Saturday, August 29, 2009

Having lunch or being lunch?

The last two weeks have had me repeating a phrase that I learned many years ago from my high school journalism teacher, the astute and sapient Anne Sharp, when we either
came across or created an image to represent the dangers of school administrators attempting to spin us, the student newspaper.

The final image was of upright tiger wearing a brim hand with a card on it reading "press." The tiger was sitting in front of a picnic basket on a blanket and a person was sitting across from them. The caption read something like (and I'm sure we got the quote from somewhere; I just can't remember), "Doing business with the press is a bit like having lunch with a tiger, you don't know whether you are having lunch or you are the lunch." For those disinclined to my wrapping, winding, wreathing stories, I simplified the principle behind why I don't like doing media interviews, "Once you've been bitten by a tiger, you are a little hesitant to stick your head in its mouth."

My brief two weeks back in the media spotlight has not been a utter disaster, but, alas, I am ready for it to be done, and get back to the work of advocacy and life coaching.

Thursday, August 27, 2009

Christmas in August

Quotations are the last refuge of the intellectually lazy -- but they beat trying to think of something pithy of your own -- and this one is one of those classic quotes that I share with my high school and college students who are struggling with becoming more mature. Clichés have resonance because they reflect underlying truth, and when it comes to the fulfilling, fraught, fun-filled, fertile, formative and fluctuating, world of growing up you can't say it much better.

"Meek young men grow up in libraries, believing it their duty to accept the views which Cicero, which Locke, which Bacon, have given, forgetful that Cicero, Locke, and Bacon were only young men in libraries, when they wrote these books."

Ralph Waldo Emerson wrote this in an essay I have on my shelf at home, where he eviscerates those who would become bookworms, instead of using and abusing books, as they learn and in life, and as an ode to the power of creation and its link to action.

In the last three weeks, the first five of my clients who are college students lef
t to go back to school. I've been in touch with most of them, some of them daily, most at least once a week. Emerson's quote reminds of how what we learn in "the room" helps prepare them for action in college where they will learn things in those halls that, combined with what we learn in "the room" will be put into action in life.

Along that process of preparing, it's easy to get lost on laying the fr
amework for school, careers, for law school, and for families, that college years are not only a time for preparation, but a time for action, whether its volunteering to tutor or helping out at a hospital, or making a new friendship or directing a screenplay, coming up with a great business idea or whether its painting.

It's easy to forget that Claude Monet was 26 when he painted "The Woman in the Gree
n Dress." It's easy to forget that Bill Gates came up with the ideas that would become Microsoft while he was a sophomore at Harvard. Its easy to forget that in his early 20s, Andy Warhol was laying the foundations of his pop art, that Judy Garland had already been in "The Wizard of Oz" and that by their late 20s Janis Joplin and Kurt Cobain had done their best work and died.

Pablo Picasso once wrote, "Every child is an artist. The problem is how to remain an artist once he grows up."

My college-aged clients remind me of one of the most difficult battles of youth, the fight between preparing and doing, that usually comes along with trying to mature without letting go of our childlike creativity and hearts.

There are, as Picasso, alludes to, downsides to eradicating emotional immaturity, even if, in theory, it is a necessary victory that must occur on the road to growing up. Peter Pan, Aladdin and some of my clients are emotionally stunted in some regards, and while my desire to help them live good lives and be protected from the bad drives me to help them mature, I use a delicate chisel, their hand covered by mine, because I want to preserve as much that is good that is childlike inside them.

We worry for the emotionally stunted. We coddle them. We try to protect them from reality. Even Peter Pan, however, knew that the world was full of danger. One friend whom I told not too long ago that she likes "to believe that the world is full of cute things and well-meaning people" has taught me that wanting to believe that may come at a practical price but there is another cost, one that grown-ups often can't remember they've ever paid, of not having what I like to call Laura-like idealism.

There is something to be said for believing against belief.

I named this type of idealism for a friend who came to me one day and laid out her deep connection in an 18-year-old. He was 6 years younger than her. I am not sure how she expected to me to react. After watching her go through a year of turbulent relationships with fools -- she called them "boys" -- and a group of girlfriends from college that seemed to be playing in the junior leagues while she was still in the peewee league of emotional maturity, it, well, all made sense. None of these others were better people than her; in fact she had them topped in that area. She was able to connect with this 18-year-old so strongly because they lived in that same world, the one that Lewis Carroll lived with Alice, that I live with my friend's 8-year-old daughter Clara (who is such an inspiration that her mother calls her my daughter and my best friend has set Clara's picture to come up on her cell phone whenever I call) and why one intelligent client thinks that me sending her albino babies in swaddling clothes would be an appropriate reward for getting a 3.5 GPA, volunteering and accomplishing other goals. It's why I, with my ability to be callous and see the cruel world, feel the inkling to those kidnap some albino twins and send them FedEx to her college campus. (I am more than three-quarters of a mind to search for them on eBay or procure them from my cousin who has a penchant for producing adorable albino offspring; if anyone has any ideas on this crusade feel free to e-mail me at

My friend and her 18-year-old buddy have become the subject of ridicule of his family and whispers among friends; people joke that I can relate better to an intelligent 8-year-old than any adult; my other friend's parents worry with the words "there is no hurry" whenever she picks up someone else's baby and looks into their eyes. People who embrace growing up may look askew at us when our eyes sparkle in the face of youth, but there is a beautiful idealism that can be found there, one that perhaps we should all try not let completely go of as we become adults. So, bring me the 18-year-old friends, the 8-year-old spunky geniuses, albino babies and Alice and Wonderland. Even just for a moment.

We've got to find a way to grow up and keep those 18-year-old friends, those 8-year-old buddies, those dreams of albino babies, creating something great, conquering something new, inventing something no one has seen, writing that great work and painting that masterpiece. It can all come from a place of greatness. We've got to find a way to, like my college-aged client who is perfectly capable of communicating, to come into session, or wherever, and spend the first few minutes speaking through a panda bear.

This is always a sad time of year in general -- anytime so many young clients leave to head out into the world. It's a consolation prize, a more than adequate one for me, that they go out and put into action in their academic endeavors and lives the tools we have been crafting over the summer.

I truly love giving of myself to them and being a part of their emotional reward systems for their accomplishments. I'd do about anything to help them succeeded. As I once said it a much more shady context, "I took five grand and gave it away like f*in Santa Claus;" with my college students I've taken my heart and my mind, and given it to them like its Christmas in May, June, July and August.

I know they'll do good things with my investment. Trying is enough to make me proud.

Thursday, August 13, 2009

Looking bipolar; DDx, anyone?

Someone came to me this week to discuss school, her career and her moods. She talked about how her father had been diagnosed years ago with bipolar disorder and toward the end of our conversation mentioned that a psychiatrist had diagnosed her with "bipolar lite" soon after she stopped using cocaine and ecstasy. I found it curious. She was not closed to the idea of having bipolar, but added that she stopped treatment because of the mood stablizing medications she was on just seemed to flatten her and numb her emotions. I went through the symptoms of mania -- rapid speech, racing thoughts, decreased need for sleep, hyper-sexuality, impulse-control, grandiosity and increased interest in goal-directed activities. She said "no" to virtually everyone of them, outside of the context of times when she was abusing substances. What about psychotic symptoms, which can occur in mania and deep depressions, and can lessen the likelihood of other disorders? Not a one of them, not even E.

No mania. No hypomania. But a bipolar diagnosis.

What was going on here? Did someone misplace their Diagnostic and Statistical Manual of Mental Disorders? It has felt, at times, lately, like being trapped in an episode of "House MD" where no one is doing the DDx -- the differential diagnosis.

News this week of a study that showed that bipolar disorder was being grossly over-diagnosed hardly came as a surprise. In a little more than a year, I have seen psychiatrists reverse the diagnosis of more than a half a dozen people in the support groups and of a client in clinical practice, and I have seen a growing number of people present with symptoms that convinced them or others that they had bipolar who have turned out to have one, often more than one, other disorder.

Researchers from the Brown University School of Medicine found in a recent study , published in the Journal of Clinical Psychiatry, 57 percent of a 145 adults who said they had been diagnosed with bipolar disorder turned out to not have the condition when given a comprehensive diagnostic interview. The follow-up showed that nearly half had major depression (some with recurrent, anxious, impulsive or hyperactive symptoms that contributed to the mis-diagnosis), borderline personality disorder, post-traumatic stress disorder and generalized anxiety disorder. Some other diagnostic possibilities seen at elevated rates among this group were social phobia, anti-social personality disorder and impulse-control disorder.

This woman had symptoms of anxiety and of depression, a recurrent type of depression that moved in waves that are not similar to those in bipolar disorder. Instead of the waves being between the poles of depression on one side, and hypomania or mania on the other side, this client seemed to swing from depression to not-so-depressed to good. Everything seemed to suggest major depressive disorder, recurrent type, and generalized anxiety disorder, so I sent her off to another psychiatrist to get a second opinion following the one she received from the psychiatrist she had spoken to earlier.

A little more than a year ago, several people in a bipolar support group in Northern Virginia who had been resistant to treatment with a wide variety of mood stabilizing, anti-depressant and anti-psychotic medications were re-diagnosed or diagnosed with a condition other than bipolar disorder. For one woman in her early 40s, the suggestion by her psychiatrist that she did not have bipolar disorder, and, instead had borderline personality disorder, shook her faith in treatment, her providers and, in some respects, her identity. Understanding herself and her actions had come within the framework of bipolar disorder. She had found strong support in groups with people with bipolar disorder. It all made sense. Or, did it?

The woman had been diagnosed with Bipolar II and had experienced mood swings, however, mostly on the depressive side. She could not remember every having a manic episode, although she described what seemed to be some symptoms of hypomania in her history. She had struggled, as many people with bipolar do, with interpersonal relationships, on her job and in other settings. What the woman did not realize was bipolar disorder shared certain characteristics with several other mental disorders, including borderline personality disorder, which also includes unstable moods, impulsive behavior and problems in maintaining relationships.

In my work with support groups, it has been often difficult to distinguish people with Bipolar II disorder and borderline personality disorder, particularly when it comes to men, who tend to be diagnosed with borderline personality disorder at much lower numbers than women, and who tend to be much less accepting of the diagnosis. The mood stabilizing medications for both disorders are similar, which helps, but the types of therapy and interventions that are deployed are often different. After some time, the woman we mentioned above came to accept and even see the benefit of the new diagnosis. After a hospitalization and years of falling in-and-out of executive-level positions, she has held down a stable position for more than a year. Things are on the upswing, perhaps, because of the new understanding of her illness.

This is not a criticism of psychiatrists, psychologists and others who diagnosis. It is often hard to tell the difference between disorders like Bipolar II and borderline personality disorder. Its often hard to tell the difference between many disorders, for example, where postraumatic stress disorder ends when it develops, as it is assumed by some that it often does, into borderline personality disorder (there are other routes to borderline personality disorder, as well, but trauma tends to be a prominent one).

Bipolar shares common traits with major depressive disorder, especially the recurrent type (where the mood swings up-and-down between depressed and normal, or below normal), borderline personality disorder (with its mood swings), generalized anxiety disorder, postraumatic stress disorder and others. Confusing matters is that individuals can have Bipolar disorder and some of these conditions (such as PTSD, generalized anxiety disorder or even borderline, at the same time). It gets even more difficult to tell the difference when a client, for example, has both recurrent major depressive disorder and generalized anxiety disorder at the same time -- a combination that can look a lot like bipolar without a good differential diagnosis. Another combination that can be difficult to differentiate from bipolar are combinations of attention deficit hyperactivity disorder and major depression.

The potential overdiagnosis of bipolar disorder has been attributed to drug company marketing and the fact that there are so many more Food and Drug Administration drugs approved for the treatment of bipolar disorder. The reality is probably more complicated. Even a clinician has a doubt between bipolar disorder and major depressive disorder, and little time or means to examine the difference, the safer course is to treat for bipolar disorder because mood stablizers and anti-psychotics used in bipolar treatment are unlikely to have serious negative effects in someone with major depression, while anti-depressants alone have a risk of causing mania. In addition, people tend to be more accepting of a bipolar diagnosis than a borderline diagnosis, and certainty more accepting of it than impulse-control disorders or antisocial personality disorder. At least, a bipolar diagnosis gives tangible hope of medical treatment.

Accurate diagnosis of bipolar disorder is important because of quality of life issues, medication and therapeutic approaches, side effect risks and a variety of other factors. In my experience with the support groups, family members who suspect their loved one has bipolar disorder often realize, when told about the symptoms, that it could just as likely be borderline personality disorder or anxiety with depression. There is no question in my mind, from the support groups and clinical experience, that "soft" bipolar, where people have bipolar disorder but have yet to have experienced full blown mania (just hypomania) exists. We would be worse off if these individuals were not diagnosed or there was no diagnostic criteria that they fit within, especially since many of these individuals eventually develop full-blown mania, especially without treatment.

Bipolar II -- or "soft bipolar" -- is real, but it is also a murky area where clinicians and clients should carefully tread. It's hard to miss mania, but hypomania can not only be missed, but it can be confused as something else. I recommend a careful reading of the symptoms, reviewing the experiences of others with Bipolar II and searching your history for symptoms of other disorders. I am lucky to work with clinicians who seem to take their time and wait until they have clarity until they make a firm diagnosis.

Monday, August 10, 2009

Touched with fire

Our office manager is playing the lead role in a local production by the Sterling Playmakers' of "Thoroughy Modern Millie," a Tony-award winning musical comedy that was on Broadway in the early 2000s. I went to see it on Sunday with a client and saw several others there, a testament to our office manager's loyal following, which I attribute to her ability to relate to our unique population of clients. You can take that wherever you want. I see no need to complete the thought and connect the dots, but, in the best ways, they broke the mold when they made her. The cast and crew of the play did a wonderful job and this morning I was talking to our office manager, who did an exceptional job playing Millie, about the behind-the-scenes romances, conflict and otherwise general insanity related to the cast and crew. As I told her, "there is a reason they call it drama." Anyway, the entire conversation made me think of the link between mental illness and creativity, which was only reinforced by two recent clients (one dramatic, intelligent and analytical, and the other analytical, subtle and convincingly self-deceptive) who creatively tried to avoid serious discussion, a tool that is effectively in manipulating me away from the topic at hand, at least for 45 minutes of the 50-minute session, when I decided to bring the point that I have not been lead astray home by throwing them back in the pond that we had originally started in. The aside of this post is that everything about today had me thinking about the link between mental illness and creativity, and the debates about whether allowing mental illness to flourish is a requirement and a sacrifice that the most brilliantly creative must have to make. It's a debate that cannot truly be answered here, but I do think that in so many ways, being outside the box assists artists of all stripes. A good resource on the topic is Kay Redfield Jamison's Touched With Fire, an evidence-based look at manic depression and creativity.

Monday, August 3, 2009

Swan diving

Oh, yeah ... swan divers always go mad
- my friend, Liz Kelley, on those of us who love and live to the point of madness and seem to believe that it is the only sensible way to either love or live.

Sitting across from one of my most creativity, thoughtful, helpful, self-aware and troubled clients last week, I thought of this quotation. She's a swam diver. In everything in life -- the beauty, the ball, the gray -- she swan dives, sometimes in her own best interest and for her own thrill. Sometimes between that's what swans do. That's how they eat. Those who they get their nourishment. As like swans dive because that is where we the door dive, swan divers like her and me do it because that's where we find our nourishment. Its in healthy? I don't know, but it seems, sometimes, the only way for us to live.

Sunday, August 2, 2009

Days of Rest; Days of Introspection

I've tried to do my best to rest during the weekend's over the summer, taking trips along the Potomac, going to New York City twice, to the islands off of Charleston, S.C. and Duck, N.C. Feeling a bit tired this weekend, I mused a bit about what the last few Sundays have been like. I went to my camera to see if I had pictures (see above) that would jog my memory, an assessment of my attempt of summer mental health self-help and the results for me. They reach look nice, comfortable, inviting. Well, pictures don't always tell the story.

As one particularly well-expressed friend once described her feelings as she sat her in her bikini, a glass of red wine next to her and her father outside by the pool while weekending at palatial mansion on the eastern coast of Florida, "Here I go again. I'm crying hysterically in paradise." There's been a lot of that going on lately.

Each picture, in its own way, is beautiful, but each hides underlying sadness. Or perhaps each shows the beauty that can be found within sadness. It's hard for me to say, or to even tell the difference - for beauty and sadness are so interlinked for me, not in some sadistic way, but for my very profession is rooted in the notion of bringing beautiful things out of the experiences that cut us most deeply.

The bottom picture, from three Sundays ago, is of the shops in beachfront Duck. I was taking this picture on vacation, while on the phone with a client who hours later would experience and enormous trauma. The next picture of a friend from two Sundays ago. She called because she was sick. She said she wanted to share I cup of coffee. I think she wanted someone safe to watch as she fell apart. Later that day she walked seven miles to an emergency room after her loved ones refused to take her to the hospital. That night, another client called from beach cottage in Delaware, crying in paradise literally, afraid that her family members would see her shed one more tear and that she would have to see the dismissive disappointment on their faces one more time again.

The final picture is from today, and it looks fun enough. I was actually watching my former neighbor's children -- they are 11, 8 and 5, and they a great. We played games, ran around, laughed, joked. Unspoken was that they had been dropped off because their mother was busy making arrangements for the funeral of their uncle, only in his 40s, who had died the day before of pancreatic cancer.

The friend who wrote about "crying hysterically in paradise," wrote in the same note, "I think the two of us are more sensitive than most people. And I don't mean it in the 'overly sensitive, easily offended' way. I mean that we're more sensitive in the way that our skin bruises easier, our eyes burn stronger, our hearts break faster and our mouths smile harder. I think the way you learned to deal with that is to shut a piece of yourself off from it, to harden your skin in order not to feel the pain, and I came along, trying to open it all up." Perhaps my skin still bruises easily. Maybe I fixate on the pain. I like to think that both are true -- and that they are reasons that I am able to live each precious moment of life to its fullest, and see how others hurt, and try to help them heal. Who knows? We all seek rationalizations for what we do and who we are. This one just seems to resonate with me - at least right now, in this particular moment.

Saturday, August 1, 2009

healing art, and art to heal

Someone sent me this video and it made me think of how helpful it is is for people who have been depressed -- I mean everything from a touch of a sad mood to I mean Diagnostic and Statistical Manual of Mental Disorders -depressed -- to use art to heal. Dancing, painting, writing, drawing, composing, playing, choreographing, videographing, filming, shooting and acting your feelings is an immensely powerful tool. We get so used to words -- using what comes out of our mouths to express ourselves when we are depressed or sad -- that we sometimes miss the power of our other gifts. This YouTube video includes pictures and other images to the Blue October song "Black Orchird" - an effort that probably helped the artist, and hundreds of thousands more.

Web-based program appears effective with insomnia

University of Virginia researchers have published a piece in the Archives of Journal of General Psychiatry that examined an Internet-based behavioral intervention for adults with insomnia.

They found that insomnia severity, wake after sleep onset and sleep efficiency all significantly improved for two thirds of those receiving the Web-based program while none of the individuals in the control group changed over time. The idea behind the research was straightforward: insomnia is a major problem, cognitive behavioral therapy is the best known treatment for insomnia, cognitive behavioral therapy is neither not available, because of cost or the location of practitioners to many people and that the Internet could be used as a conduit to deliver the treatment. The question was really only whether the treatment would work over the Internet and whether the Internet-based programs could be tailored to the individual client.

One of the researchers, Lee M. Ritterband, Ph.D, speaks about it in the video below.