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A Co-Suffering Community: Orthodox Reflections on Bipolar Disorder, Suicide, and Support

OCAMPR 2016 - On Pain and Suffering

With the theme “On Pain and Suffering” the Orthodox Christian Association of Medicine, Psychology, and Religion conference was held November 3-5, 2016 on the campus of Holy Cross/Hellenic College in Brookline, MA. OCAMPR exists to facilitate Orthodox Christian fellowship, dialogue and education of professionals in religion, psychology and medicine.

These 27 lectures, workshops, and papers were recorded by Ancient Faith Radio in partnership with OCAMPR and are made available here for free access and download. All of the talks are in audio format but In some cases a video version is provided as a way of showing the slides associated with the talk.

November 2016

A Co-Suffering Community: Orthodox Reflections on Bipolar Disorder, Suicide, and Support

Kate McCray, Ph.D. candidate in Theological studies: Christian Ethics, University of Toronto, Can.

November 9, 2016 Length: 24:38

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Ms. Kate McCray: Before I begin, in true Orthodox fashion, I’m going to apologize to everyone for any things I have been glossing over. This is a much larger paper that I’ve condensed for this format, so I’m hoping that even though I’m not able to go into much depth with several of the very difficult topics, that we’ll be able to open that up in conversation when we get to questions.

The following is a letter from a son, nephew, brother in a prominent Orthodox family in the OCA. The family released his letters to me for publication, and I share a piece of it with you now.

I am deeply mentally ill with a particularly nasty form of Bipolar Type II, and I have been symptomatic for over a year. Symptomatic is a nice word to hide emotions behind, which is something I do a lot. Used here, it means that I am in pain, sometimes really intense pain, and it means that I am putting others around me through a lot of pain and anguish. It means that I’m losing a little bit of my humanity every day.

John grew up among the incense and icons of Orthodox Christian life, with the typical values of community, responsibility, and faith in the midst of suffering. Before John took his own life, he organized letters to be disseminated between friends and family to explain both their importance and his own emotional and physical pain. He describes the scope of the last months, personal and professional highs and lows, successes in graduate school, and failures in intimate relationships. He expresses the intellectual difficulty in understanding himself and the impetus behind burning bridges and isolating himself from friendships that he loved and needed, and ultimately, confessionally, he asked forgiveness for his character flaws.

One of the defining attributes of lived experience with bipolar disorder is the inability or strained ability to separate one’s identity from the symptoms of the brain disease. John explains he habitually read about Bipolar II, especially in manic times, because “sometimes I need to remind myself that what I’m experiencing is just symptoms of an illness. I need that, because it feels like a character flaw that I am at fault for, even when the symptoms become physical.”

Although Eastern Orthodoxy certainly maintains an alternative to the individualistic or rationalistic North American church experience and model of personhood, the messages of community and responsibility do little to curb the social message that wellness and healing look a certain way, that is, calm, stable, full of understanding, and personalized strength. John wonders in his open letter if he pulled back from friends and family to become healthy. At least, that’s what he thought at the time, although he believes in his writing at the end of his life that this isolation precipitated one of the deepest depressions of his life.

The goal of his larger paper, which I mentioned, is three-fold: to connect elements of John’s death as well as others with bipolar disorder to the typical struggles, symptoms, and conclusions of patients with bipolar disorder; to critique the neo-liberal definition of self-development and personhood that places rationality, individuality, and autonomy with self-understanding at the core of what it means to be human; and to examine ways in which integrated personhood as it’s found in Eastern Orthodoxy can provide alternatives to this neo-liberal person, including ways in which Orthodoxy can better provide for persons with bipolar disorder, who are disproportionately more likely to commit suicide than those in the general population. For the sake of time, I’ll synopsize these points and give a sketch of the broader paper, which I hope will provide us with some direction in our discussion and the ability to meditate on how parish community members can become a greater community of care.

Although Eastern Orthodox conceptions of the person counter the focus on rationality and individualized strength, and although medicalization, at least in the American context, is usually based on an individualistic model of human rights, I believe it’s crucial to underscore early that my intention is to pair the community of care with the thoughtful use of medical and pharmaceutical support. Faith, in this context, includes faithfulness to the consistent care, support, love, and prayerful attention given to those in the community to those who are diagnosed with bipolar disorder and relate to their bodies in a way that the world often misinterprets—and by “the world,” also the parish community, those of us who believe that we are well. This sort of community necessitates a working understanding of bipolar experiences.

In her memoir about bipolar, Kathryn Greene-McCreight, who’s a chaplain at Yale, describes navigating the rough waters of her own symptoms while struggling to make sense of her father and brother’s depression. Retroactively, she looks back and she identifies her first depressive period at the age of twelve, as she describes an adolescence marked by what clinicians call “stressful life experiences,” including multiple suicides by classmates, friends, as well as the sudden and unexpected death of peers. During her fifth hospital stay, she says, another childhood friend hung herself while on suicide watch in another mental hospital in the state, and she surmised that after so many deaths she was “used to it,” if such a thing can be said.

Greene-McCreight’s account is hardly atypical for patients with bipolar disorder, with the onset of acute symptoms identified between the ages of 15-19 years of age and approximately 75% of bipolar patients having onset prior to the age of 18. Stressful life experiences early in life also correspond to early and more severe onset, and the trajectory of patients with an earlier onset of the disease correspond with an increase in suicidal ideation and action. Additionally, those who become symptomatic early in adolescence are disproportionately and more likely to experience increased severity of psycho-social impairment. So for most of us, adolescence is a time when you’re learning to read affect and you’re making significant connections with peer groups, but for those with mood disorders, their adolescence is largely hijacked by the experience of these symptoms. My apologies; I’m so out of breath. This pregnancy is creating this breathiness. My apologies.

There’s a study by Maree Inder, wherein the team there contends in a 2008 study that there’s an overlap between normative cognitional development in adolescents and the diagnosis of bipolar disorder during that time, and they argue that this overlap deserves greater attention. The adolescent developmental period contains building blocks for a sense of self, an independent sense of self, without which, as Inder’s studies find, bipolar patients lack key features for differentiated identity, that is, being able to say, “This is my opinion. These are my values, and when they’re sort of under attack, I can stand in those.”

Regarding the creation of the self, as the onset of bipolar symptoms occur, they’re new to all young people during adolescence and coincides with a season of newness and discoveries. So it’s no wonder that persons with bipolar disorder cannot readily demarcate between the territory of the self and the space occupied by the disease.

Talia Weiner from Chicago examines the concept of agency and selfhood within bipolar disorder and specifically self-management treatments. She questions the liberal framework—and by that she means this ethic of individualization, sort of the American pull yourself up by the bootstraps self-authoring kind of person that we hold so dear—and she sees this throughout therapeutic treatment, self-management treatments, and she points out that it’s inherently difficult for someone with bipolar disorder to be able to see themselves as autonomous, capable of rational awareness, aware of social structures. Self-management protocols ask the bipolar patient to assess, rate moods, see environmental triggers, and then become aware of their own trends such that they can predict them. Weiner contends that this expectation is predicated on a type of agency and rationality that largely exists outside of the person with bipolar. The relationship to rationality for sufferers of bipolar is muddled and self-assessment rubrics, which both expect rational agency and then reinforce the patient to have a sort of skepticism about their own experiences, such that they doubt who the self is and what they’re morally responsible for.

So within this paradigm that you can sort of see that I’m sketching, this neo-liberal kind of person that we’re all sort of familiar with, especially in a philosophical, post-Kantian kind of way—and then the Orthodox tradition that sees the person as developing in community and sees the person as being inherently dependent on the strengths of others when we fail. So Fr. John Breck, who extensively discusses in The Secret Gift of Life, he extensively discusses suicide. As I was going through his many wonderful offerings, one of the recommendations that he gives for us to reconsider suicide stood out, and I’d like to share it with you.

He questions the model of rational self-life-taking that’s sort of prevalent through all of Christian literature regarding suicide, from antiquity till now, and he recommends a re-examination of whether or not suicide is, itself, a rational act where the person rationally considers whether or not one should live or die. Now, certainly he takes time to say that category is well thought-out; it’s there for a reason. There are others in the field who also discuss those who are under some sort of duress and whether or not they’re morally responsible for self-life-taking, but for Breck, he’s acutely aware of how many people with mental health conditions, who would then have a lessened ability to assess rationally whether or not they should kill themselves, he wants us to take that into consideration when we think about suicide.

So one of his key recommendations is to be pastoral rather than canonical, not that one is lesser than the other, but that they should work in tandem with one another. In specific, he actually recommends a different relationship for the funeral rite, and he compares it to the penitential marriage service. Most of us are aware that if you get divorced in the Orthodox Church and you want to remarry another Orthodox Christian, that service is different. It’s a way for the Church to maintain a strong belief in marriage and the sacramental nature of marriage, while also recognizing that sin is a part of human life and that we fail and that we are people who are in constant need of grace. He recommends alongside that sort of model a penitential funeral service, wherein someone who has committed suicide, especially as the result of a mental health condition like bipolar disorder, that there would be an acknowledgment by the parish community that this person has succumbed to the symptoms of their disease and that this is something to be mourned and it’s tragic, but then also is separated from this model of rational self-life-taking in which the person would be morally culpable, and then, because of that, wouldn’t receive a Church burial, a Church blessing, a Church funeral.

Breck imagines the service for the funeral shaped after the penitential marriage service, and through this he sees the Church acknowledging sin and brokenness, but in a way that would not reorient the broader prohibition against rational suicide but provide a way to acknowledge that suicide stemming from mental health disorders like bipolar occur as a result of a continued and progressive battle with shame, guilt, negative assessments, hopelessness brought about by physical and neurological imbalances.

In my greater paper, I have a whole section on what clinicians call stigma stress, which is, especially in the case of bipolar disorder, the expectation that a social community will not understand or seek to accept, so there isn’t even the reaching-out to the community on a personal level; there’s the expectation of being shamed. Persons with bipolar disorder are cognitively disadvantaged in this area. What clinicians have found is that persons especially with Bipolar Disorder II, which is the strongest and most symptomatic type, that they are less likely to retain positive images of the self. Whereas for many of us, when we’re in difficult situations or depressing situations, we remind ourselves that we’re loved, we remind ourselves that we’re in a community of support, but for people with this specific disorder, they’re physically less able, physically less likely, to be able to self-assess in that positive way.

I just want to close with Breck’s recommendation that allows for the family and the church together as a community to support the person with bipolar disorder while also acknowledging real pain, and the real pain specifically involved in the loss of an individual’s life, both while they’re symptomatic and if they succumb to suicide, the real pain experienced by the family. Discussing shame and a death resulting from that shame, he says:

Our role is to surrender the victim into God’s gracious care, while we bear witness to the truth, that the saving love of Christ is even stronger than self-inflicted death. In this way, the burial draws the entire community into mourning, not only of death but of this specific loss of one to suicide as a reminder of the vitality and importance of communal understanding and care.

[Applause]

Stephanie: My name is Stephanie, and I am in school finishing up my clinical psychology degree for counseling. I had no idea that that’s really what this was about, and I’m very grateful. I wonder, as someone who’s only been Orthodox for 16 years—I’m a convert—how would a change like that be able to come into the Church? Because that’s huge. So I just wonder, because it’s compassionate, and it seems to me to be closer to the heart of Christ than the judgment that we often see when these things happen in our parishes and with people that we love.

Ms. McCray: I think I share your disposition and kind of waiting for something like this to be implemented. To my knowledge, there isn’t any canonical implementation of this such that we’d have a rubric for a penitential funeral service, but I think in lived Orthodox experience, there are quite a few priests where this does happen in the parish. It happens discreetly, it happens because there is a grace afforded to situations like this, and because of course priests with excellent training, as the ones that I know, their first concern is not only that the parish community will understand that suicide is not a legitimate option, it’s the concern for those who are left behind and what we do with the kind of pain and mourning that we’re left with. So, yes, I agree.

I think, on an individual, non-ordained, lay person’s life, being open and being aware of the very specific experiences of symptomatic bipolar disorder, listening to and being ready to receive stories of manic experiences and depressive experiences without forcing that person to fake or pass for normative is essential. The greater paper that I have goes into some community evidence where the statistics for group therapies, especially within a community of faith, are just incredible. People who feel loved by a community are exponentially more likely to seek out medical therapy, to stick with medical therapy, to be consistent in their psychiatric appointments, and to seek out hospitalization when they realize they need it. So having a community of support who’s able to hold place and listen as witnesses but also not pressure I think is essential to this sort of community being implemented.

Q1: A few weeks ago, on the GOA website, there’s a list of the saints of the day, and probably several of them don’t have any story with them. So there was one that for some reason I looked up. It was St. Domnina and her daughters, and the story was—and as I read the story, this led to a conversation I had with some friends over dinner later, which was… The story of St. Domnina and her daughters was that they were accused of being Christian and arrested by a troop of soldiers, and they were being taken in, and the group of soldiers got a little rowdy, was drinking wine, and apparently all three women asked for a time to rest and threw themselves into the river and died. My question was: How is that different from someone who refuses to let themselves be raped by this disease of bipolar disorder? I realize it’s probably a very slippery slope, but we have canonized saints who took their own lives directly. Just something…

Ms. McCray: I think my first reaction to that is to think about duress. Legally, someone isn’t culpable for their behavior under a certain level of duress. I couldn’t give witness testimony under oath if you can prove that I’m giving that testimony under duress. But duress is one of those categories that’s so fluid, especially when we’re not speaking in legal or psychiatric terms.

Q2: Can you clarify?

Ms. Kate McCray: Sure. Duress is the sort of pressure where your capacity to say no is diminished. So someone who’s tortured and makes a decision in that to renounce their faith. The broad Church tradition doesn’t hold that person as morally responsible as a person who denies their faith for their own advantage. That’s just one example that comes to mind. Then, also in the American legal system, that same principle holds, where if I can prove that you’ve been significantly pressured to the point where your ability to say no is diminished, then your testimony or your recollection of something isn’t seen as valid.

Especially in Canada right now, the context that I’m in, there’s an ongoing conversation going on about assisted suicide. The Canadian system is modeled largely after the Dutch system. There’s a lot of questions as to whether or not people with extended mental health disorders can access that kind of—well, in Canada, it’s considered palliative care. So I think—not that I have any significant answers to give, but I think that researching our tradition makes it more imperative for us to say in which situations is self-life-taking morally binding. Not that Fr. John Breck really gives a specific answer to this, but I so appreciate that he opens up the category.

Q3: More of a comment than a response to your… There are two podcasts by Dr. Rossi who also spoke here, and they’re both on suicide, part one and part two, so I’m going to quote Dr. Rossi who quotes Archbishop Demetrios of the GOA. Basically he was sitting on the committee with SCOBA, and they were talking about suicide and the pastoral approach to it. The committee was exactly on the direction “we cannot do anything; this is wrong” up until Archbp. Demetrios stood up and basically challenged everybody by saying, “Let’s say if somebody jumps from the bridge”—this is Archbp. Demetrios’ words—“who am I to say that by the time they hit the water, they didn’t repent in their hearts of what they’d done?” And these words actually turned that committee to the place where they put out a document—and again, Dr. Rossi has a link to it—with a pastoral approach that’s more open to the idea of “we shouldn’t be so quick to judge somebody.” So it’s my hope that with prayers we’re in the right direction even as clergy and hierarchy to understand it’s not so black-and-white, even Archbp. Demetrios.

Ms. McCray: Fr. George Morelli, from the Antiochian Archdiocese, is another fantastic resource for this topic. [Applause]


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