It was October 2003 and Robin had been battling her own brain for over eight months. After four hospitalizations, eleven ECT treatments, the loss of her job and health insurance, and the finalizing of a bankruptcy, she was trying to piece her life back together. It was not working for her to have too much unstructured time, during which she was ruminating about the losses she had experienced. In order to have something to distract herself and feel productive, she began to volunteer for an agency that provided care specifically to patients with AIDs. On her very first day there, however, she already had to face the realities of her new identity.
“Several people asked me what else I do,” Robin said as she was telling me about her experience in our session after that day. “It caught me off guard. I didn’t know what to say, so I just told them I’m on long-term disability.”
It had not occurred to me to try to prepare Robin for this. Of course, this standard question people ask when they are trying to get to know each other would come up. Upon meeting Robin, a young women who looked perfectly healthy, of course people would innocently wonder what she does for a living and why she had time in the middle of a Monday afternoon to volunteer. Robin worried so much about what other people thought. It would have helped if we had discussed that this question might come up, before she went there the first time. I told her I agreed being honest was best, since she needed to feel accepted by other people who knew the real her.
“So, how did the volunteering go?” I asked.
“I’m going to start going there four hours every Monday and will be driving clients to appointments,” she said. “I’m anxious about getting lost when I’m trying to find the offices, but as long as they don’t pack too many appointments into one afternoon I’ll be fine.”
Robin said she felt positive after her first day, and felt “briefly competent” afterward.
The next day, Robin called. “My brother got a questionnaire from Social Security. They’re asking him a bunch of questions about me.” I told her this was standard procedure when someone applied for Social Security Disability benefits, because they want objective information from someone who knows the applicant well.
“I didn’t sleep at all last night,” she said. “I was obsessing about a lot of different things, but mostly the Social Security paperwork made everything more real. I would prefer to be in ‘la la land’ where I believe I’ll be going back to work whenever they have an opening. But I know this isn’t true, which makes me depressed.”
We discussed the possibility of her former supervisor receiving a questionnaire from Social Security as well, and how she should handle this. As we wrapped up our session, Robin agreed to let me know if her sleep did not improve.
In our session the following week, Robin said she had gone to volunteer, but they had no clients who needed her to drive them anywhere. She said they had her do some filing, but she only stayed for a couple of hours.
Then, as we kept talking, Robin started saying things I was not expecting or prepared to hear. Although I shouldn’t have been, I was probably more stunned than I had been during the previous eight months.
“I was feeling okay after volunteering, until I went to bed. “Then, I couldn’t sleep. I began to obsess about suicide including what I’d write in a note, what songs I’d want to have played at my memorial service, and who’d need to be contacted after I am dead.” She said it took her several hours to get to sleep.
“Robin, what happened? You have been feeling so much better overall! What caused your mood to shift so suddenly?”
“I was really anxious about going to volunteer on Monday. Then I felt let down when they didn’t have much for me to do. I’m trying to accept that I won’t be going back to my job. But I’m having trouble getting past this.”
We talked again about the big picture of her life and her treatment, and about all the progress she had already made. We talked about all the progress she could continue to make in the future.
“It feels like it would be too hard to make the changes it would take to make things better enough,” she said, sounding very hopeless.
Robin went on. It was, as was often the case, as if she felt compelled to confess to me. “Yesterday I was seriously thinking about overdosing. I had everything ready. I even had the CD of songs made, the note written, and the list of people to contact.”
What? I couldn’t believe what I had just heard. I thought we were past this! Throughout the entire time since Robin’s meltdown, she had never carried it this far. She had never written a note. She certainly had not made a CD of songs for her memorial service. It indicated that she had not only been obsessing, she had been meticulously planning to carry out an attempt! After hearing this, it was one of those moments when I was suddenly not even remotely calm on the inside, but I relied on my ability, honed over many years of practice, to remain calm on the outside and ask the right questions.
“What stopped you?” I tentatively asked, not sure what I would hear.
“Well, Christi and I had plans to get together. After I decided to kill myself, I had to call her to cancel our plans so she wouldn’t be worried about me. I expected to just leave a voice mail, but she picked up the phone. She was so disappointed about me canceling, I changed my mind and decided to go over there before I killed myself.”
Thank God for Christi! Although I had never met Robin’s friend, I had heard a lot about her and liked what I had heard. Inside I was thinking I would give her a big hug if I could. She had no idea how helpful she was to Robin that night. I was trying to digest the reality that, again, Robin had planned a suicide attempt without me knowing it and could have easily, in an impulsive moment, carried it out. It was a painful reminder that no matter how hard I had worked to help her, and no matter how much progress she had made, Robin could still very well end up dead.
“So, I am assuming by the time you got home from Christi’s place you had shifted enough to keep from carrying out your plan?” I asked.
“Yes. I guess part of me doesn’t want to kill myself, because I don’t want to hurt people. Besides, I think there is also part of me that is too chicken. I’m really afraid I’d just screw it up and make things worse.”
In hindsight, I should not have been surprised by Robin’s near suicide attempt. It is widely known and discussed among clinicians that people are often at high risk for suicide when they are coming out of a serious depression. There are many theories about why, and probably lots of different reasons for different people. I suddenly remembered that Robin had talked about needing to finalize her bankruptcy as a barrier in terms of suicide, so she did not leave a financial mess for her family. That barrier had recently been removed. Robin was feeling hopeless about being able to adjust to her new identity and not returning to her previous job. In hindsight, it made sense that she was having more suicidal thoughts.
I asked the question I had asked so many times before during that year. “Do you need to be in the hospital, Robin?”
“I really want to avoid that if I can,” she said. We discussed the fact that she had not been drinking despite her increased depression, and was not showing significant signs of mixed mania. I told her I would talk to Dr. Greene the next day, and we would go from there.
“Dr. Greene, it’s Sharon,” I said after paging him the next morning. “Robin has been doing much better since her last hospitalization, but her sleep has started to get disrupted and she has been more depressed in the last week or so. She is back to ruminating about suicide.”
After some discussion in which I told him about the events of the previous day, Dr. Greene made the decision to increase both Robin’s Abilify and Depakote doses. I called her to let her know.
“How are you this morning?” I asked, hoping to hear she was feeling better.
“I didn’t sleep very well. I still can’t stop thinking about suicide,” she said. “I feel like I’m waiting for something bad to happen to give me an excuse to do it.” She agreed to make the medication changes Dr. Greene had suggested.
Robin and I continued to talk through her grief issues as we waited to see what the medication changes would do. We continued to have some contact on the phone during the week, in addition to meeting in therapy once a week. She continued to refuse to talk on the weekends, as she did not want to feel “too dependent” on me.
So, when she called me on a Sunday in late October 2003, I knew she must not be doing well. It remained highly unusual for her to contact me without a planned time to talk, especially on a weekend.
“I still can’t stop thinking about suicide. I’m having a hard time and need to refocus away from those thoughts.” Wow! This was a shift! Robin had overcome her anxiety about calling me in order to proactively try to avoid being self-destructive. I was surprised, and thrilled by the change. Robin described a clear pattern over the previous few days of doing okay during the day when she was busy and distracted, but getting more depressed toward evening and ruminating about suicide at night. Then, she said something truly remarkable.
“I don’t want to kill myself,” she said. Clearly, unambiguously, and unqualified. For the first time since her meltdown, she said it. Thank God. “I’m frustrated that my brain keeps going there. I’m tired of trying to fill time to keep myself distracted. I just want to stop thinking about it.”
I don’t know what happened that caused Robin to suddenly get clear. I don’t know whether her near miss the previous week had scared her, or whether she was beginning to benefit from the medication changes. But, what a relief it was to hear those words. Robin finally felt clear she did not want to die.
We talked about ways to help her brain shift. I suggested we think about ways to increase the barriers in terms of acting on her suicidal thoughts. “What do you think you could do that would make it harder for you to act on those thoughts in a weak moment?” I asked.
Robin was open that she had a stockpile of old medications she was no longer taking, which had been part of her plan for overdosing. She decided that night to get rid of all of the extra medications she had in her apartment. She reluctantly agreed to pour out all of her alcohol, even though she had not recently been drinking. And, after some discussion she agreed to delete her recently written suicide note, in which she gave final instructions, from her computer. Robin, finally, was clearly serious about wanting to stay alive.