Category: Annals of Bipolar Recovery

Today is a big day. A milestone.

To explain why, I first need to explain what a “fear ladder” is. It’s a concept in Cognitive Behavioral Therapy for the treatment of phobias and other anxiety disorders through exposure therapy. It works like this. The patient identifies their greatest fear. For someone with a phobia of spiders, for instance, it might be having a spider crawl on them. This gets a score of 10/10 and is placed at the very top of the fear ladder. They also describe something that they would be a little afraid of… but which, unlike touching a spider, they could actually handle being exposed to. Examples might be: talking about spider, making a drawing of a spider, recalling to mind a time when they saw a spider, and so on. This would be rated 1/10 and placed on the lowest rung of the fear ladder for their spider phobia. The therapist then helps them think of spider-experiences that are progressively more fearful, ever higher rungs on the ladder.

The next therapeutic step is the much harder one. The patient performs the task at the lowest levels until these don’t cause fear at all. Continuing with the example, they talk about spiders, look at drawings that resemble them, etc., till these drop off the ladder entirely. Then they continue moving up the ladder. They watch a video of a spider until it no longer provokes fear. They go to a zoo and look at spiders through the glass.

What’s happening progressively is that the person’s brain is learning that these events are not in fact dangerous; and all the while the phobia lessens.

Eventually, they come to the top of the fear ladder. They hold a non-venomous spider in their hand. They’ve conquered their fear.

Back in January, I did a fear ladder about leaving home. This was provoked by my panic attack as Anita and I tried to go to visit my father 400 km away, one so severe that we had to abandon the trip. The lowest rank on my “travel ladder” was leaving the house with Anita to take a walk. Things higher up included going shopping (3/10) and walking to work alone (4/10). Going to Toronto with Anita to stay with family was around 6/10. At the very top of my fear ladder was travelling by myself up to Esnagami Lodge, a trip I had won on New Year’s Day and really, really wanted to do. Just thinking about it made me cry in fear — even though it’s something I had done many times before and even though it’s one of my favorite places to be.

Well, I have been climbing my fear ladder all Summer. I drove to Brighton to see my dad with Anita in May, and later returned all on my own. I went fishing in Goderich several times, 100 km away from London, first with friends, then by myself. I went to the Yukon with my friend Jay and flew home by myself.

Today I write this post in the Toronto airport, waiting for my flight to Thunder Bay. When I get there, I will pick up a rental car and drive on my own to Nipigon. I’ll fish there, on Lake Superior, for two days with a guide I don’t know (!). Then I drive three more hours northeast to Nakina, Ontario, where I will spend a night by myself at a roadside motel. Finally, I fly into the Lodge on Friday morning.

It’s an amazing achievement. I feel really proud and really grateful to the family, friends and mental health clinicians who have helped me get so far.

This week’s CBT homework has three parts: Identify some ways in which I feel inadequate; describe the emotions that derive from them; and compose a compassionate letter to myself “from the perspective of an unconditionally loving friend” about the perceived inadequacies and how they make me feel.

The inadequacies I decided to focus on all arise as symptoms of my Bipolar as it has become more severe and progressively interfered with my work life. That is, ways that my mental health has recently prevented me from performing academically at my previous level. First, I cannot concentrate as well as I used to. Second, I often forget even what I’ve just read. Third, I frequently lack the energy to complete complex intellectual tasks. Fourth and finally, because of anhedonia, I lack the motivation necessary as well.

How do these limitations make me feel? Sad and fearful. This is no surprise. These are the twin emotions that are the hallmarks of depression and anxiety respectively. I feel sad that I am functioning below par academically. And, among other things, I fear that I’ll never recover. When I reflect on my poor concentration, memory, and energy/motivation, I get so anxious that I want to lie down, sleep and just blissfully forget. In addition, I also feel like I am letting down my students, my research team, and my faculty colleagues. I feel I’m letting myself down too.

Here’s my attempt at a compassionate letter to myself.

Dear Rob

I am so sorry that you have been feeling sad and fearful. I’m sorry in particular that you’ve been feeling inadequate in terms of how well you can concentrate, remember, and act. I know that’s very hard. I’ve felt inadequate too.

First, know with 100% certainty that I am here for you in your suffering. You can always share your painful thoughts with me; you can always just hold my hand; we can always go for walks and such.

I also want to tell you that, from my perspective, there are positives that you may not be noticing. Granting that these are inadequacies, they aren’t among the biggest. There are still so many things that you have been able to do even over these very trying months. Yes, these make your academic performance subpar, but you perform perfectly well in many domains. Mostly, then, you’re not letting people down. What’s more you are getting over the symptoms in question: you’ve made enormous progress on them since January. Enormous. And you continue to improve almost weekly. This includes on the academic front. Think of what you are doing professionally now that you couldn’t when the ECT treatments were ongoing. You are reading an academic textbook, actively and effectively taking part in a reading group, supervising graduate students’ written work, and drafting research and teaching plans for the upcoming academic year.  

Finally, dearest friend, even if all that weren’t true, you’re still valuable as a person. Good, valuable people may sometimes lack concentration, energy, and motivation. They forget things they’ve just read. A person’s inner value – your inner value – persists regardless. You recognize this about others; embrace it about yourself.

My fear symptoms have been really bad the last few days. I am just exhausted from feeling frightened all the time. This seemed a good occasion, then, to remind myself of the tools I have to deal with anxiety.

I have mindfulness tools:

– “dropping an anchor”, which involves acknowledging the fear-like sensations, then coming back to the body through paired muscle relaxation – tensing a muscle group, and then releasing the tension and enjoying that release – then grounding myself with my external senses

– allowing the fear-sensation to be there, not resisting it

– body-scan and other guided meditations

– visualizing happy places

I have lots of positive self-talk practices:

– that it’s not even really fear, because there is nothing I am afraid of; instead, it’s only a fear-like sensation; and that sensation itself cannot harm me

– that nothing really bad will happen if I make the wrong decision or otherwise make a mistake, that I’m still a good person

-that the fear isn’t bigger than me; I have experienced it before and have always been okay

I have related mantras:

– “I am determined. I am loved and supported. I will be okay”

– CLUM-C: “Change is constant, loss is constant, unfairness is constant, mistakes are constant, conflict is constant”

I have breathing techniques:

– rapid inhale through the nose to a count of three, then slow exhale through pursed lips counting to five

– placing my hand on my abdomen and feeling my belly expand as I breath in

I can distract myself in positive ways:

– by connecting with friends and family, in person, on the phone, on the net

– by doing physical exercise

I have safe spaces where I can go if it gets really bad:

– my bed

– lying down in the car

It’s important not to spend too much time lying down in my safe posture (on my back, with my arms crossed), but it’s also important not to feel embarrassed about sometimes needing to take refuge in order to feel safe.

My therapist Rachel S. asked me to reflect on the things that tend to bring on my fear. Sometimes it seems like nothing brings it on. It just shows up, a matter of too much cortisol building up in my brain for no reason. Sometimes I just wake up afraid and stay afraid all day. Nonetheless, there are some patterns, and it helps to recognize them.

The triggers fall into categories.

There is having to make decisions, including small decisions – e.g., choosing what to eat from the fridge or deciding what task to do next. Relatedly, making plans causes those “fear blooms” in my chest, i.e., where the fear starts above my heart and spreads outwards. Planning, you see, means there are lots of decisions to make.

Any kind of correction by another or conflict, no matter how small, can induce feelings of panic.

There is having open, free time where I don’t know how to fill it. Related to this and to decision making, fear often strikes when an activity is ending — because I need to decide what to do next and there may not be anything to distract me.

Fear attends occasions when others are relying on me.  

It comes up when I’m away from my safe place and my safe person, e.g., away from home or away from Anita.

Also, anything that reminds me of the passage of time and of aging brings up fear. Seeing an elderly person, but also seeing someone I knew as a child who has grown up. Or hearing that the year is 2022; or realizing that 1992 was thirty years ago.

I become afraid in busy crowds (e.g., at restaurants and the theatre).

Finally, I get more anxious as I recognize that I’m a little anxious. I think: “Here comes the fear. I hate the fear.”

Why do those various things make me anxious? I’m not sure. I don’t have good introspective access to the causes, even when I recognize that they are caused. I can float an introspectively plausible hypothesis, however, that covers at least many of the categories.

The hypothesis: I’ve suffered a massive loss of self-confidence in myself, together with coming to see my world as a more dangerous place. As I like to put it, I’ve come to believe that my world is getting harder while I am simultaneously getting softer. Many of my fears stem from the conviction that I won’t be able to cope as this progresses; eventually there will come a time when the world will crush me.

Making decisions causes anxiety because I don’t trust my ability to make the right decision. Every decision is a potential occasion for a mistake. And making a mistake, however small, is “evidence” that I can’t cope anymore. There’s also the meta-judgment: this is such an easy decision, why are you having trouble, what’s wrong with you?

Note too how I respond to being corrected. That fear is about mistakes too.

Having people rely on me causes anxiety because I think I’ll fail them. I may let them as well as myself down. The potential mistake becomes more important because it’s not just me who will suffer when I get it wrong.

If I am no longer competent, I need Anita all the time. And I can’t afford to venture far from familiar, secure places.

As for the passage of time, it brings to mind that my capacity to deal with the world is diminishing. My body is developing more problems. My mind is less sharp. Aging also confronts me with the unknown, and I am very afraid of the unknown now that I don’t trust in my ability to overcome adversities.

Rachel’s follow up homework is to make a list of the tools that I already have at my disposal to deal with these fears. That will be my next post.

It’s hard to recognize that I’m not at the lowest point. Every new stage of this month’s long depressive episode is a “fresh hell”. But, though it doesn’t feel like it, I have been worse. Compared with January, my sadness is much better and my suicidal urges are far less. And I’ve made progress on the agoraphobia, even though I backslide: e.g., I’m not afraid of going to work, or of running.

The major symptom that I’m struggling with nowadays is anhedonia, i.e., the inability to take pleasure in things that used to interest you. (‘An’ means loss, ‘hedon’ means pleasure.) People suffering from anhedonia lose interest in sex, food, reading, TV, social engagement, etc. They lose weight. They withdraw.

A friend asked: isn’t that just like feeling apathy? From the inside, it’s not. When experiencing anhedonia, you want to want those things. you know they are good things, that you like them. Intellectually, then, you’re not apathetic towards them. But you aren’t in fact motivated to do them either. They have no emotionally positive valence for you. Anhedonia is like when your taste buds are dulled by a cold. You know that in some sense this coffee tastes the same as the other day; yet it doesn’t, it’s bland.

Anhedonia is never easy, but it’s especially hard right now for two reasons. I have so much time on my hands. I took sick leave to do my ECT treatments and thereby cleared my schedule. This gives me extra time to fill. Damn. Second, I have very little concentration, so, even where there’s an activity that I might want to do, I may not have the mental energy to do it. I’m finding it hard to write this, for instance.

Anhedonia may be better than suicidal depression and agoraphobia, but I’m working like mad to get over it. I’ve come up with a bunch of ideas.

• There are situations which still motivate me, even though pleasure doesn’t. For instance, I still feel pulled by responsibility, and by accountability to others. If I can make doing a task a duty, that might get me to stick with it. Then, once I am fully engaged, maybe I’ll enjoy it.
• I’ve noticed that I do well with answering email. I think that’s because I like doing a task and then checking it off. So, I will try to slice up activities for myself into “chunks”. E.g., just read five pages of the novel as a task, as opposed to “read your novel”.
• I’m looking desperately for new activities; ideally, connected to my values. I’ve tried birding and found it soothing. I am checking out video games – I just bought Stardew Valley on my phone and my friend Gavin will teach me how to play tomorrow. I’m looking into audio books. (Other suggestions warmly welcomed.)
• I try to have a schedule for each day, loaded onto my calendar.

I am also hopeful that my ECT treatments, which restart tomorrow, will help with the anhedonia.

I haven’t written anything on the blog for a long time. In large part it’s because I’ve been so unwell. I’ve never been this bad for this long.

In particular, I’m becoming agoraphobic, afraid to be away from Anita and outside the house. That’s a new symptom for me and a really bad one.

Meanwhile, I have just started up with a CBT group out of Toronto Western hospital. Frankly, I fear that I won’t learn much new content, given how much I know about the general approach already, but I value the group work and the structured “home practice”.

Speaking of which, our first homework was setting mental health SMART goals. SMART stands for Specific, Measurable, Achievable, Relevant, Time-related. Or something like that: different people define SMART slightly differently.

My overall chosen goal was to combat the encroaching phobia. But that’s too broad to be SMART. So, with my therapist Rachel’s help, I have narrowed it down to something that can be checked off each day, which is realistic, and contributes to keeping agoraphobia at bay. My SMART goal is… to have one destination each day, ideally without Anita.

So far, I am doing well. I took a family of Sudanese refugees out shopping at Costco on Saturday and then to an Asian supermarket on Sunday. I also went birding with a friend, a one-time supervisee, on Sunday morning. Today I walked to the grocery story and drove to Hannah W’s office. (Long-time readers of the blog will know that she is my mental health Occupational Therapist.) I also ran 10.5 k yesterday by myself. That felt really good.

Tomorrow, I am going to campus to teach in person for the first time in two years. That’s a big “destination”, even though it used to be nearly my second home. Anita will take me there because I’m really anxious about this step, but it still counts.