I’ve published a piece on bipolar and spirituality. The link is here.
Matthieu Zellweger, Ph.D., a Swiss scientist and photographer, shoots haunting, surreal and journalistic pictures of manic depression that make it seem like the subjects are experiencing unreality in real time. The pictures in “Worlds Beyond” featured in the scientific journal the Lancet are staged but give one the feeling of experiencing the states in which the subject has experienced. His journalistic work on the subject were documented in “Invisible Handicap,” which can also be viewed on his web site. The pictures have a haunting beauty of this otherwise mysterious, sometimes frightening illness. The surreal-like quality of “Worlds Beyond” helps bring one immediately into the mind of the subject. I interviewed Matthieu about “Worlds Beyond” after reading his essay in Navigating Bipolar Country by Merryl Hammond. His work has been featured around the world in many publications such as the New York Times. Here is a transcript of our chat.
AZ: Where in Switzerland are you?
MZ: In Rolle, near Geneva, in the French-speaking part of Switzerland
AZ: What type of cameras do you use? digital, print or both?
MZ: Both, depending on the specific project. The project “Worlds Beyond”, and the eponymous book was shot only digitally, however.
AZ: Where did you do your education for photography and health science?
MZ: I am an autodidact photographer. As an adult, I participated in a few carefully selected Masterclasses. For the health science part, I was educated and trained in Switzerland (Ph.D) and Japan (Post-doc).
AZ: What is your process for creating the dreamy effect in your work?
MZ: Slow speed, mainly, and the right amount of movement, lighting and instinct.
AZ: How do you capture people going through manic episodes?
MZ: I met only few people during manic episodes. All people featured in the book were in a stable period of their life and/ or disease. For people during manic episodes, I asked for permission, then usually secured a second and a third level of consent by, for instance, contacting the person again at a later stage or asking the doctor looking after that person if the consent was acceptable or not. Some pictures that I have shot around people unable to give a suitable agreement were simply never published or used.
AZ: What was your interview process like?
MZ: For the pictures in the book, I only selected people whom I had already met and interviewed for the first, journalistic part of the project. They were all in a stable period of their life and/ or disease. I recontacted them and asked if they would be willing to share with me some details of their choosing on their own manic phases. Then I reconstructed images based on these details and, with their agreement, staged them. All the pictures in the book are thus deeply personal to the subject on the pictures because they are reconstructed using elements specific to that one person and nobody else. The images are also staged, posed and later validated by the people who participated. In that sense, they are not journalistic, but artistic. The journalistic images of this project are kept separate in a project titled “Invisible Handicap”.
AZ: What is it like to play the voyeur in someone experiencing unreality?
MZ: I do not know. The role of a photographer is to uncover realities that society prefers to ignore, to show the invisible. My work ethics is such, however, that I am extremely careful to secure the agreement of all parties before I start shooting. This is even more the case for staged pictures, such as the ones in “Worlds Beyond” inasmuch as the protagonists in the pictures took an active role in giving me details about their manic phases, agreed to the project and the pre-arranged shootings, etc. This was very much a collaborative effort.
AZ: How is photographing mental illness unlike documenting your other work?
MZ: Mental illness is, as one protagonist put it, an invisible handicap. It is more delicate to show something invisible.
AZ: What countries did “Worlds Beyond” take place in?
MZ: Switzerland, UK, USA
AZ:Was it exhibited in any place besides the Lancet? like a gallery?
MZ: It was not, but it was widely featured in newspapers, magazines, television. It still may be exhibited at a later stage. In addition, the third part of the project, “His Name Was Alban” was exhibited in Switzerland and printed as a portfolio of conceptual, fine art photographs.
AZ: What was your thinking about capturing manic depression using the blurry effect?
MZ: I did capture it in many different ways, since the entire project had three chapters: “Invisible Handicap”, “Worlds Beyond” and “His Name Was Alban”. Only the latter two use the blurry effect. Initially, I saw it as a suitable way to distinguish the journalistic images from the staged ones. Later on, it became clear that it was rather adequate to describe the inner mental space of someone who had, literally, taken me into their mind.
AZ: What is your favorite photograph in “Worlds Beyond”?
MZ: Not sure I have a favourite one. They all tell a story, perhaps several stories, to the extent that they talk about one person and about the connection that I established with that one person, the trust they placed in me and, sometimes, the friendship that resulted.
AZ: You have a scientific background. How does it interplay with your art?
MZ: It helps me start a new project by exploring quickly the state-of-the-art knowledge on a question I might ignore all about. It also guides my choice of topics to photograph.
AZ: Have you documented other health related stories in photography?
MZ: Yes, several: stillborn children; domestic violence inflicted upon men; depression; suicide survival.
AZ: Who are your photographic inspirations?
MZ: Anyone able to tell a story, stir emotions and surprise me by taking me on a journey with a photo essay.
To view his “Worlds Beyond” series please visit https://matthieuzellweger.com/en/photographies/worlds-beyond. To view his other work, visit http://www.matthieuzellweger.com. Matthieu Zellweger is represented and distributed by Haytham-REA, Paris.
Disclosure in Romantic Relationships is Important to Increase Understanding about Mental Illness
My mania plays out in rapid speech, racing thoughts, odd ideas at all hours, little to no sleep. My manic hypersexuality has led to a one-night stand and many unpleasant relationships, the kind where it’s ticklish when you later bump into him in the supermarket. I was married to my manias, with no hope for a “normal” life with a “normal” man. That’s why when I met Robert at the synagogue where I worked, I felt ambivalent about entering a new relationship with anyone.
In college, I was diagnosed with rapid cycling, type 1 bipolar disorder. I dated but the relationships usually ended before I disclosed my illness. I left men wondering about my eccentric behaviors, wild nights, and strange ideas about the world. I felt broken.
There was also this: I couldn’t have children. My psychiatrist had warned me that pregnancy could worsen my moods and psychosis and getting off meds was not an option. If I got pregnant, I would likely end up hospitalized, which my family was trying hard to avoid. Having been hospitalized a few times, another might break us emotionally and financially.
My father reassured me that couples without children had more freedom. He said, if you want to nurture someone, adopt a cat. I didn’t want to be a spinster with her cats; but I didn’t need more bad relationships.
So, when Robert walked into the synagogue that day, my back was up. He was six-foot-four with sweeping brown hair like Hugh Grant in Notting Hill. I couldn’t help but feel attracted to him physically. I chatted with him like he was just another congregant, brushing off his flirtation. I pretended not to notice his advances. He brought in gifts, cards and made a donation to the synagogue when my grandfather died.
Inevitably, my hypersexuality kicked in and I decided that Robert would be good to fool around with, a friend with benefits. I agreed to a date at Starbucks, although I still wanted to play hard to get. Over conversation I learned his brother, mother, sister-in-law, and dog had recently died and he lived alone. This was perfect for fooling around, I thought. If we went to my place, my overbearing Jewish mother would be home.
The date went well, and we talked over Messenger every night from there on. We shared this kinetic sexual energy plus I could talk to him about anything. One night, we fought about how I was putting him off.
He called me “crazy.”
I knew it was the time to disclose my bipolar. I felt myself falling for him and this would be the way to avoid heartbreak; I could disengage without too much hurt on either side.
So, I sent him an email, something new for me. I usually slammed the door in men’s faces well before I had to hear their reaction.
I think I love you despite our differences. But there is one thing you should know about me before we move forward in our relationship. I have this thing called bipolar disorder. It doesn’t change who I am or my love for you, but it does come with intense swings of high emotion. I can understand if you have fears about getting more involved with me. There is most likely going to be trouble sometime in our love story, but there will be good times as well. I hope this doesn’t change your mind about me.
Then I waited.
I received his email a day later. He wanted to talk at his house over dinner. I was terrified, but agreed to go, figuring he just wanted to let me down in person, like a gentleman. When we talked, I painted a picture of what my illness had been like and what would become if I went off lithium and my antipsychotic.
To my astonishment, he responded with unconditional love. He divulged that his brother had struggled with mental illness and alcoholism. I didn’t promise him that my illness wouldn’t rear its ugly head in our relationship, but I promised honesty.
Six months later, I introduced him to my psychiatrist. Another few months later, we were engaged. We have a loving, fun marriage for 11 years and adopted a kitty named Sunshine.
“Because Black people are less likely to be diagnosed with ADHD at younger ages they are more likely to develop a substance use disorder,” Strohl said. “It is systemic to associate certain groups of people with certain substances such as marijuana. We need to have a better conversation about substance use.”Katrina Strohl
Katrina Strohl (They/She/He) is the creator of the podcast Absolutely Not! About setting boundaries in the workplace and emphasizing the vocabulary needed to name harm in those spaces. Katrina is a psychological safety consultant, boundaries strategist, and mental health advocate who identifies as Black and Samoan and Queer. In 2018, she tried to end her life and while in the hospital was diagnosed with Post-Traumatic Stress Disorder PTSD, Major Depression Disorder, and substance use disorder. But more recently, she was diagnosed with Attention Deficit Disorder and Hyperactivity ADHD. Katrina is a veteran who served as an aviation structural mechanic in the US Navy.
During Katrina’s first hospitalization, she was one of two Black women and was constantly called the other woman’s name.
“We are at the lowest point in our lives and constantly dehumanized,” Strohl said.
Most of the time during the hospitalization Katrina spent going to sessions and lying their way out of the hospital. Katrina was a single mother of a three-month old son and they needed to get back with their son. The hospital let her go in four days.
Two months later Katrina took their own life again. Katrina had no support as a single mother and when they had to breast pump or take their son somewhere Katrina’s employer in the office she worked as an administrative assistant didn’t understand. They brought Katrina into a room and criticized and berated Katrina.
“I felt like I didn’t have a place on the planet anymore,” said Strohl.
During her second hospitalization, Child Protective Services got involved and made Katrina prove that their son lived in a happy, safe family or he would be taken away.
“This is when I decided I needed to move forward and figure out what we needed to be safe,” Strohl said.
“I left the practitioners who diagnosed me with PTSD, MDD, and substance use disorder because they weren’t helping me,” Strohl said. “They didn’t give me resources I needed to feel better.”
Katrina then went to a few white, women therapists who acted dismissive whenever she brought race into the picture.
“A Black woman therapist was the first person who taught me about boundaries that most people learn in their first therapy session,” Strohl said.
Katrina doesn’t take medication anymore and has a new Black woman therapist; the old one turned out to be homo/transphobic. This therapist correctly diagnosed her with ADHD. This was shocking to Katrina but she felt it rang true when her therapist asked her during her evaluation if she felt like she had a motor inside her that never stopped. Katrina cited an article that said Black children are less likely to be diagnosed with ADHD and it often leads to suicide.
“I’m still processing the diagnosis and I cried a lot in the final assessment because it rang true,” Strohl said.
“Growing up there was an ugly stigma toward ADHD in the black community,” Strohl said.
“Because Black people are less likely to be diagnosed with ADHD at younger ages they are more likely to develop a substance use disorder,” Strohl said. “It is systemic to associate certain groups of people with certain substances such as marijuana. We need to have a better conversation about substance use.”
Today Katrina is self-employed and works with organizations to make them aware of what psychological safety looks like and how to create boundaries for employees.
“I create boundaries in everything I do. Every facet of my business helps me hone into who I am.”
“I have to figure out new boundaries because I live with ADHD.”
“With the PTSD, I cannot be in emotionally activating conversations for longer than 45 minutes and I cannot be interrupted or my thoughts will derail.”
“Sometimes my work makes me sad and the responses I get from my posts on social media is eye-opening as people with my shared identities and lived experience have been through the same things.”
Katrina knows their work is creating a safer world for their son to grow up in. Katrina can be found at http://katrinastrohl.com.
How reframing my inner dialogue makes all the difference
I’m an over-thinker as most bipolar people are. My inner critic constantly berates me. I let him, who I call Arthur, live rent free in my head. As a result, I don’t feel good enough, like my writing is not good enough for publication. It’s an endless cycle.
Since being diagnosed bipolar 1 over twenty years ago, it’s a struggle to accept compliments or believe in myself. I simply have had made too many mistakes, had disastrous manias, and despairing depression. It’s hard to love yourself and find your purpose when mania has made you a slut, an imposter, and a generalist with no follow through.
I want to become someone who commits and completes projects not someone so embodied by imposter syndrome that she feels her voice is not needed in this world, that she does not deserve the good that will come from her hard efforts.
I use affirmations in a journal daily, practice gratitude, and meditate emptying my shell of all negative thoughts about myself. But sometimes my inner critic can be so powerful.
My therapist suggested a combination of dialectical behavioral therapy (DBT) and cognitive behavioral therapy (CBT). She said I have to reframe my inner dialogue and stop ruminating on the negative. She said I needed to make a list of the past events that trigger my thoughts and then write a conversation with each of them, a sort of saying good-bye but also learning the lesson they taught me.
Since I am a writer, I thought having this conversation with my inner critic would be as easy as telling him to pack up and go. How wrong I was. I sat with my notebook blank for a long time in the coffeeshop. I was afraid of my own power, fearful of letting go of what would happen if my words became a self-fullfilling prophecy. After five minutes of twiddling my pen, I began to write in my perfect journal with my sketchy handwriting.
I began telling my inner critic how he was hurting me and my career as a writer. He answered me back with snide comments and slurs I cannot write here. But somehow through writing a conversation with him I realized some truths about myself.
I broke through my resistance by telling myself that I am enough. I just needed to cut through the bullshit and show up in this world giving it my all. I needed to work harder than the rest but not feel I had to be smarter than them. Giving my all was all I needed to do, to be.
I had to stop comparing myself to others and caring more for what others were doing. I needed to put myself first. One of my favorite authors Dani Shapiro says one must write in the dark before they can truly understand and experience criticism or praise of their work. I had to put myself in this proverbial creative cave by not caring about what others thought of me or how their work was somehow better than mine, how their voice was somehow more relatable.
Of course, writing in the dark in the days of social media and a constant barrage of news and features on others doing extraordinary things can be hard. The blue light of the pulsing tweets and posts made head spin with envy and self-doubt. My therapist suggested as a rule I only go on there once a week and spend only 15 minutes scrolling. She also suggested I stop checking other people’s web sites and blogs incessantly. I needed to put me first.
I began to incorporate these ideas into my daily writing schedule and I found that my writing became deeper and insightful. I found that I could remember more of what really mattered. I found that telling myself that “I am enough” gave me the power to tune out the other voices, especially that of my inner critic.
So, get yourself a notebook and a pen and begin to have this self-conversation today. Don’t wait! After all, you are enough.
How PTSD Becomes Self-Sustaining in Civilian Survivors of War
Research maps out how trauma takes on a life of its own
New research on Balkan war survivors sheds light on the persistence of PTSD.
As the war in Ukraine wages, and the world watches millions of refugees flee for their lives, we are reminded of countless prior wars. While media attention mobilizes our outrage and the outpouring of immediate help to affected civilian populations, what happens after the wars end?
We know that war takes a massive toll on the people, but our understanding of how the effects unfold for years after is still evolving. Do we forget to pay attention after the cameras stop rolling? What can we learn from past wars about post- traumatic stress?
PTSD Begets PTSD
Researchers Schlechter, Hellmann, McNally and Morina conducted a study of civilian survivors of 1990s Balkan wars, including those who had stayed in their countries of origin (including Bosnia-Herzegovina, Croatia, Kosovo, Macedonia and Serbia) and those who had settled in Germany, Italy and the UK. The results wee recently published in the Journal of Traumatic Stress (2022).
Study authors focused on PTSD among war survivors to understand how symptoms emerge and change over time, and specifically how earlier symptoms predict and maintain later symptoms. Common symptoms of PTSD, including avoidance of trauma and emotional numbing, get in the way of people getting treatment, as do systemic issues like stigma and lack of resources, including paucity of qualified clinicians and lack of screening in at-risk groups in primary care settings.
Up to 227 million adult war survivors are estimated to have PTSD. A systemic review of PTSD and Major Depressive Disorder (MDD) (2021) in countries affected by war in the last three decades suggests that 316 million people suffer from war-related PTSD and/or MDD. Half of the people in that study had both PTSD and depression, with about a quarter of people having one or the other, but not both.
PTSD can take on a life of its own, especially if left unchecked. Once trauma sets the brain off on a dysregulated pathway, it can become a self-regenerating system. Brain network activity is altered by trauma; for example, we may miss what’s right in front of us-problems in a relationship, a health issue-because we are so busy guarding against the return of past threats. Intrusive memories of past trauma may trigger further hyperactivation, leading to a cascade of symptoms.
Avoidance, akin to procrastination, may reduce short-term distress at the expense of preventing long-term restoration because we cannot become desensitized to traumatic memories. Understanding the specific pathways by which PTSD is sustained is key for successful intervention.
Survivors of War
Schlechter and colleagues recruited several hundred civilian war survivors to arrive at a final group of 698 participants, who were assessed for symptoms eight years post-war and then again one year later. Participants completed the Life Stressor Checklist-Revised to appraise stressful (potentially traumatic) experiences before, during and after conflict. PTSD was assessed using the Mini-International Neuropsychiatric Interview and the Impact of Events Scale-Revised.
PTSD symptoms of re-experiencing/intrusion (memories, intrusive thoughts, nightmares), avoidance/emotional numbing, and hyperarousal ( fear/ panic, being easily startled, rage, etc.) were analyzed using network theory to determine first the correlations among symptoms at each time point and, second, the relationship between earlier and later symptoms, to show which symptoms in the present cause which future symptoms ( causation).
The Anatomy of PTSD
Eight- and Nine-Year Time Points
Overall, there were moderate to high levels of trauma, with average IES-R PTSD scores of 2.45 at 8 years and 1.98 at 9 years (with 4 being most severe). The most frequent traumatic experiences reported were lack of food, lack of shelter, shelling, siege, and finding out a loved one had died violently.
At each time point (cross-sectional analysis)-eight years and nine years post-war-findings were similar for PTSD . The symptoms most strongly connected to PTSD were trouble staying asleep, trouble falling asleep, feeling as if trauma weren’t real or hadn’t happened, feeling numb emotionally, trying not to think about trauma, and trying to remove trauma from one’s memory.
Post-Traumatic Stress Disorder Essential Reads
There was a moderately strong correlation between thinking about trauma when one did not want to and avoiding getting upset if thinking about trauma (suppressing emotion).
Symptoms with the strongest impact (“expected influence centralities”) were having strong feelings about traumatic experiences, being jumpy and easily startled, and trying not to think about traumatic experiences. Network patterns were equivalent at eight and nine years post-war, but overall symptom severity decreased somewhat over time.
Which Symptoms Cause Future PTSD to Persist?
Looking at how earlier symptoms lead to later ones, network analysis (“cross-lagged panel network”) found five key relationships, in order of descending strength, as shown in the graph above by arrows connecting one symptom to the next. Thicker arrows indicate stronger causality:
- Difficulty concentrating led to trying to remove trauma from one’s memory.
- Difficulty concentrating led to trouble staying asleep.
- Trouble staying asleep led to pictures about trauma popping into one’s mind.
- Trying not to talk about trauma led to trying to remove trauma from memory.
- Reminders of trauma causing physical reactions led to difficulty concentrating.
The biggest predictors of future PTSD symptoms were:
- Getting physical reactions from traumatic reminders.
- Difficulty concentrating.
- Trouble staying asleep.
The symptoms most caused by prior symptoms were:
- Avoiding letting oneself get upset.
- Trying to remove trauma from memory.
- Acting like one was back at the time of the trauma.
- Dreaming about trauma.
Unpacking the Persistence of PTSD
Participants in this sample had a significant burden of post-traumatic symptoms, reflecting the findings from earlier studies on war trauma. Eight years later, they continued to report a high level of symptoms, which were lower the next year. It’s tempting to wonder whether participation in the study itself had a therapeutic benefit, by combating avoidance and raising awareness of problematic symptoms.
Only 38.4 percent of the participants had received mental health services, and yet almost 90 percent had seen a primary care practitioner, highlighting the critical importance of screening in primary care settings.
Addressing the identified pain points may be useful in hastening the resolution of PTSD, a subject that future research can clarify. Reducing avoidance-gently increasing engagement with trauma-is important for treatment to be effective and key to recovery for many PTSD sufferers. Improving concentration may help improve sleep quality, which in turn could reduce the frequency with which traumatic memories spontaneously arise. Reducing traumatic memories reduces reminders of trauma, which would then be expected to reduce physical symptoms interfering with concentration. Body work can address physical symptoms of trauma, which increase traumatic reactions, and so on.
I Am Not My PTSD
Traumatic dynamics can end up taking over how our brains process information, experience, and relationships. Trauma can overshadow regular day-to-day experience long after the threat has passed, creating an all-present context that may be significantly disconnected from what is actually happening and leading to frequent distorted perceptions, misunderstanding, functional disturbances, and maladaptive coping.
In the extreme, PTSD may be mistaken for one’s personality, especially with early or pervasive trauma, making it difficult for people to get in touch with their authentic sense of self and shaping life choices in regrettable ways. Recognizing PTSD and addressing key therapeutic levers is a potential game-changer: The often difficult work of recovery pays off with less future regret and greater self-regard, security, and life satisfaction. We have a clearer understanding of how war causes PTSD on a collective level, and left wondering how PTSD contributes to future outbreaks of war through triggering, avoidance and excessive aggressive reactions to perceived threat.
In1 = Any reminder brought back feelings about it; In2 = Other things kept making me think about it; In3 = I thought about it even when I didn’t mean to; In4 = Pictures about it popped into my mind; In5 = I found myself acting like I was back at that time; In6 = I had waves of strong feelings about it.
Av1 = Avoided letting myself get upset when I thought about; Av2 = I stayed away from reminders of it; Av3 = I tried not to think about it; Av4 = Lot of feelings about it; but didn’t deal with them; Av5 = I tried to remove it from my memory; Av6 = I tried not to talk about it.
Ha1 = I felt irritable and angry; Ha2 = I was jumpy and easily startled; Ha3 = I had trouble concentrating; Ha4 = Reminders of it caused me to have physical reactions; Ha5 = I felt watchful and on guard.
Nb1 = I felt as if it hadn’t happened or it wasn’t real; Nb2 = My feelings about it were kind of numb.
Sd1 = I had trouble staying asleep; Sd2 = I had trouble falling asleep; Sd3 = I had dreams about it
Hoppen TH, Priebe S, Vetter I, et al. Global burden of post- traumatic stress disorder and major depression in countries affected by war between 1989 and 2019: a systematic review and meta- analysis. BMJ Global Health 2021;6:e006303. doi:10.1136/ bmjgh-2021–006303
Schlechter, P., Hellmann, J. H., McNally, R. J., & Morina, N. (2022). The longitudinal course of posttraumatic stress disorder symptoms in war survivors: Insights from cross-lagged panel network analyses. Journal of Traumatic Stress, 1–12. https://doi.org/10.1002/jts.22795
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Originally published at https://www.psychologytoday.com.