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Thank You for Apologizing

Simple words, and so important. Apologizing is hard, taking responsibility is hard. It’s especially hard for someone like my sister, whose mental illness (a form of paranoid schizophrenia) inclines her to perceive the world as a malevolent place, where people try to confuse and hurt her. When someone does something as hard as apologizing after someone does something so hard, that person deserves credit. Getting this kind of credit makes it easier to take responsibility next time it happens, makes another apology more likely in the future. And it just seems like the decent thing to do. The gracious thing to do.

But accepting an apology can also be very hard. When I feel injured, unappreciated, wrongly accused, it takes a while before I can accept an apology. With my sister, even though it’s hard for me, it’s critical to do this, and do this quickly. If I don’t, then we’re still fighting, things are still tense. My sister does not tolerate tension well. Things may well escalate, and I may then hear about it from someone else – her flatmate may call to tell me that my sister is shouting at her, or my sister may cancel her therapy appointment – and in all those cases, everybody loses. For all these reasons, it’s important to acknowledge times when my sister takes responsibility for her behavior and apologizes, and to do so quickly. But it’s so hard.

Today I was on the phone with my sister, talking with her about her schedule for tomorrow. First her social group, then the individual therapy appointment which she had rescheduled from Friday to Wednesday. We were going over the transportation schedule when my sister said “I can’t find my wallet, so I don’t have a way of paying for my rides.” I was not in my best form, I’m afraid. I was tired of her misplacing things, tired of having to figure out her schedule, tired of feeling like 50% of my life’s energy is going into her – in short, tired of being a primary caregiver. So I gave in to my anger and stress and replied snarkily with something like “well, I suggest you look for your wallet and, if you can’t find it, call everybody you’re supposed to see tomorrow and cancel.”

I made so many mistakes in that single sentence, provoked her in so many ways, and of course she got upset. She began swearing at me. I promptly hung up. I made a rule a long time ago, which has actually served me very well, that whenever my sister is screaming and/or swearing at me, I end the conversation and give her time to cool off before getting in touch again.

A couple of minutes later, I saw my sister had left me voicemail. I checked it and, unbelievably, she was saying that she’s sorry she shouted at me and that her wallet had “reappeared” (I wish she said “I found it” instead of “it reappeared”, but that’s a battle for another day). I realized right away that when I talk with her, I should thank her for apologizing and tell her how impressed I am. But I was still angry with her, and it’s hard for me to pivot emotionally so quickly, even though she did the right thing by apologizing. I am well-aware that her short temper and verbal aggression are related to her brain injury, which leads to difficulty with impulse-control. But I am also human, and feel insulted and unappreciated when she is aggressive toward me (even though, in retrospect, I realize that I was the first to be nasty on that particular conversation).

I called her back. I did not praise her or offer any positive words, just said “are you ready now to talk about tomorrow’s schedule?” and then, when she confirmed, reviewed it with her. I tried to speak with her normally, not in a resentful or annoyed manner, and I think I did okay, Later on, my sister apologized again: “I’m sorry again for the unpleasantness before,” she said, and I found myself deflating a little more. I said the words I knew were the right words to say before I had time to think too much about how I felt, before I had time to back away from doing the right things. “Thank you,” I said. “I really appreciated it when you called me and apologized, and I’m really impressed that you were willing to do that.” My sister thanked me, and that was that. I wished her a good night and we ended the conversation with very little tension.

It’s good to have a script, something I can fall back onto if I need to say the right words but I’m not in the right head/heart space. My script is the one I wrote above. It serves me well. Perhaps you too will find it useful. Repeat after me: “Thank you for apologizing. I’m really impressed that you were willing to do that.”

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Not Fighting on the Way to the Grocery Store

Today my sister shouted at me, accused me of not understanding anything, and then hung up on me. Often these are the opening notes of serious drama. Thankfully, I was able to apply some hard-earned lessons and ride it out without significant casualties, by remembering to do a few key things:

  • Take a deep breath
  • Lower my sense of urgency
  • Ask my sister what’s hurting
  • Ask my sister if she took her medication

Sudden Storm

It’s a pretty day and I’m driving to get groceries, my almost-3-month-old son in the back seat. I call my sister to say hi. She tells me about her recent confusing interaction with her housemate (the housemate invited my sister to join for a yoga class, then left without her). As we work through what happened and what to do next, my sister starts shouting at me: Why did you bring me to California? My life is horrible! You don’t understand how bad it is! You’re just sticking me here and nobody cares!

And then she hangs up.

Immediately the potential catastrophes jump to my mind. She sure seems agitated. Is she going to be aggressive toward her flatmate (again)? Will the flatmate text me (again) to say that she is leaving because she isn’t feeling safe? Will my sister spiral down and I will have to rush over there and hospitalize her, or maybe…

Connecting Instead of Fighting

I take a deep breath and ignore the rush of catastrophes I was imagining. I fight down the urge to call back right away. It’s not urgent. After all, in the times when I hung up on my sister (which I usually do if she is screaming at me), I didn’t like it when she immediately calls me back, and continues doing so endlessly. My sister is alone in the apartment, so she can’t take it out on her flatmate. Let’s give her some time to calm down, and also some time for me to calm down.

I finish grocery shopping and call her back 20 minutes later. She answers calmly, sounding tired. I ask her about her pain: Do you still have a headache? Yes, she says, and proceeds to describe with astonishing detail the exact location of the ache (an inch into her skull, above her right eye and to the side, etc. etc). We talk about which medication she can take and about drinking enough water. Then I suddenly realize that if she’s this worked up in the middle of the day, perhaps… I ask Did you take your medication this morning? and she says No, she didn’t. So she is probably having some rebound anxiety from missing her morning anti-anxiety medication.

A few years ago, I would have asked her why she didn’t take her morning medication… which would have sent us both down the rabbit hole. I dodge that bullet and instead explain that missing taking medication on schedule can contribute to her headache, and she says Oh, okay. Will you take it now? I ask, and she says Sure, hold on. Then we talk about about the medication she can take for her headache, and about the importance of drinking enough water. She asks how my son is doing, and we finish the conversation. In the evening I get a voicemail message from her: She went with her flatmate to the afternoon yoga class, where she only lasted for 15 minutes. But she went. And she sounded decent.

One More Day Ends Without a Crisis

It could have gone much, much worse. It has, in the past. Maybe I’m finally I’m learning something. In the past I would have argued with her, called her right back, argued with her some more, probably riled her up further, maybe driven up to make sure everything is okay (read: to be angry with her in person), spent a lot of time anxious about her potential breakdown, and generally have my day ruined. Instead, being able to reduce my sense of urgency and connecting with her in a caring way turned out to have made for a much better day – hopefully for both of us.

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If It Ain’t Broke… Don’t Make Changes to Medication

My sister isn’t prescribed a lot of medication, relatively speaking. Every morning she takes Sertraline (anti-depressant, which helps take the edge off of her agitation) and Lorazepam (to reduce anxiety). Every evening she takes Olanzapine (anti-psychotic). She has been using these medications for a few months now and has been generally doing well, with relatively few incidents of extreme agitation/aggression (and those tend to happen when she skips her medication).

I accompanied my sister for her latest visit to the psychiatrist, who said that Lorazepam is not something he usually recommends taking daily, but rather only as-needed. He explained that the effectiveness of the drug goes down when it’s used frequently, and that each pill is really only effective for the 4 hours after it is ingested, rather than for the whole day. My sister, of course, was only too happy to agree to remove it from her list of daily meds and to only take it as-needed.

So she did.

One or two days later she screamed at me while we were talking on the phone, after weeks of not being this agitated. At the time I thought perhaps the circumstances were stressful for her–she had been complaining about a sore throat and asked if we could schedule another botox injection for her vocal cords–and let it go. But the following day she screamed at me again over the phone, and again on the third day (at which point I blocked her, which turned out to be a very good decision).

The coinciding of her stopping with the morning Lorazepam and her becoming much more agitated was hard to ignore. And even though correlation does not equal causation, it was still very suggestive. And of course the causality of the Lorazepam was testable, if my sister were willing, by having her start taking it again.

I called my sister’s psychiatrist to consult with him and to task if it’s reasonable to go back to having my sister take the Lorazepam daily (during our first visit to the psychiatrist, we all agreed that it’s okay for me to communicate directly with the psychiatrist if I have any concerns). He reiterated that the pill should only work for a few hours after it’s ingested, but that if I see such a clear shift in behavior then it’s okay to go back to a regimen that was working, if my sister is willing.

I emailed my sister’s personal helper, who noticed my sister was more agitated, and asked that she discuss it with my sister and suggest adding the Lorazepam back to the daily meds. After they met, the helper said that my sister agreed to take it every other day, which was a good enough start.

I met with my sister a few days later and, after spending a nice hour together (we went out to pick up her medication, went to Five Guys for veggie sandwich and French fries), we went back to her place to arrange meds for the week. We were adding one more medication that my sister has been waiting to receive for a while (Amitriptyline, a daily pill that my sister’s primary care physician prescribed with the hope that it will prevent my sister’s frequent and severe headaches), and I suggested that my sister resume taking the Lorazepam daily. I pointed out that my sister seemed more agitated since she stopped taking it, has been driven to shouting on multiple days, and seems more tense in general. i was in a pretty good place emotionally during the conversation, and I think I was able to communicate this from a place of caring, rather than being accusatory or condescending, A little to my surprise, my sister agreed almost immediately, and arranged her medication accordingly.

It’s been over a week since then, and my sister seems well. I learned two things:

1) Even though the effect of each Lorazepam pill is supposed to be fairly brief, it seems to change the entire day for my sister. Maybe it’s because she starts days with less agitation. Maybe she metabolizes the drug differently than the drug companies (and the psychiatrist) think. Either way, the evidence seems pretty clear.

2) There was no reason to change the medication regimen, since it was working. I’m all for using the least amount of medication possible, but in this case dropping the daily Lorazepam resulted in a significant deterioration in the quality of life for both my sister and people around her. I don’t fault the psychiatrist for suggesting to switch to as-needed, but I’m glad we got it back to daily.