Robin had just received her second ECT treatment, and had to meet with her supervisor the following day. She was very worried and upset about the prospect of losing her job. “I can’t go back to living with my parents,” she said. “I’d have to get rid of Epiphany.” Her parents had a dog who would not easily adjust to having a cat in the house. “And, I have too much debt. I can’t go without income.”
“Robin, let’s just take one step at a time,” I said, trying to reassure her despite my own worry about what her supervisor would say. “Just see what Jennifer has to say tomorrow. Try not to make any assumptions.”
It was the worst possible timing for Robin to have a job crisis. She had just started receiving ECTs. Having to worry about her job and financial situation was the last thing she needed. I had not told Robin how frustrated Jennifer, her supervisor, had sounded when we talked the previous week. It concerned me.
“So, who makes the decision about how many ECTs I need? And when will that decision be made?” Robin seemed to be thinking quite clearly, despite having had her second ECT procedure earlier that day. It was a good question. I told her I assumed the decision would be made by Dr. Sanchez, the psychiatrist who was administering the ECTs. Since I also wondered what he was thinking, I told Robin I would talk to Dr. Sanchez the following day.
“Usually by the second or third treatment I can tell whether the ECTs are helping,” Dr. Sanchez said when we talked. “By the end of the week I will decide whether we should schedule more treatments for next week.” This was helpful information, but I was concerned he would be making a decision so quickly. Robin was so depressed, and we were out of other options. I did not want him to decide prematurely that ECTs were not helping. We didn’t have a back up plan.
The next day, Robin called after meeting with her supervisor, clearly upset. “I’m blowing it,” she said. “Jennifer said they are reassigning all my cases. If I don’t go back to work by the end of next week, they can’t guarantee my job. And if I go back and can’t do my job, I’ll lose it. I have to let them know by early next week what I’m doing. I don’t think the ECTs are working. This just feels like another sign that I’m supposed to kill myself.”
I couldn’t blame Jennifer who was, I was sure, speaking for the administrators of the agency where Robin worked. I didn’t blame them either. They had all been very supportive and flexible about Robin’s need for time off. I understood why, as her protected medical leave was expiring, they felt they needed to push the issue. But this ultimatum could not have been more poorly timed for Robin, or for me in my efforts to help her get stabilized.
Despite the job crisis, Robin was showing subtle signs of improvement. Psychomotor agitation and retardation are both signs of significant depression. Robin had demonstrated agitation when she was experiencing mixed bipolar symptoms. Once the Depakote stabilized her mania, she had begun to show significant psychomotor retardation. When people experience this they are noticeably slowed down. They respond to questions more slowly and they move more slowly. Robin was not only significantly slowed down, but there was also her completely flat affect which had been present for months. I noticed a difference in Robin in terms of these issues, even on the phone, after her second ECT. She was responding to questions more quickly, indicating that her brain was processing things more easily. Her voice sounded more animated. She just wasn’t as “flat” as she had been for so long. I had spoken to her mother on the phone earlier that day, who also said she felt Robin seemed less depressed during the previous few days.
“Robin, other people often see signs of improvement before the depressed person feels better,” I said. “I think you’re showing these signs.” We talked about what I had noticed, and what her mother had said. I acknowledged that the bad job news had not helped her mood, but reassured her I still thought the ECTs were starting to decrease her depression.
“I’m planning to have the next one on Friday,” Robin said. “I’ll see what Dr. Sanchez recommends. I don’t have much choice. Just so you know, I told my parents I’ll let them know if I feel like I need to go to the hospital.”
Wow. This was huge. Robin was thinking more clearly! The fact that she had this conversation with her parents was an indication of improvement on many levels. She was being open and letting them help her. She recognized she may need to go back to the hospital, and was willing to do so if necessary. She was basically saying, again, that she wanted to stay alive. I was encouraged.
Robin and I met the following day, later in the day after her third ECT. She was tolerating the treatments well. They were being done early in the morning. She said she was a bit groggy for several hours afterward, but then felt okay. There had been no signs of significant memory loss or confusion. She seemed to be thinking clearly enough to process the ramifications of the discussion she and Jennifer had the previous day. But, I planned to call Jennifer to ensure Robin was remembering and processing the conversation they had accurately.
“I feel like they’re trying to push me out the door. It’s making my depression worse, not better,” Robin said. “I understand why they need to reassign my cases, but it upsets me. I don’t know how I’m supposed to decide anything about my job by next week, when I may be continuing to have ECTs.”
I reassured her I would call Jennifer to get clarity about what the administrators at her place of employment were thinking. This seemed to calm her down for the moment. I decided to get clearer about the financial pressure Robin was feeling.
Robin and I had previously talked in general about her financial stress. On that day, when she was so worried about losing her job, we talked more specifically. She told me how much credit card debt she had and that she was only able to pay the minimum payments, even when she was making her full-time income. This meant she had been making very little progress toward paying off the debt.
“If I lose my job, I won’t even be able to make the minimum payments,” she said. “I have no savings. I’d have to move in with my parents and get rid of Epiphany!”
I needed to, somehow, combat the enormous pressure and hopelessness Robin was feeling about her job, her financial situation and her future. I needed her to be okay with the possibility of having to tell Jennifer she could not return to work the next week, since I knew she would not be ready by then. Robin desperately needed a way to relieve some pressure.
“Have you ever considered filing bankruptcy?” I tentatively asked, not knowing how she would react to this question.
“I actually have thought about it,” Robin replied. “I’ve never seriously considered it, though. I’m afraid I’d feel too much like a failure.”
“Think about it as a way to get a fresh start,” I responded. “Your whole meltdown is creating a fresh start in many ways. Now that we know what we need to do in treatment, I still think you will eventually end up feeling better than ever before. Since you are so seriously thinking about killing yourself anyway, why don’t you at least consider bankruptcy as an option so you can see how much it helps to get out from under all that financial pressure. You really have nothing to lose.” I would not usually be so direct with a client about recommending a step as drastic as bankruptcy. But I was desperate. I needed Robin to feel like she had options other than killing herself.
“Maybe I’ll talk to Bob about it,” she said. I was surprised she was even willing to consider it.
I called Robin’s supervisor the next day. I needed to help Jennifer understand that Robin would not be ready to return to work the following week, and to see if there were any options that would allow her to keep her job. I left a voice mail for Jennifer, and received a call back from the Director of Human Resources at Robin’s place of employment.
“We value Robin as an employee,” she said. “But we can only guarantee someone’s specific job position for twelve weeks. Robin’s twelve weeks is done next Wednesday. If we make an exception for one person, we’d have to do the same for others.” We clarified the bottom line. If Robin were unable to return to work the following Thursday, she would lose her job. The HR Director was kind to say they would gladly hire Robin for a different position in the future, if they had an opening and she was ready to perform the job. But, this was little comfort.
“I have to say, this puts us in a very difficult position,” I said, pleading with her. “Robin is definitely showing signs of improvement and we think ECT is what she needs to get stabilized. But she will not be ready to return to work next week. If she knows she’s going to lose her job, I’m afraid it will make it impossible for her to recover.” I didn’t want to be too dramatic, or to make her feel guilty. But, I had nothing to lose by spelling out the reality of Robin’s situation. After some discussion, the HR Director seemed to understand the dilemma and said she would discuss the situation with Robin’s supervisors.
My head was spinning. I couldn’t believe this was happening! After months of Robin being severely depressed and suicidal, and then reluctantly agreeing to ECTs which were clearly starting to help, she could lose her job before we even got a chance to stabilize her. This would mean she couldn’t pay her bills, and she’d lose her apartment and have to move in with her parents or her brother. It would be difficult for Robin’s rigid brain to integrate this even if she wasn’t deeply depressed. In her current state, I could not imagine her surviving this reality. What a disaster!
I felt like I had to do something, and went to see Dr. Sanchez. “Do you think Robin needs more ECTs?” I asked him.
“Yes,” he said. “I think they’re helping. But I also think she needs more. I’m working on getting insurance approval.”
“Robin is getting pressure from her employer to get back to work, or she’s going to lose her job,” I said. We commiserated for a minute about the terrible timing. “How long after her last ECT would she need to recover before she’d be okay to work?”
“A week should be enough,” Dr. Sanchez said. “I want to do three more treatments.”
Miraculously, the administrators at Robin’s place of employment were willing to make an exception to their policy for her, to allow for three more ECTs and a week to recover. The agreement was that Robin would return to her job half-time for the four days following Memorial Day, and then full-time the following week. It was made clear that if she was unable to do her job at that time, she would lose the position.
Robin was relieved to hear this news. After four ECTs she continued to show signs of decreased psychomotor retardation and brighter affect. She was processing more quickly and thinking more clearly. Unfortunately, she was also starting to show signs of memory loss. Because she was thinking more clearly, she was beginning to process and attempt to integrate the reality of everything she had experienced during the previous three months.
“I’ve been doing some research on ECTs,” she said in one of our sessions. “I’m surprised I agreed to them without knowing more about them. I can’t remember a lot of things about the last few months.” She asked many factual questions about events and time frames, and I provided honest answers. She was relieved that as we talked, most of the time her memory came back.
“Robin, this is a perfect example of the progress you’re making. The fact that you’re now researching about ECTs and asking questions means you’re thinking more clearly. You’re starting to process what you’ve been through, which is huge. I know you hate the memory loss, but the ECTs are helping,” I said. “You have no idea how much better you are compared to where you were.”
“I guess, but I’m still depressed,” she said. “I still can’t stop thinking about suicide. I have too much time to think when I’m not working.” Robin was still experiencing another significant depression symptom, anhedonia, which is an inability to feel pleasure or to have interest in activities that are usually enjoyable. For over three months Robin had not watched television, read books or done any of the things she normally did to pass the time. With ECTs, as her brain was beginning to experience relief from such a profound state of despair, she was beginning to recognize more clearly that she was still not herself.
“I know I completely lost control,” she said. “I don’t feel like I have it back yet. I want to go back to work. I want to get my life back to normal.” It concerned me that Robin’s rigid brain saw getting back to work full-time as the only way for her to feel back in control. I understood, though, why she couldn’t deal with the alternative of giving up her job, which would cause her to lose her independence.
With more ECTs, Robin’s affect continued to brighten. She began to joke about things for the first time in months. And most importantly, she finally began to acknowledge she was feeling better. “I’m actually looking forward to going back to work,” she said. “But I’m worried about the stress. I’m not sure if I can handle it. I’m still tired and don’t have much motivation to do anything.” She verbalized the same concerns I was having. I tried to be reassuring about how much her depression symptoms had improved.
After seven ECT treatments, although she was dramatically better, Robin continued to report feeling depressed and having some suicidal thoughts. She continued to show signs of depression, although much less severe. Because of the ECTs, she couldn’t remember how bad things had gotten just prior to her most recent hospitalization, which meant she couldn’t fully understand the progress she had made.
Although I was concerned about her remaining depression symptoms and felt it would be better if she could have more ECTs before returning to her stressful job, we didn’t have a choice. Robin needed to try going back to the job with which she was familiar, with the co-workers who knew and supported her. It would not have worked for her to give up her job and then have the pressure of knowing she’d have to start over in a new job position. New jobs were always incredibly stressful for her, even when she wasn’t depressed. Dr. Greene had made a recent adjustment to her antidepressant medication, which hadn’t yet taken effect. I was hopeful this would alleviate her remaining depression symptoms over time.
I tried to be optimistic, and at the same time prepare myself for the possibility of having to keep being Robin’s life-line if she lost her job. We were continuing to have frequent contact. It had been a very stressful and exhausting few months, but I remained clear I was doing what I needed to do. Robin was coming out of a severe depression, did not want to die, and was still not able to be open with her family or friends. I knew she would need me to continue to be very available until her symptoms and her job and financial situation were stabilized. Once that happened, I trusted we would be able to return to a more typical degree of contact, and to work on her anxiety about being more open with others.
I had plans to leave town for the Memorial Day weekend to attend a friend’s wedding. I looked forward to the much needed break. As I was preparing to leave, Robin and I discussed her anxiety about starting work the following Tuesday. I offered to talk over the phone during the weekend, and was relieved by her response.
“It’s a holiday weekend for God’s sake!” she said. “If I can’t go three days without talking to you, we definitely have a problem.” And then, she laughed. It was so good to hear her laugh. Robin was finally returning.
I wrote in my journal that night, before I left town:
“Thank God, Robin is definitely better. Because her memory is affected by the ECTs and the depression, she doesn’t remember how bad things got. She says she is still having suicidal thoughts, but she can distract herself from them for the first time in months. She’s joking more and is processing with me what has happened during the past few months, wanting me to fill in the gaps in her memory. She’s referring to it as “the debacle.” Now, that’s the Robin I know. It’s like she’s finally coming back, after months of totally not being herself. It has been wonderful to have a few rational, processing conversations with her for the first time in months. I just hope things keep going in the right direction.”