Sanity, the Serenity Prayer, and the Way of Love

Last week I just couldn't. Well, my laptop was dying. And then my printer wouldn't install. But all that within the context of everything that well, you know... So last week there was no new post.

This week, I still can't, not really. I can't find any new research that intrigues me. I can't bear the thought of yet another rant. I am determined not to spread any more pain.

But there's pain out there. There's pain in here. And this blog is about the things I can change. So this I will do.

I have a spiritual discipline that I am using to walk through these days. I am a Christian, and this is a Christian discipline, or series of ancient practices - though my guess is that nonChristians can find something of value here. I will do my best to do some translation.

It's called the Way of Love.

Every morning, I turn. Whatever happened the day before, today I recommit to follow Jesus, or to follow the Way of Love.

Part of my turning is to repeat the Serenity Prayer. In the Episcopal Church, Morning Prayer begins with the Prayer of Confession. But many years ago, I replaced it with the Serenity Prayer. My own version shifts from time to time. Lately I pray:

Grant me the serenity to face what I cannot change.
Grant me the courage to do what I can.
Grant me the wisdom to know the difference.

The Recovery Movement uses this prayer on a daily basis and does not presume theism on the part of the one who prays it. Define the one you are addressing any way that you want. Serenity, courage, and wisdom - those are the kernels.

Then I learn. I read my sacred Scriptures. I follow a set series of readings called a lectionary from Hebrew Scriptures, New Testament, and Gospels. They renew my sense of my larger context in the faith community, all the people who have endeavored to follow the Way through dark days, those people who live in the Bible and those who have looked to the Bible ever since it was written. The Koran, poetry by Mary Oliver or Rumi, substitute what catches you and connects you to something bigger than yourself...

Then I pray. And this may be the place where I lose even some Christians, because this is where it gets hard. I pray for my enemies. But hear me out. Remember the Rabbi's prayer for the Tsar, God bless and keep the Tsar... far from us! Jesus said to pray for our enemies. And I do, something along the line of He's your kid; you deal with him. I pray it sincerely, knowing that God's will for each of us is better than we can ask or imagine. So I can leave it at that.

One of the consequences of praying for my enemies is that I do not become them. I inoculate myself against the disrespect and cruelty that passes for public policy these days - to the extent that I am able.

Then I worship. Now don't get stuck here either. The Recovery Movement lets everyone define their own Higher Power. I have heard of somebody who took gravity as his Higher Power. The point is to acknowledge that I am not the center of the universe.

And that is a point worth repeating: I am not the center of the universe.

Then I bless. This may strike you as bizarre, too, unless you are familiar with my bent frame of reference by now. But seriously, this is my spiritual discipline: I go to Twitter and then to Facebook and find some way to be generous and kind. (It's easier on Twitter, fewer family triggers.) I comment on somebody else's tweet. And it doesn't have to be some stereotypically "blessing" sort of comment. Any kind of nontoxic engagement, any show of interest in what somebody else has posted is a gift.

That's where this discipline really begins to bears fruit - it sets my perspective and my relationship to the world.

Then I go. At some point in the day, I try to engage in a positive way with somebody outside my bubble. That's not as easy as it used to be in maskless days.

Finally I rest.  Because I am not the center of the universe, because I can face what I cannot do (see above), and because this whole way is not easy, I have earned and I am able to rest. Or play Candy Crush.

Nah, I am struggling, too. But my prn meds are lasting a lot longer than I might have expected.

And from an existentialist perspective, the Way of Love is simply the way I have decided to follow. I commend it to you.

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Confessions of the Good Suicide Survivor Story

I was suicidal. I nearly killed myself. I am glad I didn't do it. Because I got better.

Moral of the story: You will, too.

That's it. That's the good survivor story. Hopeful. Virtuous. I have told that story, and when I do, I get all kinds of strokes, including publication of my writing on other websites.

Some of it is true. It did get better. For me. For now.

For now.

There is more to the story. When I tell the more, I do not get publication. I don't even get acknowledgement that my submitted piece was received. I guess I am submitting to the wrong websites, to places that have one story they want to tell, the good survivor story.

And like I said, it's true, some of it. According to David Conroy, there are 50 million people alive today who have struggled, are struggling, or will struggle with suicide. 45 million of them will die of... something else. That's success, right? 90% of us will find another way.

But that's not the same as the good survivor story. Because for the 45,000,000 of us who survive, we have all kinds of stories.

Some of us spend our lives going through crisis after crisis. Yes we survive, but we're not sure it is worth the cost.

Some of us live with passive suicidality on a chronic basis, like treading water. Even if we never actually drown, the tug of the water is always there.

Some of us get better, and don't quite struggle at that same level of lethality again for now. For now.

All of these stories need to be told.

Truth be told, I have no idea whether I will be one of the 45 million who die of something else. It is my ambition to do so. But each of those trips into the abyss was deeper than the one before. And I simply cannot imagine coming back from anything as deep as that last one...

Nevertheless, I dutifully make my crisis plan. I fill out those forms about what kind of treatment I want in a psych hospital and what kind of treatment I don't want, knowing full well that when push comes to shove: 

  • I will be sent to the hospital where a bed is available, if a bed is available, not where the treatment I want is offered; 
  • I will have NO choice about who my doctor is; 
  • My advance directives notwithstanding, the doctors will do whatever they think they need to do; 
  • Chances are pretty high that I will experience trauma; and 
  • I may well come out of it worse than when I went in.

Actually, working on the plan is pretty traumatic in itself. I can't find a psychiatrist. Oh, there are psychiatrists. Last year the pdoc where I get my primary care recommended a drug combo that triggered my PTSD - not the treatment (which I refused), but the suggestion of the treatment. It would take me two minutes to find the research papers demonstrating that her suggestion was crap. Crap in general, even before she consulted my history, which also would have demonstrated that it was crap.

I asked another psychiatrist who is an expert in bipolar (and who had already told me never to take the meds my local pdoc wanted to prescribe) to recommend a new psychiatrist for me. He had no answer; he suggested I simply hope for the best.

Hope for the best.

So, I hope for the best. It does get better. Sometimes it gets worse again. I hope that if it does, it will get better again.

Meanwhile, I will keep doing all those things that keep it from getting terrible, because those things do help.

But to anyone who ever read anything of mine that did get published by those people who publish good survivor stories, I apologize if I conveyed the impression that mental illness does not suck.

I will keep doing all those things, and I encourage you to do them too, because even if they help us feel only a little better, still, feeling a little better is better than feeling worse.

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Bipolar Screening - People with Bipolar Know It When We See It

Psychiatrists and people with bipolar both have told me that my book captures what the manic experience is like.

Reviewers tend to say either, She must have written it when she was manic. Too bad her editor didn't fix it. One star. Or: She must have written it when she was manic. So glad her editor didn't fix it. Five stars.

Which gets me thinking: Doctors say bipolar is really hard to diagnose. But if people who have it know it when we see it, what if we wrote a screening tool? Bear with me here. I'm thinking something like this:

They say: A distinct period of abnormally and persistently elevated, expansive, or irritable mood.

What we hear is: Are you abnormal?

To which we answer: No. I mean, duh.

So what if they said: Has there ever been a time when everybody around you just didn't understand why the world was so great or why you felt so good? Or has there ever been a time when everybody around you was massively irritating?

That is the core symptom of mania. Moving on to the others:

They say: 

  • Increased self-esteem or grandiosity.
  • Decreased need for sleep.
  • More talkative than usual, or pressure to keep talking.
  • Flight of ideas or subjective experience that thoughts are racing.
  • Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli)
  • Increase in goal directed activity (socially, at work or school, or sexually) or psychomotor agitation
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences

How about instead, the way we would put it: 

  • Despite how shitty you feel right now, have you ever understood just how special you really are?
  • Yeah, the decreased sleep one works okay.
  • Has there ever been a time when you had to keep trying to get your point across because others were too dense to get it?
  • Has there ever been a time when others couldn't keep up with your ideas? Has there ever been a time when your ideas flowed like out of a spigot?
  • Has there ever been a time when you recognized that nothing is unimportant, when everything needed your attention?
  • Have you ever worked so efficiently that you were your boss's favorite employee or your teacher's favorite student? Have you ever had so much to do you couldn't waste time sitting?
  • Has there ever been a time when you knew that life is a banquet and most poor suckers are starving to death?

I mean, it's a matter of perspective, isn't it?

People with bipolar go seven and a half years on average from first manifestation of symptoms to an accurate diagnosis. A third of us are misdiagnosed for ten years or more. Would somebody like to turn my list into a research project, find out if it does indeed produce better screening results than what they do now? Go for it. Just mention my name.

Suicide is Not a Mystery - Get Beyond the Romance to Get to the Work

Suicidal people have not been quiet this year during Suicide Prevention Month. Most years we are the topic of conversation, not the source of the content of all these campaigns. But Twitter, at least, has been filled with our own voices this year. I have always shot my mouth off, and seldom taken the party line. Which means my voice is never included in the campaigns of the typical mental health organizations.

The following is an example, a post from a previous Suicide Prevention Month, edited with my more current thoughts on the matter.

This is Suicide Prevention Week - from September 8, 2011

When I started Prozac Monologues, I didn't know there was a Suicide Prevention Week. I spent a month writing about suicide in June, 2009. I chose June because it is the month when the highest number of suicides take place. So I wonder why the officially designated week is in September. Maybe because when everybody else is so happy about the sunshine in June, they wouldn't give any thought to the darkness? Maybe because they didn't ask those who are suicidal?

If you want to know my take on suicide prevention, here is the link for those original posts. Among the Labels in the right-side column, you will find links to other posts tagged suicide, suicide prevention, and the like.

Looking back at these posts, I wish I had less to say about suicide. But having this much to say, and frankly, a lot more, I think it's best I go ahead and say it. That was my POV for The Suicide Monologue. And I'm sticking to it. I urge you to take the same approach. If you have something to say about suicide, go ahead and say it.

You know, all those years we never talked out loud about cancer, our silence never saved a single life.

Several years ago, John McManamy, author of McMan's Depression and Bipolar Web, gave the day on his blog over to an excerpt from Nancy Rappaport's book, In Her Wake: A Child Psychologist Explores the Mystery of Her Mother's Suicide. Rappaport wrote about how even psychiatrists sit around and wonder how a person comes to the conclusion that he or she wants to die. Most of us want to live. Even those of us who want to die, for the greater part of our lives, we want to live. Her mother's diaries are full of her struggles to survive. What happens in somebody's mind to make that change? Rappaport says it is a mystery.

In Her Wake is a powerful memoir of the aftermath of suicide. People who struggle with suicide need to read such accounts to fortify them in their struggle. But I think she has misidentified the mystery.

I think every person is a mystery. 

We have our joys, sorrows, strengths, dreams, fears, failures. We have capacities and weakness that sometimes we tell to others, and sometimes they divine. But the core of the person remains a mystery.

I am a Christian, so I believe there is One to whom we are not a mystery, One who knows our true name and calls us by it. And we ourselves don't even know that name until we hear that One call it. And when we do, then we know ourselves for the very first time. 

But I don't think suicide is a mystery. 

Suicide is simple. Each of us wants to live. That is how our brains and bodies and souls are constructed, for life. And each of us dies anyway, when our brains and bodies and souls give out. Suicide is one way that we give out. We don't give up. We give out. We reach the limit of what we can survive, whether it be a tumor, lack of oxygen, or a knife that turns in our chest, whether figuratively or literally.

I learned this perspective from David L. Conroy, who learned it from his practice and from his own experience. And I confirm it in my experience. He says, and I repeat it from time to time in this blog, 

Suicide is not a choice; it happens when pain exceeds resources for coping with pain. 

After a suicide, the survivors are indeed immersed in mystery. It is the mystery of the heart of the person who died. It is the pain of questions we cannot answer. We never know the sum total of the pain another had to bear, or was able to bear, or not, nor who or what was available to help, or not. I don't know that psychological autopsies ever satisfy. What we really want to understand is the core of a person. That is the mystery.

But we can understand suicide. We can recognize its broad strokes. And we can prevent it, not every time, but most of the time, the way that suicide crisis lines do it, by relieving pain and by providing resources for coping with pain. If we can help shift that balance, between the pain and the resources, then the person at risk will be able to do what he or she really wants, to live a life worth living.

45,000,000 Suicides Prevented 

Fifty million people who are alive today in the United States have or will at some point struggle against suicidal pain. I am one of them. I have a disease with a 15-20% mortality rate. Someday I will die of something. It is my fervent prayer to be one of the forty-five million who survive suicidal pain and die of...

something else.

It doesn't improve my odds for me or you or psychiatrists or anybody else to ponder the mystery of suicide. You can't prevent mystery. You can provide resources to prevent suicide.  Here is a list to get you started.

It's a long list. It comes from David Conroy's book. Unfortunately, in its attempt to be thorough, and perhaps in the limitations of the voices consulted, certain things get glossed over.

I am thinking in particular of the major components of suicidal pain list, the items bunched into one: loss of: esteem, security, health, talent, job status, job, money, relationship, home. Let me expand. Major components of suicidal pain include shame, discrimination, job loss, crushing debt, chronic untreated health issues, solitary confinement, police harassment, white supremacy, domestic abuse, bullying, homelessness...

Why don't we have a suicide prevention month that talks about this sort of stuff? You can't medicate these pains away. You can trace their effects on suicide statistics.

This graphic is based on the research by Jasmin Brooks, et al., in that last link:

What can you do to prevent suicide? Justice. No, you can't fix it all. So pick an issue. Do something to make this world a less sucky place to live.

If you want to focus on one person, pay attention to these issues in that person's life. Make a difference in their life situation.

I expect that strategy would work for all of us. If you struggle with suicide, is there one thing you can do to make your life or somebody else's life less sucky? It's a place to start.

Meanwhile, if your suicide needs preventing right now, tell somebody. Tell somebody who cares about you (and is not an idiot). Or call 1-800-273-TALK (8255) in the US. The Trevor Project at 866-488-7386 is particularly for young people, lesbian, gay, bisexual, transgender or questioning, and the people trying to help them. There is a link at the top of this blog called Suicide - Resources to find numbers outside of the United States and other help. They can't pay your rent. But they may have some ideas that get you through that dark hole where all your own ideas disappear.

I want you to die of something else, too.

And if this post has brought somebody else to mind, somebody to whom you have said, "Call me if you need to talk," then don't wait for the person who may be clinging to the edge by their fingernails to make the call. YOU make the call. Even if you don't catch them on the edge, even if they are fine, it's one way to make this world a little less sucky.

Which we all could use.

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Understanding Bipolar Disorder - A Review

On the one hand, bipolar disorder can sweep like a tornado through a family, disrupting every aspect of daily living and relationships.

On the other hand, family members can be one of the most significant resources for a person's recovery and stability.

In my own case, my wife is the one who described the symptoms that helped my psychiatrist recognize that I have bipolar, not major depression. But once that happened, what did she, as a family member, as the member of the team with day to day, hour to hour access, receive by way of help and guidance?

Nothing. Not a word. Butkus. Like, not even a pamphlet.

Nope, nothing. She worried. She worked from home to protect me at my sickest. She shouldered every responsibility. She thought through and recommitted to and excelled at "for better for worse, for richer for poorer.

Eventually she got to Family to Family, NAMI's program for education and support of people whose family members have a mental illness. And that helped. It gave her a skill set. It let her know she was not alone. It was more than a brochure.

What she needed was Aimee Daramus's new book Understanding Bipolar Disorder: The Essential Family Guide. Daramus, a clinical psychologist with over twenty years of experience in mental health, from psych units to private practice, has written the definitive guide for family members of people with bipolar. She takes you by the hand and leads you from a chaotic landscape to a steady path.

Step by step, the information is presented in the order that it is needed. It's a good book to read over the course of a year, and to reread for a refresher as time goes on.

  • Bring something to occupy your time in the ER, where mental illness is gets to wait, sometimes for a very long time.
  • Get release of information forms signed, so that the doctor can communicate critical information with the family.
  • Let people have their own emotions and opinions; share them rather than argue over them.
  • Develop emergency plans.
  • Adopt specific lifestyle measures.
  • Don't expect to get it all right all the time.

My wife and I worked out much of this on our own. And Daramus is right, ten years later, we do not get it right all the time. Weekly family meetings help. Daramus's book reminds us of pieces that we still don't have in place.

The language is clear, simple, calm. The formatting makes it easy to follow. The anecdotes are relatable.

I bought two more copies to give to friends who could use the help. How's that for a recommendation?

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World Suicide Prevention Day from a Different Perspective

Many people who are suicidal hate suicide prevention campaigns. We notice that they are not directed at us, but at would be heroes. They publish lists of risk factors, things to watch out for in those of us who would thwart their efforts. But we fail to see listed what drives us to suicide: poverty, bills, homelessness, rape, child abuse, bullying. Nor do we hear anything about addressing these issues that might actually reduce suicide rates.

What about helping parents understand their children's sexuality so that LBGTQ children don't end up on the streets? What about bully intervention programs in schools (designed to prevent bullying, not treat the victim)? What about universal health care and food security? What about a health care reimbursement structure that encourages doctors to go into psychiatry? What about treatment that isn't demeaning? What about...

Instead, we get posters of "head clutchers." Get a grip.

I could go on. I did go on a month ago in a blogpost titled A Better Suicide Prevention Month. I suggested that people with actual experience of living with suicide might come up with something better than a head clutcher. Because it turns out we do know something about preventing suicide. We do most of the work anyway, preventing our own suicides.

How would you, somebody with lived experience of being suicidal, design a suicide prevention campaign? What messages would you like to see? What do you want to have happen in the month of September to prevent suicide?

That's what I asked. Today I discovered that people really are working on this. The website says.

RE:CREATE Psychiatry is a Mental Fight Club project that emerged in 2015 from our flagship creative space The Dragon CafĂ©, a weekly arts and health pop-up in the Crypt of St George the Martyr Church in Borough.

Mental Fight Club? I have to learn more about these people!

Meanwhile, today they posted one of their projects, a suicide prevention project, a film called Living with Suicide, scripted and produced by Eve Loren. Find out more here. And watch it below:

There could be another way to live... We need to make space for truth... Redefine what is normal... Replace compensation for the dead with help for the living... It's time to change the system... Channel self-doubt into anger... Fight.

It's time to fight.

I have to learn more about these people.

Diagnosing Bipolar - Doing Better to Prevent Suicide

How can I be a better psychiatrist for you?

Frankly, I was gobsmacked by that question. It came in response to reading my book, Prozac Monologues: A View from the Edge. The book is a comedic memoir of misdiagnosis and a self-help book for bipolar. It is both uproariously funny and brutally frank about my suicidal episodes, usually at the same time.

There are two directions to go with that question. This particular psychiatrist cares about both.

What kind of behaviors and qualities could he display that would make the relationship more helpful? Honestly, not all psychiatrists are interested in this question. I don't do relationships; I use psychopharmacology to treat psychiatric disorders, a psychiatrist once told me. Well, that had the benefit of clarifying things.

How can I improve my diagnostic skills? Nevertheless just about any psychiatrist wants to get the answer to the puzzle right, even the ones who treat patients as no more than a puzzle.

So this week I am going with the question about diagnostic skills. Buckle up for lots of links to research articles. The links appear in a different color. Click on them and end up at reports written by the experts. Or ignore the links, if you can take my word for it.

Bipolar is hard to diagnose. And they are not getting better at it. It takes 7.5 years on average from first appearance of symptoms to the correct diagnosis. A third of us are misdiagnosed for over ten years. Over time, these numbers are not improving. It turns out, telling yourself that bipolar is hard to diagnose doesn't help you get better at it. And during all those years, we patients receive treatments (antidepressants) that make our prognosis worse and flip us into mixed episodes with their heightened risk of suicide. Our lives depend on getting the diagnosis right.

There are ways to do a better job. Research validates various techniques that improve results. Many of these are a couple decades old, but for whatever reason have not found their way into standard practice. Nevertheless, some doctors, psychiatrists and family practitioners both, still ask that question, How can I improve my diagnostic skills? So here are some techniques with links to the research studies that support them:

  • MDQ, Mood Disorder Questionnaire. This is a simple screening questionnaire using real, nontechnical language that patients and their family members fill out. It's like those screens for depression and anxiety that are becoming standard practice for annual physicals. It doesn't make the diagnosis by itself; but it tells doctors whether they need to look at the question more carefully before prescribing antidepressants to treat the presenting episode.
  • BSDS, Bipolar Spectrum Diagnostic Scale. This is a similar simple screening questionnaire in narrative form. It tells a story, while the patient decides how well the story describes his/her own experience. 
Both of these instruments have sensitivity (~70) and specificity (~90) comparable to other screening instruments. This means they catch roughly 70% of those who do have bipolar and their "false positive" rate is 10%. The screens themselves can be found here.
  • Whatever screens or questions used, it is good practice to ask family members or close friends for their input. The patient notices depressive symptoms, but often does not notice or remember symptoms of hypomania or mania that the family can see.
  • When taking a history from a depressed patient, ask about overactive behavior, whether there was ever a time that the patient was able to do a lot more things, get a lot more done than usual, before asking about a time when s/he had elevated mood. It has been demonstrated that it is easier for patients to remember episodes of excess behavior than to remember elevated mood. (It was demonstrated fifteen years ago! Why hasn't this finding been incorporated into the Structured Clinical Interview, SCID-CV?)  Asking about behavior/energy first improves the accuracy of the diagnosis.

I'll leave it there. Two simple screens, two simple changes in practice, each of them are demonstrated to improve the diagnosis of bipolar.

No, I'll add one more.

  • Every episode of depression adds a new risk of "conversion" to bipolar, throwing the patient into hypomania, mania, or mixed episode. There is no length of time that confirms a diagnosis of MDD over bipolar. Screen for bipolar again with each episode and each failed antidepressant.
It is hard to change practices that doctors were taught in medical school. But what they were taught in medical school leads to a 50% success rate, also known as a 50% failure rate, in differentiating between major depression and bipolar. The mantra, bipolar is hard to diagnose, doesn't cut it when the consequence of getting it wrong leads to years of suffering, lives that go off the rails, and lives that even end suddenly and tragically in suicide.

Doctors want to do better. And they can. Research has shown them how.

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Gratitude - The Prozac Monologues Publication Edition

Fifteen years! From the hypomanic first draft of Prozac Monologues on a yellow legal notepad to a published book, and the nail file that inspired it all.

The book was officially released into the wild this week and will be celebrated in two launches, one sponsored by Paulina Springs Books in Sisters, OR, and the other sponsored by Prairie Lights in Iowa City, IA.

It's a good time to talk about gratitude. Forgive my self-indulgence. It is a day to reflect.

First, people have asked whether it was hard to write about such dark times in my life, if it retriggered some of those emotions. Occasionally, it did. Occasionally I would have a sleepless night remembering, in particular, difficult encounters in treatment. One can forgive sincerely. One can forgive over and over. Still, the brain remembers. I don't harbor resentments, but I can't always hop off the time travel machine that is my brain, how it repeats the tracks laid down by past traumas.

For the most part I kept that time machine in idle with two techniques. One is reframing, putting the experiences in a box and pronouncing the "Riddikulos!" spell over them, transforming them into humor. It has to be outrageous humor, not a simple chuckle, performing the spell like I mean it. And I do. Prozac Monologues is, frankly, hilarious.

The second technique was to place myself even further outside the frame by refocussing on exactly the right word in exactly the right position in exactly the right sentence. I practiced my craft. These experiences became the raw material on which I performed the writer's magic.

But there were other experiences in those fifteen years that I could allow myself to experience fully, feeling fully -- gratitude.

The doctor who tried so hard to help when nothing was helping -- she even took the risk of talking to an irritable priest about prayer.

The therapist who changed her dinner plans in a heartbeat when she saw the look on my face.

The psychiatrist who showed up for my guerilla party to celebrate suicide prevention week held in the hospital lobby. Complete with cake. And boy, what a cake!

The psychiatrist/researcher/professor/writer/mensch who has engaged with me and my work, supporting and promoting it when he agrees, taking it seriously even when he does not.

The publisher who believes in this book, whose own life mission is to give voice to writers whose stories need to be heard.

My wife of twenty-four years. Oh my gosh, what can one say about the ones who say the words, "For better for worse, in sickness and in health" and then stick around to keep those vows?

Batshit Crazy Support Group, where I had permission to speak the unspeakable.

Batshit Crazy Book Club -- oh, the places that our books take us!

I could go on for a while. I will go on for a while. But I will end this post (not the gratitude) with:

My dear sweet Mazie. Sometimes she knew she needed to pull me into a faster pace on our walks to improve my exercise. Sometimes she knew that my depression was too deep, that creeping was the best I could do. So she adjusted her pace to mine. And always she provided a gentle way to interact with others in the neighborhood.

Amazing Grace -- her full name was inspired by what everybody said when they saw her run, "That's amazing!" Mazie had three legs. She didn't need a fourth. She ran like the wind. She came to us that way, a stray.

We both were lost. I am so grateful that we both are found.

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A Better Suicide Prevention Month

CW: Cynical Warning.

Anybody else cringe all through Suicide Prevention Day/Week/Month? Anybody else roll their eyes at the "Ask for Help" messages? Or search the lists of "Warning Signs" to make sure you're covering your tracks?

Are you a potential helper and confused by that paragraph? Did you design this poster? Let me explain it to you. The psychiatrist doesn't accept your insurance. The psychiatrist who does accept your insurance doesn't treat your issue. There isn't a psychiatrist. The therapist is available six weeks from now. Or later. What's the point of therapy anyway, the therapist isn't going to pay your rent, if you could make rent you could manage your mental illness just fine, thank you very much.

If you call a help line, what if the cops arrive to handcuff you in front of your neighbors to help you enjoy your free trip to the ER? That's the only thing that will be free. If you go to the ER, you may or may not be admitted. Either way, the bill will leave you homeless.

When the naive, new-to-the-world-of-suicide-prevention person actually asks for help and goes through the demeaning process of not receiving it, it's like that outstretched hand, the one on top, turns around and pushes down the head of the one who has been reaching up.

Now look at this poster carefully. It claims to be addressed to the suicidal person. Your story isn't over yet... Speak up. But read the topics covered. The role of depression. Warning signs, risks, and stressors. Protective factors. Resources and tools for communication. Are any of them addressed to the suicidal person? No, they are not. This is not a conference designed for suicidal persons. It is designed for would-be suicide preventers. Whose story isn't over yet?

This will be a theme. There will be youtubes posted of somebody tackling that suicidal person on the edge of the subway track, pushing him back from the edge. I suppose this youtube encourages people to keep their eyes open in subway stations, ready to prevent a suicide.

I'm glad his life was saved. Truly I am. When I am on the edge, will I make sure a would be hero is standing by, or will I wait until I am alone?

And now to those risk factors and warning signs. Really, risk factors have nothing to do with prevention. They are about who do you (the nonsuicidal person) need to keep an eye on? That's such a warm fuzzy feeling, you know, being scrutinized. Nobody is watching the bully in school. They are watching the victim. It's the victim who is at risk for being yanked from school and placed in a special program. 

And the warning signs - like I said, these lists are very helpful for telling those of us who have plans what we can and cannot say and do in order to keep these plans concealed.

Boy am I being difficult. All you helpers out there just want to help. Here's a hint. Ask us what would help.
Following my own advice, I am asking. Not what would help? That is a later post. I am asking people who are or who have been suicidal: 

How would you, somebody with lived experience of being suicidal, design a suicide prevention campaign? What messages would you like to see? What do you want to have happen in the month of September to prevent suicide?

Give me your ideas. I want to hear from you in the comments below. Let's do something different this year.

Because the truth is, most suicides are prevented. We prevent them ourselves. It turns out, we are the experts in the field. If anybody out there is listening.

Circadian Rhythms and Fixing Bipolar's Wonky Clock

When nothing else worked, Social Rhythms Therapy got my bipolar under control. That's why Ellen Frank is my mental health hero. She invented it.

A few years ago, I spent four weeks summarizing Frank's book, Treating Bipolar Disorder: A Clinician's Guide to Interpersonal Social Rhythms Therapy. My goal was to create a patient's guide. Here is the link to Part Four. It includes links to the earlier posts.

Frank describes Interpersonal Social Rhythms Therapy like this: IPSRT [is] a treatment that seeks to improve outcomes that are usually obtained with pharmacotherapy alone for patients suffering from bipolar I disorder by integrating efforts to regularize their social rhythms (in the hope of protecting their circadian rhythms from disruption) with efforts to improve the quality of their interpersonal relationships and social role functioning.

Circadian rhythms are at the core of IPSRT. People with bipolar have difficulty maintaining the stability of our circadian rhythms, because our internal clocks, governing everything from sleep cycles to blood sugar levels to body temperature are, well, wonky.

Social Rhythms Therapy basically is a strategy to keep resetting the clock throughout the day by making sure key events (clock setters) happen the same time each day. For me that means getting up, greeting my wife, eating, beginning to write, and going to bed, each at the same appointed time each day.

People who do not have bipolar don't need to reset their clocks on a daily basis. Their brains accommodate little variations in schedule. But even they occasionally knock their clocks off the table: jet travel across time zones, changing work shifts, sleeping in on weekends. These knocks may not precipitate a mood episode. But they do have other deleterious effects.

Here is an explanation of circadian rhythms and, in particular, how they affect metabolism for all the rest of you.

So it turns out, while I have been simply trying to not go crazy, I also have been controlling my weight, taking care of my liver, and improving heart health too.

I hope you can learn the same lesson without paying the tuition I have paid!

book cover from
flair from Facebook

Will This Trauma Never End?

I found this video while trying to survive the cluster f*ck of misdiagnosis, antidepressants, mixed episodes, and a psychiatrist and therapist who didn't know what they didn't know, so it must be me and maybe I had borderline personality disorder - the go to diagnosis for patients that the professionals are tired of.

OK Go - This Too Shall Pass. And in fact, it did. I survived to... today? I offer it to everybody who is trying to survive the current COVID cluster f*ck in the US.

I don't know what it will look like on the other side. We are not going back. But we will go forward.

Meanwhile, do what you can today to build community again, to take responsibility for yourselves and your neighbors, to learn about strangers so that you don't have to be so afraid of what you do not know. The Way of Love is the way forward.

That's it. That's the post. Bless you.

To Write Love - Hope for Depression, Addiction, Self-Harm, and Suicide

There is power in a story. You tell me your story. You are seen, heard, affirmed. I tell you my story. You know that I am for real. We are not alone.

To Write Love on Her Arms (TWLOHA) harnesses the power of story to offer hope to people struggling with depression, addiction, self-harm, and suicide.

The organization itself began with a story, a young woman who was suicidal but could not be admitted into a treatment program because she was also addicted and they couldn't bear the liability of her detox.

Yes, if you think you're done after you tell your suicidal friend or family member to get help, read that sentence again. Trying to get treatment can be enough of a nightmare to push us over the edge.

But that was just the beginning. A group of friends took it upon themselves to create a safe place and treatment program for this young woman for the five days it took to detox. The treatment program was admittedly unorthodox. She stayed with friends. In rotating teams they supported her, kept her safe. They also took her to concerts, Starbucks, and church. They prayed. They smoked cigarettes. They were her hospital.

Mostly, they listened.

On the last night, she handed over the razor blade that had been in her possession the whole time. Anticipating a difficult night before going back to the other "real" hospital, she thought she shouldn't have it on her.

Her life began again from there. And TWLOHA was born. As the website says, We often ask God to show up. We pray prayers of rescue. Perhaps God would ask us to be that rescue, to be His body, to move for things that matter. He is not invisible when we come alive.

TWLOHA came alive. Today it publishes the stories of people who have survived these things, who are recovering. It "exists to encourage, inform, inspire, and invest directly into treatment and recovery."

I once was working on a novel that included the concept of "Hospice for Suicide" as a suicide prevention strategy. But I'll have to mine that concept another time. For now, story.

Today a psychiatrist on my Twitter feed tweeted about a time when he was suicidal. If you told me then that I would recover, qualify & receive a standing ovation from 1000 people at a conference in Lisbon for sharing my story, I would never have believed you. How differently I hear his words than those of another psychiatrist who tells me there is always hope.

TWLOHA's website is filled with stories. You can submit yours. Let's not walk this road alone.
photos by author and Helen Keefe

Mental Illness Podcasts: Teaching and Tickling the Mind

I have to move a lot to manage my anxiety disorder. So why did it take so long for me to discover podcasts? I can do research and fold laundry at the same time! Here are four of my favorites:

My therapist recommended The Hilarious World of Depression, hosted by John Moe, a few years ago. And I recommended it to you as part of my Giving Thanks series last November. A depressive himself, John interviews comedians, musicians, and other celebrities, asking the question, Is depression funny? Not everybody thinks so, but that's my brand. The show was recently cancelled. Sigh. But with five seasons, that's a lot of bingeable laughter to come your way. And you can often find Youtubes of the featured comics to extend your pleasure. So have at it.

I should mention that John has just published his memoir by the same name, for when you can sit still and read.

I discovered Beyond Well, hosted by Sheila Hamilton after reading her memoir about her husband's undiagnosed bipolar and subsequent suicide. It is the cautionary tale and not so funny version of my book. Well, she wrote hers first, but I don't want to say I wrote the funny version of hers. It's not always funny.

Sheila is an award winning journalist in the Portland, Oregon area whose career turned to mental health journalism after her husband's death. Her guiding principle is: We are all on a spectrum of mental health and everyone will struggle at some point in their life. Beyond Well is here to listen, affirm, and share stories to help you feel less alone in the world. And that does describe the effect of listening in on the conversations that Hamilton has with professionals and people with lived experience - to feel less alone.

Both Moe and Hamilton are included in the resource section of Prozac Monologues: A Voice from the Edge. The following are discoveries made after my project manager refused to accept any more revisions.

Kimberly Berry's Being Unnormal is like having coffee with a friend, a powerful, dedicated, and smart friend, my favorite kind of friend, who does not mince words and is a mother tiger when it comes to her kids, and then talking about the stuff that matters to the both of you: being queer, being adhd, being bipolar, being black and traumatized... Oh, and she invited an expert to join the conversation. You laugh, you feel, you think. And you show up next week to find out who shows up next.

Berry is the mother of one daughter with bipolar, another with ADHD. She is the founder of Being Normal, a coaching and consulting group that assists people navigating the world of mental health and companies to create mental health focused policies.

And then there is Gabe Howard, who hosts the Not Crazy Podcast on, along with his former wife Lisa. Not Crazy advertises itself as the mental health podcast for people who hate mental health podcasts. This is a more reflective podcast than most, if I can use that word for heated conversations about controversial issues. Reflect: consider issues from a number of angles, rather than simply educate on a topic. They take a perspective, or Gabe takes one and Lisa challenges it. Then they wrestle it into the ground, often trading positions in mid argument. The anti-psychiatry movement, mental illness humor, the role of religion in treatment... Two people with mental illness (Gabe has bipolar,Lisa depression) arguing passionately about the things that interest people with mental illness. It works.

Personally, I love it. Their conversations remind me of late night debates in my college dorm. Okay, I went to Reed College. Maybe that's not what you were doing late nights in your dorm, but it's what me and my buddies were doing in ours. Gabe's bipolar makes me feel like I am with my tribe, loud, bright, passionate.

Gabe also hosts a more conventional mental health podcast, the Psych Central Podcast where he reins in the intensity "to break down complex topics in simple and understandable ways.

I haven't read his book yet, but I post it here, because I think he puts out a quality product. This guy has been at the mental health advocacy gig for fifteen years and has earned his street cred.

So what about you? What are you listening to? Who should I add to my list?

book covers from,, and
graphic from

COVID Mask Resistance and the Death Wish

Why won't people wear masks? If their answers don't make sense, maybe we need to listen more deeply.

Truth be told, I want to respond with name-calling: selfish, anti-science, "drank-the-kool-aid"... I am tired of dodging the maskless in the street and the grocery aisle. I resent being confined to my home to protect myself from my fellow citizens. I grieve the slow, and now not so slow, decimation of the population of the United States, my native land, hurdling toward third world status as our health care system collapses, our food chain folds, and our future generations head toward long-term disability.

Side comment/serious question: There is such variation world-wide in leadership and results. Some countries have got this pandemic under control. Who benefits, who is the one who gains by our abysmal mismanagement and consequent destruction of the United States of America?

But 1) name calling is not helpful, 2) I actually care about some of these people, and in general, 3) I commit to the Way of Love. So I am stuck with listening more deeply.

Is It Time to Call a Therapist?

There is a difference between feeling depressed and having depression, which makes it hard to figure out what we need right now when - doesn't everybody feel like crap?

Pride Month Report: What Parents Can Do for Their Trans Daughters and Sons

1.8 million LBGTQ youth (13-24) in the US seriously consider suicide each year. The numbers for trans people in particular are even more staggering. According to the UCLA Williams Institute report, 81.7 percent of those surveyed by the National Center for Transgender Equality had seriously thought about killing themselves in their lifetimes, and 48.3 percent had done so in the last year. 40.4 percent of transgender people attempted suicide sometime in their lifetime.

Suicide happens when pain exceeds resources for coping with pain. This report adds evidence to that assertion. The following statistics are pulled directly and paraphrased or quoted from this report.

Mental Health Innovators Ponder the End of the COVID-19 Honeymoon

Dear Mental Health Innovators: The COVID-19 Honeymoon Is Almost Over.

The title of a recent article caught my eye. Honeymoon? Then I realized it was dated May 19, so perhaps the authors could rewrite the title with the "Almost" removed.

The authors identify predictable stages of psychological response to our current pandemic. Unbeknownst to those whose education was really less education and more training for their future jobs (so things like history were deemed a waste of time), the human family has lived through past disasters, including multiple pandemics. There are patterns to these things.

Heroic Stage

Care of the Soul and COVID-19

Ronald W. Pies is a psychiatrist, bioethicist, and professor emeritus at SUNY and Tufts. His writings often tend to the philosophical, which keeps me reading his work and occasionally engaging with him in cross conversation between Prozac Monologues and, where he served as editor-in-chief 2007-2010.

Pies' recent post is one such example where our respective disciplines come along side each other, Care of the Soul in the Time of COVID-19. He identifies five assaults on the soul made by the pandemic: impotence, grief, loneliness, mistrust, and displacement. While underlining that one solution will not work for all, he proposes cognitive therapy, gratitude, and the arts as strategies for healing.

Therapy and Spiritual Direction

As a physician, it is natural that Dr. Pies would write of problems and solutions. I too have been thinking about the larger implications of the COVID pandemic. However, I do less pastoral care these days. My thinking has been more in the realm of spiritual direction. Spiritual direction is as likely to trouble the mind as soothe it, raising questions to ponder rather than soothing manifestations of distress. So my care of the soul focuses on the questions that COVID raises about identity, values, and purpose. 


Misconceptions about Suicidal Thoughts

My publicist seems to think people have a lot of misconceptions about mental illness (she's right), because many of her questions go there. You are very open about discussing your own struggles with suicidal thoughts. What do you think are the biggest misconceptions about people going through similar experiences? So today's post will focus on suicidal thoughts or suicidality.

Suicide is not a choice

The way people talk, you'd think we sit down and make a list, pros and cons of suicide. Then based on our calculations, we make some kind of decision. She chose to end her life. Or, How could he have been so selfish.

This is called the volitional theory of suicide, suicide as an act of will. The suicide prevention approach that addresses it is to weigh in on that list of pros and cons, like Jennifer Michael Hecht's book, Stay.

You know -- Suicide is a permanent solution to a temporary problem. Or, Think of what you'll miss out on. Or, whatever. In other words, how dumb or short-sighted or irresponsible or selfish you must be to decide to kill yourself.

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