A Discussion of of Issues in the Treatment of Bipolar Disorder
In the clients who have come to me as a result of difficulties with bipolar disorder, I have consistently found them to experience powerful feelings that the damage inside is so pervasive that there is no plausible hope for psychological change, which often leads to a search for a “magical” solution instead. This state of mind can best be made clear with a case example, a man in his 20s, with mood swings that reflect the usual high/low dynamics of bipolar disorder.
Ethan was a remarkably sharp and accomplished young man, who had just graduated from college; he desired to be a writer. He came to me becauseof depressive episodes so extreme he felt hardly able to carry out his ordinary responsibilities. He worked at a clerical job to get by in spite of his depression, attempting to write in the evening and on weekends. If he were feeling intensely depressed, he couldn’t manage to write a word. After work, he’d usually succumb to a state of immobility, scarcely managing to feed himself, watching mindless TV shows. He suffered from intense insomnia and frequently slept but a few hours.
He wanted intensely to have a relationship but felt completely without value, as if everything about his adult functioning self was a mask, and that as soon as any person got emotionally near to him, they’d discover that he was an impostor. He would represent himself as a loser, “damaged goods,” or “a miserable piece of shit.”
The topic of “shittiness” oftentimes came up in our work. He had a reoccurring dream that the toilet in his bathroom would back up and his apartment would fill with sewage. Or sewer pipes in the ceiling would break. In those dreams, he’d feel thoroughly powerless to do anything about the broken plumbing or sewer problem. The damage felt hopeless. In our therapy together, I would take up his dreams in two ways. The overflowing sewage symbolized both his “backed up” feelings which he felt unable to endure or deal with, as well as the despair he felt about his interior damage. We returned to this issue time and again, particularly his doubt that our psychotherapy together was powerless because (a) I couldn’t possibly cope with all his “shitty” feelings either, and (b) the damage was plainly too vast.
Sometimes, the depression would lift and he’d enter a hyper-industrious condition, writing for hours at a time and all through the weekend. He’d formulate a “brilliant” design for a new novel and write 20-30 pages at a time. He wouldn’t stop to revise but simply went on with a manic momentum in the hope of finishing the novel within a few weeks, selling it to a publishign house and moving up to an idealized life in which he’d be a well-off, preeminent and critically hailed author. He felt progressively more anxious during these periods; though he came to his sessions, to me he seemed difficult to get in touch with and he became mistrustful and belligerent if I attempted to go into his compulsion to write. Ultimately the manic stage would peter out and he’d sink back into depression, junking the incomplete manuscript as “worthless”.
During the manic , he obviously felt in the hold of magical thinking; beneath the surface, he feared that he was simply passing off shit as if it were something of immense value. During his uncontrollable writing phase, he unconsciously felt it as a kind of evacuation, too, as if he were magically getting rid of all the bad insufferable emotions. He couldn’t go back and take another look at his work or revise it for to do so might deflate the manic triumph of his creation as well as bring 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 do anything realistic to improve, either in terms of his writing or his damaged inside world; only magic could solve his problems. Over and over, we had to revisit those shitty awful feelings, endeavor to understand them and help him to bear his own emotional experience. It was the toil of years. In the course of time he completed and sold a novel but continually struggled to free his writing from the world of magic.
Joseph Burgo PhD is a clinical psychologist with 30 years experience in the field. He writes a psychotherapy blog for individuals who aspire to continue to grow and hear more about diagnosis subjects such as bipolar disorder.
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