The Ethics of Disclosure

For many years now I've chosen to be candid about having bipolar disorder, and I have a variety of reasons for doing so. Many are pragmatic. But one is not: "[Being up front about bipolar disorder] gives me a chance to combat, in a small way, the stigma that still attaches to mental illness. If a professor protected by tenure cannot summon the modest courage required for such an act, I do not know who can."

The quotation comes from a column I wrote three years ago. And although in it I used the phrase "modest courage," it would be more accurate to say "moral courage." That is to say, I would feel craven or gutless if I remained discreet about having bipolar disorder, even though the fact that I'm high-functioning means that people are oblivious to my having the disorder unless I tell them.

So if I kept this information to myself, would it be unethical? And if so, why?

Here at the Army War College we're midway through a ten-day course in "Strategic Thinking." I'm responsible for most of the remaining lessons -- the Uses of History and the capstone Gettysburg Staff Ride, for obvious reasons. And a bit less obviously: Ethical Reasoning, which comes up tomorrow. (I say "a bit" less obviously because anyone who knows my body of work is aware that much of it deals with the problem of moral judgment in war.)

At the AWC we faculty do not have carte blanche to prepare our own lessons. The readings, learning objectives, and the basic approach are designed by a lead instructor. The rest of us can adapt the lesson within certain limits, but we can't leave the reservation entirely. This sounds like a strait jacket, but it's really the only workable approach given the way that education is delivered here; i.e., within twenty tightly knit seminar groups with faculty members assigned to teach one particular group, and that group only, for most of the academic year.

This year the lead instructor has adopted what strikes me as a reasonable, easy-to-grasp approach. We're asked to discuss ethical reasoning through just two lenses: deontological, or principle-based reasoning; and teleological, or results-based reasoning (the latter primarily taking the form of utilitarianism).

What light do these forms of ethical reasoning shed on the ethics of disclosure? Indeed, are ethics even involved?

Certainly to me it feels unethical to keep silent about having bipolar disorder. From experience I know that my candor has been helpful to people who either have a mood disorder or know someone who does. So from a teleological perspective, I suppose a case could be made that if I remained silent I would deny those people whatever assistance or comfort I might otherwise provide. And one could add that my silence would do nothing to undermine the stigma associated with such disorders.

All the same, this strikes me as a pretty weak case. Equally weak would be to argue from a deontological perspective -- that I must be candid about the disorder as a matter of principle.

It therefore seems to me that only two conclusions are possible: either I'm mistaken to believe myself under a moral obligation to be open about having bipolar disorder; or else some other ethical framework must apply.

It seems to me that another ethical framework does apply: aretaic, or virtue-based reasoning. This basically flows from a moral imperative that is rooted in character, that comes from within. It differs from deontological and telelological ethics in that, unlike these two, it does not attempt to be universally prescriptive. Put simply, just because I perceive it as a moral imperative to publicly acknowledge having bipolar disorder, doesn't mean that everyone should. This was the basic problem with the tactic of "outing" gays. Yes, it would show that being gay was fairly common and would thereby reduce the stigma of being gay. It would also increase the political clout of the gay community. And one could certainly advocate in favor of having gays come out of the closet. But to strip from a person the option of privacy was wrong.

As I've pointed out in the past, my situation with bipolar disorder has certain analogs with battle stress injury, in particular the need to manage the two conditions and the stigma that clings to them. Military policy has become quite enlightened about encouraging service personnel to seek treatment for battle stress injury and, as much as possible, eliminating the adverse consequences of doing so. Here at the Army War College it's estimated that as many as a third of the incoming resident class have some symptoms of Post Traumatic Stress Disorder, and there are several ways by which officers can seek treatment confidentially. (The most obvious of these is to visit a chaplain, all of whom have both training and experience in counseling persons with PTSD.)

But policy will get you only so far. The culture remains one in which battle stress injury is still too often regarded as weakness. It may be okay for an enlisted man to receive treatment for PTSD. It may even be okay for an officer or senior NCO to receive treatment for PTSD. However, as I often heard officers maintain during my first year here at the Army War College, it is not okay for officers or senior NCO's to disclose publicly that they are being treated for PTSD. My comment in a post I wrote last year about the military use of antidepressants, etc., also applies here:

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it’s OK for you to take these meds, but tacitly it’s really not because I wouldn’t be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that’s the role I often play with my students.) Such an officer’s example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.

I broached this subject to a number of officers and national security analysts and got the same response. Double messages, they acknowledged, do have adverse effects on organizations. But in this case it was just too bad. It would be fatal for officers who took medications for combat-related anxiety or depression to discuss it with their soldiers or, for that matter, anyone else. To command effectively an officer has to appear strong, and the stigma of weakness attached to battle stress injury was too potent to challenge.

In the months since, however, I've discovered that a few generals have done exactly as I proposed.

On November 8, 2008, USA Today reported that Maj Gen. David Blackledge had received "psychiatric counseling to deal with wartime trauma, and now he is defying the military's culture of silence on the subject of mental health problems and treatment." His decision to speak up apparently came from two sources: First, a statement from Admiral Mike Mullen, the Chairman of the Joint Chiefs of Staff, for leaders to set an example for all service personnel: "You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it." And second, a campaign developed by Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, to encourage service personnel (and their families) to share their stories. Blackledge volunteered to help.

On November 26, 2008, in an article picked up by Army Times, USA Today highlighted a four-star general, Carter Ham, who had also disclosed publicly that he was getting treatment for battle stress injury, partly to serve as an example to other service personnel -- "You need somebody to assure you that it's not abnormal. It's not abnormal to have difficulty sleeping. It's not abnormal to be jumpy at loud sounds. It's not abnormal to find yourself with mood swings at seemingly trivial matters" -- and partly to undercut the stigma surrounding battle stress injury. The article went on to discuss Brig. Gen. Gary Patton, who had also chosen to talk publicly about having battle stress injury.

A March 2009 CNN article further explored the cases of Generals Ham and Patton, and offered clues about their reasons for coming forward:

"If you go ask for help somehow you believe it or you might believe others think it of you, that you're somehow weak. That's wrong and intellectually we all know it's wrong, but it's still there. It's still palpable in some communities," Ham said.

Patton wants to see a change in the way post-traumatic stress disorder is viewed by the military.

"We need all our soldiers and leaders to approach mental health like we do physical health. No one would ever question or ever even hesitate in seeking a physician to take care of their broken limb or gunshot wound, or shrapnel or something of that order. You know, we need to take the same approach towards mental health," Patton said.

Having two generals talk publicly about their own battles with stress and how counseling helped should help remove some of that. Patton said he wants servicemen and women to know that they can come forward.

"Know absolutely that your chain of command and your leadership in the military at our highest levels recognize this issue and want to encourage our soldiers to seek out that mental health assistance," Patton said.

Again, neither deontological nor teleological ethical reasoning seems to apply here. Generals Blackledge, Ham, and Patton (and for that matter Admiral Mullen and Brig. Gen. Sutton) do not come close to arguing that it is a moral imperative for all officers to publicly battle the stigma associated with battle stress injury. But plainly, it seems to have been a moral imperative for them -- a case of aretaic reasoning in action.

The Nick and Betsy and Diamond Head

Three years ago veterans of the USS Nicholas -- "the Nick," they call it -- a World War II era Fletcher-class destroyer on which my father served, created an online discussion forum. Since I was already on the mailing list of their reunion association, I got an invitation to join.

I promptly posted a message asking to hear from personnel who had served aboard the Nicholas during the same time as my father, and of course I was particularly interested to hear from anyone who actually knew my father. Since any such individual would have to be on the high side of seventy, I had low expectations. But to my surprise I heard from someone almost immediately. Though I gather he had only a nodding acquaintance with my father, he had a clear recollection of the part of the ship where my father worked. Moreover, he had compiled a database of info on Nicholas personnel and could tell me more or less the exact dates of my father's service on the vessel.

That sent me poking around boxes of old photos to see what images might exist of Dad's service on the Nicholas. I found a few from his days in basic training at San Diego, but nothing Nicholas-specific save for a yellowed clipping from the Honolulu Star-Bulletin reporting the ship's arrival at Pearl Harbor. The story included a photo of the Nicholas and two sister ships in her destroyer squadron.

I knew for sure that Dad had slides of his days on the Nicholas, so I tracked them down in a storage box and went through them, using I checked out a 35mm slide projector from my university. I don't think I'd seen the images in thirty years. Quite a few slides had been ruined in a basement flood back in the 1970s. But I still found about two hundred from his time in the Navy and about fifty that dealt specifically with the Nicholas. The best of them I scanned using a transparency adapter and uploaded to the forum site.

It was very odd to go through all those slides. Since most of the boxes weren't labeled, I viewed quite a few that proved to be of our family in the 1960s and early 70s. Many of these had not been completely destroyed by the flood but still had damage from too much humidity. Bleeding and discoloration in the dye had made them like something from an opium dream. Others were in perfect condition but had people in them -- friends or extended relatives of my parents -- whose names are now forever lost.

Those of my father's days in the Navy showed him having the time of his life. Many slides depicted his friends at parties, holidays, or excursions in California and Hawaii. A surprising number were of "Betsy," his first car, a 1950 Ford sedan purchased in March 1956 for $478.80 (he kept the bill of sale). And whenever my father appeared he had a cocky stance and a flashy grin, displaying the trademark gap between two upper incisors that gave the grin an infectious, boyish charm.

Of those involving the Nicholas, comparatively few depicted life at sea. But he was a sucker for sunsets, particularly if a companion ship were silhouetted against the red horizon. He also liked ports of call: Hong Kong, Yokohama, Nagoya, and so on. And whenever Nicholas returned to Pearl Harbor, he could never resist a shot of Diamond Head. (Decades later, when he and my mother took lessons in oil painting, he would try his hand at capturing a sunburst falling on Diamond Head after a storm.)

In short, between the images of him and the images he took, my father seemed jaunty, happy, alive -- striding into the wider world, making new friends, his whole life ahead of him. This was the man I still dimly remember from my earliest childhood, the man I rarely saw thereafter. Who could know, looking at that grinning face, the rage that lay beneath?

Thirsting for Love

Of late I've been thinking a lot about how to pursue certain issues -- the onset of the bipolar disorder and significant episodes that convey some idea of the subjective experience of the illness. But I've been concerned about how to do so without bringing specific persons into the narrative. Even if I omitted their real names and disguised certain of their characteristics, they would still be recognizable to friends and acquaintances.

In the main I think I can work around this. The unavoidable exception is my parents, both of whom are long deceased but whose lives I would like to address with fairness and empathy. Consequently before raising matters that involve them, I would like to introduce them a bit.

To start things off, here is something I wrote four years ago:

Seventy years ago today my mother was born in Norfolk, Virginia. I cannot say she led a happy life. Her childhood home was drenched in anger and abuse. Her troubled 23-year marriage ended in divorce. At age 29 she was institutionalized for several months with a mental illness diagnosed first, erroneously, as schizophrenia and later, correctly, as bipolar disorder. Ten years later she was diagnosed with breast cancer. The disease finally killed her a few weeks after her forty-seventh birthday.

My mother was part of the last generation of American women raised to embrace what Betty Friedan would call “the feminine mystique”: the idea that a woman’s highest calling was to be a wife and mother. She usually described herself as a “professional homemaker.” She never read The Feminine Mystique. She didn’t have to. She lived Friedan’s critique of it day to day. She would like to have escaped, but hampered by her bipolar disorder in addition to the usual difficulties of women of her era and station, she stayed in the trap. But she never stopped trying to get out. She immersed herself in self-help books. She drowned herself in religion. Once or twice a year she overdosed on sleeping pills. Through it all she composed short, didactic essays on how to live life and wrote a lot of clumsy poems.

I seldom think of her without recalling these lines from Spoon River Anthology, especially the last two:

I AM Minerva, the village poetess,
Hooted at, jeered at by the Yahoos of the street
For my heavy body, cock-eye, and rolling walk,
And all the more when “Butch” Weldy
Captured me after a brutal hunt.
He left me to my fate with Doctor Meyers;
And I sank into death, growing numb from the feet up,
Like one stepping deeper and deeper into a stream of ice.
Will some one go to the village newspaper,
And gather into a book the verses I wrote?—
I thirsted so for love!
I hungered so for life!

A Futile Consistency?

"The most successful people," I once heard the entertainer Kenny Rogers say in an interview, "are the most consistent." I was never a huge Kenny Rogers fan, but I had to admit he was certainly successful and certainly consistent, so he probably knew what he was talking about.

That's not particularly good news for people like me.

If, as Ralph Emerson famously maintained in Self Reliance, "A foolish consistency is the hobgoblin of the little minds," then I suppose a futile consistency is the hobgoblin of minds afflicted with bipolar disorder.

On the one hand, depressions drain you of energy, pushing even the most modest of projects beyond your ability. People looking from the outside assume that if you had sufficient will power you could just power through, but will power is among the very first things that depression strips from you. The former talk show host, Dick Cavett, suffers from periodic depressions. He once explained that when you're depressed the cure for depression could be on a night stand fifteen feet from you, and you would not have the will power to rise from your bed and get it.

It is, on the other hand, not much better with hypomanic episodes, which though characterized by energy and creativity also increase distractability and decrease impulse control, so that you go off on tangents instead of focusing on whatever main task lies before you.

The best solution I have found is, at best, a partial one. It involves finding ways to be as consistent as possible in at least one area of life. Consistency in that one area helps you understand that whatever the strength of the illness, you are not powerless against it. The thing I fear most about the disorder is that it creates the temptation to give up.

Hence these almost daily reports of my comings and goings to the gym. Although working out is a good thing in itself, it's also a tangible way to show myself that I am still capable of consistency. To try and be consistent in all areas is a recipe for despair, but if I can drill down on one area then I can remind myself that inconsistency -- one might also say unreliability -- is an artifact of the illness, not a flaw in my character. The great mistake would be to confuse the illness with my identity.

Why the Hell Did I Wake Up at 2 A.M.?

Basic to the management of bipolar disorder is what health professionals call "good sleep hygiene." This consists not only of getting enough sleep but of observing habits that maximize the chances of getting a good night's sleep. Although I consider this a critical skill, I've found it difficult to master, and some of the things that work for me run counter to the usual advice. For instance, it's recommended that one not watch television before retiring and above all that one should not sleep with the television on. Television, observes the Sleep Disorders Center at the University of Maryland, "is a very engaging medium that tends to keep people up."

At the same time, the Center advises the aspiring sleeper to "leave your worries about job, school, daily life, etc., behind when you go to bed." In my experience, this has proven almost impossible. From childhood I've nearly always lain awake for at least an hour, worrying about this or that. A solution that has worked for me is a modification of the "no television" rule. I leave the TV on, but I have it play a DVD that I practically know by heart. It distracts me from worrisome topics and because I'm thoroughly familiar with the story line, it doesn't engage me enough to keep me awake.

Some DVDs work better than others. The most reliable, oddly enough, is a war movie, Twelve O'Clock High, I think because it consists mainly of dialogue and has almost no combat scenes.

Still, my sleep pattern tends to oscillate between a lot of sleep -- last week I found myself sleeping as many as twelve hours -- and comparatively little, generally only four hours a night. Last night was an extreme example. I slept only ninety minutes and awoke with the certainty that I would not be able to get back to sleep. In such instances the advice is not to force sleep but to read quietly or maybe take a warm bath. In no case should one do office work, housework, etc. This is a rule I nearly always violate, because once again it doesn't work for me. I have found it more effective to push through the day and then retire at an early hour but not too early -- say at 9 p.m. This usually results in getting sufficient sleep the next night, and I'll take an Ambien to try and make sure of it.

Although I don't become alarmed when I get too little sleep, I do start looking for signs of a potential hypomanic episode. As a checklist I use the relevant criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, which I have more or less memorized (and also own a copy).

The first question I ask myself is whether I feel refreshed, as if I had gotten a full night's sleep. That would be bad. Fortunately on this occasion I don't feel that way. I feel functional but kind of tired, and were it not for the proscription against taking naps during the day, that's probably what I'd wind up doing. (I sometimes take cat naps anyway. Even twenty minutes can restore a measure of vitality without compromising my ability to get to sleep that evening.)

Second, I ask myself whether I feel unusually creative and raring to go. Again, that would be bad.

Third, I look at whether I am easily distracted, which is another symptom of hypomania. If I can stay on task, whether it's doing dishes or paying bills, I'm less concerned.

Lastly, if the condition persists for four days, then getting a good night's rest becomes an absolute priority, and on such occasions my psychiatrist has authorized me to double the dosage of Ambien. This generally does the trick.

There are other criteria indicative of a hypomanic episode -- e.g., an unequivocal change in functioning uncharacteristic of the person when not symptomatic, and the disturbance in mood and functioning are observable to others -- but I seldom find evidence of the former and as for the latter, I am continually amazed by how rarely anyone picks up on a change in my mood and / or functioning, at least not on the "high" side of normal. Depressions, my principal bête noire, are more noticeable to friends, though not to colleagues (or if they do notice they rarely say a word).

In any event, the object is to avoid as many symptoms of a hypomanic episode as possible. And one thing I definitely avoid is the temptation to "ride the wave" of increased creativity that often characterizes a hypomanic episode. I have heard of writers, artists, etc. who firmly believe their creativity is inextricably bound to their hypomanic episodes and therefore resist treatment. I say the hell with that.

Meds - Pt 2

Every evening I take between three and six pills --invariably two of Lamictal and one of Zocor (a cholesterol-lowering drug), to which I often add one or two Klonopin and occasionally one Ambien.

Even after all these years, I still find this a little strange. From an early age I disliked the very idea of taking anything stronger than the occasional aspirin or cold medication. I didn't begin taking psychotropic medications on a consistent basis until my mid-thirties, and I somehow doubt I will ever get used to it. I've just learned to accept it as a fact of life.

Little in my civilian background equipped me to deal with bipolar disorder. Within my family a taint of shame and weakness, usually covert but hard to miss, attached to it with regard to my mother. It was not much different when I was diagnosed in 1986. Most of my friends just sort of fell away, as if my life were over and I was no longer worth the investment. Many years later, when my life was on track and the bipolar disorder obviously in hand, I became reacquainted with one of these friends and asked what had happened. "We just didn't know what to do," she replied. Which was slightly odd coming from a devout Christian as well as a registered nurse.

Within academe scarcely anyone ever inquires about the disorder. I think it makes them feel awkward. And as I've written elsewhere, a common reaction is to consider it "inappropriate" for me to openly discuss it. Almost no one has said this outright, but an academic generally has a lousy poker face. Over the years it has been increasingly difficult to find a plausible alternative explanation. And of course I live in a society that still prefers to see mental illness as a character disorder ("Snap out of it!") or as an all or nothing proposition (you're either normal or you're abnormal).

Almost the only thing that has equipped me to handle the disorder is my experience with the Army. Back in basic training the Army drilled into me a vital core principle: You do what it takes to accomplish the mission. The aesthetics don't matter. You don't need to look like John Wayne. A manly attitude is irrelevant if it doesn't translate into effective action. It doesn't matter what other people think. The mission is everything.

A second thing the Army did for me -- as it does for most recruits -- is to show you that you are stronger than you think you are.

Even so, the need to be "normal," to be like everyone else, is powerful, particularly in young people who have not yet realized that no one is normal, that no one is like anybody else, and that we all carry wounds. Initially I took medications -- lithium and Imiprimine (an early antidepressant) -- for perhaps nine months, and even then without much conviction in their efficacy. It was tough on me psychologically. Taking the pills always seemed like a bizarre eucharist, a daily acknowledgment that I was now as broken as my mother had been.

Then for over ten years I took nothing. It took not only a brush with an unmistakable hypomanic episode to bring me to my senses. It also took the maturity that comes with being older and the basic confidence that comes with having securely established myself in life.

To my surprise, the first psychiatrist I consulted prescribed nothing stronger than a sedative to help me sleep. "You've had the disorder for eleven years," he pointed out, "and during that time you've gone to graduate school, gotten your PhD, succeeded in getting a faculty position, published a prize winning book, and gotten tenure a year early. Clearly you've been able to manage the disorder. So until I know more I'm not in a big hurry to put you on psychotropic medications."

Within a couple of months, however, the hypomanic episode had been succeeded by a depressive episode that seemed unrelated to anything in my day to day life and was sufficiently debilitating that it became difficult -- though not impossible -- to function normally. Certainly, though, I could not function at my usual level and on top of that, life seemed flat and meaningless. Small reversals suddenly loomed large. The memory of old failures and regrets constantly tugged at my thoughts.

So I consulted a second psychiatrist -- not because I disliked the first but because the second one was in my health care network. The first had not been. I wanted an antidepressant but I knew enough to recognize that an antidepressant alone carried the strong risk of vaulting me into a manic episode. Consequently I would have to take lithium as well.

In July 1999 -- precisely ten years ago, come to think of it -- I had a manic episode that simply blew through the lithium, and when the second psychiatrist somehow refused to accept this fact, I got rid of him and found the psychiatrist I continue to see to this day. I'll call her Jennifer -- it's hard to call her "Doctor" since we both have doctorates, although mine is merely PhD. Jennifer put me on depakote, which worked fine except that, as I mentioned in Part 1, it had the effect of ratcheting up my weight. When I discontinued it, I was startled by how rapidly my weight returned to normal.

As I indicated earlier, we substituted Lamictal and gave it the dual role of antidepressant and prophylactic against mania. But in the depakote years we tried and discarded any number of antidepressants after experimenting with different dosages of each over a period of months. There were so many I can't recall them all. Looking over a list of antidepressants, however, I recognize at least four: Celexa, Lexapro, Effexor and Wellbutrin. I'd bet money there were at least one or two others. [Update: Seroquel and Neurontin, though in both cases quite briefly.]

None of them, as far as I could tell, worked worth a damn. We finally hit upon Lamictal (even when I was on depakote). Lamictal is interesting in that you start with a negligible dose and it takes over a month to gradually ramp up to therapeutic levels. That's because in rare instances it has an undesirable side effect, namely a severe, life-threatening rash that from descriptions sounds practically like spontaneous combustion.

Fortunately I had no problems with it. It seemed to mitigate, though it did not eliminate, the depressions, and gradually we came to suspect that the depressions were often triggered and / or exacerbated by environmental factors, of which (perhaps) more in a future post. This past spring, however, although I was here at the Army War College, an environment in which I have thrived, I experienced a series of depressions in which the reprieves were so fleeting it was basically a single continuous depression lasting almost three months. We responded by doubling the Lamictal (from 100 to 200 mg per day). I've been fine since then.

Part 1 - Part 2

Meds - Pt 1

These are the medications on which I rely to manage Bipolar Disorder. (The generic name for each medication is given in parentheses.) Because the disorder varies in intensity from one person to another, and because each person's biochemistry is unique, what works for me would not necessarily work for someone else.

Main line of defense: Lamictal. Has anti-manic and anti-depressant properties. Basic tool for combating the disorder.

Close support: Klonopin. Mood stabilizer. Comes in handy for mitigating serious depressions and anxiety attacks. Also has some sedative properties.

Reserve support: Ambien. Used occasionally when it seems likely I will not otherwise get enough sleep.

Discontinued: Depakote. Along with lithium, the standard prophylactic against mania. But even at low doses usually results in weight gain -- in my case as much as thirty pounds -- and given the history of heart disease in my family and the conscientious way in which I have addressed the disorder, my psychiatrist and I decided two years ago to rely exclusively on Lamictal coupled with good sleep hygiene. Has worked well: no hypomanic episodes during that period.

Part 1 - Part 2