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Column | August 01, 2009

Personal Accounts: Severe Mental Illness and Psychotherapy

Barbara A. Kunkle

Psychiatric Services 2009; doi: 10.1176/appi.ps.60.8.1013

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Ms. Kunkle lives in Pennsylvania and may be contacted at bakunkle@windstream.net. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.

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I remember my first hospitalization for severe bipolar depression in 2006. While I was being escorted to my hospital room, I was preoccupied with the belief that "it" was over now—my life, as I had known it, was over. I had lost the struggle to hide the symptoms of severe bipolar depression. I could no longer consider myself a normal person. This was my obsession: I must present as normal and hide my psychosis at all costs. I must hide the "shadow man" that I saw in the corner of the therapist's waiting room, the bloody battle scene, the nights and days of endless, nearly comatose sleep, the emergency calls to my therapist when the high bridges seemed seductive, and the silent cries for help that hid the haunting echoes and voices of insanity. These images and thoughts resulted from perceived abandonment and alienation and increased feelings of guilt over my diagnosis of severe bipolar depression.

After I'd spent several days in the hospital, my psychiatrist made adjustments to my medication. The dark obsessions, hallucinations, and voices quieted. The shadow man and the bloody battles disappeared. I think I was the most vulnerable in the hospital because I had to depend on strangers for help, rather than my treatment team, with whom I had established a relationship. The issue with hospitalization is that although it keeps you safe, it takes you away from your familiar intervention team. During this hospitalization, I remember feeling deeply wounded and calling out for help—and needing more help than I had ever needed before. My mind had drifted far away from everything I once knew. I felt helpless and didn't know what the outcome would be or if I wanted to survive.

To be discharged from the hospital, I needed to take increasing doses of Ativan or Klonopin. I needed to see my psychotherapist twice a week and take an antidepressant, a mood stabilizer, an antianxiety drug, and an antipsychotic. This is what it took to keep me safe at that time.

My mood disorder has always been complicated by borderline personality issues. I am not sure how much of my personality disorder contributes to my depression or how much my depression contributes to my borderline issues. Left untreated, the borderline personality disorder meant, among other things, that I could not let go of an issue even if it had been resolved. It meant always using a good-bad, black-white, either-or way of thinking. It also meant that no amount of life meaning could fill the empty void that inhabited and inhibited my spirit.

Being a very sensitive person, my coping skills are not as adequate as the coping skills of most others. As a child, my thinking was done for me because my decisions were made by my authoritarian parents. I was very sensitive to rejection because, according to my religiously fundamentalist parents, the ultimate rejection was by God. If I expressed an independent thought, I was viewed as a bad and unlovable person. My sensitivity revealed my fearfulness, which was the theme in my therapy for years. I would get very angry with my therapist, rather than speaking about the fear. I believed that if I got angry, I would not have to deal with the fear.

I would build up thick walls to communication while being careful whom I trusted. This lack of trust extended to what I chose to talk to my therapist about. This guarded communication was an insurance policy to avoid admitting my fear. Isolation was an unfortunate side effect of my fear, which left me even more vulnerable to depression. My moods were unstable. Since childhood, I had been told by authority figures that my mood came across as either sky high or rock-bottom low. These mood swings continued untreated into my adolescence and adulthood.

During my psychotherapy, my social attachments felt insecure. For example, I was very concerned about the availability of my therapist, and for the longest time I would not allow him to have limitations. Only after my therapist presented this issue in therapy did I allow him to have limitations, but not without processing my fear of rejection. As I became more connected to my support systems, I learned that it is not always the big interactions that make a difference; sometimes small interactions, ones that take little time, can make a remarkable difference.

One of my symptoms was agoraphobia, which developed in 2007. I went from a deep, dark loneliness where I didn't want anyone to leave my presence to seeking time alone in the refuge of my house. My demons were in control there, but agoraphobia is a hell unto its own. People did not understand my behavior. I knew my behavior was crazy, but I couldn't be any way but agoraphobic. During my agoraphobia, I experienced spontaneous energy drops. I would begin a day with plenty of energy and then quickly lose momentum. I was traveling a vicious cycle. In time and with more intensive psychotherapy, my energy slowly returned. My resilience increased with the momentum of each day's progress toward recovery, and my improved libido was now becoming part of my relationships. The depression had taken away all desire for intimacy, when it was all kinds of intimacy I needed in order to recover. As I improved, I was able to experience intimacy rather than isolation.

After losing three family members in a short period and with a cancer diagnosis of a fourth, profound loss was a common theme that wove my grief and depression together. I was investing a lot of emotional energy in both. I wondered if my unresolved grief had turned into clinical depression. It had been some time since these losses, and I still didn't have the energy or desire to work through these emotions. At one point during my depression, I could not sustain enough energy to get through therapy sessions. My therapist and others told me I looked gaunt, pale, and exhausted. At one point, too weak to speak, I had to leave the session early.

As of this writing, ten months after the onset of my most severe breakdown, I am experiencing relief from my symptoms again. This is only after a therapeutic history of confronting demons in the dark shadows of my psychic, physical, and spiritual pain, along with several hospitalizations and medication adjustments. I have made peace with my demons, and I have a new, meaningful life. My depression is no longer resistant to medication, and I sleep eight hours a night and not at all during the day.

One of the most effective techniques my therapist used was rephrasing the trauma of my first hospitalization. When I related to my therapist during the first hospitalization that I thought my life was over, instead of letting me believe this, he stated that another possibility was that the isolated trauma was now over and I didn't have to hide it anymore. This changed the way I looked at my trauma.

I was asked by another therapist how my therapist was able to bring me back from the edge when I was in crisis. At that time, I was deep in suffering and could not identify the process. Looking back, I would answer that question in this way: "My therapist listened and really heard me describe my pain. Even though recovery through psychodynamic therapy was foreign to me at first, my therapist eventually created a safe place within this type of therapy for me to explore pain." My therapist never overreacted or overresponded to anything I said. There was no judgment or expected time frame for me to recover. He listened attentively and commented subtly and with compassion in his voice, which marked how he was engaging his soul in his work.

My psychotherapy was successful, and my symptoms lessened. There was resolution of conflict, and I achieved more and more independence from my therapist. My quality of life has been renewed. I still have days when I feel depressed or anxious and experience mood swings, but the swings are not as frequent as they used to be. Being "recovered" doesn't mean being symptom free. Depression may well recur, and I may always need to see a therapist and take psychotropic drugs. Recovery is stabilization and maintenance on a daily basis.

Seeds of healing were planted by working with a competent therapist and nurtured by our therapeutic alliance. The seeds grew into a great oak tree, and with nurturing by human nature, it provided a shade for my pain and a recovery for my mind, body, and soul.

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Barbara Kunkle, M.A.; Personal Accounts: Severe Mental Illness and Psychotherapy. Psychiatric Services. 2009 Aug;60(8):1013-1014.

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