Note: This is a serial blog. To start at the beginning, click on Chapter 1 – The Meltdown under “Categories” and start at the bottom.
After doing some investigating, I had a difficult conversation with Robin about options for continuing to cover the costs of her mental health treatment without insurance.
“Robin, I’ve learned you would probably be eligible for Medicaid if you aren’t working. And, you would qualify for a state funded program which enables you to have a 95% discount for all the services provided here (at the agency). Without income, you’d also probably be able to get your medications free through the drug companies that manufacture them. They have what are called patient assistance programs,” I explained some of the details of these options, which could theoretically allow her to give up the expensive insurance through her former employer and still be able to live in her apartment. Thank God she was physically healthy and had no health costs other than mental health treatment.
Robin was silent for a few moments as she took in the information I was telling her. “It will take me a while to accept being on the other side,” she said. “I’m used to being the one helping people get government assistance, not the one receiving it.”
She was silent for a while longer. She seemed to be processing the reality she was facing. Then she said, “When do you think I’ll be ready to go back to work again? Do you think it’ll be six weeks? Or do you think it’ll be more like six months or even longer?”
I knew I had to be honest with her. I was afraid of upsetting her, but I knew she needed to hear the truth. I shifted in my seat. “I don’t think it will be six weeks,” I said tentatively.
“I agree,” said Robin, staring at the floor.
We both acknowledged her sadness about this, and how hard it was for her to admit the degree to which her stress tolerance had been affected by the previous eight months. I wanted her to feel some hope, however, as she tried to accept that she would be unlikely to return to her previous job in the near future.
“I think you’ll get approved for long-term disability, Robin. And, you should probably apply for Social Security disability at some point too. If you got approved for that, and I think you would, you could work part-time in addition. This might be a good option for a while so we can focus more in therapy on helping you really heal.”
“What do you mean?” Robin was finally, as a result of the ECT treatments, thinking clearly enough for me to explain some of what I had been thinking in terms her treatment plan, and what we needed to focus on in therapy in the future so she would keep getting better.
“Well, first of all, in the past you’ve never been willing to actively work on decreasing your OCD symptoms. If you weren’t putting all your energy into managing the stress of a full-time job, we could work on this,” I explained.
I reminded Robin that I thought her illness was partly biological and partly psychological, as are most mental illnesses. “I think the biology part includes primarily bipolar disorder and OCD. Taking the right medication and managing stress helps keep the bipolar symptoms stable. There are specific cognitive and behavioral strategies for decreasing OCD. But, I also think there are specific psychological issues that perpetuate and magnify your depression and always have,” I said. “I wasn’t completely aware of these before your meltdown. It’s been so helpful that you are finally being completely open with me. We now have an opportunity to help you really heal.”
Robin seemed interested in hearing more, so I kept going. “Until your meltdown, when you finally let me know what you’d been thinking and how out of control you had felt at times, I was not aware of how alone you were or how negative your view of the world is. I think those two issues…lack of social support and the absence of a world view that includes any sense of meaning in life, have always made you more prone to depression. Those are issues we can work on in therapy.” Robin agreed that these issues had always contributed to her feeling of hating her life. We talked about how much anxiety it had always caused for her to be open with people, and that she had already made significant progress by being open with me. We talked briefly about spirituality and the degree to which her existential belief system had reinforced and magnified her depression.
“I just think, Robin, you should allow yourself some time to heal. Not just heal enough to get back to a full-time job, but really heal. So you are happier with yourself and your life.”
“That seems impossible,” she said.
I assured Robin we would talk much more about all of these issues. I just wanted her to have a sense that there was a life beyond disability, and that it could actually be an improvement over her life prior to her meltdown. I knew she couldn’t possibly imagine it at that time. But I hoped she would stick around to let us work on helping her get there.
It was August 2003. Robin still had a few more weeks of short-term disability income she could count on, and was waiting to hear about whether she was approved for long-term disability benefits through her former employer. She met with her attorney and learned it would likely be the end of September before the hearing would be scheduled to finalize the bankruptcy process.
Robin continued to report ongoing, daily suicidal thoughts. She focused on trying to keep herself busy while she waited for the events that would finally allow her to relax a bit and feel more settled. She managed to mostly avoid alcohol, and spent lots of time with her family and friends to distract herself.
One day, completely unexpectedly, I received a voice mail from Robin’s mother asking me to call her back. I was shocked. She never called me! I, of course, was immediately worried it was bad news. I quickly called Robin, keeping my voice calm when she answered the phone so I didn’t alarm her.
“I just wanted you to know your mom left me a voice mail and wants me to call her back,” I said. “You’ve signed a release of information form, but I wanted to find out what you are comfortable with me telling her. Or, if there is anything you don’t want me to tell her.”
Robin took a few minutes to think about what to say. “You can answer any questions she has. Just don’t tell her I’ve been having suicidal thoughts,” she said. “I don’t want people hovering over me.” Robin insisted I call her back to tell her about the conversation with her mother after I finished it.
“I just wanted to check how Robin is doing,” said her mother on the phone. “I’m concerned that she’s been acting like things are too okay, and when I ask her how things are going she’s very vague.” I knew Robin had returned to her instinctive pattern of minimizing her symptoms with everyone other than me. She still experienced enormous anxiety related to being too open or vulnerable with people, including her family members. Now that her mother was aware of that pattern, she was picking up on the signs that something was wrong. I was very relieved. This was, in my mind, an enormous positive change.
I explained to Robin’s mom that although Robin continued to do much better, her job situation was still a big issue. We talked about the stress she was experiencing as she waited to hear about disability and about the financial ramifications she was facing.
“Robin is thinking much more clearly than she was for a long time,” I explained. “But this means she is now processing appropriate emotions of grief about everything that has happened over the last seven months. And she is in huge limbo about what comes next.”
Robin’s mother was very understanding and supportive, as always. She expressed her intention of talking to Robin about it, and I encouraged her to do so. When I called Robin and told her about the conversation, though, I did not expect her reaction.
“I don’t want my mom to know everything that’s going on,” she said. “I only agreed to have you talk to her because I didn’t want to hurt her feelings. And I wanted to know why she called.”
“Robin, obviously your mom loves you and is concerned. And, I think she’s trying to make changes in your relationship so you are more comfortable being open with her.”
At first, Robin’s anxiety about her mother being let in to her world through me, caused her to say “I don’t want it to change.” After we talked a bit, however, she admitted she and her mother were very connected, and very similar in many ways. We talked about how healing it could be for them both to work on becoming closer, and that this was an example of what we had discussed in our previous session about increasing her social support. In typical Robin fashion, however, she said. “That’s fine, but I just don’t want her calling me all the time to check on me.” Baby steps, I found myself thinking.
As the days went on and Robin continued to experience the ambiguity associated with not knowing whether long-term disability would be approved in time for her to avoid a gap in her income when the short-term benefits ended, she began to become more anxious and depressed. Her suicidal thoughts, as usual, intensified. When we talked about them, Robin made it clear she had no intention of killing herself before the bankruptcy was finalized. Despite the increase in suicidal thinking, she was still sleeping okay and drinking only an occasional social drink.
Things changed, however, dramatically and quickly. We talked in a planned phone call on a Monday in late August.
“I’m more depressed,” Robin said. “I drank three beers on Saturday night and then I couldn’t sleep all night. I was thinking about what I would write in a suicide note.”
She went on to say she had gone to dinner with her friend the previous evening, and brought up the topic of her cat. “I asked Christi if she would take care of Epiphany if anything ever happened to me. She told me she would,” Robin said matter-of-factly.
I knew Christi knew Robin well enough that she probably knew the reason for this question, and was likely uncomfortable. She was put in the impossible position of disappointing Robin, or making it easier for her to kill herself. I felt bad that she had to make that decision, but inside I was thinking “No, Christi! Removing a suicide barrier for Robin is not helpful!” I kept asking Robin questions, as I got a sinking feeling in the pit of my stomach that we were going down a familiar and dangerous road.
“How much sleep did you get last night?” I asked.
“Very little,” Robin said. “I didn’t take Trazodone because I don’t want to be on any more medication. I know I’m not thinking very clearly.”
All of a sudden I had a horrifying thought. I wasn’t sure at all, because her situation could easily be causing her to have increased depression. But, I remembered that Dr. Greene had increased Robin’s Celexa dose in mid-July, and added Trazodone for sleep in mid-August. Both of these were anti-depressant medications, and in the absence of enough mood stabilizing medication, could cause someone who has bipolar disorder to experience symptoms of mania. Dr. Greene and I had discussed this possibility, but he believed the Depakote and Geodon she was taking would prevent this from happening. I didn’t want to alarm Robin, partly because I was not at all sure that mania was part of the issue. But, it came to my mind.
I focused with Robin on the most important issue which was that she needed sleep. I confronted her about about needing to take her medication as prescribed. We had been down this road so many times before, that all I had to do was sound mildly irritated and Robin’s need to avoid making me angry led her to agree.
The next morning, however, my suspicion from the previous day was confirmed. Robin was clearly experiencing a mixed bipolar episode.
“I slept better with the Trazodone,” she said. “But I’m still having trouble thinking clearly. I feel crazy and out of control.” Thank God, Robin and I had gotten to a point where she felt comfortable telling me this was how she was feeling.
“Robin, I’m concerned that the Celexa increase a few weeks ago, coupled with the Trazodone, is destabilizing you,” I said. She acknowledged she was experiencing all the symptoms of mixed mania including irritability, increased anxiety, racing thoughts, and difficulty controlling her impulses. Robin admitted she had cut on her arm the previous night, for the first time in many months.
“All I want to do is go buy some vodka and get drunk,” she said.
After some discussion about options for keeping her safe while we stabilized her symptoms, and Robin refusing to consider staying with a family member, she agreed to re-enter the hospital. It was her fourth hospitalization in eight months.
Coming Next: Robin’s Thoughts on Rock Bottom