Next to Normal Digital Dramaturgy

Next to Normal: Digital Dramaturgy From Feeling Electric to Next to Normal A brief production history

Workshops and readings The musical, originally called Feeling Electric, was first seen in a 2002 reading at the Cutting Room in New York City, featuring Norbert Leo Butz as Dan and Sherie Rene Scott as Diana, with a subsequent staged reading in October 2002 at the Musical Mondays Theater Lab in New York.

In 2005 it was workshopped at Village Theatre (in Issaquah, Washington) featuring Amy Spanger as Diana, Mary Faber as Natalie and Deven May as Dr. Madden. In September 2005 the Barrow Group Arts Center production ran at the New York Musical Theatre Festival featuring Spanger as Diana, Joe Cassidy as Dan, Annaleigh Ashford as Natalie and Anthony Rapp as Dr. Madden. Second Stage Theatre workshopped the piece in both 2006 and 2007, featuring Cassidy and then Greg Edelman as Dan, Alice Ripley as Diana, Mary Faber and then Phoebe Strole as Natalie, Rapp as Dr. Madden/Dr. Fine and Skylar Astin as Henry.

Off-Broadway and pre-Broadway productions Next to Normal was produced off-Broadway under its current name at Second Stage Theatre from January 16 through March 16, 2008, directed by Michael Greif, with Anthony Rapp as assistant director and musical staging

by Sergio Trujillo. The cast featured Ripley as Diana and Brian d’Arcy James as Dan. The surname of the family was changed from Brown to Goodman. Although the show received mixed reviews, it was criticized by at least one reviewer for pushing an irresponsible message about the treatment of bipolar disorder and for failing to strike the proper balance between pathos and comedy.

After revisions to the show, a pre-Broadway regional theatre production ran at the Arena Stage in its temporary theatre in Crystal City, VA, November 21, 2008 through January 18, 2009. Michael Greif returned as director. Ripley and most of the offBroadway cast participated, but d’Arcy James remained in New York to play the title character in the musical Shrek, being replaced by J. Robert Spencer. Asa Somers, who played Dr. Madden and Dr. Fine, was also replaced by Louis Hobson. The changes included removing “comic songs and glitzy production numbers” and substituting some

songs that are complementary to the emotional content of the book; the production received rave reviews.

Broadway production 2009 Next to Normal began previews on Broadway at the Booth Theatre on March 27, opening on April 15, 2009. The cast from the Arena Stage production returned as well as the director, Greif. The musical was originally booked for the 1,096-seat Longacre Theatre, but, according to producer David Stone, “When the Booth Theatre became available... we knew it was the right space for Next to Normal.”

Reviews were favorable. Ben Brantley of the The New York Times wrote that the Broadway production is “A brave, breathtaking musical. It is something much more than a feel-good musical: it is a feel-everything musical.” Rolling Stone Magazine called it “The best new musical of the season—by a mile.” Next to Normal was on the Ten Best of the Year list for 2009 of “Curtain Up.” Next to Normal set a new box office record at the Booth Theatre for the week ending January 3, 2010, grossing $550,409 over nine performances. The previous record was held by the 2006 production of Brian Friel’s Faith Healer with a gross of $ 530,702.

Twitter Production 2009 In early May 2009, about six weeks into the Broadway Production, Next to Normal began publishing an adapted version of the show over Twitter, a social media network.

Over 35 days, the serialized version of the show was published in the form of tweets, short messages utilized by Twitter, a single line from a character at a time. The Twitter performance ended the morning of June 7, 2009, the morning of the 2009 Tony Awards.

US Tour Next to Normal began its first national tour of North America and Canada at the Ahmanson Theatre in Los Angeles, California on November 23, 2010. The tour played in 16 cities in the U.S., ending in Toronto, Ontario, Canada on July 30, 2011. Alice Ripley reprised her role as Diana and was joined by Asa Somers as Dan, Emma Hunton as Natalie, Curt Hansen as Gabe, Preston K. Sadleir as Henry and Jeremy Kushnier as Dr. Madden/Dr. Fine.

Where it all Started

by Brian Yorkey (Book and Lyrics) Reproduced, with permission, from the Arena Stage website Here's the annotated song list from our presentation of the 10-minute musical version of Feeling Electric at the BMI Musical Theatre Workshop, of which we were both members, in the spring of 1998.

Feeling Electric (Preprise) Ensemble An early version of a song that stayed with the show all the way through our OffBroadway debut.

Night Woman This short song, in which the lead character laments staying up all night waiting for her son to come home, also survived for many years.

Good Morning, Good Morning, Hello Woman, Husband, Daughter However, this peppy, borderline-insipid attempt at a big, scene-setting opening number did not survive for many years. It didn't survive past this presentation. Oh, and you'll notice that none of the characters had names. We thought it made the show more universal. I was reading and seeing a lot of Albee at the time. I was young and pretentious. And now I'm older.

The Last Time You Felt Right Woman, Doctor, Son An early version of a moment that has stayed in the show, in various forms—when the doctor asks the woman to talk about the last time she felt emotionally well.

I Dreamed a Dance with You Woman This is the only song that has survived intact, from this first presentation to the show you'll see at Arena Stage.

A Shock to the System Doctor, Husband One of my favorite songs we ever wrote for the show, it was cut in rehearsals for NYMF. I miss it. Tom doesn't, I don't think.

I Would Like to Go Have Pizza Daughter The less said about "I Would Like to Go Have Pizza," the better. Though I will say that it was beautifully performed in our BMI presentation by one Laura Pietropinto, who as fate would have it is the Assistant Director on this production.

Feeling Electric Ensemble The shock therapy sequence. An early version of the song. People actually sang "buzz."

It seemed like a good idea at the time.

Aftershocks Son A short version of a song that has also survived—though this one has been in and out of the show over the years, you'll hear its full, and we think and hope best, version at Arena Stage.

Four Seconds, Fifteen Years Woman, Doctor

A short section of this song survives, now called "Seconds and Years." The full version is lovely, but spends most of its time telling the audience what they already know. And in theater as in algebra, review is boring.

A Shock to the System (Reprise) Doctor This dramatic moment is still in the show, albeit in entirely different musical form— Diana's return trip to the doctor late in act two is a reprise of the song "Make Up Your Mind."

Feeling Electric (Reprise) Ensemble Believe it or not, this whole version of the show took just over 12 minutes to perform.

Everyone sang fast. What's amazing, looking back, is how much the shape of this version is actually like the shape of what we have now. They're so different, but we've managed to hold on to the spark, pardon the expression, that first inspired us to write the show. And the final version—spoiler alert! it's a bit longer—awaits you at Arena Stage.

The Evolution of a Song (Click to Listen)

by Brian Yorkey (Book and Lyrics) Reproduced, with permission, from the Arena Stage website

The Shock of Treatment

Insights from ECT patients Bipolar Hope and My ECT Experience Posted by Julie Fast on bphope.com, January 2011 I had 13 ECT treatments last summer when my depression became stronger than my medications and treatment plan. In other words, the depression was really bad. I, and all of my health care team agreed that ECT was a viable option and one that might work very well.

ECT is not shock therapy—it’s electro CONVULSANT therapy. In other words, you are wheeled into a hospital room and hooked up to a machine that puts convulsions into your brain—with the hope that this will stabilize your brain chemistry.

Unfortunately, my ECT didn’t work. (That’s another story!)

My doctor quoted that up to 70% of people who get ECT find relief from chronic depression. I wish I had been one of them. I know for sure I would get it again if it had worked.

And yes, the memory loss has been really, really bad. And the experience was scary and I don’t feel I had enough medical support, but I will exchange memory loss for a depression free life any day. Please know that I do not take this experience lightly and know that many have had terrible experiences with ECT, but there are many who are alive today because of ECT. I feel there needs to be balanced coverage.

The ECT Chronicles Posted by “Sparky” on ALittleSpark.wordpress.com. For the master list of ECT-related entries, click here.

ECT #17 (my second maintenance treatment): 6 July 2007 Is this how I should feel after ECT? Because if that’s the case, this is pretty good.

Today was another ECT day. Only a few people were getting ECT today, probably because it’s the holidays. When I woke up from the treatment, once again I was unable to remember what month or day it was. In fact, I had totally forgotten that the fourth of July had already past. But as I found out today’s date, I also found out that my seizure lasted for 60 seconds. Finally! In the past, there were many times when I didn’t quite reach the adequate duration of 25 seconds. In one session, they had to shock me twice because the first seizure was so short. It’s kind of odd to be celebrating my seizure length, but I took it as very good news.

And the good news didn’t just end there today. I honestly have felt much better after the treatment. It helped that my doctor had prescribed me some Lortab (hydrocodone/ acetominophen) for the really bad headaches. I usually end up taking a really long nap and lounge around my house afterward, but today I felt well enough to accompany my sister to a few stores in the afternoon. I realized I wasn’t imagining my emotional state when I spoke to Robin, my professor/friend, on the phone and she thought I sounded “upbeat.” Upbeat. That word hasn’t been used to describe me in a long time.

Even if this mood doesn’t last, now I know that I have a very good reason to be having maintenance ECT. ECT #18 (maintenance ECT #3): 23 July 2009 My mother came into town (well, country) just yesterday, and what does she get to do first thing today? Take her daughter to ECT. Somehow it’s become some sort of a routine for her to take me to the psych hospital whenever she’s here. What a lovely mother-daughter activity.

I’ve been concerned about the decline in my mood since the treatment two weeks ago, and I somehow wanted to express that to my doctor. Thankfully, my ECT psychiatrist Dr. F was back from vacation, so we chatted for a bit before the procedure. Seeing that I’m a little better at just writing stuff out rather than talking, I wrote him a note about how I just wanted to evaporate into the sky while I was overlooking the landscape from the airplane. He told me that because the last ECT did make me feel better for a while, as I have more treatments, my suicidal inclinations should dissipate. “You’re still young,” he assured me. I must say that his calmness and smile actually made me feel somewhat encouraged. I’m grateful that he’s my ECT doctor and that he’s still working even though he’s in his 70s.

Before I was given my shot of Brevital, the anesthesia, for the first time, the nurse put the electrode headband around my head. I had actually never seen how the currents were administered to my head. With the new machines, it’s just two patch-like electrodes, but because they’re using the sine-wave machine on me, they are wrapping an old-fashioned device on me (my headband looks even older than this one).

And next thing I know, I’m awake.

As I was wheeled back to the prep room to get my stuff, the nurse let me know that I had a 50-second seizure. Hooray. It’s all because I’ve halted taking alprazolam (Xanax), she said. I’m hoping that the longer seizures will lead to a better outcome.

It’s a relief when I can say that I feel better after the ECT. The question now is, how will I hold up until my next ECT two weeks from now?

ECT #19 (my fourth maintenance treatment): 6 August 2009 Is it really August already?

This morning was yet another ECT day. When I arrive at the receptionist’s desk, the receptionist knew my name immediately, a sure sign that I’ve been there quite a few times. Though this isn’t a fun experience, I find myself feeling a little less nervous each time I get to the hospital. A large portion of that has to do with just how nice everyone is at Parthenon Pavilion. The entire staff seems to put me at ease. I am truly thankful I am being treated at this hospital. Of course, one of the nurses did tell me today that she thought I looked fine since the day she first met me. I guess I can take that as a compliment, though it makes me wonder if the rest of the staff is skeptical as to why I’m even getting ECT in the first place.

I am also especially grateful that Dr. F is my ECT psychiatrist. When I tell him the news that I was going to graduate school in the fall, he gives me a big smile and then highfives me. He then listens to me speak for a few minutes. My thoughts are lot less dark than it was but since the faint death thoughts remain, he decides it’s best that I have one more ECT at a two-week interval before we spread out the treatments. I agree. It is what it is, I say to him. And right after speaking with Dr. F, my anesthesiologist, Dr. H, injects me with Brevital. I’m immediately out.

And then I’m awake. I am wheeled back to the waiting room to gather my belongings, and I’m given some paperwork to sign. My sense of time and date always goes out the window right after treatment, so when I hand them over, a nurse looks at me and says, “It’s not June 29 (a date I signed on the paper); it’s August 6.” I also could not remember at all where I will be attending graduate school, even though my mom, sister and I drove down to the school just yesterday. “Where am I going to grad school?,” I ask the nurse after my treatment. She informs me which school I’ll be going come fall.

I should just be glad I really don’t have real memory issues.

ECT #20 (my fifth maintenance treatment): 25 August 2009 Prior to coming to the treatment, there’s a ‘ECT caregiver report’ that someone has to fill out regarding how I’ve been doing. It asks questions like “Does the patient seem depressed?” among other 16 similar questions. I personally didn’t feel that the last two weeks went over too well, but to those questions, my sister answered no to all of them, as usual. So, when Dr. F looked at those answers on the questionnaire then heard me speak about how horrible I felt this past week, he gave me a confused look and asked me why there’s such a discrepancy between what my sister observed and what I was

telling him. All I could tell him was how no one, not even family members, can really tell from my exterior when I’m sad and that I tend to come across as constantly in a good mood. I don’t know if my answer made any sense to Dr. F, but as he walked to the ECT machine, Dr. H injected me with Brevital. I’m out within seconds.

I did not feel well after the last treatment, but this time around, I felt amazingly clearheaded and okay (just a little headache, but what can you expect after a seizure’s been induced via your brain?). However, I kept thinking about that conversation with Dr. F right before the ECT. Do I present a different self to other people on purpose, or do I just naturally look happy? I think my general demeanor just strikes people as pleasant, and honestly, I’m not trying to fool people on purpose. Perhaps I’ve masked how I feel for so long that I can’t even tell if I’m putting on some sort of an act. The thing is, I used to not even be able to tell a doctor exactly how I felt. It’s not obvious, but I’ve actually come quite far in terms of expressing how I feel to others.

The one place where my true self seems to be on display pretty consistently is through my writing. Somehow I find it much easier to arrange words on the paper rather than having to speak them. This journal is probably a very good example of my innerthought process. I guess the problem with only revealing myself in writing is that I can decide who sees my writing so these feelings are still contained to just me and the journal (or other written material). But would my life become any better if I chose to reveal more about my insides through my exterior? Must I work to match my outer shell with my inner feelings?

Maybe my real self is what people see on the outside. It’s my inner self that needs to work to get to who I really am.

ECT #39 (24th maintenance treatment): 7 July 2011 Today was another day for electroconvulsive therapy treatment. I haven’t felt very good lately, so I really did not feel like telling my ECT psychiatrist what’s been going on—but I knew I kind of had to. When Dr. F came to my stretcher/bed in the treatment room, I told him about how I experienced a sort of hypomania last two weeks and then reached a low this week. I guess he took my comments to mean that I can’t quite stop having ECT just yet (though I don’t think it was going to end today by any means).

We’ve been spreading the treatments out to every eight weeks, but we compromised for the next ECT to be seven weeks from now. Until this week, Dr. F had been talking about how I’m coming close to the end of all this ECT, but I guess I ruined that chance now.

I usually have more to write on my treatment days, but I don’t really have much to say today. I came home and mostly slept for hours. I don’t usually feel that much better til tomorrow, so I guess I have to wait until then.

Electroconvulsive Therapy is nothing short of miraculous Posted by Aqua on VicariousTherapy.blogspot.com on 16 January 2010 I apologize for disappearing offline for so long. I have been in the hospital receiving ECT (electroconvulsive therapy) and have had limited access to my blog.

Since mid-December I have been receiving left-unilateral electroconvulsive therapy 3 times a week; on Monday, Wednesday and Friday mornings. I have had 13 treatments so far and am scheduled to have at least one more this coming Monday.

I am not sure if more are scheduled this coming week, but once I am discharged from the hospital I will be receiving outpatient ECT first probably once a week, then once every couple weeks, and then maintenance ECT will continue at once a month.

How I feel right now is nothing short of miraculous. I have spent most of my adult life battling depression; especially in the last 10 years. In the past 10 years I had very little relief from my mood disorder. I feel like I spent the last 10 years just trying to survive each day.

By the time I entered the hospital I was the closest to suicide I have ever been. I was spending every waking moment planning my demise. I had given up hope. I was completely distraught. I could not take life the way it was anymore.

Today, and for the past week, I feel like I want to live. I feel excited to be alive, happy to be breathing. I feel blessed to be alive. I feel like I have been given a chance again.

I feel incredible. I feel hope that I have not felt in a long, long time. I am eternally grateful to everyone who helped, supported and encouraged me to survive this illness and receive the treatment I needed to become well.

Medical Terminology Psychotic Depression Psychotic depression, more technically known as major depressive disorder with psychotic features, is a far less common disorder than simple depression.

Psychotic depression is characterized by not only depressive symptoms, but also by hallucinations or delusions. Often psychotically depressed people become paranoid or come to believe that their thoughts are not their own (thought insertion) or that others can “hear” their thoughts (thought broadcasting).

Those with psychotic depression are usually aware that these thoughts aren’t true.

They may be ashamed or embarrassed and try to hide them, sometimes making this variation difficult to diagnose. Risk of bipolar depression, recurring episodes of psychotic depression, and suicide are increased after its onset.

Researchers aren’t exactly sure what causes major depressive disorder with psychotic features (psychotic depression), but it’s frequently associated with high levels in the blood of a hormone called cortisol. More cortisol is released during times of stress— biological and psychological. There are no obvious risk factors, though it is known that those with a family history of depression or psychotic illness will be more susceptible.

Symptoms that occur more commonly in psychotically depressed patients include anxiety, agitation, hypochondria, insomnia, physical immobility, constipation, and cognitive impairment.

Treatment for psychotic depression requires a longer hospital stay and close followup by a mental health professional. Combinations of tricyclic antidepressants and antipsychotic medications have been most effective in easing symptoms. Lithium is sometimes added to this combination for those with bipolar disorder. Electroconvulsive therapy is generally a second line treatment. Researchers are also studying the effectiveness of RU-486 (“emergency contraceptive”).

Bipolar Disorder Bipolar disorder affects 1% of the population, with equal representation in both genders. The illness is characterized by sudden and intense mood swings; patients oscillate between manic and depressive episodes, which can last anywhere from a few weeks to a few years, with interspersed remission periods. Manic episodes are characterized by prolonged periods (at least a week) of feeling “high,” restlessness, irritability, impulsive behavior (often risky sexual and financial decisions), exaggerated speech and movement patterns, and an inflated sense of self-importance. Depressive episodes, conversely, include feelings of hopelessness, tiredness, loss of interest in enjoyable activities, inability to concentrate or make decisions, and persistent thoughts of self-harm or suicide. A clinical diagnosis requires that a patient experience at least five or more symptoms nearly every day for two weeks.

What’s distinctive about bipolar patients is that their mood swings will frequently emerge without any clear external triggers. Additionally, a bipolar patient’s mood swings tend to be more intense in nature and have more profound and lasting consequences; patients often find their careers, their finances, and their relationships in jeopardy as a result of extreme manic or depressive behavior, and nearly one third of bipolar patients attempt suicide at least once in their lives. In some extreme cases, patients’ mood episodes might even have psychotic elements—a manic patient might genuinely believe he or she has magical powers, and a depressed patient might believe he or she is responsible for some natural disaster or political crisis. Others experience frequent hallucinations, which can occur both in manic and depressive episodes.

Another challenge with BPD is that, even among confirmed cases, there exists a lot of variation in the nature and scope of symptoms. Indeed, the prevailing psychiatric wisdom touts a “bipolar spectrum,” which includes several gradations of the illness.

Because the roots of bipolar disorder are so multifaceted, there’s no definitive cure for it. But through a combination of sustained therapy and medication, many individuals with the disorder are able to live productive and fulfilling lives despite the illness.

Psychogenic memory loss Psychogenic memory loss is amnesia brought on by a psychological—rather than physiological—cause.

Psychotherapy Psychotherapy (also known as talk therapy, counseling, psychosocial therapy or, simply, therapy) is a general term for treating mental health problems by talking with a psychiatrist, psychologist, or other mental health provider. Psychotherapy is a process

focused on helping the patient heal and learn more constructive ways to deal with the problems or issues within his/her life. Therapy can take various forms—cognitive behavioral therapy, mindfulness-based cognitive therapy, psychodynamic therapy, or a combination of these—but at the center of each is the caring relationship between a mental health professional and a patient. Generally, psychotherapy is recommended whenever a person is grappling with a life, relationship, or work issue or a specific mental health concern, and these issues are causing the individual a great deal of pain or upset for longer than a few days.

EMDR Eye Movement Desensitizing and Reprocessing (EDMR) is a relatively new form of psychotherapy, in which patients are asked to focus on a negative stimulus—an anxiety, a traumatic memory, a self-image etc.—as their eyes follow the therapist’s finger moving back-and-forth in front of them. The steady eye movements are said to numb the patient’s negative thoughts, allowing him or her to process them with more perspective, and, eventually, to construct positive and healthy meanings from them.

For example, a victim of sexual abuse might, through EDMR, transform a sense of guilt and shame into empowerment and pride at having survived the ordeal.

Psychopharmacology Psychopharmacology is the study of drug-induced changes in mood, thinking, and behavior. These drugs may originate from natural sources (such as plants and animals) or from artificial sources (such as chemical syntheses in the laboratory). The use of drugs to alleviate the symptoms of mental disorders makes psychoactive agents— especially antipsychotics and antidepressants—among the most widely prescribed pharmaceuticals today. In psychopharmacology, researchers are interested in a wide range of drug classes such as antidepressants and stimulants. Drugs are researched for their pharmaceutical properties, physical side effects, and psychological side effects as they interact with particular target sites or receptors found in the nervous system to induce widespread changes in physiological or psychological functions. Much debate surrounds the use of stimulants to treat attention-deficit problems and the side effects of antidepressants, especially for children. The general effectiveness of antidepressants when measured against a placebo remains controversial, although the treatments that prove most effective combine drugs with psychotherapy.

Lithium The drug of choice for treatment of bipolar disorder, lithium is a mood stabilizer typically used to reduce the symptoms of manic episodes—including hyperactivity, anger, reduced need for sleep, and poor judgment. The standard dosage is 1800mg a day (900mg in the morning and at night), but every patient ultimately needs to find exactly the right dosage for him or herself, which can be a delicate balance to strike: too little is inevitably ineffective, but too much might result in chronic lithium toxicity, which can lead to slurred speech, tremors, kidney failure, and cognitive impairment, among other things.

Adderall Adderall contains a combination of amphetamine and dextroamphetamine, central nervous system stimulants that affect chemicals in the brain and nerves that contribute

to hyperactivity and impulse control. Adderall may be habit forming.

Xanax Xanax (alprazolam) belongs to a group of drugs called benzodiazepines. It works by slowing down the movement of chemicals in the brain that may become unbalanced.

This results in a reduction in nervous tension (anxiety). Xanax is used to treat anxiety disorders, panic disorders, and anxiety caused by depression. Mental and physical dependence can occur. Side effects include lightheadedness, and in patients with panic disorder, early-morning anxiety and anxiety symptoms between doses of Xanax can occur.

Valium Valium (diazepam) is used to relieve symptoms of anxiety and alcohol withdrawal, and it may also be used to treat certain seizure disorders and help relax muscles or relieve muscle spasm. The drug is a benzodiazepine, belonging to the group of medicines called central nervous system (CNS) depressants which slow down the nervous system.

Common side effects include shakiness, unsteadiness, trembling, or other problems with muscle control or coordination.

Electroconvulsive Therapy Electroconvulsive Therapy (ECT) has been a long source of fodder for Hollywood’s dark imagination. Immortal scenes from One Flew over the Cuckoo’s Nest (1975) and Requiem for a Dream (2000) depict patients strapped into a Frankenstein-esque table, screaming and writhing in agony.

Today, patients are required to sign a consent form before any treatment is administered, and they’re given anesthesia and muscle relaxants so they’re not conscious during the procedure. Once sedated, the patient will receive quick pulses of electrical current from strategically-placed electrode pads—ECT can either be unilateral, with electrodes on just one side of the brain, or bilateral, with electrodes on either side—creating a controlled one-to-two-minute seizure. Due to the muscle relaxants, there’s very little to see in a modern day ECT procedure (usually nothing more than the patient’s toe moves), but using an electroencephalogram (EEG) doctors are able to monitor a significant increase in brain activity. After the seizure is complete, the patient is transported to another room for recovery.

Although scientists haven’t been able to identify the exact neurological process, the prevailing theory is that the seizure alters the chemical makeup of the brain, which in turn mitigates the symptoms of depression, schizophrenia, and mania.

Given the substantial risk involved—side effects can include headaches, nausea, muscle pains, and moderate to severe memory loss—and the lingering stigma attached, ECT is generally used only as a last-ditch resort, if more conventional methods of treatment have proven ineffective or if the patient is at imminent risk of harming his or herself.

Typically, treatment is administered three times a week (usually Monday, Wednesday, and Friday) for two to four weeks, with less frequent “maintenance therapy” visits continuing for months or years after.

Like any medical treatment, the results of ECT vary from patient to patient.

Immediately after the procedure, nearly all patients experience some kind of confusion—not knowing who they are or why they’re there. This typically lasts for a few minutes or hours, and sometimes even a few days. Beyond that, some patients experience more significant kinds of memory loss: in one California study, about 20% of patients reported memory loss lasting for three months or longer. In such cases, it’s often the memories in the weeks immediately before and after ECT that are most affected (and it’s generally patients’ autobiographical memories that are impacted, not their memory of historical events or other collected knowledge). In other very rare cases patients will report losing significant amounts of past memories. Sometimes these memories return with time and a certain amount of prompting; sometimes they don’t.

In 2000, registered nurse Barbara Cody wrote a letter to the Washington Post about her debilitating experience with ECT memory loss. “Shock ‘therapy’ took my past, my college education, my musical abilities, even the knowledge that my children were, in fact, my children,” she wrote. “I call ECT a rape of the soul.”

Perhaps Ernest Hemingway, who received ECT treatments in 1960, put it best: “It was a brilliant cure, but we lost the patient,” he famously said.

Unsurprisingly, experts in the field are deeply divided about ECT, both from a medical standpoint and an ethical one. Some hail it as one of the most effective methods of treating mental illness; others denounce it as a dangerous quick-fix that only works to the extent that it wipes out a patient’s memory and cognitive abilities—a kind of civilized lobotomy. Indeed, there is one thing that ECT’s advocates and detractors can agree on: the procedure itself is not a panacea. No matter how effective ECT may be in temporarily reducing harmful symptoms, patients suffering from mental illnesses still need therapy and/or medication in order to stay healthy in the long run. rTMS Often considered a more moderate cousin of ECT, Repetitive Transcranial Magnetic Stimulation (rTMS) uses an electromagnetic coil placed against the scalp to stimulate the area of the brain associated with depression. Because rTMs uses a magnetic pulse instead of a direct current, the procedure is much milder than ECT; the patient does not require anesthesia beforehand, will not experience a seizure, and will likely not suffer from the kind of memory loss and other adverse side effects that often accompany ECT. The patient will usually attend treatment sessions five days a week for three to six weeks, with little to no maintenance visits afterward. Like ECT, patients who receive rTMS treatments still need to take medicine and attend therapy in order to stay healthy.

Intestinal Obstruction An intestinal obstruction is anything that blocks a person’s bowels and impedes their digestive abilities. The obstruction may be caused by a mechanical disruption—in other words, something gets in the way of the intestine, like a tumor, gallstone, hernia or impacted stool—or a condition known as Paralytic Ileus, where the intestinal muscles simply don’t work but there are no physical obstructions. This can be ascribed to any

number of root causes: bacterial infections, decreased blood supply to the intestines, and chemical or electrolyte imbalances, to name a few. Symptoms of ileus include abdominal pain, constipation, gas, diarrhea, and vomiting. It is especially common in infants, and, when left untreated, can lead to blood and lung infections that may be fatal.

Recreational use of DXM, or “Robotripping” “Robotripping” is a high induced by ingesting excessive amounts of Robitussin (which contains dextromethorphan, or DXM, a common cough suppressant). At high doses, dextromethorphan is classified as a dissociative general anesthetic and hallucinogen, similar to the controlled substances ketamine and phencyclidine (PCP).

Also like those drugs, dextromethorphan is an NMDA receptor antagonist. It often manifests in euphoria, auditory and visual hallucinations, and a loss of motor abilities.

Dextromethorphan generally does not produce withdrawal symptoms characteristic of physically addictive substances, but there have been cases of psychological addiction.

Due to dextromethorphan’s SSRI (selective serotonin re-uptake inhibitor)-like action, the sudden cessation of recreational dosing in tolerant individuals can result in mental and physical withdrawal symptoms similar to the withdrawal from SSRIs. These withdrawal effects can manifest as psychological effects, including depression, irritability, cravings, and as physical effects, including lethargy, body aches, and a sensation of unpleasant tingling, not unlike a mild “electric shock.”

“Didn’t I See This Movie?”: Understanding Next to Normal through Literary Resources and Pop Culture “Evolving Stages: Representations of Mental Illness in Contemporary American Theatre” (excerpt) Reprinted with permission

Mental Illness in Popular Media edited by Lawrence C. Rubin (McFarland and Company, 2012) pages 165-183 as “Evolving Stages: Representations of Mental Illness in Contemporary American Theatre.”

[O]nly a musical with widespread popular appeal could make widely visible a new sensibilities in portraying mental illness in the American theatre; that musical came in the form of Tom Kitt and Brian Yorkey’s Next to Normal which opened on Broadway in April 2009. Next to Normal offers an in depth study of the toll mental illness takes upon afflicted individuals as well as their family members, of the promises and disappointments of pharmaceutical, electroshock, hypnosis and talk therapy, and of the complicated interplay between experience, predisposition, repression and substance abuse in disease. Such dark material, a stark contrast with the dreamy love stories typically associated with musical theatre, was not wholly unprecedented, but did break important new ground. Reviewing Next to Normal for Time Out New York, Adam Feldman describes it as “that rarest of Broadway species: a thoughtful, emotional musical for grown-ups after acknowledging that “it is not easy to pull off a musical about psychotropic drugs and electroconvulsive therapy.”i Anthony Rapp, the actor who originated the role of Mark in Jonathon Larson’s Rent, took part in the workshops that lead to next to normal. In his foreword to the published

text of next to normal, he reflects upon the changing face of the American musical.

While acknowledging the success he has enjoyed performing in mainstream musicals, he fully understands those who have “allergic reactions to the cornball razzamatazz of the old-school shows.”ii Working on both musicals, he describes feeling “blessed to sing songs that expressed matters of life and death in a musical vocabulary.”iii […] next to normal benefitted from formal innovations in musical theatre while enhancing character development and undertaking wholly original investigation of complex subject matter. While certainly not devoid of humor or spectacle, the main achievement of the musical lays in offering a multi-dimensional representation of serious mental illness.

Weaving together a range of attitudes and beliefs about causation and treatment, by dignifying the pain not just of the ill person but that of her family members, and never suggesting the possibility of infallible, permanent solutions, next to normal engages meaningfully with earlier depictions of mental illness. next to normal presents the protagonist’s central delusion through a theatrical device […]. However, next to normal takes more time to reveal that Diana’s son, Gabe, appears only to her but these scenes are written to make him seem no different than the other characters. As a result, […] the show portrays creates delusion as somewhat matter of fact, plausible, and fully ingrained into Diana’s “normal” day to day world.

Isolating Gabe through unique costuming or special effects or otherwise distancing him from the rest of the action might make for more sensational theatre; however, in taking the approach they do Kitt and Yorkey iterate the reality that mental illness frequently exists just beyond the surface of “normal.” Their musical begins with a number sung by all four members of the family indicating hectic lives and strained relations, but nothing apparently beyond the dysfunction experienced by many families.

Diana: They’re the perfect loving fam’ly, so adoring, And I love them ev’ry day of ev’ry week.

So my son’s a little shit, my husband’s boring, And my daughter, though a genius, is a freak.

Still I help them love each other Father, mother, sister, brother, Cheek to cheek.iv The characters scramble to get ready to face the day. Diana bustles about making sure everyone gets breakfasts and then begins to make sandwiches to pack for lunches.

Only after this semblance of routine has been established does the façade of normal begin to erode. Diana’s efficiency evolves into manic energy and she begins to deal loaves of sliced bread like cards covering the kitchen table and part of the floor.

Diana’s long suffering husband, Dan, copes with her illness through repeated assurances that life will improve everything will improve and putting his faith in the aptly named psychiatrist with whom they initially work.

Dan: Let’s go see Doctor Fine. This is just a blip. Okay? Nothing to worry about.

I’ll wrap up the, um, sandwiches, and then we will go.v

Such reassurances eventually sound hollow to even Dan who concedes he has been struggling primarily to convince himself. Waiting outside while Diana sees Dr. Fine, Dan sings, “Who’s crazy? The husband or the wife?”vi Dan’s fierce attachment to Diana and his determination to remain supportive, which psychologists call co-dependency, erodes his own emotional health. At play’s end, Doctor Madden (notably portrayed by the same actor playing Dr. Fine earlier in the production) offers to find a psychologist for Dan who replies, “Oh, no, I. Yes. I would. Thank you.”vii The basic shape of this response is in keeping with the musical’s larger assessment of mental health treatment; in the end, an imperfect option trumps having no option.

Diana sees Dr. Fine who offers her pills coming in all colors of the rainbow. When one regimen does not work, another is tried with Fine admitting “eventually we will get it right.”viii These interactions enable a witty musical interlude set to the tune of “Some of My Favorite Things,” from The Sound of Music with “Zoloft and Paxil and Buspar and Xanax” and a series of other drugs taking the place of “Girls in white dresses with white satin sashes, snowflakes that fall on your nose and eyelashes” as the “favorite” things. ix Fine’s warnings about possible side effects and Diana’s experience of them expose one of the downsides of pharmaceutical treatment. And when Dr. Fine determines that Diana is stable only when she tells him, “I don’t feel like myself. I don’t feel anything” clearly refers to other reservations about medication.x In one of the show’s most striking musical numbers, “I Miss the Mountains,” Diana mourns for the loss of feeling brought on by medication. Numbing effects, diminished creativity, and the loss of individuality frequently fuel arguments against the use of drug therapy. On a certain level, these arguments correspond with theories that mental illness is merely a label used to denigrate individuals too passionate to conform to societal norms. next to normal resists the impulse to define mental illness and the psychiatric profession with broad strokes, however, and acknowledges how psychotropic medication does prove effective. Bolstered by Gabe’s insistence that going off her medication represents an act of bravery, Diana becomes manic. She finds these episodes liberating at first and Dan is convinced that things are better than ever.

Drifting further and further from reality, Diana throws a birthday celebration for Gabe. She displays a cake boasting eighteen candles and performs a solo rendition of “Happy Birthday.” Dan and Natalie look on in horror. Making the spectacle particularly unbearable for Natalie is that Henry is a guest in their home for the first time. Her hopes to keep Henry from knowing the whole story of her family collapse as she is forced to explain her mother’s pathological denial of a child’s death.

After the disastrous evening with Henry, Diana must admit the truth about going off her medication and Dan locates a psychiatrist, Dr. Madden, who offers alternatives to drug therapy. Hypnosis leaves Diana with overwhelming sadness without resolving issues related to Gabe. Determined to make greater progress, Madden turns next to Electro Shock Therapy (ECT) The prospect of ECT initially horrifies Dan. Scenes of Madden trying to convince Dan of the safety and effectiveness of the treatment are juxtaposed with scenes of Gabe urging a desperate Diana to join him “in a place” where “the pain goes away.”xi A parallel to the earlier scene about medication, an element seduction of underlies this exchange and Gabe again proves persuasive. Diana attempts to take her own life. This crisis convinces Dan to try ECT and when we see Diana again, she is on

a gurney about to be rolled into a treatment room. Gabe materializes and coaxes Diana to refuse again treatment. Diana rediscovers her conviction in a song making allusions to One Flew Over the Cuckoo’s Nest: “Didn’t I see this movie, with McMurphy and the nurse?”xii In other references to the larger context of her problem, she sings,” “I’m no Sylvia Plath. I ain’t no Frances Farmer.”xiii The Broadway production placed Diana in between her husband and (late) son; something of a pawn in their power struggle in a clear expression of oedipal tensions. For much of the time, Diana’s gaze remained fixed on Gabe, but in the last moments of the act she turned slowly towards Dan and gave her assent to ECT. When the second act begins, a dummy lies on the gurney while Diana “watches” herself undergo shock therapy. Such staging gives physical expression to rather abstract philosophical thoughts about identity. Diana understands that on one level she remains the same woman she longs for in “I Miss the Mountains,” however she also exists within the pain of her own dysfunction, fear, confusion and loss. After completing a series of ECTs, Diana has essentially no memory. The severity of her amnesia, in relation to the actual experience of people undergoing ECT, seems a bit too transparently contrived as a plot device. Nonetheless, she returns to Dan and Natalie something of a blank slate. Having been encouraged by Madden to use mementos to help free her memory, they sit with her at the table. In keeping with his determination to remain positive, Dan shares souvenirs from their wedding day and photos of Natalie playing on the beach. The way he relishes the possibility of recreating Diana’s emotional life poses perplexing existential questions. Should medical procedures truly enable an adult to bury memory of former experience, who does their patient really become? Without awareness of our own past and the way it has shaped our outlook, can we have truly stable identity? Apalled by her father’s plan, Natalie shares entirely different mementos, such as a newspaper story about an incident where Diana created a public spectacle, photos capturing Diana’s destruction of house and property (and even running over a family pet) and pieces of evidence documenting Diana’s absence at key events in her daughter’s childhood.

Natalie alternates verses with Diana in the Act Two opening number, “Wish I Were There.” The two characters are separated from one another, with the staging of Diana’s ECT experience on one level and Natalie’s interactions on another. Natalie has begun abusing prescription drugs and gives an embarrassing performance playing wildly improvised music on the piano quite unlike that she prepared. The parallel scenes underscore the shared experience of a distancing from self: Diana alienated by the current running through her body and Natalie divided from herself by drug abuse. This staging also expresses Natalie’s complex relationship to a mother she at once needs desperately and finds repellent. Understandably, Natalie fears suffering a fate similar to her mother and there is even some suggestion that Diana’s own mother may have been manic. (In consultation with Dr., Diana explains that her mother too was “highspirited, so much so that she was kicked out of the PTA).xiv In addition to raising the issue of genetics and chemical dependency, representation of Natalie’s predicament provides other insights into mental illness. The lyrics in her first solo reveal a plan to get a musical scholarship to attend Yale as means to escape and her parent’s home.

The song also makes significant references to engage with the idea of “mad genius” and mental illness:

Mozart was crazy.

Flat fucking crazy.

Batshit, I hear.

But his music’s not crazy.

It’s balanced, it’s nimble, It’s crystalline clear.xv When Henry enters the scene, early for his reservation of the same practice room, an interaction about opposing tastes in music and lifestyle helps throw into relief Natalie’s disposition. References to Natalie in an earlier musical number have already characterized her as rigid and perfectionist. Her staunch defense of classical music against Henry’s preoccupation with improvisational jazz along and generally prim tone reinforce this impression. As difficulties at home compound, she tries on a completely opposite demeanor. Her jump between two extremes--from an intolerance of even marijuana use to the abuse of potent chemicals, from a pianist dedicated to a narrow elitist definition of music to a the recital the reckless improvisation at her recital-uncontrolled improvisation reflects impulses common in coping with mental illness.

Indeed, drastic solutions to the puzzle presented by mental illness inform many of the trends discussed earlier in this chapter. What Natalie, and indeed all the characters come to accept, is the futility of searching for a formula to resolve the problem of living with mental illness.

Eventually, Diana’s memory of the trauma of losing a child is freed. Realizing the need to sort out difficulties alone, she moves out. Natalie finally trusts Henry’s assurances that he can cope with the unpredictable course their relationship might take. She accepts that instincts may fluctuate, but need not be expressed in their totality: that identity is not stable but subject to constant, though often subtle, shifts in perspective.

And, in one of the play’s most gut-wrenching scenes, Gabe breaks down Dan’s resistance to him. Forced to “see” and engage this son and all he represents and the two collapse into one another. And finally has mentioned at the outset of this discussion Dan agrees to seek help from a system that may be fallible, but also capable of support.

In giving theatrical expression to the need to embrace the ambiguity surrounding mental illness, Kitt and Yorkey’s make a significant contribution to the American theatre. That they manage to do so in the form of a popular Broadway musical is particularly remarkable. From the predictable to complex, embracing melodrama, comedy, heated social commentary and perplexing questions; the evolution of images in the American Theatre from melodrama to a up multifaceted Broadway musical echo the voices engaged in never ending conversation about madness.

Literary Resources • Living with Someone Who’s Living with Bipolar Disorder by Chelsea Lowe and Bruce M. Cohen MD PhD • How You Can Survive When They’re Depressed by Anne Sheffield

• Bipolar Disorder: A Guide for the Newly Diagnosed by Janelle M. Caponigro MA, Erica H. Lee MA, Sheri L Johnson PhD, Ann M. Kring PhD • Understanding Paranoia: A Guide for Professionals, Families, and Sufferers by Martin Kantor MD • Living Well with Depression and Bipolar Disorder: What Your Doctor Doesn't Tell You...That You Need to Know by John McManamy • The Noonday Demon: An Atlas of Depression by Andrew Solomon • An Unquiet Mind: A Memoir of Moods and Madness by Kay Redfield Jamison PhD • Madness: A Bipolar Life by Marya Hornbacher • Darkness Visible: A Memoir of Madness by William Styron • Electroboy: A Memoir of Mania by Andy Behrman • SHOCK: The Healing Power of Electroconvulsive Therapy by Kitty Dukakis and Larry Tye • Electroshock: Restoring the Mind by Max Fink Movies, T.V. Shows, and Plays • A Delicate Balance • A Dirty Shame • American Beauty • Arlington Road • Arrested Development • August: Osage County • Beetlejuice • Blue Velvet • Buried Child • Caroline, or Change • Clybourne Park • Disturbia • Death of a Salesman • Donnie Darko • E.T., the Extraterrestrial • Edward Scissorhands • Frances • God’s Pocket • Homeland • Life of the Party • Lifelines • Little Children • Long Day’s Journey into Night • Magnolia • Modern Family • My So-Called Life • One Flew over the Cuckoo's Nest • Ordinary People • Parenthood • Poltergeist • Revolutionary Road • Serial Mom

• • • • • • • • • • • • • • • • •

Silver Linings Playbook Smile The ‘Burbs The American Dream The Cocktail Hour The Dining Room The Goat, or Who is Sylvia The Graduate The Ice Storm The Ice Storm The Safety of Objects The Simpsons The Stepford Wives The Virgin Suicides The Wonder Years Trouble in Tahiti Who’s Afraid of Virginia Woolf?

Feldman, Adam, “Review of next to normal” . (Time Out: New York, 23 April 2009.

Available at http://newyork.timeout.com/arts-culture/theater/35112/next-to-normal ) np ii Rapp, Anthony, “Foreword,” next to normal by Tom Kitt and Brian Yorkey, NY Theatre Communications Group, 2010) , ix iii Rapp, xiii iv Kitt, Brian and Thomas Yorkey, next to normal, NYC: Theatre Communications Group, 2010), 9 v Kitt and Yokey, 15 vi Kitt and Yorkey, 17 vii Kitt and Yorkey, 103 viii Kitt and Yorkey, 18 ix Kitt and Yorkey, 18 x Kitt and Yorkey, 18 xi Kitt and Yorkey, 52 xii Kitt and Yorkey, 6 xiii Kitt and Yorkey, 57 xiv Kitt and Yorkey, 39 xv Kitt and Yorkey,15 i

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