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).

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.

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

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

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

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

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

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

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

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.