Run to Failure - Pt 2

Originally published in Blog Them Out of the Stone Age on December 10, 2005

"Run to failure" is a term I learned many years ago in a war and technology course. It's used by engineers when designing something that has lots of moving parts. You design, say, an aircraft engine. You build a prototype and let it run until it fails. Then you root around the prototype until you locate the specific part that failed. You figure out why it failed, design and manufacture an improved version of the part, install it and then run the engine until the next failure. You repeat the process until you have an engine that meets or exceeds the required specifications. That's "run to failure."

Over the last two decades, I've used "run to failure" numerous times to improve the system I've evolved to protect myself from the sort of acute manic episode that evidently killed Rigoberto Alpizar. An analogous concept would be the "lesson learned" analysis commonly employed by the armed forces: you create a doctrine, then revise it in light of practical experience -- war games or actual battle.

I described the core of the system in a previous post. Briefly, it's to marshal as many resources to combat the illness as I can: medications, therapy, good sleep hygiene, regular exercise, and so on. Equally important is to have in place a strong network of friends and colleagues who know that I have the disorder and have been briefed about its symptoms. This network has proven itself so thoroughly that the question of whether to be private or "out of the closet" about the disorder is a settled issue with me. It is better to have as many people know about the condition as possible.

True, there are downsides. I've no doubt that my openness makes some people uncomfortable and that they rationalize their discomfort by telling themselves -- and perhaps others -- that it is "inappropriate" or that I have "boundary issues." It is even possible that I could never get a job in another university. Tough. One of the things I learned in the Army is that you do what is necessary to accomplish the mission. My first mission is survival. Other considerations take a back seat.

The network protects me in two basic respects. First, I have around me a number of people who have received a memo detailing the symptoms of bipolar disorder and explaining what to do in the event they develop concerns about my behavior. The first step is to approach me and inquire. If they're not satisfied with my response, the memo has the name and phone number of my therapist and psychiatrist. The next step is to contact them and relay their concerns. As a last resort, they are authorized to direct me to go to a hospital emergency room, in which I event I am to go there, period. I get no say, since in the nature of the case, my ability to make wise judgments is in question.

Second, on very rare occasions, when I know that I have "decompensated" to a fairly serious degree but when my psychiatrist and I are on the case, so to speak, and working through a treatment plan to get me "recompensated," I will employ a regimen borrowed from one of my hospital stays but which I conceptualize in military terms. At the heart of it are the three general orders I learned in basic training and which are so ingrained in me I can recite them from memory even in the midst of a complete psychotic break:

1. I will guard everything within the limits of my post and quit my post only when properly relieved.

2. I will obey my special orders and perform all my duties in a military manner.

3. I will report violations of my special orders, emergencies, or anything not covered by my instructions, to the commander of the relief.

The idea of adapting these general orders to cope with the bipolar disorder occurred to me when I was first hospitalized for mania in 1986. I felt that I could not fully trust the medical professionals around me -- they gave me meds that back-fired, for instance -- and at the same time I understood that something was definitely very wrong with my own capacity to judge. It seemed a no-win situation.

Trying to think while acutely manic is like trying to read a newspaper in a high wind. I remember saying to myself, "A no-win situation. A no-win situation. I've been in a no-win situation before. When was it?" Finally it came to me: Phase I -- the indoctrination phase -- of basic combat training. During that phase, recruits are constantly placed in situations or asked questions to which there is no correct response: you'll get bitched out for anything you do or say. The purpose is to break down a recruit's resistance and to make them more receptive to training. It also reproduces, in very modest fashion, some of the stress one is apt to experience in combat.

One of the first things we had to do in that environment was to memorize those three general orders. In many respects they were the key to getting out of Phase I and into more advanced phases (there were four in all) in which we were treated more and more as real soldiers. As soon as my manic mind was able to grasp Phase I as the no-win situation I had previously experienced, the next step was obvious. I would use the three general orders as the template to regulate my conduct in the hospital.

Part 1 - Part 2 - Part 3 (coming)

Run to Failure - Pt 1

Originally published in Blog Them Out of the Stone Age on December 9, 2005

Left: Anne Buechner and her husband, Rigoberto Alpizar

Two days ago the couple in the photo were returning to Florida after a brief missionary trip to South America. The international leg of the flight was behind them. They had cleared customs, boarded a second aircraft, and faced only the final, brief trip from Miami International Airport to Orlando. Suddenly the man, 44-year old Rigoberto Alpizar, began acting in a way that attracted the attention of the flight crew and an air marshal on board the craft. The marshal became convinced that Alpizar had a bomb and, when he bolted from the plane rather than heed the marshal's command to halt and lie down, the marshal shot him dead.

The story has been international news for a couple of days now. The dominant theme has been that it was a "good shoot" -- that is, the air marshal behaved properly in the circumstances -- and serves as evidence that security measures entrenched since 9/11 are working as they should. But it soon transpired that Alpizar was not, in fact, carrying a bomb. His behavior owed not to lethal intent but rather to his medical condition: He suffered from bipolar disorder and, in medical terms, had "decompensated," apparently because he was off his medication.

The fate of Rigoberto Alpizar has begun attracting comment within the mental health segment of the blogosphere. Shrinkette, a psychiatrist in Eugene, Oregon, poignantly juxtaposed a news excerpt with a passage from Kay Redfield Jamison's famous memoir of her struggles with bipolar disorder:

Witnesses aboard an American Airlines jetliner say that Rigoberto Alpizar's wife pursued him, saying he was mentally ill, just before federal marshals shot and killed him. Air marshals said Alpizar had announced he was carrying a bomb.

Later, no explosives were found. The incident remains under investigation.

"She was chasing after him," said fellow passenger Alan Tirpak. "She was just saying her husband was sick, her husband was sick." When the woman returned, "she just kept saying the same thing over and over, and that's when we heard the shots."

"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering..."

-Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.

One of Shrinkette's readers left this comment:

I understand 100% why the air marshall did what he did. I really do. But I can seriously imagine the turmoil and pain the man was in. I'm bipolar. I've been in a psychotic state, I've heard things, seen things, nearly cut off my own hand because something in my head was telling me it would be a good experiment. Being bipolar we have a responsibility to take our medication, but even then it can be difficult, a daily struggle. I am not saying that the air marshall was wrong: he discerned a threat to the larger group and was doing as he was trained. But I have an incredible amount of compassion for the man and his wife. NO ONE knows, nor will they ever, what that couple went through, both at that moment, and the days leading up to it.

But Becky, a 22-year old Indiana woman who blogs about her struggles with bipolar disorder at Tidal Moods, was less sympathetic -- in fact, not sympathetic at all:

Some people are suggesting that the air marshals behaved inappropriately. Those people are wrong. A clearly insane person can still have a bomb and just because someone is behaving bizarrely does not mean they aren't dangerous. This man said he had a bomb and authorities have no choice but to take him seriously.

As a person with bipolar, I'm outraged by the media's obsession with the fact that the man's family claimed that he suffered from bipolar disorder. It's irrelevant. It doesn't factor into the air marshalls' deliberations about whether or not the man is a threat and the only reason the media even mentions it is because it makes the air marshalls look like assholes when they aren't.

At the risk of sounding like a heinous bitch, I have little sympathy for this man and his family. By the time you're 44 years old, you know what it's like to live with bipolar disorder and you know whether or not you're one of those people who requires medication to maintain sanity. Clearly, this man could not behave normally without his medication and there is absolutely no reason for him not to take it. It's not like a bipolar person is going to fly off the handle if they miss one dose of their meds. For his wife to be aware of his failure to take his meds, he had to have missed more than a dose and at that point, my sympathy dies. Even if he lost his bag and his medication was gone, he could still go to a hospital or contact a pharmacy and his psychiatrist to get more. There is no excuse for not taking your meds if you know that you pose a danger to others without them. None at all.

Becky's post has so far attracted 21 comments, though most of them are off-topic -- early in the thread someone criticized her for being foolish and "narcissistic" to write publicly about her bipolar disorder. (That little gem of idiocy generated a spate of coments and counter-comments from Becky, the idiot, and several of Becky's readers which is worth reading for its own sake.) But of the responses that addressed her post directly, opinion was about evenly split between those who thought Becky was being harsh on Alpizar and those who thought she had a point.

My personal view is that Becky has a point and also that her stridency on the subject stems from fear. Anybody with bipolar disorder -- me, for instance -- can't help but reflect that in the right circumstances, we ourselves could suffer Rigoberto's Alpizar's fate. One way to deal with this fear is to blame Alpizar for what happened: Alpizar had bipolar disorder. Alpizar did not take his meds. Alpizar got in a situation where he was killed. I myself will take my meds and therefore I will never get in such a situation.

Actually, you can take your meds and still get in precisely that situation. Six years ago I was hospitalized for acute mania exactly one day after a blood test showed that the correct level of lithium was present in my body.

No: meds alone aren't a guarantee. The strategic problem of survival is more complex than that.

It is no coincidence that in the last decade, a significant amount of my research as a military historian has focused on situations in which people have tried to frame workable strategies for resistance in an intractable environment, when the odds are stacked heavily against them. I live that situation every day of my life. And over time I've brought my military training as well as my historical training repeatedly to bear on the problem.

Let me tell you some of the tactics I've evolved to address it.

Part 1 - Part 2 - Part 3 (coming)

Valuable Partners

Originally published in Blog Them Out of the Stone Age on September 8, 2005

The Ohio State University is still on the quarter system, which means, among other things, that Autumn classes do not begin until late September. So around here the students are just now beginning to return. But four of my five graduate advisees are in town now, so this morning we're going to meet as a group.

Within the history department I have a foot in two fields: American History to 1877 and, of course, Military History. My career has largely been a matter of shifting my weight back and forth between them, sometimes laying stress on the one, sometimes on the other. That is not uncommon. Indeed, I think it is pretty much the norm for professors in thematic fields. Two of my advisees are early Americanists; three are military historians. In other years the balance has actually been the other way. And indeed, two of the three dissertations that I have signed as principal adviser were in early American history.

But the dividing line is artificial. As Clausewitz says, "War has its own grammar but not its own logic." The logic is driven by the policy of governments and the passions of people, among many other things. So a good military historian has to be a broadly grounded historian. And since the United States is a country that was literally made by war, a good American historian must know some military history.

Still, the brute fact of the job market is that positions in American history far, far, far exceed positions in military history. Which is why I insist that my military history advisees, when it comes to their PhD general exams, should be as strong in their second field--which is usually early American history--as their first. I'm not trying to be a jerk about it; I'm trying to maximize their chances on the job market.

I will give an example. The day I gave my job talk here at Ohio State, the first question I received had nothing whatsoever to do with the subject of my presentation. Instead I was asked what I thought of the debate between Eugene Genovese and James Oakes as to whether the antebellum South was a pre-capitalist society or whether it was as capitalist as the North, albeit in different ways. The whole point of the question was to show me up, to demonstrate that I knew nothing beyond pure military history, whatever that is. Guns and battles, I guess.

You might think I resented the question, but that's like thinking a a baseball player at bat resents the pitcher on the mound. It gave me precisely the opportunity I needed to destroy the stereotype about "narrow military historians." I launched into a discussion of the main works of Genovese and Oakes, explained the reasons for their disagreements, and concluded that it was too early to tell which one was right. My questioner later told me he wasn't really satisfied with my answer and I'm sure it wasn't as good a response as he could have given. But so what? Most of the people in the room were non-Americanists who didn't know a damn thing about the Genovese/Oakes debate. To them it sure sounded as if I knew what I was talking about.

Contrast that with the impression I would have made if I had said, "I don't know about that." Or worse, tried to stumble through an answer on the basis of dim memories of a debate on which my grasp had been tenuous to begin with. I would not have recovered. Worse--because to tell you the truth I didn't really believe this department would actually hire one of its own no matter what I did--I would have let down the military history program. I always thought of my real objective as making the program look as good as possible in the eyes of the department. If I got the job, that was gravy.

And pretty good gravy it has turned out to be.

So my military history advisees need to see my early American advisees as valuable partners. But what do the American advisees get out of it? Well, they almost invariably choose me because military history informs their research or because they want to be historians of the Civil War era, and any historian of that era ought to know a good deal about military history. They need my military history advisees as pards, too.

Beyond these remarks I don't actually know what I'll tell them when we meet. In a way my main job is just to bring the coffee and croissants and let them renew acquaintances or get to know each other if they haven't met already. I would tell them about the fact that I have bipolar disorder if they didn't all know it already. It is one of the first things I tell potential advisees. I want them to see that I am not ashamed about it and I think of it, and manage it, as an illness. I explain the symptoms and tell them what to do and/or who to contact if they become concerned about me. I think it is their business to know, because they are placing a good deal of their future prospects in my hands. And if they can't handle the knowledge it is better for both parties if this is recognized at the outset.

But thus far my graduate students have been comfortable with my frankness on this subject and even somewhat reassured, because it implies that they can come to me with their own concerns when necessary. It is, to be sure, a matter that has to be handled in a sure-footed manner, because it is important to maintain a professional demeanor and to preserve, in a healthy way, the distinction between my status as a faculty member and theirs as a student. But they are also adults--actually remarkably accomplished adults--and they deserve to be treated as such.

SITREP

Originally published in Blog Them Out of the Stone Age on July 12, 2005

It's been nearly a month since my last blog post. That's partly because I have adhered to my rule of making this blog an aid to productive scholarship, not a diversion from it. It's partly because the next posts that follow logically from Crash and, especially, Shadow Warriors, Pt 8, are ones that I have been reluctant to write, much less publish -- though I guess in the next few days I will have to embark on them. But mostly it has been due to the fact that I've spent much of the period in a state of clinical depression.

What does that mean? Well, according to the standard diagnostic manual used by the American Psychiatric Association, it means that I met the criteria listed in Facing the Demon.

As I mentioned in a previous post, I have bipolar disorder, also called manic-depressive illness. The condition was diagnosed when I was 26; I am now 45; I will have this condition for the rest of my life. I have seen it blight the lives of some people but in most cases I have found that people manage the illness fairly well. The medications now available help a good deal, as does the diminishing stigma attached to illnesses of this sort, which makes it easier for people to get treatment rather than avoid it from a sense of shame. In my own case, I have also found it useful to keep a very tight handle on the diagnostic criteria associated with the disorder. (In Facing the Demon, I tried to give an impressionistic sense of this utility.)

Nevertheless, if you look over the criteria you'll find that by definition a major depressive episode can be identified only after a significant amount of time has passed. Officially the period is a full two weeks, though to be sure, a psychiatrist closely acquainted with a patient seldom hesitates to intervene long before then. Still, it takes time for a pattern of symptoms to emerge. Even the depressed person isn't always aware of being depressed until a few days have gone by. And although this site typically gets around 80-120 hits per day, it was not until yesterday that anyone inquired whether the dearth of blog entries might indicate that something was amiss with my health.

I knew that such an inquiry would come eventually, however. I knew which person was most likely to inquire. I knew it would come as an email, and I knew what the subject line would say: "SITREP?"

SITREP is military speak for Situation Report. If somebody asks for a situation report they are asking to know the status of your unit and the progress of its mission.

The person who requested the SITREP was an officer currently posted in Baghdad. I wrote back:

Thanks for checking up. I appreciate it.

Things are OK now, but as you surmised, until recently they weren't going so well. I had another depressive spell, this one longer than usual--probably long enough to qualify formally as a clinical depression. It may have been due in part to some tweaking in my medication. The meds have been tweaked again, and I'm doing better, though whether this is a cause and effect relationship, or correlation, or coincidence, just plain beats me. All I know is that I have had more trouble with the bipolar disorder this year than in any preceding year I can recall.

A subsidiary reason I haven't been keeping a blog is that when I am OK I'm busy doing other things. At the moment, for instance, I'm writing a 5,500-word chapter for The Osprey Companion to the American Civil War. If I needed the blog to help with my productivity I'd use it, but I've never wanted to get in the trap of letting the blog distract me from the stuff I really need to do.

I hope things are going OK at your end. Thinking about what "at your end" signifies sort of puts what's going on in my life into perspective.

Afterward it occurred to me that dealing with this bipolar disorder is a little bit like combatting an insurgency, and vice versa. For instance, I can say in retrospect that a depressive episode occurred, but neither I nor anyone else can say with much certainty what caused it, when it began, why it reached the level of intensity it did, and why it finally lifted. Similarly, although it is obvious that the United States is contending with an insurgency in Iraq, I don't think anyone can say exactly when it began, or explain the dynamic that feeds it, or gauge -- save in a very rough way -- the progress the United States has made in fighting it. Or say when it will end. In the case of bipolar disorder, it will never end, though I am told that the disorder tends to be roughest on people in their thirties and forties and tends to abate with age. Yet the presence of the disorder doesn't preclude the possibility of leading some measure of an ordinary life, just as the presence of an insurgency doesn't necessarily halt the normal functioning of a society. As military historian Eliot Cohen observed in a recent op/ed piece, "Counterinsurgency is inherently a long, long business. Conceivably, the Iraqi insurgency could collapse in a year or so, but that would be highly unusual. More likely Iraq will suffer from chronic violence, which need not prevent the country as a whole from progressing."

"The history of a battle," the Duke of Wellington famously maintained, "is not unlike the history of a ball. Some individuals may recollect all the little events of which the great result is the battle won or lost; but no individual can recollect the order in which, or the exact moment at which, they occurred, which makes all the difference to their value and importance." He wrote those words to dissuade a would-be historian of the battle of Waterloo, but of course his injunction did nothing to inhibit the crafting of hundreds of books on the battle. Societies have a need to find meaning in events just as individuals have a need to find meaning in their own lives. Yet when thinking about this latest depressive episode, I wonder. . . . "The meds have been tweaked again, and I'm doing better, though whether this is a cause and effect relationship, or correlation, or coincidence, just plain beats me." The only battlefield was my own life, and yet I can see what Wellington was driving at. I wonder what simile Wellington would have found to describe the history of an insurgency?

Facing the Demon

Originally published in Blog Them Out of the Stone Age on June 5, 2005

But besides the achievement of this functional and corporate aim, the rote-learning and repetitive form and the categorical, reductive quality of officer-training has an important and intended -- if subordinate -- psychological effect. Anti-militarists would call it de-personalizing and even de-humanizing. But given -- even if they would not give -- that battles are going to happen, it is powerfully beneficial. For by teaching the young officer to organize his intake of sensations, to reduce the events of combat to as few and as easily recognizable a set of elements as possible, to categorize under manageable headings the noise, blast, passage of missiles and confusion of human movement which will assail him on the battlefield, so that they can be described -- to his men, to his superiors, to himself -- as "incoming fire, "outgoing fire," "airstrike," "company-strength attack," one is helping him to avert the onset of fear or, worse, of panic and to perceive a face of battle which, if not familiar, need not, in the event, prove wholly petrifying.

-- John Keegan, The Face of Battle

Diagnostic Criteria for Major Depressive Episode

For a diagnosis of a major depressive episode, these are the signs and symptoms doctors are looking for:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood.

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains.

4. insomnia or hypersomnia nearly every day.

5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness of being slowed down)

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms do not meet criteria for a Mixed Episode [i.e., a Mixed Bipolar Episode in which manic and depressive features are simultaneously present].

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Reference: These criteria are excerpts from Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, p. 327, © 1994, American Psychiatric Association.

Adapted from HealthyPlace.com

National Public Radio interview with Andrew Solomon, author of The Noonday Demon: An Atlas of Depression (you'll need RealPlayer to access; it's worth it)

The Scare - Pt 2

Originally published in Blog Them Out of the Stone Age on April 28, 2005

Deception is a fundamental aspect of war. The enemy systematically tries to mislead you as to his real intentions and capabilities, which leads to uncertainty and therefore often anxiety. The most formidable adversaries are usually masters of this. I once wrote on this subject using as my example Confederate cavalry general Nathan Bedford Forrest:

"Warfare, despite its various refinements, touches basic human emotions. The most fundamental of these is fear. It is not difficult to imagine that Forrest's [prewar] days on the Mississippi frontier had educated him in the coarse art of instilling fear. The key was to rattle an opponent and keep him rattled. Forrest had an expression for it: "Keep up the scare." When he advanced toward [the Federal garrison at] Jackson [Tennessee] with kettle drums beating to simulate infantry, and when he suddenly swung on his pursuers at Parkers Crossroads, Forrest was doing his best to generate fear. There was nothing really novel in this approach: the violence of war can have no other purpose than the creation of fear through the threat of wounds and death. But Forrest was unusually clear-eyed about the value of inflicting fear. He did it instinctively and he did it well."

The experience of depression is often much like this. Joy simply drains out of life, replaced by listlessness, anxiety, even outright dread. The actual cause of the depression may be biochemical but the mind, spurred by the illness, searches for a circumstantial explanation and always finds it. In broad outline the illness "keeps up the scare" by playing on universal fears: that one is a failure, that one is unloved and unlovable, that life itself is meaningless. But the details are insidiously specific to each individual because the illness, in effect, knows what scares you most.

Part 1 - Part 2

The Scare - Pt 1

Originally published in Blog Them Out of the Stone Age on April 28, 2005



Part 1 - Part 2