In mid-September 2003, approximately two weeks after her fourth hospitalization, Robin began to display noticeable signs of a further lessening of depression. Her affect was brighter. Her thinking continued to become clearer. She moved more quickly and responded to questions more easily and with more depth (less psychomotor retardation). She was beginning to look more and more like the Robin I had known before the year of depression that led up to her meltdown, rather than the depressed and slowed down version of Robin I had been seeing for many months. She had clearly been improving as a result of the ECTs, but this was a new level of “better.” She even began to say she was feeling considerably less depressed.
“I really think the medication changes Dr. Greene made when you went into the hospital, lowering the Celexa and changing Geodon to Abilify, are helping,” I said to her in a session one day.
“I actually don’t feel out of control like I had been feeling for so long,” she said. “It’s surprising.”
“Robin, I hate to say it, but if there was any remaining doubt about whether you have bipolar disorder, this probably eliminates it.” I said. “Otherwise you wouldn’t be responding so well to these specific medication changes.” We discussed that having bipolar disorder makes it particularly important to eliminate self-destructive behavior, especially those things that sabotage her brain’s biological stability. We talked about the enormous grief she continued to feel about losing her job, and the uncertainty her new diagnosis caused.
“I just don’t know what I’m going to do with my life,” Robin said. “And even though I’m less depressed, I’m still really anxious about whether I’ll be approved for long-term disability. If I don’t get approved I have no idea what I’ll do.”
“Anxiety has always been a big part of who you are, Robin. I think you will always struggle some with anxiety, especially surrounding big life changes. Your anxiety is completely understandable. It just can’t be the excuse for self-destructive behavior.” She was still struggling with urges to drink and I was still being firm about avoiding all alcohol.
“I’m trying to do what I need to do,” she replied. “But it will definitely help to know I can pay my bills.”
Thankfully, the next day I received a phone call from a representative of the company that provided long-term disability insurance benefits for her former employer. He wanted me to fax copies of my therapy progress notes to them, as they were considering Robin’s application. I was able to talk to him about her symptoms and the monumental meltdown she had experienced. While I had him on the phone, I let him know how anxious she was to find out not only whether she’d be approved but when she would receive her first check.
It did not take long for the reviewers at the insurance company to make the right decision. After reading the details of Robin’s experiences, I think they realized that if anyone deserved long-term disability benefits, she did. It was the following day when I received a phone call from the same representative, telling me Robin had been approved and her first check would be mailed that day. I was very happy to call Robin to tell her the news.
“This is the first good thing that’s happened in a long time,” was Robin’s reply. She was able to relax a bit, knowing she would continue to have income.
Over the next few weeks during our sessions, Robin began to try to integrate all that had happened to her during the previous eight months.
“I don’t know why, but I’m having urges to stop taking all my medications in order to see what happens,” she said one day. “I don’t understand why I need to be on so many different ones.” Robin did not remember much of what she had been through, partly due to the ECTs but also because she had been so overwhelmed with emotions that she had been dissociating at times. I explained to her the reasons each of the five medications she took had been added, and why each of them remained crucial to her ongoing stability. My hope was that hearing some of the details of how bad things had been and how each medication had helped change things for the better, would help motivate Robin to avoid sabotaging her brain chemistry.
“I hope it doesn’t get really bad again,” she said as she was clearly beginning to understand the reality of how dangerous her illness had become. “I don’t know how I would survive it.”
Robin readily acknowledged that she was back to her previous pattern of minimizing her symptoms and issues with her friends and family, and presenting herself as doing better than she actually felt. Although her mood was definitely better, she was sleeping better and her anxiety was decreased, the obsessive suicidal thoughts continued.
“I need to feel like things are getting back to normal,” she said. “I want everybody to treat me like I’m okay, not like I’m crazy.”
“That’s fine, Robin, for now. As long as you aren’t minimizing anything with me. I need you to keep working on getting more comfortable being open with me, even though your defenses are returning and it would be easy for you to fall back to what worked for you for so long. You have to be open with someone. Right now that’s me. As you get more comfortable, we’ll work on having you be more open with your friends and family.
I went on to reiterate a crucial concept she needed to integrate. “It’s important for you to shift from trying to keep everything inside and under control, which is what you’ve spent your life doing, to being willing to talk about painful feelings. I think you’re already making this shift, but it has to continue to be a focus in therapy.” She reluctantly agreed.
Once Robin was able to stop worrying about getting approved for long-term disability, her mood, unfortunately, deteriorated. As had been happening gradually over the previous few months since completing ECT treatments, she was thinking more clearly and recognizing more completely the implications of her illness. She was realizing on a new level the degree to which her life and her identity had been forever altered.
Part of the problem was that Robin lived alone and had nothing to do. She had too much time to think, and not enough contact with people. She continued to have suicidal thoughts on a regular basis, and her mood fluctuated depending on how much time she spent alone. It was clear to me that this depression was situational, but it was worsening. Robin needed something positive in her life that served as a distraction, put her in contact with people and gave her a sense of purpose.
“I just wish things could go back to the way they were before,” she said during a session in late September 2003.
“Robin, I hate to say it, but you really weren’t happy with your life before the meltdown either,” I said, trying to help her shift. “Your jobs in mental health have always been very stressful.” I reminded her of some of the specific situations we had talked about through the years that caused her to feel stressed at work. “I’m not going to dismiss your enormous grief, and I want to help you work through that. But it may also help to look at being on disability as an opportunity to find a better balance in your life and not feel so stressed.”
I frequently had clients accuse me of being too positive. I knew, at that moment, Robin probably wanted to throw something at me for suggesting that being on disability could actually be a good thing. But, I believed what I was saying and I wanted to help her believe it too. It would become a frequent topic of conversation. Robin’s stress tolerance was not high. Working full-time in mental health had always caused anxiety for her. I believed if she could find the right part-time job or the right volunteer position or both, she would be much happier than if she went back to her previous full-time work in mental health.
“I know you can’t imagine it right now,” I said. “But if you had the right balance in your life, and could get to a place where neither your work nor your illness defines who you are, you could actually feel better than you probably ever have. And, you have many people who care about you. If you could feel more comfortable letting them in and feeling accepted by them for who you really are, this would make all the difference.”
I was trying to paint a picture for Robin of a future that was very possible, and could allow her to be happier than she had ever been. She couldn’t imagine it.
“I don’t think about the future,” she said. “I never really have. I’ve always just assumed I’ll end up killing myself. It seems unlikely that I’ll ever get to a point where I’m actually happy.”
Although Robin had never been very successful at consciously shifting her rigid brain and changing her thoughts by using cognitive techniques, we talked about specific ways for her to continue to work on this. And, we talked about how to address the problem of her having too much time alone in her apartment, thinking about how unhappy she was about her life. She began to think about and explore opportunities to begin volunteering.
In therapy I continued to try to help Robin shift her thinking. Her bankruptcy hearing, which finalized the process, took place in early October 2003. This further alleviated anxiety as she no longer needed to worry about the overwhelming debt from the past, and it enabled her to stay in her apartment as long as we got the drug companies to provide her medications. But, the bankruptcy contributed to Robin’s feelings of failure, and highlighted all the negative life-changing experiences she had endured over a relatively short period of time. It caused her suicidal thoughts to increase.
“I’m tired of doing the suicidal battle in my head all the time,” she said one day in a session.
“Robin, your depression is now much less biological, and much more tied to situational events,” I said. “I actually think suicidal thoughts have become your brain’s way of experiencing strong negative emotions.” We talked about the fact that in the past she had dissociated frequently and self-mutilated, in addition to using alcohol to numb herself when she was feeling particularly depressed. She was able to acknowledge that she had not self-mutilated at all during the past year and had dissociated relatively little, given what she was experiencing. She was able to give herself credit for these signs of enormous progress. We talked about her efforts to continue to avoid numbing herself with alcohol. Mostly, we talked about the importance of finding the right balance in her life as a way to continue to decrease her depressed mood and the associated suicidal thoughts that always accompanied it.
In order to begin the process of rebuilding her life, Robin decided to start by finding a volunteer position that would work for her…in other words, that would not make her too anxious or stressed. It did not take long, with her credentials, to find a local agency that wanted her help. So, it was with enormous trepidation that Robin began a very part-time volunteer position in mid-October 2003, as a way to get out of her apartment and feel useful again.