Monthly Archives: August 2012

Subconscious Steering

When you find yourself no longer paying attention to a specific task or being entertained by the expanse of the internet or television (which I realize in this day n’ age is fairly rare), where does your mind wander?

Sometimes it can be hard to really discern where my mood is at, so I find it interesting, at times, to allow myself a moment or two to see where my mind wanders on its own, because in my experience wherever it heads first will usually be a pretty good road sign for what my mood is doing.

Where is my subconscious steering things?

Does it make a beeline to the past?

  • (Am I feeling guilty, nostalgic, pessimistic about the future, hopeful about the future, sad?)

Or does my mind wander to the future?

  • (Am I feeling anxious, excited, hopeful, overwhelmed?)

Am I returning to an amusing joke or anecdote from earlier?

  • (Am I feeling relaxed? Amused? Optimistic?)

Are my thoughts returning to a song that keeps repeating itself?

  • (Am I having other obsessive or compulsive tendencies? Does the song have a certain emotional meaning to me?)

There are probably an infinite number of possibilities, but taking a look at a thought and considering what it means to me is usually the easiest way to figure it out.

The only thing that can be difficult about this concept is being able to step away from whatever I’m thinking at the time I’m thinking it (or even right after is fine). When I am feeling particularly overwhelmed by whatever the thoughts are, that can be hard to do, so it has helped me to practice at times where I don’t find myself feeling overwhelmed by emotion in any real direction. Sometimes I’ll suddenly just ask myself, “what are you thinking right now?” and the answers have been pretty astounding… I think we do a lot of thinking that we aren’t necessarily aware of while we’re doing it.

Likewise, I think my dreams can give me a similar sort of insight to how I am doing emotionally. I hardly ever have violent dreams or straight up nightmares when I am feeling ultra-pleasant, and last weeks dreams were stressful -pretty much a mirror to the amount of stress I was experiencing at work (needless to say, I was feeling pretty overwhelmed).

I don’t normally subscribe to the idea that everything in my dreams represent something else, I just focus more on the emotions I am feeling in my dream (or the emotions I have right after waking up from them). Chances are, if I am having a dream that makes me feel anxious, I am also feeling anxious in my everyday life, I just may not have realized to what extent the anxiety was effecting me!

I’ve been trying to consider different ways to tap into those sort of subconscious road signs and make something of a mental map of how those areas work for me. So far it has been interesting, and I’ll keep you updated as I learn more.

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A Live/Work Balancing Act

I’ve been very lucky, to some degree, with this new job because even though it is full time, there is an element of flexibility to it. The hours are not exactly set, which means on a day like one I had last week when I woke up feeling horrendous, I can go back to sleep for a couple hours and see how things pan out the next time I open my eyes.

With bipolar disorder, I feel a lot of the time like opening my eyes after sleeping is something of a lottery.

I don’t know how it is for most, but  I would say that at least 75% of the time, I feel better after sleeping than I did the night before. That other 25% of the time, though, if I don’t get enough sleep, or if my sleep is full of bad dreams or waking up every 30 minutes, I wake up with the wrath of bipolar hostility sitting on my chest and within moments I can tell something isn’t quite right. That unruly jerk sitting on my chest bangs a spoon on a kitchen kettle until I am ready to strangle it.

In the past it has been common for me to respond in this way when awoken in the middle of the night from a deep sleep, it is like some kind of murderous being appears and takes my place (we call her Sleep Sarah and she is a bitch). 

Every once in a while on the verge of or on the tail end of an episode she follows me out of sleep in the morning, and I instantly know that going out or being around people is the worst possible idea I could have. The only real solution is going back to sleep, rolling the dice, and hoping some other mood is present the next time I open my eyes.

One of the days last week (and honestly I can’t remember which because they’ve all become a blur at this point) I woke up with the stomach ache from hell, and Sleep Sarah was right along side it. Normally at 5:30 in the morning it is hard for me to discern how level-headed I am feeling, but right away I knew something was seriously off. I went back to sleep for two hours and then felt infinitely better, so I went to work late.

I am extremely grateful that I have the ability to make these sorts of decisions with my new job, but it opens a door into something I am not particularly familiar with dealing with. In the past I have often opted for placing a heavy amount of weight on working, and just a pinch on taking care of myself. Looking at it now, that could be why I have had trouble with such intense burnout.

It is difficult, though, and I am sure many of you have experienced this, when your boss or manager is the sort of person who considers illness a weakness of character, or has (possibly from dealing with untrustworthy employees constantly calling in “sick” in the past) a serious skepticism for anyone who claims they might be ill, to feel justified in taking care of yourself. Being in an environment where taking care of yourself is constantly considered the wrong thing to do, knowing how to go about taking care of oneself in a reasonable way seems backwards and can be difficult to learn.

I know I’ve talked about this before, but I think this sort of thing makes a huge contribution to how people feel about themselves and things like mental illness, after all if someone has told you for years that being sick means you are weak or that people who take time away from work because they are sick are awful employees who are not to be trusted, you can be damn sure the people on the receiving end are going to do everything they can to hide the fact they have a mental illness and will probably (to put it bluntly) treat themselves like shit because of it too.

Anyway, a lot of that fear still lives inside of me. I may not be afraid anymore that people hear the words “bipolar disorder,” and I may feel a little less guilty for taking time to take care of myself, but I can’t seem to curb the nagging feeling that once theory becomes practice (if I have to miss a lengthy chunk of work, for example, because of an episode) that I might be pushing my luck too far, and suspicion and anger might make their way into the minds of those that have told me to “take care of yourself.” I realize that this is probably unlikely, but it is the only response I’ve ever experienced up to this point and it can be hard to imagine a different one occurring.

In the meantime, getting the work done and taking care of myself has become something of a balancing act, and I am extremely grateful to begin working with a new therapist this week to help me navigate it.

Holding Things Over

 

Time has disappeared, I have become baffled with the fact that there is too much to fill my day now without enough time to do it. Sleep is still very high on my list of priorities, so I have been opting to sleep as much as possible, rather than stay up until the wee hours of the morning writing posts.

Of course, that doesn’t mean I haven’t been thinking about writing them. I have a whole list of things to say -without the time to say them in! I want to get more down this weekend, but I wanted to make a quick note letting you know that I am still alive and (violently) kicking.

I have now had the experience of a minor mixed episode at work, as well as a pretty intense wave of depression (that thankfully only lasted about two days). I could feel myself slipping from a goofy, slightly obnoxious co-worker into an irritable, snappy one with no interest in the repercussions. Big things have been happening, and I am dog paddling until next wednesday when I have a chance to meet with my new therapist.

Anyway, more soon.

The Hoops We Jump Through

As many of you may know, I’ve been pretty bummed out lately because my therapist I’ve been seeing about a year now is graduating and moving on from internship. As I see her through a clinic, I am not allowed to follow her to her new business, or, at least, I’ve signed a contract saying I wont. As our time together has come to an end (today is our last appointment) I have been thinking about the improvement I’ve been seeing in my life. Less panic attacks, more fun mood charts. Less spontaneous angry outbursts, more of an ability to shield myself from people’s (seeming) attacks on me. More perspective, more assertiveness, and more relaxation.

It seems to me we’re learning our whole lives anyway, why not speed that process up a bit? Learn through an actual teacher?

Anyway, the last several weeks I have been trying like the dickens to find a new therapist. And that is no easy feat, apparently. Finding one that is somewhere between work and my home, is near a bus route, female, available after 5 pm, specializes in trauma and anxiety (which is what I am currently focusing on), while also not being someone who generally creeps me out or makes me uncomfortable has been tricky, to say the least. I’ve probably contacted about 15 different people, interviewed two, and have just now set up a first appointment with one of them.

In order to reach that appointment, though, and be able to bill my insurance, I am asked to see a general physician and get a referral.

Now, the definition of “referral” is pretty different depending on the insurance company. Sometimes it is making a phone call, sometimes it is paperwork, and sometimes it is a magical word that doesn’t actually mean anything, it is just there to scare people away. 

My insurance kicks in next week, and I figure if I can make an appointment with my general doctor in the days after that, I can make it to my first appointment with my new therapist by the end of August.

I saw my psychiatrist yesterday and he caught me wringing my hands.

“Can you do something for me?” I asked.

“What is it?” he said.

“Can you write a little letter that says my diagnosis and that you would suggest I get therapy?” I asked.

Then I explained what I just explained above. A general practitioner (someone I may not have ever met before) is going to have to decide whether therapy would benefit me, and will be the deciding factor between my insurance covering it or not. All I wanted, really, was a letter of recommendation -a letter to recommend… therapy!

It was first thing in the morning and I think he was a little miffed, but he wrote the letter for me. I really just want something that says I’m not just someone walking in off the street claiming I have bipolar disorder and want to see a therapist. Some kind of… members only card, or something. A nice, smooth ramp to help me jump through those insurance hoops!

As much of a benefit as insurance is, the beginning stages are so frustrating and stressful. Trying to do things in an order that unlocks special level-ups and gets you that damn flute so you can travel through several worlds in Super Mario Bros. 3 can be totally unnerving and leave me confused and holding on to my prescriptions saying,”what the hell?”

Cannabis Use Linked to Higher Cognitive Performance in Bipolar I Patients

Someone sent me a link to this article several weeks ago actually, but I wanted to track down the source before writing about it. It took me quite a long time, but there is an original abstract for the research document here. 

The abstract is for a paper written by a team led by Raphael J. Braga, associated with a series of Hospitals and teams in New York state. The study was done on a series of patients with Bipolar type I, 50 of whom had a history of cannabis use, and 150 of whom did not. These two patient groups are said to not have differed in age, age of onset, or global assessment of functioning.

The group with history of cannabis use did, however, have more male patients, and patients in this group also had a higher instance of history of psychosis.

But here’s the kicker; patients in the cannabis use group demonstrated significantly better performance on measures of attention, processing speed, and working memory. 

“The history of CUD (“cannabis use disorder”) is associated with history of psychosis, suggestive of poorer clinical prognosis. Interestingly, bipolar patients with history of CUD had better neurocognitive performance as compared to patients with no history of CUD.” (Pulled from the paper abstract.)

Ok, so what does this mean?

It doesn’t surprise me that cannabis users were found to have an increased occurrence of psychosis. After all, I’ve heard accounts from perfectly rational, mentally healthy people who used cannabis and experienced psychotic-type symptoms; anything from intense paranoia, to visual or audible hallucinations. If this is something that can occur for a mentally healthy individual, I would expect it to be more likely to occur for anyone who has experienced psychosis on their own. At the same time, it is possible that the state of relaxation cannabis use can put someone into might make psychotic symptoms seem much less threatening or overwhelming… which is something of a trade off for someone who is experiencing them anyway.

Washington state is one of 17 states (18, if you count the District of Columbia in there) that have legalized medical cannabis use, and I think medical marijuana is one of the number one things people with bipolar disorder send me questions about.

Is it safe?

Is it helpful?

Is a medical card something bipolar disorder would qualify me for?

I’ve heard a lot about the benefits of medical marijuana for things like PTSD and anxiety, and even occasionally about depression. Solid research, however, up to this point about cannabis use and Bipolar disorder has been hard to come by.

I think a lot of research is being done lately using substances that have been found in “unlikely places” (think of the recent research regarding magic mushrooms, or ketamine) and I, for one, am glad people are willing to think outside the box for potential treatment options for things like depression and bipolar disorder, which are very difficult to live with.

Like anything else, I’ve had some people with bipolar disorder tell me that medical marijuana has really helped them, and I have had other people tell me that they didn’t like it at all and it seemed to make things worse. Like any medication your doctor might prescribe, it doesn’t effect everyone the same way. This latest research seems to show cannabis use for this group may be more helpful than many people expected, but like anything else… it isn’t a miracle cure. I think if we keep that in mind, there are many treatment options we can try that might be helpful!

Just Another Manic (Tuesday)?

This week at work was much easier. In fact, I’d call it much, much easier as hypomanic energy filled my veins and running up and down the stairs became comforting and hilarious instead of tedious.

That said, Tuesday was a bit of a scare for me though because the age old question:

I wonder what would happen if I am manic at work?

was quickly answered.

As I watched (less in horror and more in absurd humor) as my mood shot through the roof, I began tipping the scales from quirky and energetic to just flat out odd. Of course, I thought I was being hilarious, but (survey says) that may have just been a lovely cloak of delusional grandiosity resting on my shoulders.

I am very lucky that I wasn’t in one of those irritable, or paranoid places (especially since there is a lot of whispering in the world of cubicles), and that is something I am really going to have to watch falling into (and trying to either curb or remove myself from work when it eventually happens). It was more one of the goofy, odd manias that leave me unable to verbally communicate well. I think of something to say (clever or otherwise) and when I open my mouth, the words that come out are not even in the same realm as what I was trying to convey.

“STARSHIP LOG!” is one of those odd things I shouted in a meeting, giggling to myself at first about how hilarious my intended statement was going to be, and then giggling after because what actually came out for some reason was “starship log”. Too much Star Trek lately? Probably.

Writing never seems as effected by this, so I stuck with emails and instant messaging. What else can one do when the words coming out of their mouth don’t match the words coming out of their brain?

Overall, I think I made it through the week without offending anyone in particular, and at my mid-year review (which was only actually a three week review for me) I was heralded as someone who does good work. That is all I can ask for at this point.

I have been interviewing potential new therapists (or, well, one so far) and she asked me the next day (after my manic blip Tuesday) what could have caused it. Stress? Caffeine? Sleep? Anxiety? She went through a long laundry list and I flat-out told her no to each that she listed. I track all of those things, and that gives me the best chance of maintaining them and keeping those triggers from going all askew. I genuinely believe this was just one of those waves, one of the directions my mood takes on its own, when all I am left to do is ride whatever wave it is -white knuckled, until it subsides.

Choosing an Insurance Plan

For the first time this year, I am going to be eligible for medical benefits under my new employer. This particular place of business offers three types of plans with different coverage, and at once I went to work spreading all of the papers over the living room floor trying to distinguish which would be best for an employee that needs a lot of healthcare, namely me.

Corey walked in and said,

“You know, you are the only person I know who actually reads all that stuff. I never read any of it,”

“And that is why you are shocked when you get a bill in the mail for several hundred dollars after a doctor’s appointment,” I replied.

I think a lot of people believe that as soon as they have whatever it is called benefits, healthcare is suddenly free, available wherever they want, and their benefits cover everything kind of appointment they’d like to make. I think that is the first mistake, and by not reading (or even by reading and not understanding how your benefits work) about your benefits package you’re really setting yourself up to have your pockets picked.

You should be taking advantage of these benefits, not the other way around.

I thought I would talk briefly about how you can go about getting the best care under whatever insurance plan you choose, which is something that can be difficult when you have a chronic illness or disorder (like bipolar disorder).

Looking Back

First, I’d just like to point out that for a very long time, someone with a mental illness could be denied coverage for treatment of that illness if they had it before receiving insurance coverage, or if they switched insurance providers after being diagnosed. Obviously, that is total bullshit, and I can’t tell you how many times I have been denied coverage for having bipolar disorder.

Thankfully, Obama (whether you love him or hate him) did away with that, so it is now illegal for insurance to deny coverage for “pre-existing conditions”. That is a definite win for those of us with diagnosed mental illnesses, though there are still several ways health insurance providers can deny coverage to what we need. I’ll get to that.

The Deductible

Ok, now when you’re looking at an insurance plan, they will often tell you how much it will cost you to see a provider in their “network” (one that takes that insurance plan) and how much it will cost you to see a provide who doesn’t (“out of network”). What many people skip over, though, is that chunk of money called the deductible. 

This is the amount of money that you have to pay before your insurance provider begins to chip in on your bills in many different types of situations. The higher the deductible, the more you will have to pay out of pocket before sharing the cost of your healthcare with the insurance provider.

Some insurance companies will allow you to avoid paying this if you see doctors in their network, and will only charge you a “co-pay” (a flat rate to see these doctors). However, the deductible will still need to be met for other types of care (so think about things like lab-work if you are taking lithium) or if you want help paying for doctor’s visits outside of the network.

Your Doctors

The first thing I would suggest doing is making a decision about what doctors you want to see. Do you currently have a psychiatrist or therapist who you can’t see yourself leaving, or would it matter if you saw someone brand new?

  • If you are willing to see all new doctors, you can probably use “in-network” doctors to avoid having to pay the deductible right away. If this is your chosen course of action, I would suggest going to the insurance provider’s website and doing a search for the types of doctors you want to see (to see if there are any in-network in your area).
  • If you already have a team of doctors you like, I would suggest calling each of their offices and asking if they take the insurance you are considering purchasing. If you are lucky, there is a chance that they might! If they don’t, though, that means they will be “out-of-network”, and will require you to pay for all visits until that deductible amount has been met. After that, some plans share the cost of visits (60%/40% for example).

If your doctors are out of network it may be wise to figure out if you will be paying for enough visits to actually meet that deductible.

Take your (cost of one visit) X (number of visits you plan to take in your plan year) =

If n is less than your deductible amount, it is possible you will be paying for all of those visits out of pocket. Remember, the insurance doesn’t kick in any money until this amount of money has been paid.

If is more than your deductible amount, you can expect to meet that deductible and then have insurance help pay for the remainder of your appointments.

So, if I see my psychiatrist (which costs roughly $100 per visit) once a month, that would mean $1200 annually (as I’d be in there 12 times per year). If my deductible is $500, that would be a great deal, whereas if my deductible is $1000 it would be a bit less-so. I would probably only save (in that case) about $80.

At the same time, I want to be sure to be clear that just because the amount of visits you predict doesn’t meet your deductible, it doesn’t mean you wont meet it. Other things like lab work might go toward it, or emergency visits you may not know will happen in the future, or the cost of certain types of appointments.

What do they cover?

Most of the time I have had the option of being enrolled in an insurance plan, I am provided with a booklet that outlines everything that is covered or not covered. If you were not provided this information, ask for it. Remember when I said there are still some ways insurance can deny certain things? This information is particularly important for mental healthcare, as some plans with not cover or limit the number of therapy appointments they will cover, among many other things which may be vital to our care.

What types of appointments do you expect to use? Acupuncture, massage therapy, talk therapy, inpatient hospitalization (in the event of an emergency)? Make sure you look up whether those things are covered by your potential insurance plan or not ahead of time. Some things, like therapy, may not be covered, but the amount you spend on it might be able to go toward your deductible. Other things, like massage therapy (or even psychiatry) might only be covered after a series of approvals from other doctors (basically someone signing off that you do need these services). This notion can be a bit daunting, but I’ve found that with a solid history of mental illness in place, I have never had problems being “approved” for the type of care I need. It is just another hoop to jump through, because without jumping through it they can potentially charge you without covering any of the amount for the appointment.

Personally, I’ve found it difficult to find a therapist that will actually take insurance, most of them are extremely wary (because insurance companies generally don’t pay the therapist in a timely manner). If you go to a clinic (and not an independent provider) you may have more luck with insurance and therapy fitting together better.

Annnnnd Medications…

Not all insurance plans are created equal, and not all medication coverage is equal either.

Most plans no longer have a “one-size-fits-all” approach to medication coverage, so it is no longer a question of whether a medication is covered or not. Many of the newer setups I’ve seen involve tiers, with generic drugs being in the cheapest tier. This part gets tricky, because anyone who has to be on a brand name version of a drug with a generic counterpart pays heavily for it, so if I were to need Risperdal (instead of the generic Risperidone) I’d probably pay $100 for my prescription instead of the $10 it would cost for the generic.

Mental health is one of the areas where I see this as being something of a cheat, because there are many people who either don’t have any luck with the generic counterparts of our medications or are on a medication that doesn’t have one yet.  Obviously, these drugs are still discounted, but not as deeply discounted as others.

I would suggest making a list of your medications and looking them up (most insurance companies should have a database of how much each given medication will cost). In one instance, I found that it is cheaper for me to buy Lithium at Target than it is to get it through the insurance plan I signed up for (which is a little baffling) so getting an idea of how much your medications cost now vs. how much they would cost on insurance can be an eye-opener. If you want to multiply that cost by 12 (if you fill monthly) you can get an idea of how much it will cost for the whole year.

Oh, and most insurance companies do not count medication co-pays toward your deductible, so anything spent on medications probably wont count toward reaching that amount.

Putting It All Together

Alright, so I am kind of a nerd so I usually like making up a grand total of what things are going to cost me. For those of us that need more healthcare than others, I have run across some insurance plans that would actually cost more for me to have than if I didn’t purchase insurance at all (which can be a little disheartening).

To see the difference between how much things will cost with insurance and how much they will cost without (or to compare one insurance plan with another) you can create the total cost for each situation.

First, figure out how much healthcare is costing you now:

1. The cost of your doctor visits for the year (the cost of the appointments times the number of times per year you go)
2. The cost your medications for the year (the cost of each medication times the number of refills you get per year)
3. The cost of other expenses, like therapy, lab-work, etc. (the cost of the appointment or lab-work times the number of times you go/have it done)

And add 1-3 together. For me the total is averaging about $10,000 this year and I would say that is probably a more modest estimate (compared to other years).

So next, figure out how much that same healthcare would cost with the insurance plan you are looking at. You will need to take into account everything we’ve talked about so far, so whether you are planning on using in-network doctors or out-of-network doctors (or a combination), if things like therapy are covered, and what the deductible looks like. This is a little more tricky, but here is a general step-by-step.

1. The cost of your doctor visits for the year (the cost of the appointments with insurance (either an out of network cost for non-network doctors, or the in-network copay) times the number of times per year you go). You can repeat this step for each doctor you see, or each type of doctor you see. You may also want to use this step to figure the cost of seeing your therapist, or you can wait for therapy until step 3.

Now, if the amount totaled here for non-network doctor visits is bigger than your deductible, subtract your deductible from this total cost (so if I spend $1500 on non-network doctors visits and my deductible is $1000, that leaves $500). With the amount left, multiply by the amount you are responsible for (so if your insurance covers 60% after the deductible is met, for example, you are left to pay 40% of the total amount. $500 x 40% = $200). Instead of paying $1500 on those doctors appointments, you would meet your deductible and only pay $1200.

It may not seem like this is saving much, but if your deductible is already met, that means you will have no deductible left to fill for lab-work or out-of-network therapy appointments.

2. The cost your medications for the year (the cost of each medication co-pay times the number of refills you get per year). Remember some medications might cost more than others depending on the insurance plan.

3. The cost of other expenses, like therapy, lab-work, etc. (If your therapist is in-network, multiply the co-pay times the number of visits. If they aren’t, have you met the deductible with other out-of-network visits? If so, multiply the total cost of therapy appointments for the year by the amount you are responsible for. If you go weekly and your visits are $100 apiece, you would potentially spend $5200 for the year. If insurance covers 60% (for example) after the deductible is met, you are left to pay 40%, so $5200 x 40% = $2080. If your deductible isn’t yet met because you’ve only seen in-network doctors, we would subtract the deductible ($1000) from your total ($5200) and multiply the remainder by the amount you are supposed to pay ($4200 x 40% = $1680). If you were only using an out of network therapist (and nothing else) you might still only pay $2680 instead of all $5200.

Lab work usually works the same way.

So, again, add 1-3 together and then for this total we will also:

4. add the cost of your insurance plan for the year. Let’s not forget, unless your insurance cost is covered entirely by an employer or government plan, you are probably paying weekly or bi-weekly to keep it active.

Ideally, this is when you would know if the insurance is a good deal or not, or if it covers the things that are important to you and your healthcare. 

My final suggestion is to consider the FSA.

If you are being offered insurance by an employer who also offers the option of a Flexible Spending Account, I would highly recommend it. I am not someone who has had much money, so this is the only way I’ve been able to pay for healthcare before actually saving enough money from my paycheck to do so.

The FSA deducts equal amounts from your paycheck on a pre-tax basis, and you can choose the amount you want deducted. That money, though deducted evenly through the rest of the year, is available to you immediately for using on your deductible, co-pays, medications, and a whole long laundry list of other things. The only thing I would say to watch out for is that at the end of the year, if you don’t use the money in that account you lose it. Personally, I’ve never had trouble with that (and always used all of mine very early on with the number of doctor visits I have) but it is something to consider.

I just had to decide between three different plans, and I read everything I could get my hands on and then made an excel spreadsheet to help me add everything together and compare. I requested more information on the insurance provider several times, called my doctor’s offices to ask about their relationship with my potential plan/insurance provider, and I feel confident that I know what is and is not covered.

Yes, I have bipolar disorder, and I am now working at a job that is pretty huge. If nothing else, that is a big reason to pay attention to how my new insurance works and know how it will support me and when it will not.

I think it is important for anyone to understand how insurance works, but it may be much more critical for those of us with pre-existing conditions that require careful monitoring and care. Knowing how to get the most from your insurance provider allows you to tip the scales in your favor, and might mean the difference between taking advantage of your insurance or your insurance taking advantage of you!