In August 2003, Robin’s life had completely hit rock bottom, from her perspective. In seven months she had gone from living in her own apartment and working full-time at a job she felt good about, with co-workers who liked and respected her, to facing the reality of being chronically mentally ill, bankrupt, and potentially unable to support herself in the near future (her short-term disability benefits would soon be exhausted). She had lost the job which provided both her income and her primary social support network. Although her family members were supportive, they had no idea she might need their help. She had not shared with them the details of what would happen financially if she began to receive long-term disability benefits. Her outward signs of deep depression had been alleviated, and her tendency to automatically present as if everything was okay had returned. Robin had borrowed from her family the money she needed to finalize the bankruptcy. She refused to consider talking to them about needing any further financial help.
Robin was thinking clearly enough to understand that, even if being on long-term disability meant she would not make enough money to stay in her apartment, she needed to apply for these benefits in order to keep this option open. But, she remained focused on her desire to return to work with her previous employer in September 2003, when her short-term disability benefits would end. This was the only option, in her mind, for continuing to live in a way that felt tolerable. At the same time, though, she was willing to acknowledge her own uncertainty of whether she could actually manage the stress of full-time work.
As Robin became more fully aware of her now seemingly impossible situation, she, of course, began to obsess about it. In the absence of any hopeful solutions her brain continued to focus on the relief that killing herself would, in her mind, bring. She began to have more trouble sleeping as she ruminated about her terrible reality.
In mid-August she had lunch with some of her former co-workers, in order to stay in touch with them as well as distract herself. She wanted to stay up-to-date about the potential for starting a new position in September. A few days later, we had a session.
“I’ve been feeling more depressed since we had lunch,” she said. “Everyone was talking about how slow their caseloads have been. I know they won’t need to fill any empty positions any time soon. And, as much as I hate to admit it, I know I’m not ready to go back to work.”
Robin started to cry. While clients cried routinely in my office, Robin did not. It was highly unusual for her to allow herself to be this vulnerable outside of the hospital. I knew her tears were not a reflection of biological depression that required more medication or ECTs. Her tears were, plainly and simply, an expression of profound grief.
“My job was the only thing I had,” Robin said tearfully. “I’m losing my identity, my friends, and my independence.” She was right. I had nothing to say to make this better, in any way, in the moment. I let her cry. I empathized with her pain to the best of my ability. I could not imagine the fear she was feeling underneath the enormous sadness she was expressing.
This was a more vulnerable version of the Robin I had known for so many years…the Robin who was smart, insightful, and able to think very clearly. This was the version of Robin I had not seen for so long, because she had been completely overwhelmed by her mental illness for many months. She was, in that moment, thinking entirely rationally…enough to know that her situation was without good options for getting back to any semblance of the life she had previously known. I was actually feeling pretty discouraged myself. After we had worked so hard to finally get her brain functioning again, now Robin was facing the monumental task of building a new life for herself as a person with a severe, disabling (at least for the moment) mental illness. I did not have any easy answers in terms of how to do this.
While it was vitally important for Robin to experience and feel her grief, it was also crucial for her to have some sense of hope that things could improve. In the absence of any better suggestions at the moment, I reverted to my usual stance of urging her to involve her family.
“Robin, I really think it is important for your family to know the reality of your situation,” I tentatively said. “I know you don’t want to upset or worry them. But, don’t shut them out. You know they love you. If you don’t want to tell them, I’d be happy to help.”
“They’ll find out soon enough,” she said, simply.
As we continued to talk, Robin reluctantly admitted she was back to having more intense suicidal thoughts as she felt the hopelessness of her situation. “I’m tired of having to ask for help. I’m tired of fighting. It’s too hard,” she said quietly. She was staring at the floor. Her legs were back to bouncing, as they often did during times of increased anxiety. She was fidgeting with a Kleenex. And then, she asked a heartbreaking question. “Will you be mad at me if I end up back in the hospital?”
“Robin, of course I won’t be mad at you if you need to be in the hospital!” I said, emphatically. “Do you think you need to be there?”
“I’m not going to do anything this week,” she replied. “I have to get through the meeting with my lawyer about the bankruptcy.”
Robin had always been reluctant to leave a financial mess for her family. She felt strongly that she needed to get the bankruptcy finalized in order to prevent this. I was happy about any barriers that existed, in her mind, in terms of suicide.
“I know I need to go on disability,” she said. “I can accept that. But I don’t want to ask either my brother or my parents if I can move in with them. And I don’t see any way to make things work financially on my own. I don’t know what to do!”
We were able to talk practically about whether Robin’s brother Bob and his wife needed help with child care or other things that Robin could do for them in exchange for money. She said she would consider talking to him about this. Because Robin was obsessing about her situation and not sleeping well, I told her I would talk to Dr. Greene about a medication change to help with sleep. And, I told her I would do some investigating about ways to cover her medical costs without her previous employer’s expensive insurance, which might make it possible for her to stay in her apartment. All of this problem solving helped her to feel a bit more hopeful, for the moment.
I can’t emphasize enough how important it is for therapists, when they are in a situation with a client that is emotionally intense, confusing, or overwhelming in any way, to get outside of themselves. Feedback from trusted colleagues or supervisors is absolutely crucial in terms of maintaining perspective during the enormously difficult situations we therapists encounter with our clients. I will never be able to express to my former treatment team at the agency where I worked for so many years, the gratitude I feel for their support and guidance during the long journey of stabilizing Robin’s symptoms in 2003. During our weekly meetings I kept them updated on all of the developments, and they had ridden the rollercoaster of emotions along with me. It was during August, when Robin’s life truly hit rock bottom, that I felt their support most sincerely.
Judith, my supervisor at the time, sat in on the team meetings. The rest of the team consisted of two women and two men, all psychologists and licensed social workers who had been therapists themselves for many years. We all liked each other and respected each other’s opinions. Our meetings involved giving each other feedback and suggestions about how to handle particularly difficult client situations, commiserating about agency politics and mental health system difficulties, and providing support to each other about the realities of our professional, and sometimes our personal lives. We met in one of the rooms in our department that was used for group therapy and other meetings. There were a number of chairs in this large room, and the six of us always arranged our chairs in the middle of the room in a circle…as if we were in our own little group therapy session. Sometimes it felt like that.
I was particularly anxious in August 2003 to problem solve Robin’s dilemma with my treatment team members. I needed their help. I was not prepared, though, for what I would hear. I outlined the details of her financial reality following the loss of her job, and her willingness to say she did not feel ready to return to work.
“I know Robin isn’t ready to deal with this reality,” said Gwen, one of the most wise and most experienced team members. “But I had a client once who reminds me a lot of Robin. She was a physician. She functioned well for many years, and then had a complete breakdown. Her stress tolerance was never the same after that. It took her a while to get through the adjustment, of course, but last I knew she was on disability and working part-time in a grocery store. It wasn’t ideal, but it worked for her.”
Wow! Gwen was right. Robin was not ready to deal with this being her reality. And, although I didn’t say it, neither was I. Robin was just starting to get stabilized! It felt premature to assume she would need to be on disability forever, never to return to her chosen career. After all, she had been able to do her job very competently right up to her meltdown, and we now had much more accurate information about her correct diagnosis. It seemed to me that, with some time and continued work in treatment, maybe Robin could get back to working full-time.
My other team members went on to talk about other clients who had been forced by issues of mental illness to leave full-time jobs and adjust to being on disability. I was able, myself, to think of similar examples. But, in many of these cases the need for disability was impacted by significant trauma or loss. Robin, on the other hand, had been misdiagnosed by Dr. Greene and I. Part of me knew I may be grasping, and that my ability to be objective was questionable, but debating Robin’s long-term prognosis was not what I needed to focus on. I remained hopeful that with the right medications and Robin being more open in treatment, we could get her stabilized, keep her stable, and allow her to eventually return to full-time work. I needed suggestions about how to get her through the immediate crisis.
“Even if long-term disability and part-time work is what Robin will need to do eventually, she is definitely not ready yet to accept this.” I said. “She is going to apply for long-term disability, and knows she is not ready to work full-time. But she will likely need to attempt to return to her previous job at some point. She is pretty determined to get back to working in the mental health field. She feels like her job is her identity, and she is not ready to lose that. Right now, she just needs a way to stay in her apartment and maintain her independence.”
Something suddenly shifted in the room. It was as if everyone, including me, understood Robin’s pain on a new level. For eight months, what she had experienced was so extreme, we could not really begin to relate to it. But, suddenly we were more generally talking about the reality that mental illness can shatter the lives of professional people, to the point where they can no longer do the jobs that define who they are. No one in the room admitted they were thinking about how awful it would be to have that happen for themselves. But, from the tone of the conversation and the sudden energy everyone felt about helping Robin, I suspect we were all feeling that vulnerability on some level. We all concluded what we often witnessed in our work…that mental illness is devastating.
All of a sudden, the suggestions came from all directions. Discussion of applying for Medicaid, or pharmacy discount plans, or possible ways to get the administrators from the agency to reduce Robin’s fees, etc. came forward. Practical suggestions I had not considered, which could potentially allow Robin to get her medical costs covered without insurance (therefore allowing her the possibility of staying in her apartment, maybe with a little help from her family until she could get a part-time job). Now, I felt more hopeful. I wasn’t ready to talk to Robin about any of these options, but at least I had some possible solutions I could investigate.