Bipolar advocate Gabe Howard and Dr. Nicole Washington discuss the pitfalls of getting information from our friends and from medical professionals. They also cover why the side effects of psychiatric medications may sound scary.
The hosts offer tips on how bipolar patients can better advocate for themselves, including what not to say and when it’s better to stay quiet and listen. They share a nuanced and in-depth conversation about managing bipolar disorder.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, Mental Illness is an Asshole and other Observations, available from Amazon; signed copies are also available directly from the author. He also hosts Healthline Media’s Inside Mental Health podcast available on your favorite podcast player.
To learn more about Gabe, please visit his website, gabehoward.com.
Dr. Nicole Washington is a native of Baton Rouge, Louisiana, where she attended Southern University and A&M College. After receiving her BS degree, she moved to Tulsa, Oklahoma to enroll in the Oklahoma State University College of Osteopathic Medicine. She completed a residency in psychiatry at the University of Oklahoma in Tulsa. Since completing her residency training, Washington has spent most of her career caring for and being an advocate for those who are not typically consumers of mental health services, namely underserved communities, those with severe mental health conditions, and high performing professionals. Through her private practice, podcast, speaking, and writing, she seeks to provide education to decrease the stigma associated with psychiatric conditions.
Find out more at DrNicolePsych.com.
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.
Gabe Howard: My name is Gabe Howard, and I live with bipolar disorder.
Dr. Nicole Washington: I’m Dr. Nicole Washington, and I’m a board certified psychiatrist.
Gabe Howard: All right, Dr. Nicole, you’re a board-certified psychiatrist, so you are the best person for me to ask what is the medical definition of bipolar disorder?
Dr. Nicole Washington: That’s a great question, Gabe. When we as psychiatrists or anyone in the mental health field think about bipolar disorder, we think about two mood episodes either depression and mania or depression and hypomania, depending on which type of bipolar disorder a person has. But in between those episodes, there can be extended periods of what we consider a normal mood.
Gabe Howard: All right, Dr. Nicole, everybody now understands bipolar disorder, right? Because we just rattled it off in like three minutes. But what about the treatment for bipolar disorder? And in fact, you know, don’t bore us with the treatment for bipolar disorder. You probably had to go to like medical school for eight years to learn that. Where are the pain points? Why aren’t patients and doctors connecting? Because it seems to me bipolar disorder is well understood. Doctors like you are readily available. Patients want to see doctors. Shouldn’t this whole problem just be resolved?
Dr. Nicole Washington: I sure wish it were, but that is really not the case. When you think about the typical medication that we use to treat bipolar disorder, and you go look up those side effect profiles, which most of us have. They do not sound sexy, right? I feel like a used car salesman, sometimes trying to convince somebody to take medication because I am obligated to do the like, these are the side effects that you need to know about, and I just sometimes can’t make them sound great. I’m left really trying to convince somebody that they should take the meds despite the potential negatives, which if you look them up, yeah, none of them sound like anything anybody would intentionally sign up for. So that’s, I think, a big battle. Plus, when people have been hospitalized, they learn about these meds. Right? In their communities, in the hospital. And so you might recommend a certain medication to somebody and they say, Oh no, when I was in the hospital, those people that were on that, they look like zombies or they look like this or that. And it’s so hard to get people to understand, we can’t compare ourselves. Our body chemistry is different. We’re going to respond differently. I can give two people the exact same dose of something, and one of them will say, I felt like a zombie. I felt sedated. I had no emotions, and the other person will say I felt great. So there’s a disconnect there and what they see because they sometimes see people have really negative effects. And then when they look up the side effects, it just doesn’t sound sexy.
Gabe Howard: It’s fascinating to me that you admit, like just in front of me and the whole world, you’re like, Yeah, sometimes these med have side effects that suck. The patient community is like, my doctor doesn’t care. My doctor lied to me. We get that one a lot. My doctor lied to me. My doctor told me that I would not gain weight and that I did, or my doctor lied to me and said there’d be no side effects. And there were. And then of course, there’s my favorite one, my doctor got paid to put me on this medication and doesn’t care about me. There’s little kernels of understanding in all of those things. I want to clear up one thing, pharmaceutical companies are not allowed to pay you. That is correct, right?
Dr. Nicole Washington: That is absolutely correct.
Gabe Howard: Ok, now the pushback that people get is but they’re allowed to buy you a lot of food and send you on vacation. What are the rules there?
Dr. Nicole Washington: No, so back in the day, before I was even like really practicing, that may have been true. You would hear of drug companies hosting golf trips or ski trips or things like that for doctors. I mean, that was true back in the day. You would have these very, very luxurious dinners and things like that. They have really cut down on that in recent years.
Gabe Howard: I hear people with bipolar disorder constantly complaining about their providers, and I’m not saying there’s not room for improvement, but I always ask them like, well, did you ever discuss it with your provider or are you just complaining behind their back? And listen, it’s almost always they’re complaining behind their back.
Dr. Nicole Washington: It’s tough on my end, right, because in psychiatry, we have all these boundaries that we have to be aware of even more than most physicians. And the reason for that is if you think about it, most patients share things with their psychiatrists or their therapists that they may not have shared with anyone. And so for them, our relationship is very different, but I have to try to remain as neutral as possible. And so then I have to create a lot of boundaries that sometimes people don’t like. They don’t enjoy. And I have to remind people sometimes that I am here, I am part of your team, I am here to support you. But we’re not friends, right? Like, I’m not the person you should call to say, Hey, have you been watching the Olympics? You know, I was just wondering what you thought about blah blah blah like random calls. And believe me, I’ve gotten those. And I think it’s because people get really close to you because they share things with you that they just don’t share with other people. And so sometimes those lines get blurred.
Gabe Howard: I imagine it has to be very difficult, I’m thinking about me like I just I suffered for so long and I didn’t know why. I just had no idea why. Now I was super lucky in that the person who took me to the hospital was the person that sort of imprinted on me. I was like, Oh my God, you know everything. And that person was my friend. So the boundaries were very different. But I can only imagine if I was taken to the hospital by an ambulance or by police or by a 9-1-1 call, and the first person who explained what was going on in my head was a provider, was a doctor, and I think you have figured me out. Oh, my I would. I would follow that person around like, I mean, the person who took me to the hospital, I did follow around like they were just some sort of clairvoyant. I mean, it was kind of amazing, honestly. But how do you deal with that? Because I again, I have to imagine when you tell people not only what they’ve been suffering from has a name, but that you have a solution, they want to be your friend.
Dr. Nicole Washington: Some of them do, but you know, some people are not as happy about the diagnosis, right? So there goes the stigma because you would think, you know, on the one hand, there are people who are very appreciative and think, Oh my gosh, thank you for putting a name to how I’ve been feeling for the past, however long, and thank you for having a solution. But there are some people who they are so upset at the thought of having bipolar disorder or being bipolar is what, you know, I don’t want to be bipolar.
Gabe Howard: Right.
Dr. Nicole Washington: And they are so upset about that that they will refute what I’m saying, they will tell me I’m wrong. They will come up with every reason in the world why these things happened instead of their actual reason. So not everybody is really warm and fuzzy about it. Some people are pretty upset.
Gabe Howard: Do you find that more people take the news negatively and don’t want anything to do with it? More people take it positively and they’re like, Oh my God, it’s like their aha moment? Is it 50/50?
Dr. Nicole Washington: I think the setting matters, right? So in the hospital setting, you think if somebody is coming into the hospital into an acute hospitalization due to mania, especially in a manic phase, they’re not necessarily in the best space to hear what I’m saying and not necessarily having the best of insight at that moment. So sometimes that’s tough. That’s a tough place to be to convince someone who’s in the middle of a manic episode that what they have is bipolar disorder. Sometimes that’s really difficult. In the outpatient setting, I don’t find it to be as negative of a reaction when I talk to someone about bipolar disorder because I can have an actual conversation about this is what it is. This is what it isn’t. This is why these things happen. You know, let’s go look at some reputable sites and do some research between visits and come back and talk to me about it. So it’s a much easier conversation. Whereas in the hospital, with someone who’s acutely manic, all bets are off.
Gabe Howard: What I felt like is that I’m going to have to move into a group home or that I’m soon going to be dead because I thought bipolar disorder was fatal and I thought every single person with mental illness live lived in. I don’t know. I guess a group home is what I thought. I did not realize that it was a manageable illness because I just didn’t know anything about. I only knew one person ever like a famous person who died by suicide. And I thought, Well, I mean, if a rich guy can’t, can’t beat it, I’m just I’m just honestly, I felt like relief is probably not the right word, but I accepted it immediately. I was like, Hey, I’m reading the pamphlet. Hey, this describes Gabe.
Dr. Nicole Washington: Do you think that was affected by, you said you had a friend who was involved in your care? Do you think that was affected by the fact that you already had some level of trust in the treatment team or the setting?
Gabe Howard: Here’s, I was tricked into going into the emergency room straight up. I thought that suicide was normal. I thought about suicide literally from birth. I was just I was born this way. And the problem with thinking about suicide every day since birth is that you think it’s normal, this is normal. You think that that’s what other people are thinking about. I just I always use the example that even though I’ve never seen my mother go to the bathroom, I know that she goes to the bathroom. I don’t need to see it, to know it. So even though I never heard many people talk about suicide, I just assumed that they were in fact thinking about it. It didn’t occur to me that, yeah. Listen, I had bipolar disorder. All right? Just my thinking was not great. So when she came up to me and she recognized the signs of suicidality and a mental illness, and she decided to intercede to do something, and she said, Hey, are you planning on killing yourself? Right? She did it perfect. I mean, she literally did it perfect. Like she’d taken a class. She didn’t mince words, straight in the eyes. I mean, it was, listen, it was it was wonderful suicide prevention. But I had no reason to lie. I was like, Yes, yes I am. And I thought that meant she was going to help me. Like sincerely, I thought this meant that she was going to assist me in my plan, but instead she wanted to take me to the emergency room. I thought she was nuts.
Dr. Nicole Washington: It’s pretty interesting that you even brought that up, because that is a common theme, so I will ask people, as I’m doing my questioning, you know, do you have a history of suicidal thoughts? And I cannot tell you how many people say, Well, yeah, I mean, everybody does. And I will come back with. Well, everybody doesn’t. And I will often get this deer in the headlights look like, What do you mean? Everybody does it. But it is said, just as casually as you say, like, Hey, everybody goes to the bathroom, like everybody. And it floors me, what has floored me for years. And now what you’re saying makes a lot of sense. If you have just always been this way, you just assume that everybody has it and just doesn’t talk about it. A light bulb has just gone off atop my head.
Gabe Howard: Well, I am very glad that I could be helpful. I mean, I don’t want to pat ourselves on the back, you and I came up with the idea of the show for a reason. So I mean, we obviously believe it, but I do believe that not enough people are talking about it because the connections they’re just missed. They’re just so missed. Well, how could you think that? Well, why wouldn’t I? That was the first thought that popped into my brain and nobody ever challenged it. I went to public school in the 80s. There was no psychology class. We weren’t talking about mental health. My family is stereotypically blue-collar. I don’t say that to trash them in any way. I’m just saying my father, he believes that any problem that befalls a man can be resolved by rubbing mud on it. You know, he’s a tough guy. Now, he’s like 70. So now he’s a tough guy with a hunch. But still the tough guy is still in him, Dr. Nicole. I mean, people are like, Well, why don’t your family talk to you about this? How would this work? Could you imagine my family sitting ten-year-old Gabe down and saying, Hey, do you think about ending your own life a lot? They had no reason to suspect this. We don’t teach parents how to have these conversations, but these conversations are super important, and we’ve been sort of talking about bipolar disorder in terms of depression and suicidality. Because if I understand correctly, that’s sort of the number one way that people end up getting help, after a suicide attempt or their families are worried that they might die by suicide. So the suicidality and bipolar disorder are intrinsically linked. If, please correct me if I’m wrong, but assuming that my Google search worked out, about 15 percent of people with bipolar disorder will die by suicide. That’s a scary number.
Dr. Nicole Washington: It is a scary number, and you’re right, we don’t talk to children about this kind of unless your mom’s a psychiatrist, because I will tell you.
Gabe Howard: Your mom’s got? We all need Dr. Nicole as our moms.
Dr. Nicole Washington: I will tell you at random moments, my children will tell that I will sit them down and just, Hey, how’s it going? How are you doing? You know, just randomly, Hey, you know, you’re feeling OK? Your mood is pretty good? I do mood checks. We talk about suicide.
Gabe Howard: This is an inappropriate question, so I’m going to ask it anyways.
Dr. Nicole Washington: Go for it.
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Gabe Howard: And we are back discussing the missed opportunities between patients and providers. The number one thing that I hear in the patient community is my psychiatrist is mean because they want to build a tennis court and they want to hang out on their yacht and they don’t care about me. I know you, Dr. Nicole, and I can’t help but notice that you don’t seem to have a tennis court and you don’t seem to have a yacht. Is this a barrier to patient/provider connection, where many patients believe that all doctors are millionaires riding their horses and playing tennis on their yachts?
Dr. Nicole Washington: I’ve had patients tell me that they know that I’m a millionaire or that they know that I get extra money by diagnosing them, or I get extra money from drug companies or I’m getting rich off of keeping them in the hospital. It is amazing the things that people think, and I don’t know if people just think doctors are inherently wealthy. I don’t know if they also know how much student loan debt we have compared to our incomes in general. But I can assure you, I don’t have a tennis court or a yacht. I don’t even have a pool. And I would love to have one. But I don’t because I cannot, cannot, cannot afford to do such a thing right now.
Gabe Howard: As soon as you said that, I thought, Oh man, my dad’s a retired truck driver and he has a pool.
Dr. Nicole Washington: I know, I know. Right?
Gabe Howard: You need to switch to truck driving.
Dr. Nicole Washington: I mean, well, I don’t, I don’t know, I follow. I get sleepy in the car, so probably truck driving wouldn’t be a great career for me. I wouldn’t get very far.
Gabe Howard: Plus, he’s like super grumpy and you’re super nice, so.
Dr. Nicole Washington: Hmm. Everybody wouldn’t say that, Gabe.
Gabe Howard: [Laughter]
Dr. Nicole Washington: Everybody wouldn’t say that, and everybody wouldn’t say that.
Gabe Howard: You know, my dad, he’s a super grumpy guy. He just really is. I love him to death. He’s done a lot for me. Super grumpy guy. Always sleep-deprived. He had a really hard job until he retired. And I just, I remember one time we all went on vacation and we stayed at a hotel that my dad stays at when he drives the truck and because they gave him the trucker rate because it was a ski lodge that was off-season. So just here we are. We go into this place. Of course, they all know my dad. They see him two or three times a week as part of his route. He’s staying there all the time. They all know him, and all of these people are talking to my dad like, he’s a fun guy and I’m just like, What? What on earth is this? And my dad is talking to them and tones of voices and in mannerisms, and he’s doing things I have never seen my father do. And sincerely, I am glad that I had that experience. I was younger. I was about 14, 15, and I realized, Oh my God, my dad is a completely different person when he’s not being a dad. You know?
Gabe Howard: He’s got no responsibilities. Everybody’s 600 miles away. So I got to see this idea of my father just as a person and not a husband or a dad, right? And I genuinely believe that one of the biggest issues between patients and providers is we only see each other when we’re largely often, and not largely, but we see each other when we’re in crisis. We see each other when things aren’t going well and we see each other in this setting in this medical setting. And then we extrapolate largely based on, well, bullshit. We extrapolate what’s going on after the fact. And I know both sides do it. I’m going to stick up for patients. I know that the medical community is like, Well, why won’t you take your pills? Yeah, because I can’t fill them, because I don’t have insurance, because I’m broke. But do you feel that that is a barrier to care?
Dr. Nicole Washington: I think so, I mean, people, yeah, I mean, I’m sure people think that I’m just sitting around reading the DSM for leisure in the evenings, you know?
Gabe Howard: What you’re not?
Dr. Nicole Washington: No, no, no,
Gabe Howard: Even I thought that was true.
Dr. Nicole Washington: No, no, no, no. Sometimes I use it to prop things up and lift my computer up and all kinds of stuff. But you know, when I’m outside of work, I’m actually a real person. You know, my kids would tell you, I’m a nice mom and, you know, I’m a real fun person. But in that moment, you’re right. Like, we have our boundaries and we have to keep them tight, right? Like, we have to keep them tight. And we have limited amounts of time, right? So in the twenty minutes that I’m going to see you, you don’t really have time for me to share the fun side of me with you because you’re paying for me to figure out, Are you OK? What’s going on? What do we need to do? We don’t have time for the grinning and laughing and all that stuff. But the grumpy right, so you say, Oh, my dad is a grumpy, well, from your perspective, but from a patient to a doctor perspective, what kinds of things do you think doctors do that come across as grumpy? Because maybe we don’t know that it comes across as us being mean? I think you said mean.
Gabe Howard: [Laughter]
Dr. Nicole Washington: You said that, you know, patients think doctors are mean. So what types of things do you think that doctors do that patients think are mean?
Gabe Howard: One of the things that I have noticed and then I hear a lot in the community is the disconnect on goals. I give a speech and I, you know, for providers, largely therapists, I want to be honest, there’s usually not a lot of psychologists and psychiatrists in the room there. They’re usually therapists. And I say things like, what are the goal for your patients with serious and persistent mental illness? And they say things like show up for the appointment on time, be med compliant, participate in their treatment plan. And I always point out that there’s the disconnect. If you ask the patients what their goals are, it’s to go to Hawaii. It’s to get a job, it’s to fall in love, it’s worlds apart of difference. But here’s the thing it’s that miss connections thing that I thought, see they’re so connected, they’re just so connected that the patient is going there to, like I said, go to Hawaii, get a job, fall in love. And if you can understand the treatment plan, if you can get on board with it, if you can, you know, take the medication as prescribed, if you can, that will get you closer to your other goal. But the disconnect right there is that a lot of providers are just like, well, if they would do what I told them to, they would be fine.
Gabe Howard: Listen, walk up to any adult, forget about mental illness, just walk up to any adult and tell them to do something. And I would bet you a hundred percent of adults would dig their heels in. And those are uncompromised un-sick untraumatized people who just don’t like to be told what to do. We saw from the mask mandates how America just lost their mind at this idea of just having to wear a little piece of fabric over their face because they don’t like being told what to do. Not to fall down the rabbit hole on this one, Dr. Nicole. But you can imagine if that’s how normal people reacted to something as simple as a mask, you can imagine how somebody who’s compromised, who’s traumatized, who has probably been, I do hate this word, I wish we had a lighter word, but abused by the system. And generally, small abuses like having to wait six weeks to see a doctor, having their appointments canceled a lot. These are like micro abuses, right? But, they feel like the system doesn’t care about them. And then they get lectured that they’re not med compliant or told what to do by a provider.
Dr. Nicole Washington: I think that lack of control thing is huge, though, because one of the things that will happen is, you know, a person feels like they have no control. So you think about someone maybe newly diagnosed with bipolar disorder or even they’ve had it for a while and they struggle with the diagnosis, right? You have all these people trying to tell you what to do, when to do it. Take this medicine at this time of day, go to bed at this time, forget about the hospital, right? Like, go to bed at this time. Wake up at this time, you can only eat at these times. You got to go to group here, you’ve got to do that. And we see a lot of patients, I guess rebel for lack of a better word because they’re like, No, I’m an adult. I don’t want to go to bed at nine o’clock. I want to stay up to 11. No, I don’t want to eat now. I want to eat an hour from now. And so you see a lot of that and it does come back to control. And so a lot of times, I think the big work outside of the hospital with someone who’s struggling is to figure out what can they control like, let’s figure out where they can get control back because you’re right, whenever anybody feels like they are losing control of their rights or their, you know, ability to say yes or no, I do or don’t want to do whatever it is you’re about, it’s going to be bad juju, bad juju.
Gabe Howard: But, Dr. Nicole, in a way, it also shows progress, right? They’re trying to take control of their own lives. One of the things that I often hear from the medical establishment is that, well, they’re not investing in their care, they’re not taking control of their lives, they’re not doing what they need to be doing to get well. They’re uninterested in getting better. And I think, OK, well, what exactly are they doing? And you say things like that, they don’t want to go to bed at nine o’clock, they want to go to bed. It sounds very much like they are trying to control their lives, just not in the way that you envisioned for them.
Dr. Nicole Washington: Yeah, it’s a fine line, I struggle a lot. You know, I do get into those moments where I’m like, Take the medicine, just take it. Like, let’s just take it, let’s just see, let’s just take it and you, you want that to happen so badly. Right? But it’s not because I just want you taking pills. It’s because I know that taking the medicine can help you then achieve those goals that you have, right? To get the job to, be in a relationship, to go to Hawaii, all those things. And I know that that’s the intermediate step. Unfortunately, it doesn’t always come out that way. It doesn’t always come out that the person prescribing the medicine says, Hey, I think if you took the medicine, though, it could help you with a, b and C. And if you if you do those things, those are the first steps for you to get to where you want to be and have that conversation. I think that’s where maybe some of the disconnect lies. But I will admit there are times when I’m extremely frustrated, and let’s be honest, there are times that you can’t have that conversation because the person is not in a in a good enough headspace for you to have that conversation.
Gabe Howard: These are the challenges of the bipolar community, and I’m so excited, Dr. Nicole, to do this podcast with you because listen, we’ll give you advice, we’ll give you definitions, we’ll tell you stuff, but you can Google that, right? You can get on Healthline and PsychCentral.com and find out all this information that you want. Our goal with this season is to talk more in depth. And, you know, I really like the sound of my own voice, so a podcast just seemed like the best fit for me. Dr. Nicole, did you have fun on your first episode?
Dr. Nicole Washington: I think it was fan-freaking-tastic, actually.
Gabe Howard: I love it, I love it. Dr. Nicole, it was fan-freaking-tastic, and to all of our listeners, thank you so much for tuning in. You have been listening to Inside Bipolar. My name is Gabe Howard and I am the author of “Mental Illness Is an Asshole and Other Observations,” which is on Amazon because, well, that’s where everything is. Or you can learn more about me and get the book signed by heading over to gabehoward.com.
Dr. Nicole Washington: And my name is Dr. Nicole Washington, and you can find me at DrNicolePsych.com, D R N I C O L E P S Y C H dot com, to see all the things that I have my hand in at any given moment.
Gabe Howard: Wherever you downloaded this episode, please follow or subscribe, it is absolutely free, and hey, can you do us a favor? Share the show with a friend or a colleague, whether you send them an email, a text, social media. Hey, you know, word of mouth is still a thing. Just please share the show because it’s how we grow. We will see everybody next time on Inside Bipolar.
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