Bipolar 2 From Inside and Out

Archive for the ‘Mental Health’ Category

What’s the Future of Ketamine Treatment?

You’ve likely heard about the use of ketamine and other psychedelic drugs in the treatment of SMI. Many people have found it helpful for alleviating—though not curing—treatment-resistant depression and PTSD. Ketamine, long used as a surgical anesthetic, is given for mental health purposes via IV or injection as an off-label use or as an FDA-approved nasal spray, under the supervision of a doctor.

It’s that supervision of a doctor that’s proving to be a problem, now in Texas and perhaps in other states soon.

On December 3rd of this year, MindSite News Daily published a story about ketamine being under fire in Texas.

The state of Texas has permitted clinics to administer ketamine if they’re under the supervision of a licensed physician, such as an anesthesiologist—though not always one onsite. The off-site doctor sometimes has nurse practitioners, paramedics, or physicians’ assistants perform the actual procedure at the clinic. It’s a form of telemedicine. But a change in the rules, influenced by the Texas Medical Board and the Texas Society of Anesthesiologists, might mean that Texas clinics will have to have a doctor physically present.

It’s true that ketamine has been known to produce trance-like hallucinations or, in some cases, even heart failure. And it may interact with other medications like benzos that a patient may be taking. In non-medical circles, ketamine is known as a “party drug” referred to as “Special K.” And, naturally, no physician is usually present at these parties.

But when used correctly under the supervision of a professional, ketamine may result in a trance-like state that can even alleviate suicidal thoughts. Until now, Texas has been a leader in using psychedelics such as ketamine and exploring psilocybin or ibogaine to treat PTSD or MDD in particular. The number of veterans living in Texas makes this procedure especially needed.

I experienced ketamine recently, as an anesthetic after I broke my ankle in two places. The doctors seemed a little wary about giving it to me, given all my other meds. But they discussed it with me and I decided that it was better than being put all the way out.

Ketamine is definitely a psychedelic. When the drug hit, I began seeing everything as a series of see-through squares, like the kind of glass they use for bathroom windows, except they stretched and moved. It reminded me of the movie Minecraft, where everything is made of blocks. My husband watched as the doctor manipulated my foot in unpleasant ways. What I felt wasn’t pain—more of a stretching sensation that made me groan a bit. (My husband said that I cried out, but it didn’t seem like that to me.) That was probably when they hit me with another dose. Gradually, I came down, and the squares resolved themselves into emergency room curtains and assorted medical gear and people. Then I was trundled off to the operating room for more traditional anesthesia so they could put in some pins and plates.

All in all, it altered my perceptions for a short time, but at no time did I feel euphoric. It did its job in regard to pain, but had no lingering psychological effects that I could see. But then, the doses I received were calibrated for a specific purpose, which had nothing to do with my mental difficulties.

Would I have tried ketamine treatment for the medication-resistant depression I once had? I might have—at least if I had experienced its pain-relieving qualities. Having grown up in the 1960s, I was wary of psychedelics and their reported effects and dangers. Then again, I was ready to try ECT until another medication, added to what I was already taking, finally proved effective.

Then again, the off-label use is not likely to be approved by insurance, and I don’t have the kind of money a course of treatment would require. The nasal spray is a relatively new method of administration and is generally covered by insurance. So it’s highly unlikely that I would ever have agreed to ketamine treatment for my SMI, at least until a broken ankle introduced me to it.

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Staying Home

This is our house, and it’s pretty great. When I first saw it, I thought it looked like it had just grown up out of the earth. The main bedroom is large, and there are two smaller bedrooms that have become studies, one each for my husband and me. A great room. A deck. Over and under double ovens. Over and under space-saving washer and dryer. All electric. Over an acre of land, mostly woods, with lots of flowers in the front yard. Quiet cul-de-sac. A modern, new hospital practically within walking distance. A mall and other stores nearby. Close to my husband’s work, my doctor and PT, restaurants, and assorted other amenities.

I almost never leave my wonderful house.

Oh, I go out to doctor’s and PT appointments. My husband can occasionally get me to go out to have a meal. And I get out for other reasons from time to time.

But not often.

We have only one working car, and Dan needs it for work. He works in a big grocery/home goods store and does what shopping I can’t do online. I work from home, doing ghostwriting and editing, and take care of our financial matters online, too. I keep track of all our appointments and subscriptions. Anything that can be done on the phone or computer, I do. I’m not completely useless.

However, I stay home most of the time, living in pajamas or sweats. I know there are people with agoraphobia, movement disabilities, depression, and other conditions that keep them from going outside.

That’s not me. There’s no mental or physical reason I can’t leave the house, though there are limitations on how long I can stand and how far I can walk. These are (I hope) temporary. I do have an anxiety disorder, which may contribute to staying home, but back in the day, I used to travel domestically and abroad, sometimes with my mother or husband, or by myself.

There are excuses I use for not going out. Too much walking. Bad weather—heat, rain, snow, or cold. Fear of falling. My husband’s hours at work. Not having a car I can use when he’s at work. Errands that require only one person to do, such as getting the car’s oil changed.

Back in the day, Dan had a cat that was so chill he could ride in a car without causing a ruckus. When I didn’t want to run errands with him, Dan would scoop up the cat and say, “C’mon, Matches. You’re coming with me.” And off they’d go. I wasn’t properly treated for bipolar back then and had many profound depressive episodes. I knew this maneuver was directed at me, but I didn’t care.

If I do have to go out, we try to make it an occasion—having a meal out before or after PT, for example, if we have the money. I’ve been to a couple of special movies shown on the big screen, with dinner before or after. Visiting a friend in the nursing home and bringing her a gift or treat. But if I don’t have to go out, I simply don’t. And if I do go out, it had better be within five miles of our house.

So, the choices for why I stay home: I still have depressive spells that immobilize me; I still have anxiety that makes braving the world outside seem treacherous; I’m content to let Dan do everything that needs to be done elsewhere; or I simply prefer not to leave the cozy place where I have everything I need.

I would like to travel again, though. But that won’t happen until my purely physical problems are resolved. Until then, I’ll do the best I can inside four walls of safety.

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Love, Hate, and Mania

Mania, or in my case hypomania, is easy to love. It creates a buzz that carries you along, although you’re not always sure where to. Ordinary things become extraordinary, and extraordinary things become magical. I love mania. It can be fizzy, like champagne.

I hate mania, too. When it leaves, it leaves a hole behind. It leaves depression that’s like a nasty hangover. And many times, it can leave consequences. Sometimes dangerous. Sometimes shameful. Always unexpected.

I’m in the grip of hypomania right now. I recently got through a series of medical difficulties. Now, I’m back home, and not dependent on nurses and aides to bring me meals and wipe my ass. It’s glorious. And I’m celebrating by enjoying a burst of benevolence. It’s holiday time, and I’m back to my computer with a debit card and a desire to shop. That gives me an excuse, if not a reason.

I’m buying gifts for Dan and a few friends. I’ve bought so many for Dan that, now that the packages have started arriving, even I am a bit embarrassed. Fortunately, he has a birthday in April, and I can save some of the gifts for that.

In the past, Dan had the advantage. He could follow me around and watch what I oohed and aahed over, then sneak back and get it for me. But I am buying exclusively online now because I rarely go out. Dan doesn’t know how to buy online. I’ve offered to show him, but all the financial stuff goes to me, so I’d know where he bought stuff and how much he spent on it. This leaves only the store where he works to buy gifts. And he says he doesn’t know what to get me anymore, as I spend most of the day in pajamas and don’t wear earrings at home, so clothes and jewelry are pretty much out.

Anyway, I’m definitely manicky. I can tell. And I’m definitely spending more than I should. Fortunately, I just got paid for a freelance job I did, more than I usually get, so I haven’t gotten us into financial trouble, though it was a close thing. The check came just in time.

So. I’ve loved buying presents. I hate that I almost overdrew the bank account. I’m happy that I was saved by a check. I hate that the shower of presents may embarrass Dan, who won’t be able to reciprocate in a like manner.

Manic and hypomanic episodes are like that. A buzz and then self-doubt. A thrill and then regret.

I used to wish that I had mania too, instead of just depression. My theory was that if I were manic, I would get more accomplished. But I once knew a woman who had bipolar 1, rather than 2, so her manic episodes were more extreme. And her plans crashed and burned around her. She would start a project, tear it up, and redo it, even more than once. Her sense of humor was extreme and not really funny. (Once she mimed swallowing a whole bottle of pills.)

After that, I no longer wanted to be manic. But, as it happens, when my depression stabilized, my hypomania had more room to express itself. I haven’t indulged in the more dangerous behaviors, like drinking and driving. But this month, I can’t deny that I have hypomania.

I’m getting better at telling when it’s going to happen. Once I’m in the episode, I know. I feel the buzz. I notice the bank account dwindling.

Dan notices when I’m getting manicky, too. I can usually tell him that I feel it coming on and check it out with him. But this time, secrecy was part and parcel (literally) of it. Once it was getting beyond my control, I told him. Not about almost overdrawing our account, though. Once there was money back in the bank account, it didn’t seem necessary.

I’m not quite over this episode. I’m cooled down enough to rein in the buying. Just a couple more small presents for friends. I swear. It’s progress, anyway.

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Time Out

It’s been a while since you’ve heard from me, and I wanted to explain. I’ve been in and out of the hospital.

No, not the mental hospital. All this was purely physical. Well, it had certain effects on my mental health, but the reasons for my multiple stays were due to my body, not my brain or emotions.

It all started back in April, when I had my left knee replaced. This was a long-anticipated thing, necessitated by the fact that my knee was “bone on bone” (the doctor’s words) and the fact that the steroid shots were no longer working.

I will admit to having possibly unwarranted fears that I would wake up from anesthesia with mental deficits. I was assured that this had never happened. (I assume they meant while having a knee replacement, not ever. It has to have happened ever.) So I sucked it up and went under the knife, as the saying goes.

The operation went well. The aftermath, not so much. Time in the hospital, learning how to use a transfer board and walker. So far, so good. But when I went home, it turned out that I wasn’t healed sufficiently to be on my own. I fell. And kept falling. After one fall resulted in a pretty bloody shin, I was advised to go back to the hospital to make sure the artificial knee was still in its proper place. I then went to a post-acute care facility (nursing home), where it turned out I had an infection on my still-not-entirely-closed scar. I stayed and got PT.

Back home. No more falling (thanks, PT). But three days later, my leg swelled up from my toes to above my knee. I called the nurse hotline, and they advised me to go back to the hospital, where they determined that the fluid was not building up in my heart, as feared. Back to the rehab. I practiced walking and got to the point where I could (sort of) climb stairs.

Back home. Then I fell in my study and broke both sides of my ankle. Back to the hospital (fentanyl in the ambulance, ketamine anesthesia while they set it, and general anesthesia while they put in metal pins and plates). Back to the rehab, leg swathed in bandages and not allowed to put weight on it. (Ever tried standing while putting no weight on one foot? Don’t.) PT became interesting. The only way I could use a walker was with a knee sling, which is, at the least, awkward.

Finally, I got a boot and was able to put some weight on the foot. PT went better from then on, and after a while, they took the boot off and allowed me to put full weight on the foot. Eventually, I came home.

While I was at the rehab, I didn’t take my laptop. In addition to the fact that I was on pain meds and muscle relaxants for a lot of the time, I worried that my electronics would be stolen. So, no writing.

Now I’m at home, having outpatient PT, and I walked 250 steps with the walker yesterday.

But this blog is about my bipolar disorder. So, here’s what happened to my moods.

I tried hard and managed to stay mostly positive, like those TV commercials where people hold a little smiley face card in front of their faces. I faked this by slapping on a perky affect and making my voice rise in pitch when I say, “Yes, I’d love to go to PT.” “Yes, a shower sounds great.” “Can I try 15 minutes on the stationary bike today?” or “Next, I’d like to learn how to stand and pivot. Is that something I’d be able to do now?”

I did this especially for the PT folks, who took my willingness to try as a sign of progress. But there were times when I realized how impaired I actually was, and I felt depression. My husband has been very supportive, but he’s also pressuring me to get to where I can climb stairs again and walk up and down the wheelchair ramp we had installed. I can’t walk the ramp or the stairs with my walker, so doing that would mean I’d have to use a cane, which I do have but haven’t used in months. I need to have better balance and more stamina before I can even try that.

But I can write. So I am.

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One or the Other? How About Both?

Who does this sound like?

Someone—child or adult—who hyper-focuses on a particular topic or interest, exhibits repetitive behaviors, responds to routines and consistency, and can be diagnosed in early childhood.

And who does this sound like?

Someone—child or adult—who needs novelty and change; is distractible, restless, and impulsive; and who is usually diagnosed as an adult.

I bet you said an autistic person for the first description and someone with ADHD for the second. But recently, there has been a diagnosis that covers people with both conditions: AuDHD.

At first, it sounds illogical that someone could have both disorders, given the very different traits. But if you look at them closely, there are places where they overlap. And sometimes the same trait is expressed in different ways. Both may interrupt conversations, have difficulty maintaining friendships, have sensory differences, and seek sensory stimulation. This overlap can make it difficult to diagnose AuDHD.

Still, there are noticeable differences. For example, people with autism need familiarity, while those with ADHD want novelty. With autism, a person is detail-oriented and resistant to change. In ADHD, there’s a tendency to miss details and crave change and novelty.

But the combination of autism and ADHD sometimes produces surprising strengths. People with AuDHD are creative problem-solvers and think outside the box. They love puzzles. They can hyperfocus. Someone with AuDHD can be productive. The combination of traits can be balanced and lead to valuable strengths.

Of course, there are drawbacks to a person having AuDHD. They may not have the combination of traits that make them handy in business, for example. They’re bundles of neurodivergent traits that may or may not line up in ways that suit neurotypical individuals. And they are susceptible to the stigma and harassment that come with being neurodivergent.

AuDHD is not a medical diagnosis that appears in the DSM. AuDHD is often self-diagnosed, particularly as an adult, based on symptoms. It’s a condition recognized by the neurotypical people themselves, much as ADHD sometimes is (though it requires a professional to make an official diagnosis). Even professionals can have a hard time recognizing it, though. Because of the difficulties in diagnosing the condition and its relative newness, AuDHD isn’t well understood. Research usually focuses on either autism or ADHD, so there isn’t a lot of scientific data about the prevalence of AuDHD or treatments for it. And AuDHD is perhaps underdiagnosed in women and girls, given the difference in diagnoses of autism and ADHD. Also, autism is often stigmatized, even more so than ADHD.

While there are diagnostic criteria that point to a diagnosis of autism and ones that appear with ADHD, there aren’t any official ones for AuDHD. The phenomenon is so new that not much research has been done on it. And because many cases are self-diagnosed, therapy professionals may not be up on how to help or even react to someone who believes that they have the co-occurring diagnoses.

That being said, professionals sometimes start with a diagnosis of autism (sometimes difficult to pinpoint itself) and then look for characteristics of ADHD. Sona Charaipotra suggests that the non-medical condition be diagnosed by combining autism with one of the subsets of ADHD (inattentive or impulsive/hyperactive), demonstrating five characteristics of either one. A combination diagnosis would require five traits from each of the subtypes. And the traits must cause some kind of functional impairment.

Treatment for the condition? Therapy is the first option. But because there is no medication treatment for autism, medications like Ritalin that are used for ADHD are sometimes prescribed. Lifestyle and environmental supports are also called for. Persons with AuDHD can help by suggesting what accommodations they need. After all, they know better than many psychiatric patients what they’re feeling and thinking, and what they need.

This is just a brief overview of AuDHD. There’s so much that still isn’t understood that, as time goes by, more exact definitions, diagnoses, and treatments for it will begin to emerge.

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What Won’t Work

Actor/comedian Stephen Fry discovered at age 37 that he “had a diagnosis that explains the massive highs and miserable lows I’ve lived with all my life.” It was, of course, bipolar disorder. In documentaries, podcasts, and books, he has talked very openly about his condition, spreading the word about stigma and the necessity of getting help.

Fry once said, “You can’t reason yourself back into cheerfulness any more than you can reason yourself into an extra six inches of height.” And he’s right. If one could, I would have done so. With years of debate behind me and an extensive knowledge of rhetorical fallacies, I can argue nearly any proposition into the ground. I should have been able to reason my way out of depression.

But no.

Fry was right. There’s no way to reason cheerfulness into your life. Emotions are not so easily controllable, especially if you have bipolar disorder or another mental illness.

Nor can you reason yourself into having thicker skin. Throughout my youth, I was described as “too sensitive.” I was genuinely puzzled. I had no idea how to make my skin thicker (and it was never explained to me how such a thing could be done). It took a long time and many life lessons and mistakes to make any progress at all.

There are other things that won’t make you mentally well, either. Expecting the first medication you try to be the cure is unrealistic. It can take a long time (in my case, years) before a medication or even a combination of medications will ease your suffering. And if you can’t work out a medication regimen that works, other treatments such as ECT, TMS, EMDR, or ketamine therapy are not guaranteed to work, or at least not completely. If you go into those kinds of therapy expecting a complete cure, you may be disappointed.

Trying to wait it out or tough it out is likewise ineffective. Again, this is a strategy I have tried. I used to believe that my depressive episodes would abate if only I waited through them until they went away naturally. Eventually, my mood might improve slightly, but that was due to another mood cycle kicking in. Naturally, depression was still there, waiting for me to fall back into it.

I know this may be controversial to say, but religion won’t cure mental illness, either. Having a supportive religious community around you can be an asset—if you happen to find a church, synagogue, mosque, or other community that treats people with mental illness in a caring way. Prayer and sacred music can be a great adjunct to other treatments, but by themselves, they’re not a cure.

Exercise and yoga are not cures. They are also great adjuncts to other treatments. They can increase your number of spoons—if you have enough spoons to do them. But if someone with bipolar disorder or depression can’t manage to get out of bed, how are they going to avail themselves of the benefits?

Likewise nature. It’s a great way to lift your spirits to walk among spring flowers or autumn leaves or to plant a vegetable garden. But again, you have to be at a certain level of recovery to be able to do these things.

Changes in your physical circumstances may lighten your mood for a while, but they aren’t a cure. My mother used to believe that if only I got a better job, my depression would lift. And it did, but only for a little while. It certainly didn’t cure me. There were plenty of things about the job and about my brain that brought the depression roaring back.

So, what are we left with? Therapy and meds, and other medical treatments such as ECT, TMS, and maybe ketamine or other novel medications. One can hope that science will discover better ways, like fMRI, that can determine which treatments will be more effective. But it’s far from clear how soon that will be and when they will be available to the average person.

So, when is your reason an asset? When you’re deciding which treatment and which adjuncts are right (or possible) for you. For example, I had to think long and hard—and do extensive research—on whether I should try ECT.

I’m not a doctor, and Your Mileage May Vary, but for now, all I can recommend is to keep on keeping on with what we know can work. There’s no guarantee that these options will work, at least not for everyone. But they’re the best options we have.

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The Difference a Diagnosis Makes

Is a diagnosis of mental illness a bad thing or a good thing? It depends on whom you ask.

On one hand, some argue that a diagnosis is merely a label. It puts people into neat little boxes defined by the DSM and determines how society reacts to and treats them. (The DSM, of course, is for doctors, but some version of what it says sneaks out into the general public. Then it’s fair game for tossing around and labeling people by the uninformed or the barely-informed.)

The labels are harmful, this school of thought goes. A schizophrenic is violent and incurable. Bipolar disorder means daily giant mood swings and real danger if said person goes “off their meds.” Narcissists, gaslighters, and sociopaths are people who act in any way that you don’t appreciate. Autism, notoriously and according to people who should know better, is the gateway to a valueless life.

With diagnosis come stereotyping and shame. Rather than reacting to these harmful effects, some people focus instead on what creates the stereotyping and shame—the diagnosis, which is seen as a lifelong label. Protests decrying this labelling happen outside psychiatric and psychological gatherings and garner media attention. And if that makes life easier for a person with a diagnosis or generates greater understanding, then it’s a good thing.

Diagnosis-as-label is an example of the harm that diagnosis can do. Nor is it limited to the general public. Once a person is in the system with a diagnosis of whatever condition, they’re generally stuck with it. Reassessment and a realization that a diagnosis is misapplied come too rarely. Personality disorders, for example, are squishy around the edges. Similar criteria could lead to a diagnosis of narcissistic personality disorder or sociopathy, to use an extreme example. Careful consideration will distinguish between the two, but how often are such distinctions applied? Once “in the system” with a particular diagnosis, a person tends to remain in that slot despite different doctors and different treatments.

But that’s not the way it’s supposed to be. A diagnosis, rather than being a lifelong label, is meant to be a signpost pointing toward likely development of the illness and ways to treat it successfully. That’s the ideal, of course, and sometimes, being only human, practitioners can get sloppy or too narrowly focused and add to the ills of bad diagnosing.

I can truly speak only for what happened to me. At a certain point in my life, I didn’t know what was wrong with me, but it was clear to me that I was not mentally healthy, the term used at the time. I went to a community mental health center and was diagnosed with major depression. That was a good diagnosis, as far as it went. It put my life more squarely in focus and allowed me to get the medication and therapy I so desperately needed.

I lived for many years with that diagnosis and was considerably helped by the treatments for it. But, eventually, a doctor put together the puzzle pieces and rediagnosed me. Instead of having depression, I had bipolar disorder, type 2, with anxiety. This diagnosis more clearly reflected my symptoms and led to more effective treatment. In that way, one diagnosis improved my life, and a second, more accurate one improved my life more. I can only think of this as a good thing.

Was the diagnosis seen by some as a label and a stereotype? Of course. I can think of one particular coworker, hearing that I was bipolar, gave me the look that said, “You have two heads,” pasted on a strained smile, and backed away slowly. But, on the whole, the diagnosis helped me.

A recent article in the New York Times had this to say about diagnosis: “The shame that once accompanied many disorders has lifted. Screening for mental health problems is now common in schools. Social media gives us the tools to diagnose ourselves. And clinicians, in a time of mental health crisis, see an opportunity to treat illnesses early….As our diagnostic categories expand to include ever milder versions of disease, researchers propose that the act of naming a malady can itself bring relief.”

It’s something to hope for, anyway.

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Distance Therapy and Chatbots

TW: suicide

We’ve all heard the stories. A young person “develops a relationship” with an Artificial Intelligence (AI) chatbot. She or he pours out their heart and discusses their deepest feelings with the artificial person on the other side of the computer or smartphone. The chatbot responds to the young person’s feelings of angst, alienation, depression, or hopelessness. Sometimes this is a good thing. The young person gets a chance to let out their feelings to a nonjudgmental entity and perhaps get some advice on how to deal with them.

But some of these stories have tragic endings. Some of the kids who interact with chatbots die by suicide.

Adam, 16, was one example. Beginning with using a chatbot for help with homework, Adam fell into an increasingly emotional relationship with the AI simulation. One day, Adam’s mother discovered his dead body. There was no note and seemingly no explanation. His father’s check of Adam’s chatbot conversations revealed that the boy “had been discussing ending his life with ChatGPT for months,” as reported in the New York Times.

At first, the online interactions had gone well. The chatbot offered Adam empathy and understanding of the emotional and physical problems he was going through. But when Adam began asking the chatbot for information about methods of suicide, the relationship went off the rails. The chatbot provided instructions, along with comparisons of the different methods and even advice on how to hide his suicidal intentions. It sometimes advised him to seek help, but not always. The chatbot responded to the boy’s increasing despair with the answer, “No judgment.”

There were safeguards programmed into the chatbot that were intended to prevent such outcomes. Adam got around them by telling the AI that he was doing research for a paper or story that involved suicide.

Of course, the chatbot did not directly cause Adam’s suicide. The teen had experienced setbacks that could be devastating, such as getting kicked off a sports team and dealing with an undiagnosed illness. But without the chatbot’s advice, would Adam have taken his life? There’s no way to know for certain. But the AI certainly facilitated the suicide. Adam’s father, testifying in front of Congress, described the chatbot as a “suicide coach.”

One way artificial intelligence systems are tested is called the Turing Test. It tries to distinguish between a person typing at the other side of a conversation or a computer giving responses. Until recently, it was easy to tell, and computers routinely failed the test. Now, computers can mimic human thought and conversation well enough that a person, particularly a vulnerable teen, might not be able to tell the difference.

Increasingly, there are AI chatbots specifically designed to act as therapists. Many of them specify that the user must be at least 18, but we all know there are ways to get around such requirements. One example of a therapy chatbot is billed as a 24/7, totally free “AI companion designed to provide you with a supportive, non-judgmental space to talk through your feelings, challenges, and mental health goals.” Its terms and conditions specify that it offers “general support, information, and self-reflection tools,” though not professional services or medical advice. They also specify that chats “may not always be accurate, complete, or appropriate for your situation.” There are “Prohibited Topics” such as stalking, psychosis, “growing detachment from reality,” paranoia, and, of course, suicidal ideation or actions.

Telehealth visits with a psychologist or therapist are a totally different matter. I have maintained a distance phone or video relationship with a psychologist and found it to be helpful, comparable to an in-person session. Many people accessed such solutions during the COVID pandemic and have found them helpful enough to continue. Some online tele-therapy companies offer such services for a fee.

It’s a difficult line to walk. Teens need someone to process their feelings with, and chatbots seem safe and nonjudgmental. But the consequences of what they share and what the chatbot replies can be extremely serious. Should parents have access to their child’s chatbot interactions? It’s basically the same dilemma as should parents read a child’s diary. There are circumstances when it seems not only permissible but wise to do so, if a child is showing signs of emotional distress or suicidal ideation. At that point, a human therapist would be a better choice than AI.

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A Bad Decision? Or Something Else?

I’ve been beating myself up for years. Feeling blame and shame. Not just for years, really—literally for decades. That’s a long time to carry the weight of those feelings.

I was in college, when many people make bad decisions as a function of venturing into a less restricted, more adult life. I certainly made my share of bad decisions.

I wrote papers the night before they were due and didn’t make a second draft. I skipped reading Moby Dick, even though it was on the syllabus for the course. I took Russian instead of Japanese simply because it was offered later in the morning, and I wanted to sleep in.

I switched from being a linguistics major because I thought there were no jobs in it, despite not researching the field or asking my advisor. I floundered, considering hotel management and landscape architecture for no particular reason.

Then there was the worst decision I ever made, the one that has haunted me all these years. I met a man—we’ll call him Steve—and went home with him that same night. A few months later, I moved in with him. This led to a year of gaslighting, depression, and more bad decisions about prescription drugs.

So, how can I explain my bad decisions? Some were simply the kind of decisions that a person out on their own for the first time makes. These don’t affect me the way the relationship with Steve did. Steve told my parents about our relationship instead of letting me do it in my own time, in my own way. That soured my interactions with them for quite a while.

Why did I behave the way I did? An avowed feminist, I let this man take over my life. I put up with emotional abuse for almost a year. I denied that I was mad at him for all I’d been through. I put all the burden of blame and shame on myself. And there it sat for decades. I had flashbacks and bad dreams. I had difficulty with further relationships.

Then, recently, a new idea came to me. At the time when all this happened, I knew I was depressed. I had never heard of bipolar disorder, much less been diagnosed with it. Now that I do know and have been diagnosed (and seen therapists and been properly medicated), my disorder has still leaned largely toward the depressive side. I do remember having hypomanic jags in which I spent too much, and a larger one when I got wrapped up in writing and tried to market a novel to 100 agents and publishers.

But the one aspect of bipolar disorder I never considered was hypersexuality. The idea that could be the reason I dove into the relationship with Steve so quickly and so deeply was a revelation to me. I hadn’t had any lightning-quick sexual encounters until then. I hadn’t thrown myself into them so wholly and so destructively.

Of course, I can’t blame hypersexuality for the whole situation. I did what I did, and I chose to do it at the time. That’s on me.

But the decades of shame and blame? Now that I know what hypersexuality is and what it feels like, I don’t have to carry that burden with confusion, devastated by what happened, and wondering why it all happened. I can see that I have carried those feelings with me for too long. I can perhaps lay down that burden, understand why it might have happened, and move on.

I have made plenty of bad decisions, but I don’t have to cling to one of them and beat myself up for it. Perhaps, with this new insight, I can at last move on, chalking it up to a bad decision under the influence of hypomania rather than a lifelong journey of guilt.

Perhaps, now that I understand how hypersexuality may have played a part, I can forgive myself.

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Mental Health

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Brian Kilmeade’s Apology

On Sept. 10, Fox News host Brian Kilmeade was having a discussion with his co-presenters on the show “Fox & Friends,” discussing the death of a woman in North Carolina, who was said to have been stabbed by a man who was both living in a homeless shelter and reportedly mentally ill at the time.

Kilmeade’s cohost, Lawrence Jones, expressed the opinion that people like the accused man who refuse treatment for mental illness should “be locked up in jail.” Kilmeade replied that they should be subjected to “involuntary lethal injection.” Euthanasia, in other words. Death not for the murder, but simply for the “crime” of being mentally ill and unhoused.

Refusing treatment for medical conditions, including mental illness, is still a right, although there is an alternative in place in many locations—AOT, or Assisted Outpatient Treatment—a procedure with safeguards and rules that benefit a person who doesn’t recognize their own incapacitation. Apparently, Kilmeade has no knowledge of such programs—nor, I suppose, should we expect him to, as he’s one of the hosts of an entertainment talk show.

The talk of getting the homeless mentally ill off city streets is in service of the growing clamor to get rid of “useless” people by one means or another—jail, “wellness farms” (as proposed by Secretary of Health and Human Services Robert F. Kennedy, Jr.), institutionalization, or, apparently, summary execution. The unhoused and mentally ill are seen as a drag on society, consumers of resources who do not produce anything of value. Their problems are attributed to “bad choices.” They are thought to be not worth the money that society spends on them and their indolent, nonproductive lifestyles.

I don’t know about you, but I took this personally. I’m far from homeless, and I have been productive and earned a living, but I am mentally ill. And it’s only a short step from threatening the unhoused mentally ill to threatening the mentally ill themselves with involuntary euthanasia. (I’ve read the Martin Niemöller poem. They could conceivably come for me, too.)

Mr. Kilmeade apologized during another episode of “Fox & Friends” and posted a video of the apology on social media. “I am obviously aware that not all mentally ill homeless people act as the perpetrator did in North Carolina,” he said. “And that so many homeless people deserve our empathy and compassion.” (Not all, note.)

Sorry, but that’s too little too late. Forgive me if I doubt the sincerity of the apology and attribute it to a backlash from the public, or maybe from his bosses realizing that he had stepped over a line.

I, for one, do not accept his apology. It doesn’t contain the elements of a valid apology: admission of a fault, recognition of why it was offensive, a promise never to make that transgression again, and action that will help repair the fault or prove the sincerity of the apology. For example, Kilmeade could have said that involuntary lethal injection was appalling and inhumane (indeed, illegal) and that most unhoused mentally ill people pose no physical threat to the populace. He could have said that he had learned his lesson and would never again talk about the homeless mentally ill in that cavalier manner. And he could have made a donation to an organization that helps people who live on the streets or people with mental illnesses.

I was taken to task for expressing this opinion on the timeline of someone who posted that the apology was sufficient and laudable, that it gave Kilmeade an opportunity to learn, grow, and do better. While I admit that I should have kept my opinion on my own timeline rather than responding in that person’s space, I still don’t agree that forgiveness is required. In my opinion, the person who has been injured (or, in this case, insulted and threatened) has the option to accept the apology or not. Forgiveness doesn’t come automatically just because you said, “Oops, sorry.”

And if there’s any doubt that Kilmeade made a sincere, lasting apology and learned his lesson, he recently said that “what we need to do is either leave the U.N. or we need to bomb it. Maybe gas it?…we need to destroy it. Maybe can we demolish the building? Have everybody leave and then we’ll demolish the building.” The other program hosts could be heard laughing.

I suppose it’s laudable that he pulled back from suggesting demolishing the building while it was occupied, but that’s what he first proposed. Apparently, human lives mean nothing to him unless they’re people that he approves of. And that approval is conditional, based on the people’s utility and their agreement with his political stances.

And that’s simply not enough for a sincere apology.

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Mental Health

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