Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.
I graduated from college in 1985 without a job. After debating about my future plans, I took a job as a Mental Health Technician (MHT) at a psychiatric hospital in Michigan. I wanted to get experience in the field to help decide whether to pursue a Ph.D. in psychology. This job was a good choice, as I was exposed to many realities I never could have experienced in other settings. It was a position involving both day and overnight shifts.
As an MHT at that hospital, one of my assigned tasks was to assist with electroconvulsive therapy (ECT) treatments, which were done early in the morning. There were three of us involved with these procedures, and we rotated our roles, including preparation (getting patients to the procedure room and taking their vital signs), helping with the procedure (holding the electrodes on the patient’s forehead while the doctor activated the machine to produce a seizure), and recovery (monitoring vital signs while the patient came out of anesthesia). Every Monday, Wednesday and Friday morning there were between three and ten patients, some of whom were staying at the hospital and some who came in as outpatients, receiving these treatments.
I was very young, completely inexperienced and had no substantial knowledge about the controversy surrounding ECT regarding memory loss or brain damage. Of course, I was aware there was an enormous stigma associated with it and had seen the antiquated portrayal of the treatment in the movie One Flew Over the Cuckoo’s Nest. But, I performed the responsibilities of my job as I was instructed to do, with no strong opinion about whether it was a good idea for people to be treated with ECT. All I knew was that the procedure was quick and seemed painless for patients. I witnessed many, many of these procedures over the course of a year as a Mental Health Technician before I quit the job to go off to graduate school. I never heard, after the treatments were completed, whether patients experienced lasting side effects.
What I did know was that ECT worked. I would see people come for treatments three days a week for two or three weeks, and during the course of that short time frame, I would see person after person get better…dramatically better. People would often start their procedures with completely flat affect, unable to function. Within two weeks I would see them start smiling, laughing and telling me they felt much better. Whether the improvement lasted, or whether they later regretted having ECT due to the memory loss that accompanied it, I’ll never know.
In 2003, the agency where I worked had just recently added ECT to its treatment options. I heard many of my colleagues express negative feelings about this, as they were either aware of the controversy surrounding memory loss or were caught up in the stigma associated with this treatment. Personally, I simply told people it was a treatment of last resort, to be used sparingly and only after other treatment options had been exhausted. I told them about my prior experience with ECT, and that it seemed to help people to the best of my knowledge at the time.
Robin was the only client, during my long career as an outpatient therapist, for whom I recommended ECT. In April 2003, we were clearly out of options. Robin admitted she did not want to kill herself, but also said she could no longer wait. She was already on five medications. Her severe depression had been unrelenting for over a year. We were at the point where the treatment of last resort needed to happen. Her life was clearly at stake. On the morning after our phone conversation on Easter, I went to work and immediately paged Dr. Greene.
“It’s Sharon. Robin is worse. She told me she has continued to obsess about suicide, and she is now stuck on a very specific, lethal plan.” I told Dr. Greene the details of the well thought out suicide plan that Robin could not get out of her head. “She is desperate to feel better and is ready to try ECTs, if we can get her insurance company to approve them.”
“Is she willing to go into the hospital?” asked Dr. Greene. “I’d feel most comfortable starting them as an inpatient.” I assured him Robin would voluntarily admit herself to the hospital. Dr. Greene agreed that ECT was the best option given how many medications he had tried and how depressed Robin continued to be. He agreed to talk to her insurance company, if necessary, to gain approval.
Unfortunately, overnight, Robin had changed her mind. “I don’t want to go to the hospital,” she said when I called to tell her about my conversation with Dr. Greene.
“Robin, we talked about this. I’m very concerned about how stuck your brain is and about your suicide plan. You told me last night you didn’t think you could wait any longer.” I pleaded with her not to make it difficult for us to help her.
“I agree I need to try ECTs,” she said. “But I’m afraid if I’m in the hospital I’ll just get worse. I hate being there, and I’m afraid I’ll lose my job. Will you detain me if I don’t agree to come in?”
What? No, Robin, don’t make me answer this question, I thought to myself. I was horrified that we were having this conversation. She had told me the previous evening she would come to the hospital! The last thing I wanted to do was call the police and have her brought in against her will. What a nightmare! I immediately regretted not having her go to the hospital the previous evening, and instead giving her time to obsess and get scared. Based on everything she had said to me, I assumed Dr. Greene would agree Robin needed to be detained if she wouldn’t come in voluntarily.
I had to make another quick judgment call. To tell Robin I would detain her was a huge risk. Some depressed, suicidal people, under those circumstances, would have gone and hidden somewhere to avoid having the police come to get them. My options were to tell Robin the truth and risk this happening, or lie to her and risk damaging the new level of trust we had only recently established. It was a horrible position to be in and a difficult judgment to have to make in the moment. As usual, I trusted my gut. I trusted what I knew, deep down, the previous evening. Robin really did not want to die.
“Yes, Robin,” I reluctantly said. “I’d have to talk to Dr. Greene, but we would probably detain you.”
“All right,” she said, clearly angry. “I’ll be there. Can you call Jennifer, though, and explain things? I’m really afraid I’m going to lose my job for having to take more time off work.” She wasn’t thinking clearly enough to process that she wasn’t going to be able to work if she had ECTs, whether she was in the hospital or not. I agreed to call Robin’s supervisor after she got settled into the hospital and then I waited, very anxiously. I mostly trusted Robin to honor her word and come to the hospital as she promised to do. But, I also knew she was scared and not thinking clearly.
I watched from the lobby of the hospital, where I had a view of the main entrance to the agency’s campus. I walked around, in and out of the lobby, so it wasn’t too obvious to anyone that I was hovering. I desperately waited to see Robin’s Jeep turn the corner and drive into the parking lot. It suddenly sank in for a moment…all the anxiety, energy and angst that I had put into being there for Robin during the previous three months. I was nervous, wondering if I had made a huge mistake by not talking her into being hospitalized the previous evening. I started imagining the possibility of Robin not coming and having to make a terrible phone call to her parents. When she finally arrived, I breathed a huge sigh of relief.
I watched Robin pull into the parking lot and take her bag of belongings from her Jeep. She walked slowly, with her head down, into the building. I met her in the lobby where we sat next to the big fish tank, as usual. Robin was clearly angry. Her affect remained flat, her leg was bouncing, and she looked exhausted.
“I’m not mad at you,” Robin said. “I’m mad at the situation.”
“Robin, I’m so sorry you’re going through this,” I said, feeling completely helpless. “I promise I’ll call Jennifer this afternoon and talk to her about your job. I know that’s a big worry for you. Dr. Greene is working on getting approval for ECTs from your insurance company.” Robin, clearly angry, didn’t want to talk. I was just relieved she was safe. We sat silently until the staff came to take her up to the unit.
After a phone conversation with her mother that afternoon, who called wanting to understand what was happening, I called Robin’s supervisor. “Jennifer, I’m sorry to say that Robin is in the hospital again. We are likely going to be starting ECTs in the next day or two.”
“I’m sorry to hear that,” Jennifer responded. She sounded frustrated. “I’ll have Human Resources send the medical leave paperwork to you. Obviously it would be helpful for us to know how long Robin will be out of work this time. I know it’s hard to say.”
I totally understood Jennifer’s frustration. Robin had a caseload of clients who needed to be seen and co-workers who all had full caseloads themselves. I knew it was putting them all in a difficult situation to have so much uncertainty about Robin’s ability to work going forward. But, I couldn’t give Jennifer any answers about a time frame. I didn’t know whether the ECTs would even work. I also knew that if Robin lost her job, it would be disastrous. I didn’t know if she would survive that big of a blow.
“I wish I knew how long it will be,” I said to Jennifer. “But there’s no way to know. I will get the medical leave paperwork returned as soon as possible and will keep you posted.” We hung up, and I had a bad feeling. I wasn’t going to ask Jennifer to give Robin any reassurance about her job, when she sounded so frustrated. It was unfair to ask, given how supportive Robin’s employer had already been during the previous three months, with two hospitalizations and corresponding periods of time away from work.
Once her insurance company approved the treatments, Robin appeared to be less angry and feeling more optimistic. She started campaigning to be discharged from the hospital before she even had her first ECT.
“I don’t want to be here anymore,” she said. “It’s unnecessary.” Unfortunately, her brain was still obsessing, and she was still rigidly stuck in her thoughts. The thoughts had simply shifted to wanting to be out of the hospital before the weekend rather than killing herself. The problem was, once Robin got stuck on something, it was virtually impossible to get her brain to shift. Discharging her seemed like a horrible idea.
“I’ll arrange to stay with my parents or have my mom stay with me at my apartment. I’ll make sure I’m not alone,” she pleaded.
Although I was very reluctant to agree to Robin’s request to be discharged, my gut continued to tell me she did not want to kill herself. I had to make another judgment call, this time about whether to campaign for her with Dr. Greene or whether to tell her I did not feel safe about letting her leave the hospital. I knew if I didn’t support her idea, he wouldn’t either. I decided to stall her. “If you work on putting a safety plan into place, and if your first ECT goes okay tomorrow, I will talk to Dr. Greene about it.”
The next afternoon, I went to see Robin. She sat on her bed in the hospital room, while I stood. Her affect, as it had been for months, was completely flat. She had received her first treatment of ECT early that morning and said she was feeling a bit disoriented. As we talked, it became clear she was having some difficulty remembering the events of the previous day. Otherwise, she was still singularly focused on being discharged from the hospital as soon as possible. She started crying as she talked about her most recent conversation with Dr. Greene, who told her she needed to stay in the hospital for the next three ECTs the following week.
“Why is it so important for you to be discharged?” I asked. “It would be easier and safer for you to stay while you get ECTs. Your insurance has approved it all. Help me understand.”
“I hate being locked up and not being able to distract myself,” she explained. “When I’m at home I can get out of my apartment and go somewhere…even driving around helps. I can’t even listen to music. Sharon, I promise I’m not going to kill myself while I’m having ECTs. I really want to give them a chance to work.” I believed her, and I suddenly understood.
I had always known Robin hated being in the hospital because it forced her out of her familiar routine, causing more anxiety. But I suddenly understood that it also took away her most effective ways to manage her anxiety which were to keep moving or listen to music. Robin was attending no groups, as usual, and was staying in her room where she felt safe. But, staying in her room for hours on end kept her trapped and unable to do what she normally did to distract herself from her brain’s torture. Her anxiety was magnified, and her effective coping skills taken away. I suddenly had a new awareness of Robin’s obsessive-compulsive reality and why she was so desperate to go home.
I would have preferred Robin stay in the hospital. I was stressed and exhausted from the intensity of her most recent suicidal crisis, and knowing she was safe worked much better for me. But once she was open with me about why she so desperately wanted to be discharged, I wanted to help her. I trusted her promise not to kill herself while she was getting ECTs.
I paged Dr. Greene and was able to convince him that it would be therapeutic for Robin to allow her family and friends to support her through the ECT process, rather than be so isolated in the hospital. I told him she was clearly saying she wanted to give the ECTs a chance to work. Dr. Greene reluctantly agreed to take the risk, as long as I communicated clearly with Robin’s mother about the possibility of confusion and memory loss surrounding the ECT procedures and the importance of monitoring Robin’s safety.
Robin was discharged the following morning to the care of her parents, with whom she agreed to stay. Her father planned to transport her to and from the hospital to receive ECTs on an outpatient basis. Her mother reassured me they would make sure Robin was taking her medications as prescribed. Robin and I did not have contact over the weekend. She had her second treatment of ECT early on Monday morning, and called me that afternoon.
“I don’t feel any better yet,” Robin said.
“Robin, you haven’t even recovered from your second treatment,” I replied. “It usually takes a few treatments before people start to notice a difference.”
“I got a call from Jennifer today. I only have three more days left of medical leave after this week,” she said without emotion. Robin explained that she had almost exhausted her time guaranteed by the Family Medical Leave Act, a federal law which forced employers to hold someone’s job for up to twelve weeks per year if they had a medical problem or needed to care for a family member. “I have to meet with Jennifer tomorrow to talk about my job.”