Book Review by Kevin Wolf
Ellen Forney’s newest book, Rock Steady: Brilliant Advice from My Bipolar Life will be a very helpful tool for many. Rock Steady covers bipolar mood disorder in particular, and mood disorders in general. The book provides coping tools and treatments. It’s not a graphic “novel,” because it’s a work of non-fiction that can be used as a teaching tool for the general public and health care providers interested in the topics. It has no continuing characters, except the author, who appears infrequently; and is mostly text though there are cartoon images throughout. I recommend this work for what the reader can learn about bipolar and other mood disorders, and it’s helpfulness for those considering treatment.
With the recent deaths of designer Kate Spade and chef Anthony Bourdain, mental health issues have been the topic of much discussion in the media. Newscasts often discuss the growth in suicides over the last decade and that females’ ocurrence rate is getting closer to that of males. The National suicide prevention lifeline (1-800-273-8255) is often provided. But so much more is needed. This book is a strong step in that direction.
The book’s introduction shows a cartoon character with wide open eyes telling the reader, “Hi! I’m Ellen Forney, bipolar cartoonist.” Her prior graphic work, published in 2012, was a memoir called Marbles: Mania, Depression, Michelangelo, & Me detailing her diagnosis, and coping, with bipolar disorder. Both books define the main mood disorder types: Bipolar I (Forney is here) & II, cyclothymia, unipolar depression, and dysthymia; and use a rising & falling carousel with the patient riding the range of mood states: mania, hypo-mania, mixed states, rapid cycling, euthymia, dysthymia, mild depression, and depression. Differences between Marbles and Rock Steady include the former spending a lot of time on Forney’s diagnosis, while the latter details symptoms and traits of mood disorders. Her personal coping tools are provided in the former while the latter is more general about coping and treatment for those diagnosed. And Marbles is more of a story, while the Rock Steady is a teaching/learning tool with less cartoon images and a lot more text. Rock Steady doesn’t find it necessary to include a caveat that the reader should consult their health care provider for diagnosis, treatment, and prognosis for their healthcare needs, because throughout the book that advice is clear.
Forney provides the positive and negative effects of treatment. For example, Forney’s mood stabilizers for fourteen years were lithium and lamotrigine. She had calcium build up (hypercalcemia) from taking lithium which can lead to depression, osteoporosis, and kidney stones. To figure out what to do she started writing a “stability maintenance guide” resulting in Rock Steady, which is “tools to comfort ourselves, recognize danger signs, & just live with a good deal of uncertainty & craziness.” The chapter titles are: Basics (what, where, when), Therapy, Coping Tools, Insomnia, Dealing with Meds, The Danger Zone, You Have Company, and You Rock. The end of the book provides resources, bibliography and index. Forney’s overall goal is stability while dealing with expected and unexpected change. She creates a mnemonic character SMEDMERTS (Sleep—get enough; Meds; Eat; “Doctor”—i.e., appropriate health care provider; meditation-Mindfulness; Exercise; keep a Routine; coping Tools; emotional & logistical Support system). She writes the first two are “key key” while the rest are “key.” Forney indicates that bipolar disorder comes with a non-regular body clock, so routine must be more deliberate. She shows a tool belt for coping tools. Page 22 shows a good summary of SMEDMERTS as interlocking gears. Forney defines stability as finding and maintaining balance. She’s sensitive to a persons’ access to and affordability of care. She suggests taking this pledge: “I’m not alone, things get better & worse, I can do it. SMEDMERTS! (And kiss the back of your own hand for self-appreciation & respect).” There is some relevant guidance here for all of us.
Under the therapy chapter, Forney writes, “the ultimate goals are to stabilize in the short term & stay stable for the long term …” This chapter provides the symptoms of manic and depressive episodes with visual aids like climbing hills and sliding down into holes. Forney provides her peaks and troughs as being non-existent through early 20s and then up and downs getting worse to her diagnosis at 30. She discusses misdiagnosis often as depression only, because few seek treatment during a manic event; and it’s implied that they don’t mention manic occurrences when being diagnosed. “A diagnosis should come from a knowledgeable mental health specialist,” she writes. She discusses the main mental health providers: psychiatrist, psychologist, primary care doctor, social worker, counselor, and psychiatric nurse. It’s common for help to come from two providers one for talk therapy and one for medications; and a psychiatrist can do both. Forney covers insurance, referrals, and other sources to find a provider. Forney touches on misconceptions; personal, cultural or religious blocks to seeking therapy; and not finding a therapist with a specific desired background, like your own background. She discusses therapy types: psychotherapy, medication, cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), among others. She shows a therapy session with simple drawings and footnotes interpreting what the patient and therapist are really meaning. Under medications Forney includes cautions; e.g., don’t use medication only for treatment, but use some form of talk therapy as well. She provides a page on each therapy method and hospitalization. She discusses financing methods, especially insurance, community mental health centers, and financial assistance from federal, state, or pharmaceutical companies.
Forney wants the reader to treat coping tools as a fun puzzle and shows jigsaw pieces for tools to be “easy” (make efficient habits), “convenient” (like sleeping pills on night stand—though not necessarily out of reach of children), and “ideally entertaining” (to keep interested). The tools are meant to calm and center a person. The tools might include creativity (journal, drawing, doodling, tracing, coloring book, hobby), comforting things (theater, movies, stuffed animal, reading, music (she even provides several of her playlists), being kind to yourself, working your body (bathing, posture, gentle exercise), different methods of calm breathing (Forney demonstrates one with a balloon animal), yoga, meditating mindfulness (Forney recommends cartoonist, Yumi Sakugawa’s book, There Is No Right Way to Meditate), make lists or charts, using mantras, crying/not crying, cold water, reaching out to others (friends, relatives, and support group), among other tools.
Insomnia is a problem I have periodically for a night or two. Forney writes, “Insomnia is cruel. Sleep is our #1 priority, so how can it be so evasive?! Forney doesn’t provide statistics. According to SleepEducation.org on June 15, 2018 for the general population 30-35% have brief insomnia (probably where this writer falls), 15-20% have short-term insomnia disorder less than three months, while 10% have chronic insomnia occurring at least three times per week for three or more months. Among bipolar disorder patients insomnia is pervasive (70% or more in manic or depressive phases; according to the article Sleep Disturbances in Bipolar Disorder Across the Lifespan by Allison G. Harvey, Lisa S. Talbot and Anda Gershon; Clinical Psychology, June 2009, 16:2, 256-277). Forney provides sleeping and awake tips, going to bed process (including limiting media screens, be careful with meds), going to sleep process (e.g. using relaxation techniques, white noise, apps), dealing with waking up after too short sleep (Forney’s biggest sleep problem), and advice on jet lag. Forney briefly mentions hypersomnia (excessive sleep from depression) and dealing with it.
Forney covers frustrations with medicines (prescription drugs mostly). She says taking meds doesn’t mean you’re weak, but your goal should be to get off meds, if possible. Most of her chapter on meds is for those who find meds necessary long-term. Stopping meds might result in relapse which might be more dangerous than just staying on meds; though long-term use can have its dangers. Meds can have side effects. As Forney writes, “Mood disorders are recurrent, so we have to deal with them over the long haul, somehow.” Locate meds conveniently, identify them clearly, remember to take them, and don’t double up if you ever forget to take them, she advises. Forney mentions some specific drugs, but often doesn’t explain their purpose or side effects. She discusses pill cutting, how to swallow them, not losing pills on floor, using pillbox (knowing each one) or daily dispenser, traveling with meds (including getting more than those packed), and keeping a med schedule. Keep your doctor informed of any side effects. Forney lists some solutions that might work for the most common side effects (memory problems, weight gain, and sexual problems). She shows a somewhat humorous general flowchart on “can I hang with these side effects?”
The longest chapter is called The Danger Zone to “predict, recognize, and prevent or stop an episode while there’s still time to check all the gauges, make a plan, take those steps, and/or get help.” She distinguishes between red flagpoles (stressful situations) and red flags (warning that bipolar episode might come without further intervention). The individual should be prepared for both situations. Such “flagpoles” might include, seasons changing, life change (new job, losing job), grief, changing routines, travel, loss of sleep, treatment issues, isolation, and illness/injury. Forney provides a footnote that it’s important to get an accurate diagnosis (e.g. for situational depression vs. full on bipolar depression phase). Mania red flags might be: disrupted/decreased sleep, high energy, low appetite/eating, excessive money use, mind blowing plans, and excessive sex; while depression red flags might be: lack interest in enjoyable things, in-/de-creased sleep or eating, less time with family/friends, anxiety, sadness, not concentrating, skipping personal hygiene or daily tasks, aches, tiredness, and irritability; and for both mania/depression: crying a lot, very hyped/sensitive, quick mood changes, touch sensitivity, taking things very personally, anxiety, restlessness, and obsessing. Forney provides some coping tools for some of these flags/poles, like identifying your dangers with journal, chart, perceptive doctor/friend/other; taking meds, using tools in earlier chapters as an anchor; track events/mood changes, journaling.
Forney gets very personal by annotating red flags in samples of her journal entries from 2004 during a hypomania period. These might be helpful for the journaling readers, early warning, coping, treatment, prevention, etc. Forney has two pages (138-9) on suicidal thoughts, resources and help. She mentions there are LGBTQ, hearing impaired, and teen hotlines under resources at the book’s end. Forney, in panels, shows an interview with a National Alliance for Mental Illness (NAMI) Seattle volunteer on her inpatient psychiatric stay which had helpful and unhelpful aspects. Forney covers substance abuse, typically pot (generally excluding medical cannabis) or alcohol, which applies to at least half of those with mood disorders. Staying sober is most helpful to working on mood disorders. Forney gives some questions to ask yourself to help decide if substance abuse is maybe, probably or definitely a problem.
Forney provides some statistics in the penultimate chapter on not being alone. She indicates 18% of people have some mental illness, including 10% with a mood disorder, including 3% with bipolar disorder. To not feel alone, she suggests finding people like yourself or their stories. She gives some possible books (e.g. Kay Redfield Jamison’s An Unquiet Mind), music, movies, documentaries (e.g., Stephen Fry’s The Secret Life of the Manic Depressive), websites (e.g., Depression & Bipolar Support Alliance (DBSA)), support groups, and events. She caveats message boards that the user would often know little about the person doing a post. She discusses coming out about one’s bipolar disorder. And she provides “a note on stigma.” It’s important, as Forney writes, to “Be okay with who you are” and “Feel the strength in allowing yourself to feel vulnerable.” Forney has a large collection of current celebrities, musicians, actors, memoirists, writers, social scientists, athletes, and historical figures that have or had mood disorders. For example, Forney says the soul-sucking dementors in the Harry Potter series were metaphors from J. K. Rowling’s depression.
There are a few things I take issue with in this work; some are minor. A couple of times there’s a mislabeling of chapter numbers in the Basics chapter 1. Sleeping tools are in chapter 4 not 3 (page 12 box at bottom of page); and medicine is covered in chapter 5 not 4 (page 13). Forney leaves out the affordable care act with its financial supports and requirements to cover mental health; and she doesn’t mention the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 as amended under the Patient Protection and Affordable Care Act of 2010 “that generally prevents group health and health insurance issuers that provide mental health or substance use disorder (MH/SUD) from imposing less favorable benefit limitations [e.g. co-pays or number of visits or maximums] on those benefits than on medical/surgical benefits.” www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html
Forney shows merit badges with unclear symbols at the end of every chapter. She indicates they’re for giving yourself credit for completing something. Because there are over sixty of them, I would think someone might get stressed because they haven’t done some or a lot of them. I suppose a person could use them as rewards, awards, or things to do. But once cut out, it would be hard to remember what almost any of them mean, like the “effective therapy(ies)” badge looks like a toaster with a single slice of bread sticking out of it.
These shortcomings aside, Forney’s newest work is very worthwhile for those in need of, wanting to help provide, or simply learn about, advice related to mood disorders.