My therapist held this power over me and yet could affirm that the experience I was having was not diseased or pathological, and was in fact positive, was remarkable and deeply validating and healing for me.

David Mordecai’s #MadCovidDiaries diary – 27.05.2020

One of memories that clearly marks how my life changed thanks to mental illness was being admitted to the overnight unit at the health centre of my university and having the staff person there write a giant ‘psi’ on her pad, which she then showed to the friend who had brought me in, a psychology senior.

So this has been quite the week.

Right after I submitted my last #MadCOVIDDiaries entry, my therapist called. We’ve been doing phone therapy for the last while but in Toronto, where I live, there has been an easing of lockdown restrictions. My psychotherapist was calling to tell me that my appointment the following morning would be in person.

I was livid. One of the many things I’ve worked with my therapist on over the years is my anger. I get angry very, very rarely, but when I do, historically, my temper has been spectacular. Not physically violent (though I guess shouting is as close to violence as you can get without actually touching someone), but explosive, all the more so because it seems to come out of the blue. I can count on one hand the situations in which I have lost my temper over the last ten years. However, in part because even glimmers of anger are something I feel so rarely, the middle ground – experiencing and expressing anger constructively – has in the past been hard for me.

In this case I was successful. I didn’t lose it, despite being furious. I simply said I would get back to him. He doesn’t have a receptionist so I knew it was likely that when I called back I could just leave a message. I later did this, telling him both that I was very angry and that there was no way I was coming in for face-to-face therapy any time soon.

There’s a lot we don’t know about SARS-CoV-2, but sitting in an enclosed space speaking with someone (even at a six-foot distance) who spends their entire week doing the same thing with multiple other people is not a level of risk I am comfortable with while Canada continues to report hundreds of new cases every day. Part of me admires my therapist’s willingness to be there in person for those who need to see him in that way, but I am not one of those people.

Phone therapy has been a mixed bag. The first thing I noticed was that my doc (and my therapist is a medical doctor) was talking a lot more than usual. And unfortunately some of what he said during our first phone session was uncharacteristically revealing and disconcerting. He compared COVID-19 to the flu. He made mention of some of the conspiracy theories people have circulated regarding its origins. I didn’t understand why this was happening. And coming from someone trained and still registered as a doctor it was especially strange.

Overall, my therapist raising those topics and the fact that he was willing to keep his face-to-face practice going throughout lockdown left me with the conclusion that our assessments of the risks of COVID were very different. Negotiating that risk as I have had to return to work has really been the only source of major stress in my life, so not being able to discuss it with my primary source of psychological support kinda sucked.

During #MadCOVIDChat on Twitter, some expressed surprise that I’ve been seeing my therapist for over fifteen years. I’ve actually been in some kind of counselling for almost all of the time – more than three decades – since my first manic/psychotic experience. After the experience that led to my diagnosis, my university would only allow me to return on the condition that I continued to see someone for talk therapy. This established a norm which I have maintained for almost all of my adult life. It’s taken effort, but I’ve also been fortunate to be able to access therapy either through publicly funded healthcare or at a price I could afford.

Therapy has helped me immensely and contrary to mainstream psychiatric dogma I believe it’s led to a reduction in symptoms and certainly to a huge increase in my ability to cope with them. My mood shifts now feel like something I experience with both detachment and considerable awareness, instead of as a tempestuous storm or gateway to psychosis. Current vogue is that therapy should be time-limited. While I question his attitudes towards madness and people living with serious psychiatric diagnosis (some might validly say that the experience of any psychiatric diagnosis is serious), I admire Dr. Jonathan Shelder’s vocal campaign against this belief, and we have specifically, if succinctly, discussed the special role a therapeutic relationship can play when living with serious mental illness.

Thankfully, in Canada, there is still a degree of freedom with respect to the kinds of mental-health support people can access through the public healthcare system. Many people get assessed for mental-health challenges by a doctor (not even, necessarily, by a psychiatrist) and are put on medication and never go into any kind of talk therapy. However, if you are determined you can find other support. Some psychiatrists will do ongoing talk therapy, though in my experience they are not as good at it as other practitioners I have seen. My two favorite therapists have been social workers. They are, unfortunately, not as easy to access in Canada without paying.

It took me two years of waiting to get in to see my current doctor, but he is fully covered by the provincial healthcare system. He is not a psychiatrist but a family doctor who, decades ago, chose to further specialize and train in psychotherapy. It is all he does. He is a cautious prescriber, but can and will prescribe with a clear diagnosis and/or recommendations from a psychiatrist. So he has been both my source of therapeutic support and my prescriber for years.

Other friends with a bipolar diagnosis and a longstanding therapeutic relationship with a doctor have agreed with my perspective that simply showing up regularly in a non-judgemental, affirming relationship with the same person, in the same office, has a significant positive impact on mood. I also believe that while biological psychiatry sees diagnoses as rigid things, therapy has changed me in ways that have truly shifted the actual manifestation of bipolarity. This is controversial, in part because some people can twist it into an imperative regarding personal responsibility for mental illness. Without delving deeply, I will say that I think through therapy I’ve achieved personal changes that have positively and perhaps permanently improved my experience of a serious psychiatric condition. However, that doesn’t mean that someone’s mental-health problems are something for which blame is appropriate, no matter how apparently unwilling or uncooperative they may be to do what others think would help. Even the concept of personal responsibility is fraught, despite the fact that it is widely taught as a pillar of recovery.

One of my more unusual beliefs is that sanity is tremendously influenced by social dynamics in ways that we really don’t understand. And not just through poverty, racism, sexism, homophobia, other oppression and forms of trauma. I believe that consciousness is a form of energy that works in strange ways. I believe that societies that police and punish madness do so because it represents the power of consciousness in ways that are inimical to other power structures these societies hold dear. There is power arising through our relationships that psychodynamic psychotherapy attempts to harness intentionally, not always with success and sometimes even harmfully. The dynamics labelled ‘projective identification’ are perhaps the clearest example of this power.  Social media taps into this power in odd and disruptive ways. And so does leadership.

I came to these understandings during and after my last experience of mania, three years ago, which, unlike my first experience of full-blown mania, was unusually stable and harmless. Unlike all my many other elevated-mood experiences, the insights and perspectives I gained through mania at the start of 2017 stayed with me, and evolved, after it was over.

My relationships were integral to ensuring that my experience of mania in 2017 did not hurt me or others, and more significantly, were key to ensuring that I did not progress from mania to psychosis. Although I didn’t speak to him more than once or twice a week, no relationship was more important than my relationship with my therapist. He monitored and met with me, checked in with my friends (with my permission), including a friend with a bipolar diagnosis who works as a peer support worker. I found out after the fact that they had discussed whether I needed to be involuntarily committed. That my therapist held this power over me and yet could affirm that the experience I was having was not diseased or pathological, and was in fact positive, was remarkable and deeply validating and healing for me.

So my therapist and I have achieved and been through a lot, on my own schedule rather than according to some kind of 9- or 12-session program (I’ve seen those help others, but they take a lot of effort on the part of the person in therapy to be effective). My attachment issues have been put to bed, my skills around anger have increased, I’ve become much more in touch with and aware of my emotions, I’ve learned to recognize my transference behaviour, my self-talk has changed hugely, my values and sense of self have been deeply and consistently affirmed, and my clinical mood has both become more stable, and less consequential in its instability. We’ve also, within the past year, discussed what things I yet need to work on, triumph over which would indicate it was time for our relationship to end. We are clear on what these issues are, and I am not there yet.

When I first started seeing my therapist I remember thinking I may as well have been seeing a robot; his responses seemed very rigid, and I questioned how helpful it would be. I stuck with it because I had come to know of him through a friend, himself a therapist, who saw my doctor for clinical supervision and spoke very highly of him. Much more recently, a psychiatrist friend whose own therapeutic skills I have had a chance to witness and admire told me that my therapist is someone who psychiatrists in Toronto will refer to when they are unable to find skilled psychotherapists for someone they are working with.

All of that to say, I have been in a grieving process for my relationship with my psychotherapist thanks to COVID.

I wrote to him. Being very clear on my concern about some of the things he’d said relating to COVID, expressing my anger. I set very firm boundaries in terms of not being prepared to see him in person. I did not call for the end of our relationship, but I think he realises that if we can’t continue by phone, our relationship may well be over.

In the meantime I had a previously scheduled phone consultation with one of the psychiatrists who has been responsible, with me, for determining what meds would be most helpful. Five or six years ago I became concerned about my use of clonazepam, even though it remains intermittent. I finally let go of a longstanding deep fear of antipsychotics and began to try some of the newer antipsychotics as an alternative. The phone consultation was with the psychopharmacologist who went through the list I brought him six years ago of meds I was curious about and indicated which I might want to try. Over the last six years or so I have tried four of the newer ones.

I was “seeing” this doctor for the third time in seven years on the recommendation of an emergency room physician who had seen me a few months ago, pre-lockdown, about numbness in my mouth and my ability to speak and form words clearly. I had been fearful I was having a stroke, but the ER doctor did not think that was the issue.

The psychopharmacologist could not be certain, especially without a physical examination, but he thought that these symptoms may be the start of Tardive Dyskinesia.

I’m still processing this. Few things are more defining of who I am than my ability to speak clearly and effectively.

A day after receiving my letter (which I delivered by hand; my therapist’s office was closed, so I couldn’t have been the only person to turn down in-person appointments), my therapist called. He thanked me very genuinely for my note. I was in a parking lot, about to do something work-related, and after we agreed that my next appointment would be by phone, I burst into tears. I am clearly very upset at the possible Tardive Dyskinesia diagnosis. My symptoms are still very mild, and may not even be discernible upon examination. I don’t know if they are Tardive Dyskinesia or some other condition. I don’t know if they will progress or not. I’d always understood Tardive Dyskinesia might surface later in my life based on the intensive antipsychotic treatment I had received when I was misdiagnosed with schizophrenia at 18. But now that I’m looking at the reality, it is unexpectedly upsetting.

I feel a bit closer to the #PrescribedHarm community now.

So my therapist and I have an appointment for a phone consult in a couple of days. I’m not certain that we’ve worked this all out, but we will see.

Unfortunately this will likely be my last #MadCovidDiaries entry. Now that my gardening business is operating again, my time is much more limited than I expected it to be when lockdown started. Writing is important and I will keep making time for it, but I’m not sure this is the writing I want to keep making time for. And it pulls me into Twitter which is a space of strange, not always comfortable, power.

Deepest thanks to Bethan, who has been wonderful.

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