The biggest loss after I was diagnosed was my poetry. Before my diagnosis, I wrote a lot — I filled a ring binder with it. Two inches of verse, mostly free. Then I stopped because I believed that going to readings and writing it made my condition worse. And I believed that I lost the ability to write it. I did not stop, but my output was meager and sparse. One poem a year. Some years I wrote nothing. But a part of me yearned for the truth and beauty of a fine image. So last spring, I conducted an experiment. Thanks to a psycho-stimulant that gave me a renewed ability to focus, I cautiously began to compose free verse and haiku. To my joy, I did not explode into mania. I was not writing long intense blogs as had been the signature of my mania and I did not lapse into consequent depressions. So I have begun thinking: If I can handle poetry what about spirituality? Could I attend a church without turning into a prophet? Could I handle being a member of a congregation and not its priest? So I have been contemplating where to go, what denomination suits my temperament. That is the next signpost.
I have just returned from the conference of the Depression and Bipolar Support Alliance of California. Between keynote addresses and workshops, here are the things I attended (for some, I have notes).
Keynote speaker for Friday morning, stand up comic David Granirer, on “I’m OK But YOU Need Professional Help: Creating Recovery – One Laugh At A Time!” For obvious reasons, I didn’t take notes for this one.
Adult Suicide Prevention Training (presenter Liam Mina, MSW): Liam Mina is a social worker with Didi Hirsch, a Southern California organization founded in 1942, which works on suicide prevention. After the death of Marilyn Monroe, in which they were involved in a “psychological autopsy,” they started getting phone calls, not about Monroe, but from people who themselves wanted help. So they established the first suicide hotline in the US. Now they have 24/7 service in English and Spanish, along with texting and chat for the deaf, and Korean and Vietnamese from 4:30 pm to midnight Pacific time. 90% of suicide is associated with mental illness, but 50% are not in treatment. Responding to warning signs of suicide: Build rapport, assess risk (ask directly, and for people who do say that they are thinking about suicide assess degree of risk by asking about plans and with scaling questions), establish safety (make a plan, connect to resources, ask to repeat back plan).
Ask the Pros: Kent Layton and Himasiri Da Silva. This always popular session allows people to pose questions to a clinical psychologist (Layton) and a psychiatrist (Da Silva). Topics included what to do in a crisis, what to do if you’re allergic to all the meds, what are the effects of different strains of marijuana, the difference between ADHD or ADD and bipolar disorder, whether ketamine is recommended for treatment-resistant depression (and the same question for Lexapro), what about food supplements, and the DSM-V. A few notes from the answers: Medical marijuana isn’t recommended for bipolar disorder. Useful supplements include fish oil (omega-3) and folic acid (not in place of medication, but alongside it). Da Silva feels that the DSM needs to build in more bioevidence; bipolar disorder had a large genetic component. As time goes on the DSM will become more biologically and evidence based. If you’re in crisis, keep showing up and suiting up, get up even if you can only manage a walk around the block, and don’t give up even if getting your meds right takes trial and error.
Bipolar Disorder: A Family Affair (presenter Angela Paccini): I didn’t take many notes on this one. It focused a lot on family stories, in the interest of showing what knowing roles and triggers and providing support looks like.
Bipolar Disorder – The Future (presented Da Silva): There have been four eras in psychiatry: The Asylum Era, the Psychodynamic Era, the Psychopharmacology Era, and what we are now entering, the Molecular Neurobiology Era. We still draw on what was learned in earlier eras (e.g. psychotherapy, especially CBT and DBT, helps, as do medications developed in the psychopharmacology era), but a new improvement in treatment is our understanding of pharmacokinetics and pharmacodynamics. Medications don’t provide chemicals in the form effective in the brain; first they need to be processed by the liver. Here, pharmacokinetic genes, such as CYP450, are important. The CYP450 system involves 57 enzymes responsible for drug metabolism, primarily in the liver. People can be normal, fast, or slow metabolizers, and a genetic test can show which you are. For example, only 55% of people metabolize Seroquel normally, while others metabolize faster than normal (and therefore see less effect) or slower than normal (and therefore see more side effects). Medication interactions are important (for instance, the estrogen in birth control pills can speed up the breakdown process for Lamictal). So is folate, and some people, with a variant form of the MTHFR gene, lack the ability to metabolize folate and may need, instead, to take methylfolate. Genesight offers genetic testing. Da Silva also talked about evidence based practices governing which medications should be given first (ones for which there are large scale studies supporting efficacy and few side effects).
Saturday morning keynote speaker: Antoinette Brunasso spoke on Coping with Depression and Bipolar Disorder: The Impact on Self and Family. This was a very good talk, at a level easy for a lay person to understand, largely around developing what Brunasso calls a “solid, flexible sense of self,” one that allows you to tolerate anxiety, and avoid reacting to conflict by reflexively caving, avoiding, or locking in your position, but rather work through the conflict toward a solution that works for both partners. How “fusion” can lead a spouse to get stuck in the same place as the bipolar or depressed spouse, and how developing a healthier sense of self can help you work through marital conflicts better even when one of you is also dealing with mental illness.
Reflective Functioning and Mentalization in Relation to Bipolar Disorder (presenter Nazare Magaz): Mentalizing is the capacity to imagine inner states in self and others. It can be affected by your early attachment process, which can lead either to secure attachment or to less secure forms (anxious avoidant, anxious preoccupied, disorganized); if you are a therapist, both knowing your own attachment style and recognizing that of your patient can be useful (don’t crowd someone whose attachment style is anxious avoidant). In bipolar disorder, ability to mentalize drops when you go into episode. Signs of mentalizing: You can imagine multiple states of mind that could lead another person to behave as he or she does. If you can only think of one possibility, you may be falling out of the open, curious state you need to mentalize, and instead in a place of psychic equivalence, where you have a thought about what another person is thinking and then assume it’s true. What do you do when someone else is in a place of psychic equivalence? You need to empathize with that person first. How do you develop mentalizing ability? By being around and learning from people who have it.
Lunchtime keynote speaker: David Miklowitz, on Child and Adolescent Mood Disorders. I didn’t take notes on this one, because having notepaper around a lunch table is awkward, but I did live tweet some of it after I had eaten.
Happiness with music (presenter Mike Sullivan): We played ukeleles. I didn’t take notes.
Trauma Effects – Depression and Bipolar (presenter Christine Monroe): Trauma is always part of psychotherapy. It’s part of life. This talk covered: What is trauma? How does PTSD compare to bipolar disorder (e.g. flashbacks to traumatic event compared to depressive ruminating)? What events can lead to PTSD? What puts people at risk? References: Ross Rosenberg on trauma levels. Dan Siegel on parenting. Evidence based treatments: Trauma focused CBT, exposure therapy (start mild), relational therapy, and, a particularly good therapy for PTSD, EMDR.
And that was my last workshop. I condensed my notes a lot for this post, so I may, if I find time, have a longer post on one or another of the individual sessions.
We who have come back, by the aid of many lucky chances or miracles – whatever one may choose to call them – we know: the best of us did not return.
I have just finished reading Man’s Search for Meaning by Victor E. Frankl. The book is written in two parts. The first part is an account of Victor Frankl’s experiences in several concentration camps, during WWII. The second is an account of Frankl’s system of therapy, called logotherapy, a humanistic variety of psychotherapy centered around the importance of finding meaning in your life. As Frankl says, in the first part, quoting Nietzsche,
He who has a why to live for can bear almost any how.
What ties the two parts together is the fact that, in relating his concentration camp experiences, Frankl focuses, beyond the bare fact of the abuses to which he and other Jews were subjected in the camps (those few who did somehow survive), on the psychology of being a concentration camp prisoner, both for worse (the decline, from constant hunger and weakness as much as anything, into numbness and apathy) and for better (where did prisoners find the resilience to keep going in the face of that horror). These sources of resilience include relishing brief moments of respite (a stolen potato or the chance to remove lice) or beauty (a sunset or a song), the memory of particular lines of literature and philosophy that speak to Frankl (Nietzsche, Lessing, Dostoevsky), hanging onto memories of the past (for Frankl, especially, the image of his wife, who would eventually prove to have died in another camp), humor, and seeking sources of meaning (for Frankl, an attempt to reconstruct, on scraps in shorthand, a manuscript that had been taken from him at Auschwitz, and a fantasy of a future Frankl, having survived, giving a lecture on the psychology of prisoners in concentration camps). That and a sheet of paper with the Shema Yisrael, received in the coat pocket of one who had already died, in place of the manuscript that had been taken from Frankl. When Frankl titles a postscript after his second part “The Case for a Tragic Optimism,” the fact that he has surely earned the “tragic” part of that case makes me trust the “optimism” part more.
Logotherapy, the school of psychotherapy that Frankl founded, and which he describes in the second part of his book, is a third school of Viennese psychotherapy, after Freud’s psychoanalysis and Adler’s individual therapy. In contrast to Freud’s will to pleasure, or Adler’s will to power, Frankl centers his psychotherapy on a will to meaning.
Near the end of Ingmar Bergman’s classic Winter Light, the troubled minister who is the film’s main character, can’t decide whether to hold the 3 o’clock service or not. His day has been especially depressing because he gave counseling to a parishioner who subsequently committed suicide that very afternoon, he fought with his mistress, and he has the flu. The church sexton, a disabled survivor of a railroad accident, talks to him about the part of the Gospels which he has been reading, the Passion.
Jesus, the sexton reasons, didn’t suffer all that much on the cross. Why, the janitor goes on, he personally suffered more pain in his life than the four hours that afflicted Jesus and his pain was probably much worse. No, the crucifixion is not the most important segment of the Passion. Think of the Garden of Gethsemane, he says. The Last Supper is done. The disciples who have accompanied him have no clue about what is about to happen, so they go to sleep. Jesus is all alone, so he kneels down to pray. And what does God the Father say to him? Nothing. God is silent. And that, the sexton reasons, is the most terrible ordeal that Jesus endures.
Agnostic that I am, I still value the Gospels as a guide for understanding the suffering that is happening in my life. But what I would give for a silent God at times! In the void, my depressions fill the emptiness with the voice that is the worst of the Old Testament combined with Catholic guilt. I call this my inner god — a false god to be certain — because its primary purpose is to torment me. My illness exists, according to this voice, for the purpose of punishing me. But therapist after therapist has asked me What have I done that is so terrible that I deserve this constant hammering at my self-esteem? I can throw out a number of things, but they are all trivial compared to the actions of some of my peers who feel no shame for what they wreak against others. Surely there should come a place where my penance is over? But no matter what amends I make, the god inside me continues to berate me and declare me worthless.
One reason why I value my manias is that they shut down this voice entirely. Only my own ideations occupy me — obsessively. My thoughts race from project to project, propounding desperate philosophies that enthrall me more than methamphetamine. The evil god, the blasphemer against my happiness is put to death and does not rise again until I crash. Then for more than forty days at a stretch, the god assaults me with shame.
For the depressed and the anxious, the silence of God is a scream.