Yesterday, I had the pleasure of being interviewed by the International Bipolar Foundation (ibpf.org). It was a wonderful conversation, with a listening audience, about living with Bipolar Disorder and how to best maintain wellness. It was broadcast live on You Tube, Facebook and their website.
The listeners asked lots of great questions about their own journeys. I shared my story of what it has been like to be a physician living with Bipolar Disorder, touching on issues of stigma in the clinician community, faith and treatment. We discussed how best to ensure emotional and mental health, the value of being authentic and faith.
What impressed me about the audience was their commitment to remaining well. They struggle mightily against great odds, at times, and make impressive efforts to take care of themselves in impressive ways. As I spoke, I realized once again that we are a community of kindred spirits traveling the pathway of a mood-challenged life together. I received so much more from them than I gave. It once again confirmed to me that we are in this together. None of us are alone.
If we take a thousand steps, we’ll have travelled some distance whether we’ve reached our destination or not.
Three months ago, I relapsed into a mixed mood state, having symptoms of depression and hypomania at the same time. This took me by surprise since I had been psychiatrically stable for the past several years. Why I slipped into this destabilized state, I do not know.
In response to this, the recommendation from my psychiatrist was to double the dose of one of my medications and within a few weeks my mood symptoms resolved and I felt back to my usual self. Or so I thought. Sometimes, it’s only in retrospect that I realize that all has not been not so well. It was only after a month of being a good patient and taking the elevated dose that it was obvious that something was wrong. I wasn’t having mood symptoms but I was lifeless without any interest in doing anything at all. I’d just lay around all day not writing, cooking, exercising or otherwise engaging in my life. This wasn’t depression, it was a side effect of the medication. I made the decision on my own to return to the lower dosage and a few days later, emerged from my deadened state. I was alive again. I know that despite feeling better, on this current regimen, my mood symptoms are going to express themselves and I will become ill again.
The half or zero dose guy
If halving my medication caused me to re-awaken, how could I be sure that the remaining dosage wasn’t having some deleterious effect? If I stopped taking it all together, might I become even more alive? Who am I? Am I the half dose guy or the zero dose guy? Am I still trapped beneath the weight of this smaller pill I take everyday? I’m tempted to experiment and stop all my meds and find the answer. I understand non-adherence to recommended care.
A thousand steps…and more
I continue to face what many who have psychiatric disorders face. Still searching, after so many years, for that combination of medications that will stabilize my mood yet won’t suffocate the real me. As a psychiatrist, I understand the challenges of this delicate balancing act. That said, I’m rather frustrated and pissed off that I’m forced to continue this wearying journey. It seems, at times, that there is no end in sight but I have no option other than to soldier on in this (so far) elusive search. I don’t think my feelings arise from a place of self pity. They are instead a sober realization that a thousand steps hasn’t been nearly enough.
A colleague of mine recently asked me for some help. He was wondering how best to handle a difficult situation at work. As he reached out, he half-apologized, wondering whether he might be unfairly imposing on my time. It didn’t feel like it was an imposition at all, quite the opposite. He’s such a good guy and so respectful that it’s always a pleasure to share my opinion with him and offer my advice. As he asked, I noticed something: his reaching out made me feel good even before we conversed about his work. I wondered why that was the case. After thinking about it, I figured it out. He was showing me his vulnerability.
Leaning into discomfort
His words didn’t make me think something; his words made me feel something. This expression of human vulnerability allowed for a connection between us, a moment of closeness. I know that it likely wasn’t so easy for him to ask but here’s the thing: it’s always uncomfortable to show our truest vulnerable selves. We have a saying in psychiatry that we grow only when we lean into discomfort. I believe this is true. By definition, growth is a journey where we enter an unknown world, whether we are stumbling to learn a new language or falling off our bike as a kid. Leaning into the discomfort of showing another our tender core is as challenging as it is rewarding.
Ironically, it is only through embracing this discomfort that we can find comfort. We can’t have it both ways. We either live behind thick walls, protecting ourselves, feeling alone, or we open up to the joy and pain in life by feeling uneasily vulnerable. When we say “I love you” first, when we stand at an AA meeting and say “I am an alcoholic” or when we say “I need your help”, we are extending our hands and opening our hearts. We humans are hard-wired to connect and being openly vulnerable is the only pathway to true intimacy and well being.
I’m going to do my very best to help my colleague. I’m quite sure he is unaware that he has moved me. I respect him for doing so. And perhaps in return, I will navigate through my own vulnerability, open myself up and let him know how grateful I am for this gift that he has bestowed upon me.
A few days ago, I sent two well-meaning emails to colleagues. As I read them after I had pushed the “send” button, I regretted that they were hurtling through cyberspace and landing in the inbox of these two recipients. It’s not that they had an angry tone but they were too long, divulged too much information and were a bit tone-deaf to the sensitive matters that were at hand. I know I’m not the only one who has sent emails they wish they hadn’t, but it’s not so common that I do so. It was a swing and a miss.
We can take big and little swings
I don’t like swinging and missing, but that is what we humans do. Sometimes, I wish I were a baseball player who has permission to swing and miss two thirds of the time and still be seen as a superstar. Failed swings of much greater magnitude can leave me feeling quite bad. Sometimes, shame can rear it’s head as I berate myself for doing what I have done.
Guilt I can handle because it educates me. Perhaps next time, I’ll wait a day before pushing the send button. Unlike guilt, though, shame is corrosive, telling me that I am unworthy. These two emails rose to the level of brief guilt, not shame, I’m relieved to say.
Living with bipolar disorder has caused me to have the biggest swings and misses of my life. For me, there simply hasn’t been anything worse than hurting those around me. I refused to accept that I had bipolar disorder and for many years didn’t get treatment. Despite efforts to spare those good souls pain by hiding my secret life away (the swing), I hurt them even more by doing so (the miss).
We can ease the angst of missing the ball
I have found two ways to ease the angst of sending emails I wished I hadn’t and causing pain to those I love. First, I use the “war crimes” yardstick. I ask myself: “Did I commit a war crime?” Since I didn’t, it helps put my deeds in a kinder perspective. The things I did likely may not have risen to the level that I feel they did. Almost always the case. A gentler perspective helps.
Second, I try hard to identify the impulses that drove me to take the action in the first place. The genesis is rarely to be intentionally hurtful. Most often, it’s an attempt to protect someone else; it’s an attempt to protect myself; it’s an attempt to be closer to someone; it’s a cry for help; it’s an expression of fear; it’s an attempt to receive admiration; it’s an attempt to be noticed.
Recognizing all this allows me to quickly ease my feelings of guilt. Do I expect myself to go through life without ever erring? Sure, sometimes I do. But at those times, I reflect upon what drove me to do things I did. I travel on the path of humanness just like everyone else. Sometimes that’s a bit humbling, but sometimes it allows me to feel that I have a world of fellow travelers and innumerable kindred souls. In this regard, I don’t feel so alone. And while I can disappoint myself and others, I know that my average of falling short of my high expectations is a lot better than two thirds. It’s OK to keep taking swings and realize my humanity when I miss. Immersed in a life of guilt and shame? No, thanks. Living in a world of humanness? Yes, please.
In her epic decision to crash through the wall of silence, clinician Kay Redfield Jamison made the bold decision in 1995 to reveal that she has bipolar disorder. Her bestseller, An Unquiet Mind, describes her terrible depressions that led to a suicide attempt and her elevated highs that caused reckless spending sprees and acts of violence.
Her revelation was courageous. She stepped forward at a time when others didn’t in the midst of a successful career, placing her life’s vocation at risk. Even more impressive, she went on to become one of the nation’s leading experts on mood disorders. She is the definition of a courageous trailblazer and all those who have followed in her footsteps are indebted to her bravery.
She was resistant to taking medications, something those with mental health conditions understand. Her firsthand experience lends clout to her anguish and makes her words ring true with authenticity. She has helped reduce the mental health stigma that pervades the medical community; a feat that few have dared to attempt. In so doing, she has saved lives and given hope to those who have, at moments, lost faith:
Time will pass; these moods will pass; and eventually, I will be myself again. Kay Redfield Jamison
I see her as a towering figure of truthfulness and integrity. We humans struggle to chart our own journeys in life but can’t do so without those role models who have inspired us to follow in their inspirational footsteps. There are few in life who I admire more than her. We would do well to remember all those who have cleared the way for us to survive and thrive. In our own unquiet minds, we move in the direction of peace and contentment only because others have shined a light on our pathway forward. Thank you, Kay.
I took a hike a few months back in the Blue Ridge Mountains, outside Asheville, North Carolina. Having scaled one of the peaks, I sat and saw the expansive valley below from my lofty perch. The sunshine warmed my face as I inhaled the cool, crisp air. I was on top of the world.
As all others living with bipolar disorder, I had periods when I was driven down to the abyss of depression and then episodes when I was elevated to the heights of mania. I couldn’t predict when my neurotransmitters would hijack my brain but they inevitably would. I was being repeatedly kidnapped.
The Mania of Love
Though my manic periods were ones of agitation and irritability, they were also times of euphoria and grandiosity. I was the smartest guy in the room, walked with a bounce in my step and felt that I was capable of doing things that were, in reality, well beyond my reach.
When we have a huge crush on someone, the world falls away and all that is rational is replaced with heady infatuation. In this state, we behave in ways we wouldn’t otherwise, throwing all caution to the wind. Everything feels tingly, as if we are living on the edge of ecstasy. This is a small glimpse of what mania is…an other-worldly intoxication.
As a psychiatrist, it was my duty to un-manic my patients. I was required to shift their state of giddiness into, at times, one of bland sobriety. I was like a thief in the night, robbing them of what they most loved. Turning the tables, when my psychiatrist recommended lithium to me in our very first session, I was literally being given a taste of my own medicine. The psychiatric perpetrator had become the psychiatric perpetratee.
A few years back, there was a Broadway show called Next to Normal about a mother living with worsening bipolar disorder. Once she was medicated and mood-stabilized, she longed for those periods when she was mountaintop-high manic. She sings:
Mountains make you crazy
Here, it’s safe and sound
My mind is somewhere hazy
My feet are in the ground
Everything is balanced here
And on an even keel
Everything is perfect-
But nothing’s real, nothing’s real
I wouldn’t trade my current mood stability for my prior elevations given the havoc and heartbreak it caused those around me. But, there are moments when I long for my now-medicated-and-absent euphoric core to rule the day and carry me upward toward that place far above. I love ascending the North Carolina peaks but sometimes, I do miss those mountains.
Anne has been a doctor for over 30 years. She loves her work, her patients, teaching and writing. Her voice is one of love shining a light on the need for compassion in the practice of medicine. Courageous in sharing her lived experience, she extends her hand to all of us so that we may learn from herwisdom. I’m honored to call her a colleague and friend and am privileged to share this wonderful post from her website, aptly namedTo Medicine with Love.
My comment’s on Anne’s post: Beautifully written in the warm style that befits this post, Anne speaks of her favorite patients. She writes of being drawn into their inspiring world views and what she has learned from them. As a patient herself, she describes her triumphant journey through physical and psychiatric adversity. I was struck by the lens through which she views herself and others: she is deeply human and gives us permission to embrace ourselves for being human, too. It’s such a pleasure to read. Enjoy!
Doctors aren’t supposed to have favourite patients.
We are not supposed to feel anything, really. We are supposed to be objective, dispassionate, and to not favour anyone over any other, for we are to have no feelings for any of them. No matter who they are, what they are going through, how they are behaving, how much we relate to them, or how much they inspire us. For we are scientists, and medicine is a serious business.
I thought that was true and tried to live like that once, and ended up in a rehab centre at a young age.
So, now I just live my life as a human being, who practises the art and craft of medicine, and loves it.
I now work in a small country town, and live nearby, and have been caring for some of my patients for up to 20 years. I also see them down the street, at the markets, on the beach, and I have a relationship with them, as a doctor, and as a person.
I see myself as having a relationship with all of my patients, and some of these relationships are closer than others, just as we have many friends and acquaintances but there are some we feel particularly close to. And as with all my relationships, I learn a great deal from my patients, about medicine, about people, and about life.
Going blind is not the end of the world
One of my patients is in her 90s, and when I inherited her from another doctor who had retired, she was already blind from macular degeneration. It was the dry, wear-and-tear, just-old-age kind, so there was nothing we could have done about it, even now. It came on relatively quickly, after her husband died. Her vision is only count fingers in each eye, but this does not seem to stop her from doing much. Despite her disability, she still cares for herself, writes letters, gets people to help her read the replies and listens to talking books, but mainly spends time connecting with and engaging people in conversation.
She comes to see me with her daughter, to say hello and to have her eyes checked for other treatable diseases like glaucoma. We all love these visits. We laugh and joke and just have fun together. We both know there is nothing I can do for her in a physical sense, apart from these checks, but that does not mean I shut down to her as a person.
She is not fazed by her blindness, has accepted it, and makes the most of life in spite of it.
She is not fazed by her age, is mentally as sharp as a tack, and is as joyful as she was when a young girl.
She has taught me that it is okay to just love my patients, and to say “I love you” to each other, as we would to any other old friend.
She has taught me that even if I cannot “do” anything more for my patients, that just being me with them is enough; that just being myself can be healing for them, and for me.
Having a hard life does not have to make you hard
I have another favourite patient who comes to see me for regular checks. I took his cataracts out several years ago. He is a Vietnam veteran who has been through horrors that we can only imagine, and yet he has the sunniest outlook on life, and is a big, jolly, giant-hearted man. The only sign of residual hardness is that when he gives you a hug, or shakes your hand, you feel like he may just crush the life out of you!
I have many patients whom I love dearly. Children whose squints I have operated on who have now grown tall and look me straight in the eye; people whose cataracts I have removed and who delight in being able to see clearly again (except for seeing their now obvious wrinkles); people whose glaucoma I tend to and check on regularly so that their vision is preserved for life and whose 6-monthly visits are a marker in both of our lives of the passing of time; people who gracefully submit to injections for macular degeneration, knowing that they would not be able to see without them; people who just come to see me for eye health checks and their appointments roll around with clockwork regularity and we both say we cannot believe that another year has passed already and delight in sharing stories of what the year has been for us.
My favourite patient of all
But perhaps my favourite patient of all is me. I have learned so much from being a patient – how to be a better patient, how to be a better doctor, and how to be a better person.
I have mainly learned the hard way – not seeking help when I was struggling with depression and alcohol addiction during my training, so that I had to get really sick before I was willing to submit to rehab; not seeking help after the birth of my second child when I developed an ovarian abscess due to undiagnosed pelvic inflammatory disease and let it go undiagnosed and untreated until I had to have emergency surgery for a suspected ovarian tumour; not resting after the surgery and lifting my small kids too soon and stretching the scar on my belly; seeking help when I found a lump in my leg and having a cold node removed, but not resting afterwards, going back to work and re-bleeding, causing a huge secondary haematoma that had me on the couch for far longer than I would have spent there had I heeded my surgeon’s sensible advice; not taking time off when I had to have 3 weeks’ radiotherapy when the lymphoma recurred (I had refused it the first time), but going in for treatment early in the morning, then driving to work for the day. I finally relented and let my husband come with me for the last treatment, and when I felt what I had been doing to myself, collapsed in a blubbering heap, from which I had to recover to operate that afternoon.
These life experiences have taught me that doctors in general (or perhaps just me in particular) make pretty terrible patients. We think we know better, we do not follow the rules, we do not grant ourselves the time and space needed to care for ourselves, to heal after surgery, to rest when we are ill. We expect ourselves to be superhuman, and think that the world will stop turning if we take time off to recover from illness and surgery.
But along the way I have also learned to be humble, to be compassionate, to no longer try to self-diagnose but to seek help, to have a GP I trust who knows me well and whom I see regularly for check-ups, to follow instructions when I am given them, and to understand why people don’t, which makes me much more able to sniff out people who are going to flaunt the rules in my own practice and gently set them straight.
And since I have learned these humbling life lessons, I rarely get a cold, let alone a serious illness. I work hard but give myself time off to play, I care for myself deeply, I rest when I am tired, I eat and drink in a way which nourishes my body, and I make time and space for my partner, my children, our large family and our friends. I love my life and I love being a doctor who has also learned to be a great patient.
I had the pleasure of sitting down with John Tamerin, M.D., and Mike Myers, M.D. to discuss the psychiatric needs of mental health clinicians. Dr. Tamerin has a private practice in Greenwich, Connecticut and is Clinical Associate Professor at Weill Cornell College of Medicine in New York City. He has been running a support group for those living with (and affected by) mental health conditions for over twenty years. Dr. Myers is a national expert on physician health, has authored 8 books and is Professor of Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry and Behavioral Sciences at SUNY Downstate in Brooklyn, New York.
Dr. Myers moderates the session and introduces the discussion by saying
“The sad irony is that many (physicians) do not receive the care that they so sefflessly give to others and that they need and deserve for themselves.”
When I finally admitted to myself that I had bipolar disorder and was clinically stable, I made the decision to disclose my diagnosis. I did so in a very public way at the International Conference of Bipolar Disorders. After I approached the podium, the first words I said were: “I am a psychiatrist and I am also a psychiatric patient. I have bipolar disorder.” It is uncommon for a physician to disclose their mental health diagnosis.
The reaction of my patients
When I did disclose, I was still practicing. My greatest concern in doing so was not the reactions of family and colleagues. I was worried about what might happen if my patients were to become aware of my diagnosis. I hoped that I hid my symptoms from patients over the years, but can I be sure this was the case? I believed that for some patients, knowing my diagnosis wouldn’t matter at all. Others might see me as empathic since I was living with a psychiatric disorder. But I had to conclude that my care of some patients would be impacted in a detrimental way. I was sure that some patients would be angry that I had withheld this information and would terminate their care with me. This was a sobering realization since I took the Hippocratic oath as a physician to “First, do no harm”.
Why I disclosed
I was unmedicated for most of the years that I practiced, so there might be those who believe that I should have taken medical leave each time I cycled up or down. Or, perhaps there are those who believe that I should have left the profession entirely. But given the prevalence of mental health conditions within the physician community, I don’t think the best course is to exorcise all of us who have been unwell. I recognize that other clinicians might have made a different choice than the one I did. Despite my certainty that I would negatively impact the treatment of some patients, I made the decision to disclose my diagnosis for two reasons. First, it was an act of self-healing. Perhaps selfish on my part. Second, I thought there might a greater good for my fellow clinicians in the medical community to foster a conversation about physician health. If I had to do it over again, I would make the same choice.
Reasonable people may have different views about whether clinicians who have psychiatric disorders should practice. This is fair to question. I would suggest that these are exactly the kinds of conversations we should be having. We need people of good will to come together and speak about these important issues. Then we can find common ground in our efforts to balance caring for our colleagues in need and, at the same time, placing a premium on delivering excellent care to our patients.
What do you think about my decision to publicly disclose my diagnosis?
The mental health of our nation’s doctors is not so good. Physicians are worried and depressed. The prevalence of psychiatric disorders amongst clinicians and medical students is depressingly high. The pervasiveness of clinician burnout has caught the attention of many in the medical community. But most doctors keep their mental health symptoms secreted away. They understandably worry about professional consequences if they do not. As a doctor living with bipolar disorder, I have shared my diagnosis publicly. I did this as an act of self-healing but also because I wanted to start a dialogue about a topic viewed as taboo.
Doctors fear losing their medical license
In whispered confidential conversations with peers, I have come to see that many suffer in silence. They’re afraid of losing their license to practice medicine if their diagnoses were to become known. This worry is not far fetched. Currently, each state has a board that licenses physicians. Many of these states ask unfairly broad questions such as “have you ever been treated for a mental health condition”? So, any doctor who might have had a panic attack a year ago, for example, might feel that they’d be putting their vocation at risk if they were to divulge this. It’s no wonder that practitioners go into hiding. However well intentioned, the current system is misguided. In this status quo, no one wins. We can all agree that doctors don’t want to feel depressed and patients don’t want depressed doctors. All this is particularly frustrating because treatments are so effective and doctors (and non-doctors) can be their usual highly-functioning selves when they receive care.
Physicians are being sacrificed
It’s important that we have dialogues to disrupt this unhelpful status quo. State medical boards have a duty to oversee patient care by monitoring clinicians. Understood. But, In pursuit of this laudable goal, physicians are sacrificed. It’s possible to provide excellent patient care and have healthy physicians at the same time.
The simple answer: courage and conversation
Why can’t the powers that be sit down with medical community leaders and find common ground? This is not beyond our capacity. Have I placed my medical license at risk by acknowledging that I have bipolar disorder? Perhaps I have.
If my state‘s medical board tracked me down and informed me that my license to practice medicine was at risk, I’d hope that we could have a conversation. I’d ask them to explain how they believe the current system is helpful to doctors and patients, let them know that my peers are avoiding treatment and suggest that we work together to be a positive force so doctors can stay well. And what if despite these efforts, they suspended my license anyway? If so, it would be a chilling message to those who are in hiding to remain out of view. It would be a depressing coda to my story which has been one of success and triumph-a physician with bipolar disorder, well treated, stable and highly functional. Most important, I’ll think of my worried, depressed colleagues who are committing suicide at rates that should concern us all.