Robin. “My niece has a soccer game tomorrow I’ll be going to, and then we have Easter dinner at Bob’s house on Sunday.”
Robin assured me she had no alcohol in her apartment and would not drink. We made plans to talk over the weekend to make sure she was okay. It no longer mattered to her whether I was at home or at my office when we talked on the phone. And, I was not okay waiting until the following Monday to have contact.
I was increasingly worried about Robin’s safety and would have felt less anxious if she had agreed to go to the hospital. But, I also knew the hospital wouldn’t solve anything in the long run. Dr. Greene had increased the Wellbutrin, and we were waiting for it to take effect. Robin was not being self-destructive and was sleeping, so she did not appear to be manic. If she could stay safe at home and continue to work until the Wellbutrin took effect, it would be better than her missing work and having to deal with the ramifications of that. But, her depression was just so severe! She could not stop thinking about suicide. Her brain was torturing her. I knew I needed to stay in close contact, and if she got any worse I would be pushing harder for hospitalization.
It didn’t take long for things to get worse. On Easter Sunday Robin and I talked on the phone after her family gathering. “I’m having a harder time fighting my suicidal thoughts,” she said. “I found out a guy who lives in my apartment complex killed himself by drowning. It just confirmed my plan will work. I can’t stop thinking about it.”
Robin went on to tell me the new, extremely specific, detailed and lethal suicide plan she was obsessing about. It was well thought out and would definitely have been successful if she had chosen to act on it.
“I didn’t want to write a suicide note before, but now I’ve decided I should,” she said. “I want people to understand why I’m doing it in case they are angry or have questions. I don’t want to do it until after my birthday because I don’t want to ruin my niece’s birthday or Mother’s Day or Bob’s birthday. I really want to hang on until after that, but I don’t know if I can. I can’t think about anything else.”
It was suddenly clear to me that Robin did not really want to kill herself. If she did, she would never have told me her specific, lethal plan. She would have just done it. Her reason for delaying it was to minimize the pain for her family, again not realizing they would be devastated if she killed herself no matter when it happened. But, whether she wanted to wait for irrational reasons or not, Robin was telling me she couldn’t hang on any longer.
It was time, yet again, for me to do something. I dreaded even bringing it up, but it felt clear to me what needed to happen. I’d been thinking about it for the previous couple of weeks when Robin was clearly getting worse.
“Robin, I think it’s time to consider ECTs,” I said. “I think you need to be in the hospital. I will talk to Dr. Greene about us getting your insurance company to cover ECTs, since it is now more clear that medication is not working.”
As with her previous two hospitalizations, it was clear how depressed Robin was because she did not argue with me. I was very surprised when she agreed that it was time to try ECTs. “Nothing else is working,” she said. “I can’t keep going on like this.”
Robin and I talked about whether she needed to be in the hospital that evening. She wanted to wait, and said she would go in the morning. I did not insist she go to the hospital immediately because something suddenly felt clear to me. Robin continued to be open with me rather than act on her obsessive suicidal thoughts. She clearly did not want to hurt her family members. She was working very hard not to be self-destructive. I finally knew, deep down, that Robin really wanted to live…despite her severe depression. She was ready to try anything, including ECTs, to feel better. I trusted that she would not kill herself that night. She assured me she was just going to take her meds and go to bed and would leave a voice mail for her supervisor that she would not be going to work the next day. I told her I would call her in the morning after I talked to Dr. Greene.