An Examination of of Typical Issues in the Treatment of Bipolar Disorder

An Examination of of Typical Issues in the Treatment of Bipolar Disorder

In the clients who have come to me because of problems with bipolar disorder, I have consistently found them to have deep feelings that the damage inside is so extensive that there is no realistic hope for psychological development, which often leads to a search for a "magical" solution instead. This process can best be illustrated with a clinical example, a man in his 20s, with mood swings that demonstrate the typical high/low dynamics of bipolar disorder.

Ethan was a highly intelligent and accomplished young man, recently graduated from university; he wished to be a writer. He came to me on account of depressive episodes so severe he felt scarcely able to carry out his ordinary responsibilities. He worked at a clerical job to get by notwithstanding his depression, striving to write in the evening and on weekends. If he were feeling acutely depressed, he was unable to write at all. At the end of his work day, he'd frequently succumb to a state of liveliness, scarcely able to feed himself, watching mindless television programs. He suffered from intense insomnia and usually slept but a few hours.

He wanted desperately to have a relationship but felt utterly worthless, as if everything about his adult functioning self was a false front, and that as soon as anybody got emotionally near to him, they'd find out that he was an impostor. He would portray himself as a loser, "damaged goods," or "a good-for-nothing piece of shit."

The matter of "shittiness" usually arose in his psychotherapy. He had a repeating dream that the toilet in his bathroom would stop up and his apartment would overflow with feces. Or sewer pipes in the ceiling would break. In his dreams, he'd feel completely powerless to do anything about the broken pipes or sewer problem. The damage felt insurmountable. In our work together, I would take up these dreams in two ways. The overflowing sewage stood for both his "backed up" emotions which he felt unable to endure or handle, as well as the desperation he felt about his internal damage. We came back to this topic time after time, particularly his anxiety that our work together was impotent because (a) I couldn't possibly cope with all his "shitty" feelings either, and (b) the damage was simply too vast.

Periodically, the depression would lift and he'd enter a hyper-industrious phase, writing for hours at a time and throughout the weekend. He'd cook up a "brilliant" plan for a new novel and write 25-35 pages at a go. He wouldn't stop to revise but just continued with a manic drive in the hope of finishing the book in a short space of time, selling it to a publisher and graduating to an idealized life in which he'd be a well-off, well-known and critically extolled author. He felt increasingly anxious during these periods; although he showed up for our sessions, to me he felt difficult to reach and he became distrustful and argumentative if I attempted to explore his compulsion to write. In the long run the manic state would dwindle and he'd slip back into depression, abandoning the incomplete manuscript as "worthless".

During the manic episode, he undeniably felt in the throes of magical thinking; below the surface, he feared that he was simply passing off shit as if it were something of extravagant value. While in his uncontrollable writing phase, he unconsciously felt it as a kind of emptying, too, as if he were magically escaping all the bad excruciating emotions. He couldn't go back and revisit his work or revise it as to do so might diminish the manic triumph of his creation as well as return him back in contact with the bad feelings he'd tried to get rid of.

My chore was to make clear to him over and over again that he felt hopeless to achieve anything realistic to improve, either in terms of his writing or his damaged internal world; magic alone could clear up his problems. Time and again, we had to return to those shitty awful emotions, attempt to understand them and encourage him to bear his own emotional experience. It was the toil of years. Ultimately he finished and sold a novel but continually struggled to wrest his writing from the purview of magic.

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