Tuesday, December 15, 2009

A New Home

I've received enough feedback about this blog to decide that it's worth further investment. So I've purchased a domain name, "facingthedemon.org," and transferred this blog to a Wordpress platform. To those without a technical background this means little, except that the new platform is a lot more versatile than this one. When you visit it, you'll see what I mean.

Here's the new address.

I've been encouraged by the people who've joined this site through Google Friend Connect. I've installed the same widget on the new blog, so please come over and join up again. I'd sure appreciate it.

Sunday, December 13, 2009

Mood Watch - 48

For a couple of years I kept track, intermittently, of my shifts of mood in a series of numbered posts entitled "Mood Watch." All in all I composed forty-seven of these, the most recent one dated April 3, 2008. I've decided it's a habit I ought to resume, partly because it has intrinsic value and partly because, well, it gives me something to post about on a regular basis. I have some "major" posts in mind to publish but obviously, amid the press of other business, I haven't had time to get to them.

Bipolar Disorder varies from one person to another according to individual biochemistry, life style, the level of support received, and temperament (I think people have a temperament that is independent of, though inflected by, their biochemistry). Some people with the disorder have to deal mainly with the manic side: the "highs." I struggle mainly with the depressive side: the "lows." In classic terms, depressions take the form of mainly of lethargy and a sense of worthlessness. The last time I felt this way was in the spring of this year. It lasted for a couple of weeks and was pretty awful.

Since then, however, I've had periods of energy and lethargy but without the other criteria associated with bipolar disorder. Typically I'll have a period of a week to ten days in which I can't sleep for more than three or four hours at a time, and when I wake up I'm wide awake immediately. At such times I'm on guard against an incipient hypomanic episode. I look for things like heightened creativity, inflated self esteem, a temptation to take on new projects, an inability to focus on a single task because of a desire to head off on tangents, and so on. But I don't find them. In everything except sleep I function normally. Even then, I take enough naps that in any 24-hour period I get around seven hours of sleep, which for me is a normal amount. I just can't get them all at once.

When such periods end I quickly dip into a period when, try as I might, I can't get enough sleep. I don't feel despondent, or worthless, I don't lose interest in things that ordinarily give me pleasure, and I don't lose my appetite. I just can't seem to wake up. These periods typically last about four days, seldom more than that. Their onset is abrupt. They also lift abruptly. Last week was such a period. Until last Sunday (the 6th) I felt fine. Sunday evening, though, I went to bed early, and Monday I felt as drowsy as if I hadn't slept at all. It was the same thing Tuesday. And Wednesday. And Thursday. And Friday.

The only other feature I noticed this time was a kind a vague anxiety. I didn't feel like being around people -- though at least in this instance, I didn't mind talking on the phone. I tended to stay away from email, blogging, and so on. I could say that's simply because I'm tired but it felt like something more, as if I connected these activities with something unpleasant.

Saturday I still didn't feel quite myself, but I managed to get up and about and generally had a pretty good day. The one residual effect is a sense of discouragement. I lost a week of productivity. I can't afford that. This is particularly acute in the case of my professional research and writing. It's really devastating in that department. All the same, the worst thing one can do in such situations is dwell upon it. I try to regard these periods as no different than a physical malady like the flu.

Saturday, November 14, 2009

Family to Family



I'll be speaking at a NAMI Family to Family class on Monday evening. This video tells a bit about the Family to Family program--a 12 week educational course for families of people with mental illnesses.

Sunday, November 8, 2009

Depression: One in Six

About One in Six Americans Report History of Depression
Income, marital status, gender all appear to play a role

by Brett W. Pelham

WASHINGTON, D.C. -- The Gallup-Healthways Well-Being Index reveals that 17% of respondents -- or about 40 million American adults -- report having been diagnosed with depression. The results are from more than 250,000 interviews conducted in 2009 as part of the Gallup-Healthways Well-Being Index.

Full story from Gallup.com

Thursday, November 5, 2009

Facing Facts - Update

Prior to my talk at the Ohio Academy of History -- reprinted here as Facing Facts -- a professor sent me an email saying that he looked forward to hearing it. Of course, he didn't know what "it" was, since nothing had been advertised beyond the mere fact that I was going to be the after dinner speaker.

Following the talk, a gratifying number of people came up to thank me for what I had said. This particular professor did not.

A few days ago I ran across his email and decided to ask what he'd thought of the talk. I had a pretty good idea already. Still, I thought I'd give him a chance to prove me wrong.

His response: "I had known about your condition for a long time so I would have preferred more substance on the Civil War."

Sunday, November 1, 2009

Wide Eyed

When I met him on a sidewalk
He was preaching to a mailbox
Down on 16th Avenue
And he told me he was Jesus
Sent from Jupiter to free us
With a bottle of tequila and one shoe
He raged about repentance
He finished every sentence
With a promise that the end was close at hand
I didn’t even try to understand

He left me wide eyed in disbelief and disillusion
I was tongue tied, drawn by my conclusions
So I turned and walked away
And laughed at what he had to say
Then casually dismissed him as a fraud
I forgot he was created in the image of my God

When I met her in a bookstore
She was browsing on the first floor
Through a yoga magazine
And she told me in her past life
She was some plantation slave’s wife
She had to figure out what that might mean
She believes the healing powers of her crystals
Can bring balance and new purpose to her life
Sounds nice

She left me wide eyed in disbelief and disillusion
I was tongue tied, drawn by my conclusions
So I turned and walked away
And laughed at what she had to say
Then casually dismissed her as a fraud
I forgot she was created in the image of my God

Not so long ago, a man from Galilee
Fed thousands with His bread and His theology
And the truth He spoke
Quickly became the joke
Of educated, self-inflated Pharisees like me

And they were wide eyed in disbelief and disillusion
They were tongue tied, drawn by their conclusions
Would I have turned and walked away
And laughed at what He had to say
And casually dismissed Him as a fraud
Unaware that I was staring at the image of my God

Nichole Nordeman, “Wide Eyed” (1998)

(From Christian Lyrics Online)

Friday, October 30, 2009

The Invincible Force - Pt 1

"I felt that something had broken within me on which my life had always rested, that I had nothing left to hold on to . . . . an invincible force impelled me to get rid of my existence, in one way or another. It was a force like my old aspiration to live, only it impelled me in the opposite direction."
-- Leo Tolstoy

Part 1 - Part 2 (coming)

Thursday, October 29, 2009

Weight Gain Associated With Antipsychotic Drugs

Back in 1999 I was put on Depakote, a prophylactic against mania that, as it turned out, had the effect of slowly but steadily ratcheting up my weight. When I started taking it I weighed 168; within five years I was very nearly at 200 pounds -- sometimes even a bit over. Since I'm only 5'8", that was obviously a problem, both intrinsically and because of a history in my family of heart disease.

Fortunately I managed the disorder conscientiously enough that my psychiatrist felt comfortable eliminating the Depakote and relying principally on Lamictal (which is prescribed mainly as an anti-depressant but has some anti-manic properties as well), coupled with disciplined sleep hygiene.

Lamictal is weight-neutral. I still managed to gain weight while on it, but as it turned out, that owed mainly to eating out a lot (especially fast food) and drinking a lot of beer. In mid-July I started the Weight Watchers program. I have so far lost a bit over twenty pounds, with fewer than eight pounds to go.

Still, not everyone has the luxury of such an option....
In the New York Times, October 28, 2009

Weight Gain Associated With Antipsychotic Drugs
By DUFF WILSON

Young children and adolescents who take the newest generation of antipsychotic medications risk rapid weight gain and metabolic changes that could lead to diabetes, hypertension and other illnesses, according to the biggest study yet of first-time users of the drugs.

The study, to be published Wednesday in The Journal of the American Medical Association, found that 257 young children and adolescents in New York City and on Long Island added 8 to 15 percent to their weight after taking the pills for less than 12 weeks.

The patients, ages 4 to 19, added an average of one to one-and-a-half pounds a week.

“The degree of weight gain is alarming,” said Dr. Wayne K. Goodman, head of a Food and Drug Administration advisory panel on the drugs last summer and chairman of psychiatry at Mount Sinai School of Medicine in Manhattan. “The magnitude is stunning,” he said.

Full Article

Wednesday, October 28, 2009

Friday, October 23, 2009

Facing Facts

What follows is an after dinner talk I gave last week to a group of academics at Capital University in Columbus, Ohio. I'd been asked to offer some reflections on an exhibition in Capital's Schumacher Gallery concerning the lives of Ulysses S. Grant and Robert E. Lee. (It was, incidentally, a traveling exhibit organized by the Virginia Historical Society and New York Historical Society, funded by the National Endowment for the Humanities, and supplemented by artifacts fom the Motts Military Museum.)

I dislike giving presentations that don't build toward projects underway, and since the next speaking engagements on the horizon have to do with mental health advocacy, I decided this would be a good opportunity to experiment with one. The talk was something of a high wire act, interweaving personal observations of Grant and Lee with those concerning bipolar disorder. But judging by the response I received, it worked.


It’s a pleasure to talk with you this evening about Robert E. Lee and Ulysses S. Grant, particularly in light of the exhibition at the Schumacher Gallery. I’ve heard it said that an exhibition, even when installed, is not really an exhibition. It becomes one only people come to experience it. They see in it, and take from it, meanings that the designers of the exhibition did not necessarily intend to impart. This is so because people bring to it their own experiences of life, their own concerns, and above all their own imaginations. Were this not the case, I doubt if exhibits would be at all worth the investment of time, money, and energy required to create them.

During the Civil War a pair of Union officers climbed atop a mountain to survey through telescopes the Confederate encampment beneath them. They saw soldiers brewing coffee, writing letters, reading newspapers, and washing clothes. To one of the officers this was a revelation. “My God, Adjutant,” he said to the other. “They’re human beings, just like us!” The Grant-Lee exhibition invites us to reconsider these two icons of the American military tradition, these central characters in the American Iliad. Their lives had the same common place experiences and the same complexities as our own. They were human beings, just like us.

I grew up with Grant and Lee. I got to know them through children’s books, and particularly got to know Lee through a biography entitled Robert E. Lee and the Road of Honor, written for young people by the Southern progressive journalist Hodding Carter, which I read at the age of eight. But the really critical experience occurred when I was twelve and first read A Stillness at Appomattox, Bruce Catton’s brilliant evocation of the epic struggle between these two commanders in the Civil War’s final year. When I say that I grew up with Grant and Lee I mean this, of course, in an imaginative sense, and yet the imaginations of the young can be so vivid and intense that I still sometimes feel as if I grew up with them in a literal sense. And in terms of their impact on my life, that is quite likely true in the deepest sense of truth.

Recently I turned fifty years old. That makes me just seven years younger than was Lee in 1864 and actually eight years older than Grant when he led the Army of the Potomac across the Rapidan River and into battle against Lee’s Army of Northern Virginia. My life has gone in directions very different from theirs and has taken a very different shape. But in dealing with the challenges of my life, I have often looked back on these two men, both what I thought I knew of them as a youth and what I think I know of them now.

The biggest challenge that has faced me in life began to confront me in 1986, when I was diagnosed with bipolar disorder — what used to be called manic depression. For reasons I’ll explain in a bit, it has become important to me to talk about what it is like to live with the disorder, but at the time it was something that I simultaneously acknowledged and ignored, with an odd kind of doublethink that, I have discovered, is not uncommon with people confronting facts that are unavoidable and yet still something one wishes to avoid. For the first few months I saw a psychiatrist and took medications, but then I simply stepped away from that and for eleven years thought and lived as if bipolar disorder were something I had in theory, not in fact.

A hypomanic episode I had at age 38 finally brought me to reality. With hypomania a person can be charismatic, unusually creative, and brilliantly high functioning. But those who know them well recognize that something I wrong. And if the person is wise, so does he. So early one morning, refreshed and wide awake after only two hours of sleep — notwithstanding the fact that given the pace I’d been keeping and the sleeping pill I’d taken I should have been out cold — I came to realize, and I mean really realize, that I had bipolar disorder and always would have it and was lucky during the preceding decade not to have met with disaster. I sat down at my computer and composed a sort of memorandum to myself. I’m going to read some of it here. At first it will seem to have no relevance to Grant or Lee, but then it will take a turn that should surprise you. It certainly did me.

“I’m obliged to do the one thing we humans hate: face facts. There is nothing harder. I have long been amazed to discover how even very intelligent people can so readily run from the facts. It never occurred to me to realize that I have spent eleven years running from the facts. Yet that is what I’ve done.” I went on to say that I had two main thoughts about it. The first one was obvious: “So far I’ve managed to get through the cycles through my ability to cope, though at what unnecessary personal cost I cannot imagine. How long can I expect my luck to hold? I’d better get with a psychiatrist and do what the hell he directs.”

“The second thought,” I continued, “will seem unrelated and perhaps inappropriate to the context, though I assure you it is not. It is that, while neither I nor anyone else could ever prove it, I think I now know why General Robert E. Lee halted his army on the Sharpsburg ridge on September 15, 1862, rather than do the “prudent” thing and recross the Potomac River. Instead he turned to face his much larger enemy and fought a pitched battle (the bloodiest single day of the Civil War) with a wide, unfordable river about a mile to his rear. Military historians have wondered ever since why he did it. Most of the explanations center on operational or political factors. But is it possible that Lee stood at Sharpsburg because something in his own personal history combined with these impersonal factors to compel the decision he made? If so, I think it was his father.

“Light Horse Harry Lee was, in some respects, a more successful man than Robert. He was a hero of the Revolutionary War and a governor of Virginia, among other things. Yet Harry Lee wound up dying far from home and penniless, for reasons that have to do ultimately with a refusal to face facts or to stand and face the consequences of his life. He fled the country rather than go to debtors’ prison for debts he’d contracted in a series of risky land speculation ventures. In September 1962, Robert took a risk by crossing the Potomac and embarking on a raid into Maryland while his army was reduced in numbers and ill-equipped. After the defeat at South Mountain he should have departed from Maryland as soon as he could. But perhaps something in him resisted the idea of running from the consequences of the risk he had taken. Perhaps he realized that if he did so his future generalship would be compromised. (Generals are human beings first of all; the same psychological dynamics that affect the rest of us affect them.) Perhaps in a much different way than I am doing, Robert E. Lee was also facing facts when he made his stand on the high ground west of Antietam Creek.”

I have visited Antietam many times since then, have conducted historians, laymen, West Point cadets and field grade officers on staff rides of the battlefield. I’ve thought a lot about the insight I had on that particular evening. It is still not something I can prove, and yet if anything I feel even more strongly than I did that basically I got it right. I think Lee understood that if he had withdrawn without a fight he would forever have been one kind of commander and that his army would have been one kind of army. By making a stand on Sharpsburg ridge he became another kind of commander with another kind of army — a commander and an army that enjoyed a psychological mastery over its opponent that it never really lost.

I certainly know that if I had continued to evade the fact of my own mood disorder, I would have been a very different man. I would certainly not have come to see that a central task of my life must be to talk openly about the disorder. It isn’t much fun to do. Like anyone else, I would like to lead a “normal” life, whatever that is. I don’t like having to bring upon myself so directly the stigma that attaches to mental illness. But if I, as a high functioning individual who leads what most would deem a reasonably successful life, don’t talk about it, then I’d simply be an accomplice in the perpetuation of the stigma. To give just one example: only about one college student in four believes that someone with a mental illness can eventually recover. And since about one college student in a hundred has been or will be diagnosed with bipolar disorder — to say nothing of a range of other mental illnesses — the stigma, if unaddressed, still has a very large capacity to damage.

In ethical terms, there’s no deontological or consequentialist moral imperative at work here. I’m not coming within a country mile of saying that high functioning persons with a mental illness are not allowed the option of maintaining their privacy. The moral reasoning at work here is aretaic; which is to say, it is character-driven. It flows from a personal sense of right and wrong as it applies to me. It’s impossible to trace the roots of the sense of duty I feel about this matter. But it would surprise me very little to learn that it tracks back to Lee, or Grant, or both.

I am the readier to believe this because the ethical reasoning involved is identical to that of three American generals — two of them four-star generals — who have publicly disclosed that they are in treatment for Post Traumatic Stress Disorder. And indeed, at the U.S. Army War College I have found an unusual degree of understanding and support for the choice I’ve made, because of the high incidence of PTSD in the current fight. Bipolar disorder is an illness, PTSD is an injury, but they share key features in common. Both must be managed. Both have a stigma.

I have found that in managing the disorder I regularly drawn upon my military training and experience, my understanding of military culture and history, and my background in strategic studies. The most critical feature is that this background has taught me to avoid making what I consider to be the disastrous errors of conflating the illness with one’s identity — “I am my diagnosis” — or of romanticizing the illness because bipolar disorder is associated with many creative people. I regard myself as being at war with an entity that will never rest until it has killed me, either by lifting me into a manic episode of such heights that I do something lethally foolish, or by casting me into a depression so deep that I end my life by suicide.

I cannot think of a stronger way to externalize the illness. Nor can I think of an inducement more likely to get me to manage it with sustained seriousness of purpose. Neither Grant nor Lee ever read the Prussian military theorist Carl von Clausewitz, but they instinctively understood his observation that, “in war, the best strategy is always to be very strong, first in general and then at the decisive point.” Translated metaphorically, what this means is that if you have bipolar disorder you muster every resource you can. If you have access to a psychiatrist and a therapist, you see them regularly. You take your medications. You make a priority of what the mental health professionals call “good sleep hygiene.” You work out regularly. You find environments and people that are supportive. And when necessary you divorce yourself, calmly but ruthlessly, from environments and people that are not.

You take the illness seriously, but you don’t let it rule your life. I said before that Lee achieved a psychological mastery over the Army of the Potomac that he never really lost. It was a source of enormous frustration to Grant when he tried to use that army as a tool, because it seemed to have over caution encased in its organizational DNA. Confronted on one occasion by a frantic general who warned him of a fatal blow he believed Lee was about to deliver, Grant snapped, "Oh, I am heartily tired of hearing about what Lee is going to do. Some of you always seem to think he is suddenly going to turn a double somersault, and land in our rear and on both of our flanks at the same time. Go back to your command, and try to think what we are going to do ourselves, instead of what Lee is going to do." It is the same with bipolar disorder. Although the disease is an adversary one must respect, it should not be so intimidating as to prevent one from taking the normal risks necessary to achieve success in ordinary life.

By now I hope you can see some of the personal resonance the Grant-Lee exhibition has for me. If it seems as if this understanding derives as much from the mythic dimensions of these men as from the down to earth dimension, that gets at something that as an historian, I’ve learned to accept as being true of most people who find fascination in, and derive meaning from, the human past. Myths can be myths in the sense of falsehood. They can also be myths in the sense of isolating and inscribing deeper truths. So will we ever shake the grip of our myths about Lee and Grant? I doubt it. We need it too much. Although perhaps no longer necessary as an embodiment of the Lost Cause, the myth of Lee has a more universal resonance. Sooner or later, everyone loses. The dreams of youth are left behind, the fatal diagnosis is pronounced. The idea of facing inevitable defeat with courage, dignity, and humanity — as Lee is rightly said to have done — therefore has powerful attraction.

But if we need the myth of Lee, so, too, perhaps, we need the counter myth of Grant. The world is as full of obstacles as it is of losses, and to get anywhere in life one must possess grit, drive, determination, persistence. And so we also need the image of Grant: Grant the implacable, Grant the hammerer, Grant the man who, despite everything, keeps moving on.

Tuesday, October 13, 2009

Note From a Consumer

Last Thursday I attended a showing here of Minds on the Edge: Facing Mental Illness. (My last entry showed the promo.) The documentary, the latest in the Fred Friendly Seminar series, is being aired on PBS this month. It uses a format you may have seen over the years in previous installments (since its inception there have been over a hundred):
The Seminars always begin with a little story and a problem that could confront almost anyone. The implications of this problem, whatever it may be, then ripple out to encompass larger and larger issues and trigger ethical, emotional, legal, and public policy questions that are always overlapping and sometimes in conflict. Each Seminar program brings together a carefully chosen panel that contributes professional expertise as well as personal experience to the discussion. As the panelists wrestle with the issues presented in the hypothetical story, they are encouraged not just to say what they think about an issue, but to say what they would do in difficult decision-making situations if they were personally involved. The viewers are along for the ride, emotionally and intellectually, as the story creates a link for citizens between their lives and issues in the headlines that so often seem remote, abstract and unconnected to their day to day concerns.
It's an effective method. Minds on the Edge addresses mainly the problems involved first, in getting persons experiencing a mental illness crisis into treatment (the assumption is that most such persons resist treatment); and second, the way in which the mental health "system" takes care of persons once they do get treatment. I place "system" in quotes because, as the program makes clear, no system exists, merely a jumble of well intentioned but underfunded and uncoordinated efforts by a variety of hospital, outpatient, governmental, and non profit organizations.

You can find the entire program online. It runs just slightly over an hour, and on the whole it's fascinating but pretty depressing.

In addition to watching it on PBS or online, you can watch it at a screening at some church, civic organization, or similar venue. This screening I attended was organized by the local chapter of NAMI (National Alliance on Mental Illness). About forty people were also in attendance. NAMI divides the mental health world into three types of person: providers, consumers, and loved ones. Providers are mental health professionals, advocates, etc. Consumers are people like me; i.e., those who have a mental illness and are therefore consumers (or at least potential consumers) of mental health care. Loved ones are the friends and family -- usually parents and/or siblings -- of consumers. The categories can overlap. Providers, in several instances, are also consumers. I suppose they could be loved ones as well.

By the way, I'm not wild about being called a consumer. Words carry freight. The phrase consumer not only sounds kind of weird to me but also implies that being in treatment for a mental illness is central to my identity. As I hope I've made clear by now, I dislike any phraseology that conflates an illness one has with a statement of what one is. Still, it's plain that consumer was chosen faute de mieux, so I guess I can live with it.

Following the screening was a sort of panel discussion that involved a consumer (who happened also to be the chapter president), a provider, and two loved ones (a father and mother with a son who has bipolar disorder). Early in the discussion it became apparent that most of the audience consisted of self-identified loved ones. I seemed to be one of the few consumers in attendance.

I had learned about the screening following a brief conversation in August at the annual Army War College "county fair," an elaborate event in which dozens of local merchants, non profit groups, etc., congregate for an all day event designed to give the incoming resident class and their families an idea of the services locally available. I had a brief exchange with the people manning the NAMI booth, mentioned that I had bipolar disorder, and offered to join their speaker's bureau if they had one. They did. The most appropriate one seemed to be a program called In Our Own Voice. Here's a description from the web site:

In Our Own Voice (IOOV) is a unique public education program developed by NAMI, in which two trained consumer speakers share compelling personal stories about living with mental illness and achieving recovery.

The program was started with a grant from Eli Lilly and Company.

IOOV is an opportunity for those who have struggled with mental illness to gain confidence and to share their individual experiences of recovery and transformation.

Throughout the IOOV presentation, audience members are encouraged to offer feedback and ask questions. Audience participation is an important aspect of IOOV because the more audience members become involved, the closer they come to understanding what it is like to live with a mental illness and stay in recovery.

IOOV presentations are given to consumer groups, students, law enforcement officials, educators, providers, faith community members, politicians, professionals, inmates, and interested civic groups.

All presentations are offered free of charge.

My first presentation is slated for November 16 at a Family to Family Education Program, a free, 12-week course for family caregivers of individuals with severe mental illnesses.

I have, of course, written in several venues about having bipolar disorder. But, aside from speaking to a psychology class at Dickinson College, this will be the first time I've given a regular talk on the subject. I feel slightly daunted at the prospect. To begin with, I'm fortunate enough to have a mental illness that, compared to what others have to face, is mild. It's a pain in the ass sometimes, but it's never seriously interfered with my ability to function normally. Indeed, I've always felt that from a mental health advocacy standpoint, my chief value is as a high functioning individual willing to say forthrightly that he has a mental illness. People who can keep their diagnosis private generally tend to do so.

As a corollary, I worry that anything I have to say will be a) irrelevant to the situations of my audience; or worse b) will convey the disastrous impression that if I can manage the illness so "easily," then so could their family members if only they applied themselves. The only solution I can think of is to offer the appropriate caveats, concentrate on my own experience, and avoid saying anything that sounds prescriptive. And anyway, the main thing I would want to convey is how impressed I am that they are actively supporting their loved ones -- I mean consumers. Aside from being under the care of a psychiatrist and therapist, I can think of nothing more critical to helping someone with a mental illness manage it most effectively.

Thursday, October 8, 2009

Minds on the Edge

Tuesday, September 29, 2009

Ambushed

Dana Jennings, who blogs in the New York Times about his struggle with prostate cancer, writes today that he is "recovering well from an aggressive case of prostate cancer" and that all "physical signposts of health are pointing in the right direction."

Which would be fine, except that he is depressed. And feels ambushed.
This isn’t about sadness or melancholy [Jennings writes]. It’s more profound than that. Broadly, I have a keen sense of being oppressed, as if I were trapped, wrapped up in some thick fog coming in off the North Atlantic.

To be more specific, I’m exhausted, unfocused and tap my left foot a lot in agitation. I don’t much want to go anywhere — especially anyplace that’s crowded — and some days I can’t even bear the thought of picking up the phone or changing a light bulb. All of this is often topped off by an aspirin-proof headache.

The fatigue frustrates me most. When I envision myself it’s as a body in motion, walking or running, not foundering in bed. On one recent day, I slept till 10 in the morning — getting 11 hours of sleep — then took a nap from noon to 2. And I was still tired.

I’ve had occasional depression over the years, but nothing as dogged as this. When I first learned that I had prostate cancer, I wondered about depression. But after the shock of the diagnosis wore off, I was sharp and clear-headed. I wasn’t depressed as I went through treatment — surgery, radiation and hormone therapy. I was buoyed by a kind of illness-induced adrenaline.
Jennings' description resonates with me in two respects. First, it resembles my own experience of depression. With me the dominant symptoms are usually hypersomnia and fatigue. And he's not kidding when he says there are days when changing a light bulb seems impossibly hard; with me that's standard.

Sure, there's also a general sense that my life is awful and will never get better, but most of the time I'm able to dismiss that as the distorted thinking typical of depression. In and of itself it isn't bad. What sucks is the loss of productivity, so that even when I'm back to normal I feel -- accurately -- that I'm badly behind in my work. And if only two or three weeks elapse before the next depression, the biochemically induced sense of hopelessness is reinforced by an existential sense of despair. I feel like I'm in a ditch so deep I will never be able to claw my way out.

Second, it confirms something my therapist has told me for years: People who have experienced both cancer and depression often maintain that of the two, depression is worse. Of course, as Jennings' case indicates, it isn't an either/or proposition. For at least one cancer patient in four, it's a both/and.

Toward the end of his post, Jennings declares, "It’s harder to write about the weight of depression than it is to write about prostate cancer and its physical indignities. Cancer is clear biological bad luck. But depression, no matter how much we know about it, makes part of me feel as if it’s somehow my fault, that I’m guilty of something that I can’t quite articulate."

Of course, that kind of guilt has nothing to do with depression. It's an artifact of our culture. Physical illness okay (with some exceptions), mental illness not okay (with no exceptions at all).

Friday, September 25, 2009

The Perpetual Voyage

I rather dislike having been so critical of my parents in the previous series. It isn't so much that I now disagree with anything I wrote back in 1997 (the posts, you'll recall, are excerpted from a journal I kept back then), as it is that nowadays I have a much stronger sense of the personal burdens my parents faced. I cannot say I miss them or look back on them affectionately. But I do feel great sympathy for them, and a sense of regret that they were never able to escape the traumas of their own childhoods and find the life they expected would be waiting for them once they reached adulthood, settled down, and had a family.

I think most of us at some level expect that eventually our lives will find safe harbor somewhere. That was true of them. It certainly was once true of me.

I remember a few lines from MacKinlay Kantor's Glory for Me, a book-length poem that was the basis for the Oscar-winning 1946 film The Best Years of Our Lives:

When all my labors and trials are o'er
And I am safe on that beautiful shore
O, that will be
Glory for me.

The poem has to do with the return from war and the "beautiful shore" is home. But if it applies at all, it applies to heaven. In life the voyage is perpetual. You simply exchange one series of challenges for another. Or rather, the challenges arise, and you can choose either to meet them, resent them, or ignore them. But they don't ignore you. And if you don't face them, they wind up owning you.

At some point I'll return to the narrative of the onset of bipolar disorder and discuss with candor what it's like to experience a manic episode or a bout with clinical depression. But for now I'll just say that having long internalized the idea that the disorder is something I have, rather than a component of who I am, the challenge has not been--as it is for some--to figure out where my personality ends and the effects of the disorder begin. Rather, aside from simply managing the disorder from day to day, it has been to separate the effects on my life that stem from the existential pain of my childhood, and the effects that stem from the biochemical abnormality.

Wednesday, September 23, 2009

Onset - Pt 5

The revelations in Notebook 11 kept me up until 3 a.m. or so, particularly the entry in which I told Mom something was wrong with me and she blew me off. I talked about it today with my sister. Even before I broached this new information she said, “Do you ever feel that when we were growing up, nobody was really paying attention?” When I read her some of the entries I’d come across, she concurred that they did sound redolent of a mood disorder, and when I got to the entry about Mom she was not surprised. It seemed to us that Dad and Mom alike were determined that there would be just one designated patient in the family and Mom was it. By 1977 she had learned to exploit it—it was her main leverage on Dad, even more than her knowledge of his affair—and she pressed it for all it was worth. It was always very striking to me how courageously Mom dealt with her breast cancer and how craven she was about the manic depression.

Dad, for his part, resented the hell out of the fact that he had to pay Mom’s medical bills. I ran across an entry which reports that Dad had told their marriage counselor as much. I was surprised he’d admit it. As with a lot of the stuff I read, I had no memory of it, though it certainly sounded like Dad. My sister said she recalled the incident vividly. Moreover: “Do you remember,” she asked, “the expression ‘You get yours.’?” In Dad’s book, if he was paying for your medical bills (in the case of my Mom), or for ballet lessons (in the case of my sister) then they were getting theirs. The idea that a husband and a father owed his family things like time, energy, attention, and empathy was alien to him. Anything he did for you, he generally did so you’d get off his back.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Monday, September 21, 2009

Onset - Pt 4

To my surprise--because I don’t recall this at all--it turns out I wasn’t totally clueless about what was going on:
13 February, 11:16 p.m. . . . For what it’s worth, I think lack of sleep has a great deal to do with my emotional condition, much more than is usual with most people. I hope this proves the case. If so I may be able to end once and for all my more severe attacks of melancholy. . . . Must be cautious, must not stick my fragile mind in situations it cannot cope with.
I don’t remember this next incident, either, and when I saw it I just sat for a long time, staring in disbelief:
17 February, 12:16 p.m . . . I talked with Ma, briefly, about the mental peculiarities that have plagued me since June [1976]: how I oftimes seem to live in unreality, suspended in twilight, how my decisions & actions have not been of the first order. She dismissed the surreality as melodrama, and the “decisions & actions” bit by saying I had never been much of a decision maker & the ones I’m making nowadays are as good or better as any I’ve ever made. Also that, on balance, I am outwardly better adjusted than ever before. I could not make her see that inwardly I feel chaotic.
Oh you made her see, all right, I thought. It’s just that our family already had a designated patient and you weren’t it.

You bitch. You fucking bitch.

By this time I’m skipping school on a regular basis. No one seems to notice. A few days later I impulsively hop in a car with several potheads with whom I worked. Soon after occurs an amazing string of flirtations, make-out sessions, all night drunks, and so on with an array of girls--just off-hand I can think of a half-dozen, and I’m probably missing at least a couple--at the center of which soon emerges Jennifer, of suicide note--“I love Jennifer, desperately and impossibly”--fame. Barely three months separate the day I penned my entry about vainly trying to convince Mom that something was wrong, to the day I swallow a bottle of barbituates like so much popcorn.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Friday, September 18, 2009

Onset - Pt 3

The more I read, the more certain patterns began to appear: rapid cycling from euphoria to despair, disproportionate anger in response to slights, a loss at times of a sense of boundaries. Re the latter, for example, here’s my entry concerning a live broadcast of the high school quiz show In the Know, in which I was a contestant:
25 January, 11:20 p.m. . . .We lost by 180-125. I did well; I think everybody did, but there was one fellow on the other team who was really very good; he accounted for almost all their pointage. At halftime I included “failing French II my junior year” when listing my accomplishments; afterward a girl approached me and asked, “You said you failed French. How come?”
“How come I failed, or how come I said it?”
“Both.”
“Well,” I smiled, “I failed French ‘cause I didn’t study, and I said because it was a hell of a thing to say.”
B--- C--- & the old 1st team were there; B--- tried to console me but I didn’t need consoling. “I enjoyed myself. It was probably the most enjoyable game I’ve played.”
By February I am having trouble sleeping--up all night and having to sack in half the day to make up for it. I begin to take long, restless evening walks.
10 February, 2:34 p.m. - I permitted myself to sleep late yesterday, intending so far as possible to go easy on myself and insure I wouldn’t get fatigued . . . Worked 4:45-9:15, closed. Once home I watched “Rollerball” on TV, then abruptly set out on a long run that carried me [a distance of about 4 miles] before a police cruiser pulled up in front of me. The cop asked me where I was going, I explained, briefly, whereupon he told me to go back home. I was angered but wanted no trouble, and so complied. I spent several long moments up among the apartments where Sharon [a former girl friend--not her real name] lives, staring at that hillside and at the cold gleaming stars. It was a mistake for me to do this, because it thrust me almost immediately into a violent spasm of confused despair. Running back to the house I noticed that everything looked strangely alien, as if I were on another planet. Flashing automobiles looked futuristic, the dawn-like glow of the city gave me the impression I was light-years from home. A blood moon was out, hanging dully on the horizon, oval and hazy. The telephone poles looked like crucifixes. I could almost see men nailed upon them. Mighty weird.
Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Wednesday, September 16, 2009

Onset - Pt 2

I decided to rewind the tape to the beginning and dub the tape onto a fresh one. But when I played it all I heard were satanic warblings like something out of The Exorcist. I quickly realized what had occurred: the tape, in rewinding, had bent over on itself, so that I was now listening to the two tracks backwards. The problem looked reparable but I didn’t want to fool with it that night, so I put it aside and cracked open Notebook 11.

Arbitrarily I began reading the entries from mid-November 1976 onward. Very quickly I realized why I seldom take these strolls down memory lane. It is hard to confront the fact that you were once seventeen and lacked your present-day “maturity,” though in practice maturity often amounts to nothing more than an ability to disguise one’s real personality and foibles. Indeed, once I got into the entries I had a lot of respect for the young author, who somehow did not quite seem to be me. Since my memories of that period are as vague as anyone’s after the passage of twenty-one years, I found that reading the entries from 1976 did not so much jog my memories as create them, the way a good novelist can “create” a memory of, say, Lady Chatterley with her lover.

The journal has three striking attributes. First, it is on the whole astonishingly well-written. Although a first draft, hastily dashed off night after night, many of the developments it describes come alive on the page, and I think that even if I were wholly unfamiliar with my life I’d still be able to get a pretty good feel for what it was like. Second, it is preoccupied with girls to a degree that, even to me—who certainly remembers that part of the story—is just incredible. Third and (I think) a corollary of the second, the moods of the author are all over the map, and the cycling from upbeat joy to gloomy melancholy is very rapid—so rapid that it reminded me of Kay Redfield Jamison’s criticism of using the term “bipolar disorder” to describe the illness. The imagery of “bipolar” is linear—a swinging pendulum from one extreme of the emotional spectrum to another. Jamison postulates offhandedly that mania may in fact be a frantic flight from an incipient depression. But whatever the case, it was evident that I had some sort of mood disorder, and just as evident that, except in broadest terms, it was hard to shoehorn the symptoms into a classic framework of bipolar disorder.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Tuesday, September 15, 2009

When a Parent’s ‘I Love You’ Means ‘Do as I Say’

From yesterday's New York Times. It reinforces the point I made in the Onset prologue:

More than 50 years ago, the psychologist Carl Rogers suggested that simply loving our children wasn’t enough. We have to love them unconditionally, he said — for who they are, not for what they do.

As a father, I know this is a tall order, but it becomes even more challenging now that so much of the advice we are given amounts to exactly the opposite. In effect, we’re given tips in conditional parenting, which comes in two flavors: turn up the affection when they’re good, withhold affection when they’re not.

Thus, the talk show host Phil McGraw tells us in his book “Family First” (Free Press, 2004) that what children need or enjoy should be offered contingently, turned into rewards to be doled out or withheld so they “behave according to your wishes.” And “one of the most powerful currencies for a child,” he adds, “is the parents’ acceptance and approval.”

Likewise, Jo Frost of “Supernanny,” in her book of the same name (Hyperion, 2005), says, “The best rewards are attention, praise and love,” and these should be held back “when the child behaves badly until she says she is sorry,” at which point the love is turned back on.

Conditional parenting isn’t limited to old-school authoritarians. Some people who wouldn’t dream of spanking choose instead to discipline their young children by forcibly isolating them, a tactic we prefer to call “time out.” Conversely, “positive reinforcement” teaches children that they are loved, and lovable, only when they do whatever we decide is a “good job.”

This raises the intriguing possibility that the problem with praise isn’t that it is done the wrong way — or handed out too easily, as social conservatives insist. Rather, it might be just another method of control, analogous to punishment. The primary message of all types of conditional parenting is that children must earn a parent’s love. A steady diet of that, Rogers warned, and children might eventually need a therapist to provide the unconditional acceptance they didn’t get when it counted.

But was Rogers right? Before we toss out mainstream discipline, it would be nice to have some evidence. And now we do.

Full article

Monday, September 14, 2009

Onset - Pt 1

Excerpted from journal entries made in December 1997

For weeks now I have found myself fascinated by the revelation that I have manic-depressive illness, as opposed to having had a manic episode eleven years ago from which I heroically recovered. It has been a powerful distraction from almost everything else that has a claim on my life. I manage to tear myself away, but “tear” is definitely the correct verb. As soon as I decently can I’m drawn back into the bipolar world like a dog to its vomit. Outwardly my life looks as bland as can be, but inwardly I’ve embarked on one of the most absorbing adventures I have ever had. I’ve been learning about the illness, reflecting on what it means to have one’s personality so powerfully shaped by moods, and spelunking down long shafts of memory. It’s a pity so much of this will have to be recorded in summary form if it’s to be recorded at all. But that’s the only realistic possibility.

I could start at lots of points, but I think I’ll just start with last night. I was watching Mystery Science Theater 3000. Usually if anything can distract me from the cares of the day, MST3K will do it. But after a while I noticed I wasn’t following the film or the wisecracks very well. I was too busy ruminating about the probable onset of the illness.

My gut feeling has been that it probably began with an undiagnosed manic episode in the winter of 1976-77, followed by a suicidal depression in May 1977. To test this theory I cracked open Notebook 17, the fourth installment of a journal I’d begun keeping in April 1975. The first entry was for March 15, 1977. I had not read far before I had the sense that I was reading the words of someone who was hypomanic, but of course when you’re looking for something as subjective as evidence of a mood disorder you’re quite likely to find it, especially in the writings of someone seventeen years of age. I quickly decided to backtrack into the previous installment, Notebook 11 (forget trying to understand my numbering system), but before doing so I skimmed through up to the point of the suicide attempt, which occurs on page 59. It’s introduced with deadpan flippancy: “Monday Jennifer [a girl friend with whom I’d just broken up—not her real name, by the way] was not at school. Tuesday I saw her, Wednesday I sent her flowers. Thursday I committed suicide.”

The preceding three weeks of entries are unhelpful, because they’re not really entries, just obscure notes to remind myself about events that, for the most part, have long passed from memory. For example: “Tuesday, 10 May—No school—OHC—The Kent Affair—I Was There—1:30—Olan Mills Proofs—Morse Rd: IWT—Ponderosa for lunch—5:35-10:35.” I can guess at some of this, judging from my general recollections of the time, but in terms of any direct recollection of that particular day, I haven’t a clue. And it goes on like that for an entire page: nine days of entries, the last of them just eight days prior to the suicide attempt, for which a catch-up entry dated June 2 provides the basic background. But those nine hectic days probably held a good clue to what was going on with me that shifted my thoughts toward suicide, and it seemed a pity I could not unlock the code.

Finally at the bottom of the dehydrated entries I found a notation, “Taped Entries For These Dates are on Cassette Two.” Great, I thought. “Cassette Two,” whatever that is, is long gone. Then abruptly I realized it wasn’t—I’d just seen a cassette tape by that label among some stuff I brought up from the basement. I checked, found the tape, played it, and sure enough, I heard my own voice from across half a lifetime.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Sunday, September 13, 2009

Onset - Prologue

Until now my posts have concentrated mainly on the challenge of managing bipolar disorder. In effect, I’ve looked at the illness from the outside. Yet what exactly am I trying to manage? I could rehearse the clinical criteria for manic depression. But you can easily get that elsewhere. The way in which this blog can be of most utility is, in addition to explaining the methods by which I manage the disorder, to explain the metaphorical demon that I face in terms of the subjective experience of having the illness.

This won’t be fun to do. But quite some time ago I wrote the first series of posts that focus on what it’s like when the demon attacks. I’ve long held them in reserve, partly because I did not want to post anything on impulse – it is imprudent for people with bipolar disorder to take any major step impulsively – but primarily because, well, this won’t be fun to do. You just put this stuff out there. Anyone can read it. Anyone can make of it anything they want. And while I anticipate that most people will be supportive, inevitably there are people out there who will not.

Even so, I’ve taken a deep breath and scheduled the series to begin publishing tomorrow morning. The entries will appear at staggered intervals, usually about every other day. The series will deal with the onset of the disorder, which in my opinion occurred nearly a decade before it was diagnosed. And rather than adopt a narrative approach in which I base the account on what I knew at the time, I'll write in the full light of what I've learned from therapy and from long personal reflection.

But before the first post appears, I have time to make one final comment about my parents. As I’ve said in the past, while by and large I can leave specific persons out of this and future accounts, my parents are another matter. And of all the things about this venture that give me pause, the principal one is that, in the nature of the case, I shall have to criticize my parents. To be precise, I shall have to hold my parents responsible for the errors they made in raising me.

No one, surely, would deny that parents have incalculable impact on their children, particularly during the early years when the family environment they create for a child becomes his template for understanding the world in general.

Although few people have heard of Dorothy Law Nolte, most are at least passingly familiar with her poem, “Children Learn What They Live,” written in 1959 and originally circulated in the Torrance (California) Schools Board of Education newsletter. In the decades that followed, Nolte revised the poem several times. Here is the last version, published in the book Children Learn What They Live (New York: Workman Publishing, 1998):

If children live with criticism, they learn to condemn.
If children live with hostility, they learn to fight.
If children live with fear, they learn to be apprehensive.
If children live with pity, they learn to feel sorry for themselves.
If children live with ridicule, they learn to feel shy.
If children live with jealousy, they learn to feel envy.
If children live with shame, they learn to feel guilty.
If children live with encouragement, they learn confidence.
If children live with tolerance, they learn patience.
If children live with praise, they learn appreciation.
If children live with acceptance, they learn to love.
If children live with approval, they learn to like themselves.
If children live with recognition, they learn it is good to have a goal.
If children live with sharing, they learn generosity.
If children live with honesty, they learn truthfulness.
If children live with fairness, they learn justice.
If children live with kindness and consideration, they learn respect.
If children live with security, they learn to have faith in themselves and in those about them.
If children live with friendliness, they learn the world is a nice place in which to live.

The poem underscores the power that parents wield and consequently the responsibility they must accept. In psychotherapy a very common initial approach is to explore the way in which the client was raised, the way they perceive their parents as having treated them, and the life lessons they learned from their parents, good and bad. The sessions tend to concentrate on the bad. This is necessary in order to revisit, and begin to undo, the damages of childhood, which vary in type and intensity from one client to another but which involve deep existential pain and distorted thinking (for example “you can’t trust anybody” or “I’m not worthy of love, success, etc.”) based on messages ingrained on the client, sometimes deliberately but usually inadvertently, by their parents.

The relevance of this to bipolar disorder is that I have found that a key to managing the illness is the ability to distinguish between depressions that are a function of biochemistry and depressions that have an existential source. Even more crucially, in order to find the strength to face the demon of bipolar disorder, I have had to confront, and cease to be haunted by, the ghosts of the past.

While in my opinion unavoidable, the process gives rise to the stereotype that therapy is all about blaming the parents and excusing clients from their own decisions and behaviors. It is true that some clients, unwilling to take the next step -- where are you in all of this, you’re no longer a helpless child, you don’t have to stick with the patterns you grew up with, you have the power to improve your life -- remain immobile for a long time or else terminate therapy altogether. However, the purpose is never to blame the parents, which is pointless and self-defeating, but simply to acknowledge that, relative to the child, they for years exerted almost god-like power and the impact of that power must be well understood.

And of course, it’s not as if these parents themselves had perfect fathers and mothers. They often also emerge from childhood with pain and distorted thinking, and while raising their children they either grapple with, or repress, or act out the imperfections of their own childhoods.

The Prussian military theorist Karl von Clausewitz maintained, “In war everything is simple, but the simplest thing is very difficult.” Parenting is like that. Your objective is to love your children and raise them as best you can. Some parents think hard about the best way to do this and some pretty much follow the playbook learned from their own parents, but parents are almost continually shaping their children’s lives. There’s almost no downtime. And seemingly benign words and actions can have far different impacts than intended. The simplest thing frequently turns out to be very difficult indeed.

For instance, yesterday I heard a father rebuke his toddler with the words, “Why aren’t you minding your mother?” And I thought to myself, what possible response could the toddler give to such a question? So why couch it as a question? Maybe it just rolled off the kid’s back, but growing up I heard such rhetorical questions all the time, followed by the command, “Answer me!” It was a classic Catch 22. If you didn’t answer, you were insolent. If you did, you were insolent. And yet I doubt my parents ever considered this, still less that they intentionally placed me in a double bind. They were simply aping what they’d often heard other parents say within their immediate and extended families.

So in the posts that follow, bear in mind that I have neither the intention nor the desire to blame my parents for anything. But I am going to hold them responsible for the choices they made during the years when they had all the power and I had none, just I must hold myself responsible for the choices I make, now that I hold the power over my own life.

Prologue - Part 1 - Part 2 - Part 3 - Part 4 - Part 5

Thursday, September 10, 2009

The Normal


Sorry for the long hiatus between posts. It's the consequence of three things.

First, the academic year here at the Army War College has again gotten underway. I've been very busy.

Second, I've felt tired a good deal of the time, for reasons I don't really understand. I had supposed it might be a manifestation of the mood disorder. The disorder takes a variety of forms, including a waxing and waning of energy level. But after living with this frequent fatigue for a while and talking it over with my therapist, I don't think that's the case. It seems to be more physically based. It may be simply that it's taking me longer to get used to my workout regimen than I anticipated.

Third, I haven't had much to tell you.

Actually, that's not quite correct. I've got plenty to tell you. I'm just not that anxious to do it.

It's funny. On the one hand, I grew up with, and to some extent have internalized, the stereotypical American male tendency to play the strong, stoic type. On the other, I've had a lifelong itch to share what I think, feel, and believe--it's the central trait that has made me a writer. And I can think of few things more worthwhile than to communicate candidly about what it is like to live, day in and day out, with bipolar disorder. So you'd think it wouldn't bother me to get on with it.

But despite everything, there's still the urge to keep silent, to just be "normal." As if anyone were normal. And yet the desire to be "normal" exerts a powerful tidal pull, intensified by the ubiquitous signals in our society that reinforce it. It puts me in mind of a soliloquy from Equus, Peter Shaffer's amazing play. In it, the psychiatrist Martin Dysart meditates on the nature of his work:
The Normal is a Holy Ghost. . . . The Normal is a murderous, non-existent phantom. And I am his priest! My tools are very delicate. My compassion is honest. I have honestly assisted people in this room. I've talked away terrors. I have relieved many agonies. But also--beyond question--I have cut from them parts of individuality repugnant to this God.
As I hope by now is obvious, I consider bipolar disorder an illness that I happen to have. I don't think of it as something that defines me and certainly not as part of my individuality. I wince every time I hear phrases like "he's bipolar"; to my ears it's the same as saying that someone with cancer is cancerous. No: the part of my individuality repugnant to this God is the part of me that has the courage to be genuine. And neither my psychiatrist nor my therapist nor my friends try to cut it from me. All too often, I want to cut it from myself.

Monday, August 17, 2009

The Ethics of Disclosure

For many years now I've chosen to be candid about having bipolar disorder, and I have a variety of reasons for doing so. Many are pragmatic. But one is not: "[Being up front about bipolar disorder] gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can."

The quotation comes from a column I wrote three years ago. And although in it I used the phrase "modest courage," it would be more accurate to say "moral courage." That is to say, I would feel craven or gutless if I remained discreet about having bipolar disorder, even though the fact that I'm high-functioning means that people are oblivious to my having the disorder unless I tell them.

So if I kept this information to myself, would it be unethical? And if so, why?

Here at the Army War College we're midway through a ten-day course in "Strategic Thinking." I'm responsible for most of the remaining lessons -- the Uses of History and the capstone Gettysburg Staff Ride, for obvious reasons. And a bit less obviously: Ethical Reasoning, which comes up tomorrow. (I say "a bit" less obviously because anyone who knows my body of work is aware that much of it deals with the problem of moral judgment in war.)

At the AWC we faculty do not have carte blanche to prepare our own lessons. The readings, learning objectives, and the basic approach are designed by a lead instructor. The rest of us can adapt the lesson within certain limits, but we can't leave the reservation entirely. This sounds like a strait jacket, but it's really the only workable approach given the way that education is delivered here; i.e., within twenty tightly knit seminar groups with faculty members assigned to teach one particular group, and that group only, for most of the academic year.

This year the lead instructor has adopted what strikes me as a reasonable, easy-to-grasp approach. We're asked to discuss ethical reasoning through just two lenses: deontological, or principle-based reasoning; and teleological, or results-based reasoning (the latter primarily taking the form of utilitarianism).

What light do these forms of ethical reasoning shed on the ethics of disclosure? Indeed, are ethics even involved?

Certainly to me it feels unethical to keep silent about having bipolar disorder. From experience I know that my candor has been helpful to people who either have a mood disorder or know someone who does. So from a teleological perspective, I suppose a case could be made that if I remained silent I would deny those people whatever assistance or comfort I might otherwise provide. And one could add that my silence would do nothing to undermine the stigma associated with such disorders.

All the same, this strikes me as a pretty weak case. Equally weak would be to argue from a deontological perspective -- that I must be candid about the disorder as a matter of principle.

It therefore seems to me that only two conclusions are possible: either I'm mistaken to believe myself under a moral obligation to be open about having bipolar disorder; or else some other ethical framework must apply.

It seems to me that another ethical framework does apply: aretaic, or virtue-based reasoning. This basically flows from a moral imperative that is rooted in character, that comes from within. It differs from deontological and telelological ethics in that, unlike these two, it does not attempt to be universally prescriptive. Put simply, just because I perceive it as a moral imperative to publicly acknowledge having bipolar disorder, doesn't mean that everyone should. This was the basic problem with the tactic of "outing" gays. Yes, it would show that being gay was fairly common and would thereby reduce the stigma of being gay. It would also increase the political clout of the gay community. And one could certainly advocate in favor of having gays come out of the closet. But to strip from a person the option of privacy was wrong.

As I've pointed out in the past, my situation with bipolar disorder has certain analogs with battle stress injury, in particular the need to manage the two conditions and the stigma that clings to them. Military policy has become quite enlightened about encouraging service personnel to seek treatment for battle stress injury and, as much as possible, eliminating the adverse consequences of doing so. Here at the Army War College it's estimated that as many as a third of the incoming resident class have some symptoms of Post Traumatic Stress Disorder, and there are several ways by which officers can seek treatment confidentially. (The most obvious of these is to visit a chaplain, all of whom have both training and experience in counseling persons with PTSD.)

But policy will get you only so far. The culture remains one in which battle stress injury is still too often regarded as weakness. It may be okay for an enlisted man to receive treatment for PTSD. It may even be okay for an officer or senior NCO to receive treatment for PTSD. However, as I often heard officers maintain during my first year here at the Army War College, it is not okay for officers or senior NCO's to disclose publicly that they are being treated for PTSD. My comment in a post I wrote last year about the military use of antidepressants, etc., also applies here:

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it’s OK for you to take these meds, but tacitly it’s really not because I wouldn’t be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that’s the role I often play with my students.) Such an officer’s example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.
I broached this subject to a number of officers and national security analysts and got the same response. Double messages, they acknowledged, do have adverse effects on organizations. But in this case it was just too bad. It would be fatal for officers who took medications for combat-related anxiety or depression to discuss it with their soldiers or, for that matter, anyone else. To command effectively an officer has to appear strong, and the stigma of weakness attached to battle stress injury was too potent to challenge.

In the months since, however, I've discovered that a few generals have done exactly as I proposed.

On November 8, 2008, USA Today reported that Maj Gen. David Blackledge had received "psychiatric counseling to deal with wartime trauma, and now he is defying the military's culture of silence on the subject of mental health problems and treatment." His decision to speak up apparently came from two sources: First, a statement from Admiral Mike Mullen, the Chairman of the Joint Chiefs of Staff, for leaders to set an example for all service personnel: "You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it." And second, a campaign developed by Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, to encourage service personnel (and their families) to share their stories. Blackledge volunteered to help.

On November 26, 2008, in an article picked up by Army Times, USA Today highlighted a four-star general, Carter Ham, who had also disclosed publicly that he was getting treatment for battle stress injury, partly to serve as an example to other service personnel -- "You need somebody to assure you that it's not abnormal. It's not abnormal to have difficulty sleeping. It's not abnormal to be jumpy at loud sounds. It's not abnormal to find yourself with mood swings at seemingly trivial matters" -- and partly to undercut the stigma surrounding battle stress injury. The article went on to discuss Brig. Gen. Gary Patton, who had also chosen to talk publicly about having battle stress injury.

A March 2009 CNN article further explored the cases of Generals Ham and Patton, and offered clues about their reasons for coming forward:

"If you go ask for help somehow you believe it or you might believe others think it of you, that you're somehow weak. That's wrong and intellectually we all know it's wrong, but it's still there. It's still palpable in some communities," Ham said.

Patton wants to see a change in the way post-traumatic stress disorder is viewed by the military.

"We need all our soldiers and leaders to approach mental health like we do physical health. No one would ever question or ever even hesitate in seeking a physician to take care of their broken limb or gunshot wound, or shrapnel or something of that order. You know, we need to take the same approach towards mental health," Patton said.

Having two generals talk publicly about their own battles with stress and how counseling helped should help remove some of that. Patton said he wants servicemen and women to know that they can come forward.

"Know absolutely that your chain of command and your leadership in the military at our highest levels recognize this issue and want to encourage our soldiers to seek out that mental health assistance," Patton said.

Again, neither deontological nor teleological ethical reasoning seems to apply here. Generals Blackledge, Ham, and Patton (and for that matter Admiral Mullen and Brig. Gen. Sutton) do not come close to arguing that it is a moral imperative for all officers to publicly battle the stigma associated with battle stress injury. But plainly, it seems to have been a moral imperative for them -- a case of aretaic reasoning in action.

Wednesday, August 5, 2009

The Nick and Betsy and Diamond Head


Three years ago veterans of the USS Nicholas -- "the Nick," they call it -- a World War II era Fletcher-class destroyer on which my father served, created an online discussion forum. Since I was already on the mailing list of their reunion association, I got an invitation to join.

I promptly posted a message asking to hear from personnel who had served aboard the Nicholas during the same time as my father, and of course I was particularly interested to hear from anyone who actually knew my father. Since any such individual would have to be on the high side of seventy, I had low expectations. But to my surprise I heard from someone almost immediately. Though I gather he had only a nodding acquaintance with my father, he had a clear recollection of the part of the ship where my father worked. Moreover, he had compiled a database of info on Nicholas personnel and could tell me more or less the exact dates of my father's service on the vessel.

That sent me poking around boxes of old photos to see what images might exist of Dad's service on the Nicholas. I found a few from his days in basic training at San Diego, but nothing Nicholas-specific save for a yellowed clipping from the Honolulu Star-Bulletin reporting the ship's arrival at Pearl Harbor. The story included a photo of the Nicholas and two sister ships in her destroyer squadron.

I knew for sure that Dad had slides of his days on the Nicholas, so I tracked them down in a storage box and went through them, using I checked out a 35mm slide projector from my university. I don't think I'd seen the images in thirty years. Quite a few slides had been ruined in a basement flood back in the 1970s. But I still found about two hundred from his time in the Navy and about fifty that dealt specifically with the Nicholas. The best of them I scanned using a transparency adapter and uploaded to the forum site.

It was very odd to go through all those slides. Since most of the boxes weren't labeled, I viewed quite a few that proved to be of our family in the 1960s and early 70s. Many of these had not been completely destroyed by the flood but still had damage from too much humidity. Bleeding and discoloration in the dye had made them like something from an opium dream. Others were in perfect condition but had people in them -- friends or extended relatives of my parents -- whose names are now forever lost.

Those of my father's days in the Navy showed him having the time of his life. Many slides depicted his friends at parties, holidays, or excursions in California and Hawaii. A surprising number were of "Betsy," his first car, a 1950 Ford sedan purchased in March 1956 for $478.80 (he kept the bill of sale). And whenever my father appeared he had a cocky stance and a flashy grin, displaying the trademark gap between two upper incisors that gave the grin an infectious, boyish charm.

Of those involving the Nicholas, comparatively few depicted life at sea. But he was a sucker for sunsets, particularly if a companion ship were silhouetted against the red horizon. He also liked ports of call: Hong Kong, Yokohama, Nagoya, and so on. And whenever Nicholas returned to Pearl Harbor, he could never resist a shot of Diamond Head. (Decades later, when he and my mother took lessons in oil painting, he would try his hand at capturing a sunburst falling on Diamond Head after a storm.)

In short, between the images of him and the images he took, my father seemed jaunty, happy, alive -- striding into the wider world, making new friends, his whole life ahead of him. This was the man I still dimly remember from my earliest childhood, the man I rarely saw thereafter. Who could know, looking at that grinning face, the rage that lay beneath?

Tuesday, August 4, 2009

Thirsting for Love

Of late I've been thinking a lot about how to pursue certain issues -- the onset of the bipolar disorder and significant episodes that convey some idea of the subjective experience of the illness. But I've been concerned about how to do so without bringing specific persons into the narrative. Even if I omitted their real names and disguised certain of their characteristics, they would still be recognizable to friends and acquaintances.

In the main I think I can work around this. The unavoidable exception is my parents, both of whom are long deceased but whose lives I would like to address with fairness and empathy. Consequently before raising matters that involve them, I would like to introduce them a bit.

To start things off, here is something I wrote four years ago:
Seventy years ago today my mother was born in Norfolk, Virginia. I cannot say she led a happy life. Her childhood home was drenched in anger and abuse. Her troubled 23-year marriage ended in divorce. At age 29 she was institutionalized for several months with a mental illness diagnosed first, erroneously, as schizophrenia and later, correctly, as bipolar disorder. Ten years later she was diagnosed with breast cancer. The disease finally killed her a few weeks after her forty-seventh birthday.

My mother was part of the last generation of American women raised to embrace what Betty Friedan would call “the feminine mystique”: the idea that a woman’s highest calling was to be a wife and mother. She usually described herself as a “professional homemaker.” She never read The Feminine Mystique. She didn’t have to. She lived Friedan’s critique of it day to day. She would like to have escaped, but hampered by her bipolar disorder in addition to the usual difficulties of women of her era and station, she stayed in the trap. But she never stopped trying to get out. She immersed herself in self-help books. She drowned herself in religion. Once or twice a year she overdosed on sleeping pills. Through it all she composed short, didactic essays on how to live life and wrote a lot of clumsy poems.

I seldom think of her without recalling these lines from Spoon River Anthology, especially the last two:

I AM Minerva, the village poetess,
Hooted at, jeered at by the Yahoos of the street
For my heavy body, cock-eye, and rolling walk,
And all the more when “Butch” Weldy
Captured me after a brutal hunt.
He left me to my fate with Doctor Meyers;
And I sank into death, growing numb from the feet up,
Like one stepping deeper and deeper into a stream of ice.
Will some one go to the village newspaper,
And gather into a book the verses I wrote?—
I thirsted so for love!
I hungered so for life!

Sunday, August 2, 2009

A Futile Consistency?

"The most successful people," I once heard the entertainer Kenny Rogers say in an interview, "are the most consistent." I was never a huge Kenny Rogers fan, but I had to admit he was certainly successful and certainly consistent, so he probably knew what he was talking about.

That's not particularly good news for people like me.

If, as Ralph Emerson famously maintained in Self Reliance, "A foolish consistency is the hobgoblin of the little minds," then I suppose a futile consistency is the hobgoblin of minds afflicted with bipolar disorder.

On the one hand, depressions drain you of energy, pushing even the most modest of projects beyond your ability. People looking from the outside assume that if you had sufficient will power you could just power through, but will power is among the very first things that depression strips from you. The former talk show host, Dick Cavett, suffers from periodic depressions. He once explained that when you're depressed the cure for depression could be on a night stand fifteen feet from you, and you would not have the will power to rise from your bed and get it.

It is, on the other hand, not much better with hypomanic episodes, which though characterized by energy and creativity also increase distractability and decrease impulse control, so that you go off on tangents instead of focusing on whatever main task lies before you.

The best solution I have found is, at best, a partial one. It involves finding ways to be as consistent as possible in at least one area of life. Consistency in that one area helps you understand that whatever the strength of the illness, you are not powerless against it. The thing I fear most about the disorder is that it creates the temptation to give up.

Hence these almost daily reports of my comings and goings to the gym. Although working out is a good thing in itself, it's also a tangible way to show myself that I am still capable of consistency. To try and be consistent in all areas is a recipe for despair, but if I can drill down on one area then I can remind myself that inconsistency -- one might also say unreliability -- is an artifact of the illness, not a flaw in my character. The great mistake would be to confuse the illness with my identity.

Thursday, July 30, 2009

Why the Hell Did I Wake Up at 2 A.M.?

Basic to the management of bipolar disorder is what health professionals call "good sleep hygiene." This consists not only of getting enough sleep but of observing habits that maximize the chances of getting a good night's sleep. Although I consider this a critical skill, I've found it difficult to master, and some of the things that work for me run counter to the usual advice. For instance, it's recommended that one not watch television before retiring and above all that one should not sleep with the television on. Television, observes the Sleep Disorders Center at the University of Maryland, "is a very engaging medium that tends to keep people up."

At the same time, the Center advises the aspiring sleeper to "leave your worries about job, school, daily life, etc., behind when you go to bed." In my experience, this has proven almost impossible. From childhood I've nearly always lain awake for at least an hour, worrying about this or that. A solution that has worked for me is a modification of the "no television" rule. I leave the TV on, but I have it play a DVD that I practically know by heart. It distracts me from worrisome topics and because I'm thoroughly familiar with the story line, it doesn't engage me enough to keep me awake.

Some DVDs work better than others. The most reliable, oddly enough, is a war movie, Twelve O'Clock High, I think because it consists mainly of dialogue and has almost no combat scenes.

Still, my sleep pattern tends to oscillate between a lot of sleep -- last week I found myself sleeping as many as twelve hours -- and comparatively little, generally only four hours a night. Last night was an extreme example. I slept only ninety minutes and awoke with the certainty that I would not be able to get back to sleep. In such instances the advice is not to force sleep but to read quietly or maybe take a warm bath. In no case should one do office work, housework, etc. This is a rule I nearly always violate, because once again it doesn't work for me. I have found it more effective to push through the day and then retire at an early hour but not too early -- say at 9 p.m. This usually results in getting sufficient sleep the next night, and I'll take an Ambien to try and make sure of it.

Although I don't become alarmed when I get too little sleep, I do start looking for signs of a potential hypomanic episode. As a checklist I use the relevant criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, which I have more or less memorized (and also own a copy).

The first question I ask myself is whether I feel refreshed, as if I had gotten a full night's sleep. That would be bad. Fortunately on this occasion I don't feel that way. I feel functional but kind of tired, and were it not for the proscription against taking naps during the day, that's probably what I'd wind up doing. (I sometimes take cat naps anyway. Even twenty minutes can restore a measure of vitality without compromising my ability to get to sleep that evening.)

Second, I ask myself whether I feel unusually creative and raring to go. Again, that would be bad.

Third, I look at whether I am easily distracted, which is another symptom of hypomania. If I can stay on task, whether it's doing dishes or paying bills, I'm less concerned.

Lastly, if the condition persists for four days, then getting a good night's rest becomes an absolute priority, and on such occasions my psychiatrist has authorized me to double the dosage of Ambien. This generally does the trick.

There are other criteria indicative of a hypomanic episode -- e.g., an unequivocal change in functioning uncharacteristic of the person when not symptomatic, and the disturbance in mood and functioning are observable to others -- but I seldom find evidence of the former and as for the latter, I am continually amazed by how rarely anyone picks up on a change in my mood and / or functioning, at least not on the "high" side of normal. Depressions, my principal bĂȘte noire, are more noticeable to friends, though not to colleagues (or if they do notice they rarely say a word).

In any event, the object is to avoid as many symptoms of a hypomanic episode as possible. And one thing I definitely avoid is the temptation to "ride the wave" of increased creativity that often characterizes a hypomanic episode. I have heard of writers, artists, etc. who firmly believe their creativity is inextricably bound to their hypomanic episodes and therefore resist treatment. I say the hell with that.

Wednesday, July 29, 2009

Meds - Pt 2

Every evening I take between three and six pills --invariably two of Lamictal and one of Zocor (a cholesterol-lowering drug), to which I often add one or two Klonopin and occasionally one Ambien.

Even after all these years, I still find this a little strange. From an early age I disliked the very idea of taking anything stronger than the occasional aspirin or cold medication. I didn't begin taking psychotropic medications on a consistent basis until my mid-thirties, and I somehow doubt I will ever get used to it. I've just learned to accept it as a fact of life.

Little in my civilian background equipped me to deal with bipolar disorder. Within my family a taint of shame and weakness, usually covert but hard to miss, attached to it with regard to my mother. It was not much different when I was diagnosed in 1986. Most of my friends just sort of fell away, as if my life were over and I was no longer worth the investment. Many years later, when my life was on track and the bipolar disorder obviously in hand, I became reacquainted with one of these friends and asked what had happened. "We just didn't know what to do," she replied. Which was slightly odd coming from a devout Christian as well as a registered nurse.

Within academe scarcely anyone ever inquires about the disorder. I think it makes them feel awkward. And as I've written elsewhere, a common reaction is to consider it "inappropriate" for me to openly discuss it. Almost no one has said this outright, but an academic generally has a lousy poker face. Over the years it has been increasingly difficult to find a plausible alternative explanation. And of course I live in a society that still prefers to see mental illness as a character disorder ("Snap out of it!") or as an all or nothing proposition (you're either normal or you're abnormal).

Almost the only thing that has equipped me to handle the disorder is my experience with the Army. Back in basic training the Army drilled into me a vital core principle: You do what it takes to accomplish the mission. The aesthetics don't matter. You don't need to look like John Wayne. A manly attitude is irrelevant if it doesn't translate into effective action. It doesn't matter what other people think. The mission is everything.

A second thing the Army did for me -- as it does for most recruits -- is to show you that you are stronger than you think you are.

Even so, the need to be "normal," to be like everyone else, is powerful, particularly in young people who have not yet realized that no one is normal, that no one is like anybody else, and that we all carry wounds. Initially I took medications -- lithium and Imiprimine (an early antidepressant) -- for perhaps nine months, and even then without much conviction in their efficacy. It was tough on me psychologically. Taking the pills always seemed like a bizarre eucharist, a daily acknowledgment that I was now as broken as my mother had been.

Then for over ten years I took nothing. It took not only a brush with an unmistakable hypomanic episode to bring me to my senses. It also took the maturity that comes with being older and the basic confidence that comes with having securely established myself in life.

To my surprise, the first psychiatrist I consulted prescribed nothing stronger than a sedative to help me sleep. "You've had the disorder for eleven years," he pointed out, "and during that time you've gone to graduate school, gotten your PhD, succeeded in getting a faculty position, published a prize winning book, and gotten tenure a year early. Clearly you've been able to manage the disorder. So until I know more I'm not in a big hurry to put you on psychotropic medications."

Within a couple of months, however, the hypomanic episode had been succeeded by a depressive episode that seemed unrelated to anything in my day to day life and was sufficiently debilitating that it became difficult -- though not impossible -- to function normally. Certainly, though, I could not function at my usual level and on top of that, life seemed flat and meaningless. Small reversals suddenly loomed large. The memory of old failures and regrets constantly tugged at my thoughts.

So I consulted a second psychiatrist -- not because I disliked the first but because the second one was in my health care network. The first had not been. I wanted an antidepressant but I knew enough to recognize that an antidepressant alone carried the strong risk of vaulting me into a manic episode. Consequently I would have to take lithium as well.

In July 1999 -- precisely ten years ago, come to think of it -- I had a manic episode that simply blew through the lithium, and when the second psychiatrist somehow refused to accept this fact, I got rid of him and found the psychiatrist I continue to see to this day. I'll call her Jennifer -- it's hard to call her "Doctor" since we both have doctorates, although mine is merely PhD. Jennifer put me on depakote, which worked fine except that, as I mentioned in Part 1, it had the effect of ratcheting up my weight. When I discontinued it, I was startled by how rapidly my weight returned to normal.

As I indicated earlier, we substituted Lamictal and gave it the dual role of antidepressant and prophylactic against mania. But in the depakote years we tried and discarded any number of antidepressants after experimenting with different dosages of each over a period of months. There were so many I can't recall them all. Looking over a list of antidepressants, however, I recognize at least four: Celexa, Lexapro, Effexor and Wellbutrin. I'd bet money there were at least one or two others. [Update: Seroquel and Neurontin, though in both cases quite briefly.]

None of them, as far as I could tell, worked worth a damn. We finally hit upon Lamictal (even when I was on depakote). Lamictal is interesting in that you start with a negligible dose and it takes over a month to gradually ramp up to therapeutic levels. That's because in rare instances it has an undesirable side effect, namely a severe, life-threatening rash that from descriptions sounds practically like spontaneous combustion.

Fortunately I had no problems with it. It seemed to mitigate, though it did not eliminate, the depressions, and gradually we came to suspect that the depressions were often triggered and / or exacerbated by environmental factors, of which (perhaps) more in a future post. This past spring, however, although I was here at the Army War College, an environment in which I have thrived, I experienced a series of depressions in which the reprieves were so fleeting it was basically a single continuous depression lasting almost three months. We responded by doubling the Lamictal (from 100 to 200 mg per day). I've been fine since then.

Part 1 - Part 2
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