The Dilemma of DualityPosted: December 11, 2011
My sister and I went to lunch today. When she called to discuss restaurants, she suggested a pricey place where we’d gone as an early Thanksgiving treat. Keep in mind that whenever we go out, I pay.
“That’s a restaurant for special occasions, Jerri. That’s not the kind of place I go for an everyday lunch.”
“Yeah, I know. I’m just hungry. And I was thinking about that wedge salad. It was so good and I feel like wine.”
“Well, I want it.”
“The place where we’re going doesn’t serve it.”
“Well then, let’s go some place else.”
Grrrr. It’s not that I have issues with wine. Or that I’m a cheapskate. Its just that Jerri has a dual diagnosis of bipolar disorder and substance use disorder—its irresponsible to buy her alcohol.
Jerri hates the substance disorder label. Moving here gave her the opportunity for a fresh start and she didn’t want me to tell any of the mental health professionals about that diagnosis. I couldn’t honor that request. She was in pretty bad shape and I’m not equipped to determine what is psychosis and what is drugs. When Jerri was in her 20’s, she was terribly addicted to cocaine. She believes the ECT treatments she had in her 30’s cured her of cravings and I’m pretty aware of where her money goes each month. I’m confident she’s not buying street drugs but I’d only be fooling myself if I didn’t acknowledge there are other ways to get them.
What most disturbs me is the unhealthy relationship she has with ADHD meds. I’ve seen her beg and conjole her psychiatrist and her internist for a prescription. In the past when she’s been told “no”, she’s looked for another doctor. That is a classic red flag. Bryce has been very clear that if she does that with him, she will lose Telecare as a service provider.
I’ve been quite vocal with both Bryce and her internist about my concerns. Bryce will not prescribe ADHD meds for her but her internist continues to do so. He sees her monthly and tests for substances each time before writing the prescription. I still think its a bad idea.
Ritalin is the only one of her meds that she never forgets to fill. It’s also a schedule 2 controlled substance. “I need it”—three of the scariest words in sister-of-dual-world— “and I can’t focus without it,” she says. “I can’t read. I can’t crochet. If you only knew what it was like for me when I don’t have it, you’d understand.” I am concerned that Jerri tries to solve every issue with medication.
Before she moved to her current living arrangement, she would hide the bottle or carry it everywhere she went. It was like her most prized possession. “Do you know the street value of this stuff? Everyone is after my medicine.”
In the past year, there have been about 6 times that her medicine has “disappeared” or she’s gone out of her right mind after filling the prescription or she’s “flushed it” because she’s realized she can’t trust herself with it. Really? Do I seem that naïve?
Once when we went to the beach together and I was keeping up with her meds, she took 4 pills when I wasn’t looking. She woke the entire house that night talking to herself. I thought she was having a manic episode until I did a pill count. She denied taking them and even went so far as to accuse my sister-in-law and my husband–utterly ridiculous to anyone who knows them. She became so out of control, I forced her into the car at 4 am and drove the 3 hours back to Durham where her case worker stepped in to help.
Afterwards, I started second-guessing myself. Maybe I’d been wrong and she was manic. Maybe I’d handled the whole thing terribly wrong. I contacted one of Jerri’s former psychiatrists – someone who’d been helpful to me in the past – and described the beach episode. Before I mentioned the missing pills, she said “that’s not mania, that’s substance abuse.”
And see, that’s my problem. I can’t always tell the difference. And I can’t rely on Jerri to help me. Jeffrey, a therapist, says, “You know how you can tell an addict is lying? Her lips are moving.” It’s incredibly difficult to have a relationship with someone you have to assume is always bending the truth.
How do you know when it’s mania verses substance abuse verses a side effect of her medication? Once she had an episode so bad, she couldn’t figure out how to put on clothes. Her internist found cocaine in her system. Jerri denied having any knowledge of how it got there – she said her rooming house mates must have slipped it to her. Jeffrey would say “lying” but her story is not entirely improbable. Both housemates were also unstable and she was not getting along with them. She found a new living arrangement shortly thereafter.
Another time, I stopped by and Jerri wasn’t herself. She wasn’t thinking clearly and had strange muscular contortions. I called Bryce, thinking she had taken too much of her medication, and he said what I was describing actually occurs when someone has missed 2 to 3 days of the antipsychotic she takes.
Its also difficult for me to view substance use disorder the same way I view bipolar disorder. I’m just being honest. Experts consider both to be biological illnesses. There’s a fine line between substance abuse, where a person might still exercise choice and quit, and addiction, where the brain is biologically transformed with insatiable craving. How do I know she’s actually crossed that line and this is not just self-medicating?
In the end, I’m not sure it really makes that much difference. What I do know is the old adage you-got-to-let-em-hit-rock-bottom doesn’t work with Jerri. So I’ve had to draw boundaries. I’ve told her I don’t believe Ritalin or drugs like it are in her best interest. I will not help her with this medication. I won’t drive her to the pharmacy to pick it up or to her monthly doctor’s appointment. And I will not listen to any stories about how it mysteriously disappeared or someone stole it or how it must have fallen out of her backpack on the bus. My sister may be bipolar but she is still an adult free to make her own choices even ones that interfere with her recovery. I cannot control her. I can only control me.