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.
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