The weekend before Robin was supposed to resume working full-time in June 2003, she stopped taking all of her medications. She admitted she was feeling unsure about managing the stress, and was feeling pressure from me to refrain from acting on her strong urges to drink alcohol.
During the time between her ECT treatments and her return to work, Robin wanted to decrease the frequency of our contact. She indicated she was feeling “too dependent” on me, and she desperately wanted her life to return to normal after such a difficult time.
I decided to shift from automatically scheduling regular phone calls, to asking Robin to tell me when she wanted to talk next. This allowed her to have control and flexibility about the frequency of our conversations without having to be the one to initiate calling me after hours (which was still hard for her). She could stay connected or distance, depending on how she felt. I was relieved when she asked to talk after her first day of full-time work.
“I broke down and took Depakote last night, but I didn’t take the rest of my meds.” Robin said. “I didn’t sleep at all.” Oh no! I was instantly worried.
“Robin, I’m really concerned about you sabotaging yourself. You’re setting yourself up to lose your job. Why do you think you’re doing this?” I asked.
“I know it’s not rational,” she replied. “I’m just not ready to give in to having to take all those meds. I think the reality of everything I’ve been through in the last six months is really starting to sink in. I’m trying to assimilate it all.”
“We have a lot to process about what’s happened and I know this feels overwhelming. But if you don’t take your medication tonight and you go a third night in a row without any sleep, you’ll be seriously jeopardizing your job.” I was firm in the tone of my voice. I was concerned. But I was also, for the first time, feeling anger toward Robin. After everything we had been through in the previous six months and after all the extra effort it had taken to arrange the opportunity to return to her job, I was very frustrated about her clearly self-destructive behavior. Part of me understood she was reacting to the enormous stress she felt, along with grief about having to accept her new diagnosis. But she was not giving herself a fair chance to get back to work successfully. She was thinking more clearly. It didn’t make sense that she was setting herself up for disaster. I think she could sense the anger in my tone.
“I’ll take my meds tonight,” she said. “I don’t want you to be mad at me.” Good, I thought.
Robin took her medications, slept well, and said she felt “refreshed” at work the next day. But, that feeling didn’t last.
“I came home from work to lots of bills, and there’s a problem with my checks I need to deal with at the bank. And, my car is not working right.” Robin said she felt overwhelmed by all these new issues and drank three drinks to numb herself.
“I just wish the last six months hadn’t happened,” she explained. “I don’t want to be on antipsychotic medication. I’m really stressed about money and know I need to file bankruptcy, but that bothers me. I don’t feel good about it at all.”
“Robin, you’re experiencing completely appropriate feelings about your situation,” I said, trying to reassure her. “The fact that you are thinking clearly enough to be processing these emotions is a sign of the progress you’ve made.”
We talked about her suicidal thoughts. “My family has been really supportive since I had ECTs and they know I’m stressed about work. I know they’d be really upset if anything happened to me. And besides, I just can’t get past the cat thing. I can’t kill myself.” Wow. I was relieved to hear Robin finally acknowledging that her family members would be very affected by her death. It was another example of the degree to which she was thinking more clearly. And she was making huge progress in terms of being open with her family. But, she wasn’t better enough.
In our session that week Robin admitted she had again skipped all of her meds the previous night because she was drinking, and had then called in sick to work. She was not purposely sabotaging herself. The stress of trying to work full-time and process everything she had been through, as well as the financial pressure she was feeling as a result of not receiving her full pay for a number of months, was overwhelming her.
Despite the drinking, the stress and the lack of sleep, Robin’s affect continued to remain brighter than it was prior to the ECTs. She said she felt okay at work, even with little sleep. She was more focused on the future despite ongoing obsessive suicidal thoughts. She reassured me she was not planning to kill herself, and she began to take all of her medications again.
Robin briefly began to sound better than she had since before her meltdown. She acknowledged feeling better as she was starting to feel a bit more settled into her job. She was still anxious about it, but said the anxiety was manageable. For a few days, she began to sound and act like her old self.
Robin had always enjoyed reading and watching sports on television. During the entire six months following her meltdown, she had not done either. Anhedonia, or the inability to enjoy anything, is a part of severe depression and Robin definitely had this symptom. She said she often had the television on without the sound, trying to distract herself, but couldn’t focus well enough to pay much attention to the programs. As she briefly felt better and believed maybe her life could return to the way she wanted it to be, she was able to watch sports again.
The improvement, though, was short lived. During the weekend after her first week of full-time work, Robin admitted that on Friday night she took “much more” Ativan than she was supposed to. She did not know how many pills she had taken, but said she woke up “groggy and thick headed.”
“Robin, we had just talked on Friday and you said you were going to take your meds as prescribed.” I couldn’t hide my surprise. She had overdosed? Really? “What happened?” I asked.
“I know it makes no sense,” she said. “It was impulsive. I just wanted to make sure I slept, and I wanted to see what would happen.”
“Robin, you seem to be trying to precipitate a crisis,” I confronted her. “You are pushing me to have to do something, and you are clearly jeopardizing your job. What’s going on?”
“It’s not conscious,” Robin insisted. “I don’t know what’s going on. I just can’t stop obsessing about suicide. I guess I haven’t decided about living or dying yet. Part of me wants to live and watch my nieces and nephew grow up, but I’m having a harder time controlling the other part.”
Thank God she was talking to me about her ambivalence. I was grateful for that. But, it was hard for me not to get anxious about the conversation. Robin was basically telling me she had impulsively overdosed. She could have easily misjudged the amount and killed herself by accident that night. We talked about the hospital, and she was adamant about not wanting to go. She insisted she was going to go to work the next day.
I started wondering, again, whether I needed to have Robin detained. I didn’t want to put her in the hospital, knowing it wouldn’t solve anything. It would just cause her to lose her job which would make everything worse. And, after three hospitalizations in six months during which she mostly refused to participate in the programming, I knew she would likely continue this pattern. The decision, as always, came down to a judgment call on my part about whether I thought Robin would be safe, or whether her situation was dangerous enough to warrant having the police haul her to the hospital against her will.
At that point, after we had been through this so many times before, I felt clear I needed to trust that if Robin wanted to kill herself, she would be dead. She continued to stay connected, even after she had said she wanted distance. I didn’t want to jeopardize her trust in me. My gut told me that to detain her would be a bad idea.
Overall I was feeling completely helpless, exhausted, and frustrated by Robin’s ongoing self-destructive behavior. In my own mind I started questioning whether I was doing her any good. I think she could sense my frustration as I again talked about the dilemma her behavior caused for me.
“Robin, you are putting me in a bad position again. Now you are overdosing. What am I supposed to do about that?”
“I’m really sorry,” she said. “I’m not trying to upset you. I can understand why you might be angry at me.” Great, I thought. Robin is depressed and suicidal and now has the belief that I’m angry at her, which will just give her one more reason to kill herself. This was not going well.
“I’ll try harder,” Robin insisted. “I’ll take my meds, as prescribed, and I promise I won’t drink tonight.”
We hung up the phone, and I was upset. It was clear that things were coming to a head. I had no idea what the outcome would be, but I was running out of optimism. Robin was clearly in control of her own destiny, and the probability of her keeping her job was looking bleak. I didn’t think she’d kill herself that night, but I went to bed and contemplated the very real possibility that after all we had been through, Robin was going to eventually end up dead.
The next day, at around noon, she called me at a time when we had not planned to talk. I immediately knew something was wrong.
“I called in sick to work today,” she said. “I feel like I’m losing control again.” She confessed that she had drank and skipped most of her medications the previous night, even after we had talked and she promised not to do this. “I wondered last night if I need to be in the hospital,” said Robin. “This morning I went to the river and had the urge to jump in. I was able to stop myself, but I realize I’m overwhelmed and not in control.”
“Robin I really think you need more ECTs,” I said. “You didn’t have enough of them before. I think it’s time we really get your depression under control.” I knew I was suggesting that she needed to quit her job. I knew what a big deal this was. But, it was clear to me she wasn’t going to be able to keep it. As we talked, this became clear to her too. I told her I would call her supervisor to find out what her options were in terms of her job and disability benefits, and I would call Dr. Sanchez about scheduling more ECT treatments.
In June 2003, six months after her meltdown, Robin lost her beloved job with the team of co-workers and supervisors who were so supportive to her. Thankfully, her supervisor told her they would “hire her back in a minute” if they had a position open and she was well enough to perform the job. The Human Resources manager at Robin’s place of employment said she still had three months of short-term disability benefits left, and that she would retain her health insurance coverage during the time when she was collecting those benefits. She also had long-term disability benefits which she could apply for if needed.
“I guess it’s better to take time off and get well rather than going to work, acting crazy, and getting fired,” Robin said when she learned about how her benefits worked. This was another example of the degree to which she was thinking more clearly despite her self-destructiveness in the face of the work pressure. We had a rational discussion about whether she needed to be in the hospital.
“I want to avoid going there if I can,” she said. “But I’ll go if I need to.” She admitted she was feeling more depressed about the reality of losing her job. She admitted her impulse control was weak, and she agreed to pour out all of her alcohol. And most importantly, Robin acknowledged she did not want to kill herself.
Dr. Sanchez was able to get insurance approval for three more ECT treatments, which were scheduled to start on the Friday after she lost her job. The day before her first treatment I arrived at work to a voice mail from Robin saying she didn’t sleep much the night before and was ready to go to the hospital. I knew if she was suggesting it, this was significant. I immediately got Dr. Greene to call in the orders and I called the admissions department at the hospital to get prior authorization from her insurance company. I was scheduled to see many clients that day, and asked Robin if she would be able to have her mom or a friend come with her to be admitted.
“I’ve already made the decision,” Robin said. “I’m coming in. You don’t need to worry about me backing out.” I knew she would be anxious when she arrived and asked the admissions staff to take care of her as quickly as possible. Later that afternoon I received voicemails from both the admissions staff, and from Robin.
“I couldn’t do it,” Robin said in her message. “Please call me.” What? She didn’t go? My heart sank for what seemed like the millionth time in six months. I was getting tired.
Robin said she had gotten to the hospital to find many people in the waiting room, complaining about how long they had been there.
“I almost had a panic attack. I had to leave,” Robin said. “I’ve changed my mind. I don’t need to be in the hospital. I haven’t been trying hard enough.” She said she would work much harder to avoid drinking, and would take all of her medications as prescribed. “I’ll spend more time at my parents’ house.”
I was not able to get Robin to agree to stay with her parents or her brother. But she did agree to allow me to talk to her mother and her brother about calling every evening to check in with her, which would provide accountability in terms of making sure she wasn’t drinking.
I was especially concerned because I was again scheduled to leave for a vacation, this time to spend time with my family. Although I planned to check in with Robin periodically by phone, I would be many hours away and it would be difficult for me to help facilitate a hospitalization if she needed it.
Dr. Greene and I consulted about the fact that he had called in orders for Robin to be hospitalized, her insurance had approved it, and she had then backed out. We had to be on the same page about whether she needed to be detained. We had to explain to the insurance company why we thought it would be safe for her to remain an outpatient while she received more ECTs.
“I think it is actually better for her to have her mother and brother call her every day, and to be aware of how out of control she feels,” I said to Dr. Greene. “If she was in the hospital she would just be isolated in her room and it would be harder for her family and friends to support her. And, it was Robin’s idea to go to the hospital. I think we need to support her and let her family be there for her, since she is saying she wants to stay alive.” Thankfully, Dr. Greene agreed.
Robin’s mother and her brother were both very willing to check in with her by phone, and her father agreed to transport her to the early morning outpatient ECT treatments.
I left town for a week of vacation on the day Robin began her second round of ECTs.
During the five hour drive to my parents’ house, I began to process the extent to which I had been affected by the previous six months, working to help keep Robin alive. I remembered that at the beginning, while she was still in the hospital for the first time, I had felt strongly that the whole experience was going to be as significant for me as it was going to be for Robin. As I drove, and thought, and cried, and felt many emotions, I tried to fall back to my spiritual perspective and imagine what the purpose for both of us could possibly be as we were living through a complete nightmare.
Robin was definitely better, but still very depressed. She admitted she didn’t want to kill herself, but still could not stop obsessing about it. If she didn’t stop sabotaging herself, I was quite certain she would end up dead whether she wanted to or not. I was realizing more and more clearly that I did not have control over Robin’s fate. It wasn’t completely clear whether she did either.
All I knew for sure at that moment was that I needed a break. I was exhausted…mentally, physically and emotionally. I knew I desperately needed some distance to get perspective about the life and death struggle I continued to witness.