Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.
Robin returned to her job half-time on the Tuesday after Memorial Day in 2003. After seven ECT treatments and a week to recover, she was less depressed than she had been in many months. She was, however, very anxious about her return to work. The stakes were high and she said she felt enormous pressure, knowing she would lose her job if she could not do it successfully. On her first day back to work, the pressure magnified.
“I talked to Jennifer today,” said Robin in a phone call that afternoon. “She told me I made some of my co-workers uncomfortable when I was at work before, because I was talking about suicide. I don’t remember that, but I want to make sure everyone knows I’m better and won’t do it again.”
Robin and I briefly problem solved ways for her to do damage control with her co-workers. Later that day I got a second phone call from her. I was surprised, since she never called twice in one day.
“I left a voice mail for Jennifer asking if there were a lot of people who were concerned about the comments I made, and whether I could just talk to people individually about what happened,” Robin explained. “She said she thinks I should talk about it to everyone in our treatment team meeting on Friday.” I was horrified. Jennifer did not know how anxious this would make Robin. What a terrible thing for her to have to worry about on her first day back to work! Robin said she was so anxious about the prospect of addressing her co-workers in a group, she was feeling strong urges to get drunk.
“I’m really afraid I won’t sleep tonight,” she said. “I know you’ll be mad at me if I drink, and I don’t want to take too much Ativan. That’s why I called.”
I was still sympathetic in terms of Jennifer’s situation. She was looking out for her team of employees. Robin was returning to work with the blessing of Dr. Greene and me, who had both declared her ready. I assumed Jennifer figured that if Robin was able to do her job, she should have been able to handle talking to her co-workers about things she said that were upsetting to them. But for God’s sake, did she have to bring it up on Robin’s first day back to work? The last thing she needed was the anxiety of being so publicly vulnerable!
I actually had no idea whether Robin was ready to do her job successfully. She had improved significantly with the ECTs. But she was also still experiencing depression symptoms and intrusive suicidal thoughts. I was concerned that she needed a few more ECTs in order to really alleviate her depression.
Dr. Greene and I had released Robin to return to work partly because she would not have dealt well with losing her job. If she had been unable to even attempt to return, this would have ensured worsening depression. Dr. Greene and I agreed we needed to give her a chance to get her life back. I hoped getting back into her usual routine, surrounded by supportive colleagues and supervisors, would help Robin keep the momentum going in terms of the progress that had begun with the ECTs.
But, Jennifer telling Robin on the day she returned to work that she needed to make herself vulnerable to all of her co-workers, in a group, was a disastrous start. Robin had severe anxiety about being open with her family and closest friends. How was she possibly going to talk to a group of her co-workers about the experiences she had been through? She expressed feeling humiliated by the fact that she had upset her co-workers with things she didn’t remember saying. She said she didn’t sleep at all the night before the meeting.
Miraculously, Robin managed to get through the meeting with coaching and reassurance from me, and some anti-anxiety medication. She called to tell me about it that afternoon. We discussed the fact that she had made it through the first four half-days of her return to work, including the stressful team meeting. I expected her to feel relieved and pleased with herself. Instead, she sounded more depressed.
“It was a big step for you to make it through this week,” I said trying to be encouraging.
“Last night I was looking at some of the paperwork I got when I was discharged from the hospital the last couple of times, and when I had ECTs,” Robin said. “I can’t believe that all happened.” She was thinking much more clearly than she had been in months, and was continuing to try to process the reality of everything she had been through. The ECTs had left some gaps in her memory, which we had been discussing so she could piece together the events of the previous few months.
“I know I look like I’m doing better on the outside. Everyone keeps telling me how much better I am,” she said. Robin had said her family and friends had been noticing and commenting on the improvement. Her affect was definitely brighter and the psychomotor retardation was gone. This was very noticeable to everyone. Her sarcastic sense of humor, which is typically a big part of who she is, had returned.
“I may be better, but I still feel the same on the inside,” she said. “I hate myself and I hate my life.”
“Robin, remember there’s a difference between biological and psychological depression,” I said. “Your biological depression is definitely better. The medication is managing the mania. The ECTs have helped the depression. You’re joking around for the first time in months, and all the outward signs of depression have decreased. That’s what everyone sees. But the psychological depression is related to all the stress and uncertainty about your job, your financial stress, and your need to keep working on being more open with people so you are less isolated. I think you still feel depressed because of these issues. We’ll keep working on all of this.”
“I have to tell you something,” Robin confessed. She was still feeling compelled to tell me when she behaved self-destructively. “I drank a wine cooler last night to help me sleep.”
“Robin, I understand you were really anxious last night about the meeting today. I’m not excusing the drinking, but I know it was a hard night. Remember, I can’t reinforce self-destructive behavior. Please don’t continue to put me in that bind.”
Robin talked about her concern about the upcoming weekend, and her fear about having no plans and “too much time to think.” Although I offered to plan a time to talk, she did not want to have contact with me over the weekend. We had cut our sessions back to once a week and were talking less often. Robin was trying to decrease our contact so she did not feel “too dependent” on our connection. I would have preferred we had waited until she was settled into her job to decrease our contact. But I knew Robin needed to feel like her life was returning to normal. As she had gotten better, she felt more uncomfortable depending on me so much. I needed to honor her need to distance from me.
Although I was concerned about how depressed she sounded, she promised to refrain from drinking and assured me she wouldn’t kill herself over the weekend. We made plans to touch base by phone after her first full day of work the following Monday. Later that afternoon, Robin completely freaked me out.
The department where I worked had a small reception area and waiting room, and a large open area with ten offices where my co-workers and I saw clients. The reception area, which was separate from the office area, had mailboxes for each therapist. I would often see clients back-to-back with only a short break in between sessions. During these breaks I would listen to voice mail messages, check my mailbox and chat with people in the reception area for a minute or two, and maybe make brief phone calls.
I was scheduled to see several clients that Friday afternoon, as I often was. Because it was a short week following the Memorial Day holiday, I was especially busy. Late in the afternoon, in between back-to-back clients, I came out of my office and went to check my mailbox as usual. I was stunned and confused by what I found.
In it was a CD from Robin. We had exchanged a couple of CDs by that time. We had just talked on the phone a few hours earlier. The title of the CD was “Thank You.” Inside the cover Robin had written, “Sharon, this is an obnoxious repetition of the same song, but I could fill the whole CD with it and it would still not be enough. I stopped at fifteen times.”
What? I had no idea what to think. Why was she thanking me? Okay, I understood that she would want to thank me, but why then? I had no idea what song she had copied fifteen times, intending to express her gratitude to me. I had no ability to listen to it at that moment. It would have to wait.
I knew Robin was having a rough time. I felt and understood her need to distance from me. She had been open about it. My sudden fear was that this was the “thank you” that was really the “good-bye.” It had been such an intense few months. It had all culminated in ECTs followed by Robin’s return to work after disclosing to her employer she had needed ECTs to get stabilized, which embarrassed her. She had been forced to publicly discuss her mental health issues with her co-workers, which was incredibly difficult. The thought of returning to work full-time the next Monday was causing high anxiety for her. She felt enormous pressure about succeeding at her job. Mostly, she had endured the treatment of last resort and was still feeling “the same on the inside.”
It was completely out of character for Robin to just stop by and leave something in my mailbox. And, I was aware research shows that people with severe depression are actually at a significantly higher risk for suicide when they are starting to recover (because they have more energy and ability to formulate and carry out a successful suicide plan). I was worried that this is what was happening for Robin.
There were many reasons why, if Robin was actually going to kill herself, this was a logical time for her to do it. And then she had just dropped off this CD….thanking me. What the hell? I really believed, more than I ever had before, that Robin might be saying good-bye to me as she then went to carry out her suicide plan.
Many thoughts went through my mind. Mostly, I was just worried. But I also found myself thinking about the reality that if Robin decided she really wanted to kill herself, I would not be able to stop her. At that point in my career, I had never had an active client commit suicide. My co-workers and I had talked about the commonly discussed concept that if one works as a therapist long enough, they would eventually lose a client to suicide. I had supported several colleagues through this painful experience. This was just part of the high stakes career I had chosen.
Despite all this, I could not just do nothing. I quickly dialed Robin’s cell phone number. I needed to check in with her and find out how she was. She didn’t answer the phone. Oh my God! I left a message asking her to call me back.
I’m not sure how I managed to concentrate through my next client’s therapy session. This was another automatic pattern therapists learn. It is important to be able to give enough of one’s attention to whoever is in the office, no matter what else is going on outside the office. I managed to do this well enough, but in the back of my mind I was worried and distracted.
After I finished the session, my last one for the day, I tried calling Robin again. I felt somewhat bad about doing this because I knew I was meeting my own anxiety needs. I had already called once and left a message. As a therapist I knew I should stay objectively detached, and the fact that Robin had said she wanted distance from me meant I really should leave her alone. But, in this instance, I couldn’t.
This time, Robin answered the phone. “Robin, I got your CD,” I said. “I wanted to thank you for it. Where are you?”
“I’m just driving around,” she said. She continued to sound more depressed. I did not tell her how much she had scared me by dropping off her CD.
“Robin, I’m concerned about you. I know you’re feeling depressed, and you’re anxious about working full-time next week. You told me you were worried about the weekend and having too much time to think. You’re feeling a need to distance from me, but I think it’s okay if we stay in close contact until you are settled with your job situation. If you want to talk this weekend it’s okay.” Boundaries should only be extended if it is in the client’s best interest. I knew she felt she needed to distance, but with all the uncertainty about her job I thought it was premature. It became clear as we talked that my fear about the CD she had dropped off…that she was going to go kill herself, was unfounded. Thank God. But my anxiety about it made me feel that it would be better if we talked later that weekend. She agreed to do so.
Robin and I talked that Sunday. She said she had continued to be more depressed all weekend. “I’ve been thinking about everything that’s happened in the last six months,” she said. “I don’t know if I’m going to be able to handle the stress of working full-time.”
Robin went on to say she had not slept much the night before and had “forgotten” to take her medications that morning. She admitted she had been thinking all day about overdosing on Depakote, but did not do so because she was still concerned about what would happen to her cat if she killed herself. She said she was also worried she would be unsuccessful in her suicide attempt and make things worse.
“Did you take your meds last night?” I asked, suspecting this may have contributed to her lack of sleep and increasing instability.
“No,” Robin confessed.
“Robin, you are sabotaging your treatment. What’s going on?” I was calm on the phone, but inside my heart sunk. Just when I thought things were getting better. The ECTs had so clearly been helping. I had hoped she was better enough to return to work, but it was starting to become clear that the stress may just be too much.
“I don’t know. Maybe I’m subconsciously trying to lose my job to give myself a reason to kill myself,” she said. “I just don’t want to be on all these meds. I know it doesn’t make any sense. I just feel too much pressure.”
Robin went on. I was impressed with how direct she was able to be with me. “I know you’ll be disappointed if I screw up. Maybe part of me is trying to get you to back off.”
Wow! That was a reality check. Robin had been trying to tell me she needed distance. I certainly did not want to be contributing to the pressure she felt.
“Robin, if you want me to back off, I will. You don’t need to sabotage your treatment to make that happen. Thank you so much for being honest with me.” I felt very, very bad about any possibility that I may be contributing to the pressure Robin was feeling. The idea of distancing from her scared me, since I knew she would be at much higher risk if I did so. But she was better in so many ways. She was thinking so much more clearly than she had been in many months. I realized, in that moment, that whether Robin wanted to stay alive and work through all the ramifications of being diagnosed with a severe mental illness was her decision to make. I needed to let her make it. I needed to back off.
This sudden realization made me very sad. I couldn’t hide my sadness as I apologized for not hearing her when she told me she needed some distance from me. I asked her if she needed to be in the hospital to stay safe, knowing she would lie to me if she planned to kill herself.
“I’m not planning to kill myself tonight, Sharon,” she said. “I’m going to work tomorrow. I’ll probably end up going back on all my meds,” she said. “It will be unpleasant if I don’t.”