Everyone in the clinic knows Tim. He wanders into offices, sits in doctors' chairs, collects pens and notepads from desktops, and is alternately engaging, entertaining, irritable, and argumentative. Tim is a 28-year-old married, unemployed man with bipolar illness who recently was referred to the clinic from a private psychiatric group when his insurance ran out. His new psychiatrist—a resident—is beleaguered by telephone calls at 4:00 a.m. when Tim is fighting with his wife or at 2:00 p.m. when he has questions about his medications or other practical matters.
In addition to having bipolar illness, which was first diagnosed when he was 18 years old, Tim suffers from hyperthyroidism, diagnosed when he was 12. The resident, having engaged Tim's cooperation, juggles his medications, constantly challenged by fluctuations in his thyroid screen. Does psychotherapy have a role in Tim's treatment plan? How can the psychiatrist balance the patient's neediness against the heavy service demands of a busy public-sector clinic?
Bipolar disease is a lifelong illness. Jamison (1), in her magisterial book An Unquiet Mind, offers us a vivid glimpse of her interior life as she struggles to survive her critical illness. The sine curve of exacerbations and remissions complicates clinical management. Many patients don't achieve a full interepisode recovery. Those who do achieve it still have to contend with serious psychological issues associated with the impact of a chronic disease. Thus it is imperative that clinicians recognize the importance of combining pharmacotherapy with psychotherapy.
In today's world, with overwhelming service demands, one may be seduced by the hope that newer medications will resolve these problems. Topiramate, lamotrigine, or gabapentin will keep Tim from fighting with his wife, resolve his family's anxiety, and enable him to have positive interactions in his social life and to become gainfully employed. Sure! That silver bullet has not yet been invented and probably never will be. There will always be a need to assist patients with their reentry into society and to repair the interpersonal damage that results from their troubled behavior and skewed cognitions. Thus we need to focus attention on the therapeutic possibilities and tasks in our psychological work with patients who have bipolar illness.
Scott (2) organizes the psychotherapeutic objectives under three headings: adjusting to the reality of the illness; loss; and compliance with medications and other treatment demands.
Adjusting to the reality of the illness
Patients who calmly accept their diagnosis and comply fully with treatment are the exceptions. Goodwin and Jamison (3) describe the predictable reactions of patients who learn that they have a chronic, recurrent, and potentially life-threatening illness. These reactions are denial, anger, ambivalence, and anxiety, all of which must be approached in psychotherapy.
Patients must be helped to deal with their psychological reactions to loss, including loss of relationships, loss of employment, and loss of self-esteem. The effect of bipolar illness on marriages, children's well-being, and extended family relationships is often devastating and seemingly irreversible.
Compliance with an informed treatment plan that includes medications and other forms of treatment requires the development of a working alliance with the patient, which of course hinges on knowing who this person is who suffers from bipolar illness.
Who is this person named Tim? Tim is not just "a bipolar"; he is a man who has bipolar illness. The more we know about the Tims, Janes, Joes, and Ellens, the better chance we have of being able to talk with them, to reach the essential person underneath the manifestations of illness. Interpretations in supportive therapy are made not to open the doorway to the unconscious but to facilitate patients' understanding of why an event today may be particularly and personally stressful for them.
Tim emigrated to the United States with his family when he was ten years old. What was the move to a new and alien culture like for him? At age 12 he developed hyperthyroidism. What occurred? What has it been like for him to be in and out of hospitals, unable to hold a job, and completely dependent on his parents, siblings, and new wife? The answers to these questions may contribute to the understanding and management of Tim's frequent calls to his psychiatrist and of his inappropriate behavior.
What can clinicians do? There are only so many hours in the day, and there are a lot patients to see. Many patients have chronic and persistent mental illness and need long-term supportive psychotherapy coupled with cognitive learning and psychodynamic understanding. Meeting with these patients in a group setting has proven to be valuable, even for patients who have bipolar illness. Group therapy not only is an economical use of therapists' time but also has been proven to have advantages over individual psychotherapy sessions.
Kanas (4) and Graves (5) have both suggested that contrary to traditional thinking and the pessimism of the past, patients with bipolar disorder can be treated in homogeneous groups with concomitant pharmacotherapy management. Kanas reviewed the literature and found that therapists who used techniques involving education, support, and facilitation of group discussion of relevant psychodynamic and interpersonal issues were able to provide a positive therapeutic experience for their patients. Graves described enhancement of medication compliance, effective challenge of denial mechanisms, and the facilitation of increased awareness of internal and external stressors as effective tools in the therapeutic armamentarium of potential ways to increase understanding and influence the course of this complicated illness.
The group therapy techniques described by Andres and colleagues (6) for patients with schizophrenia and schizoaffective disorder are also relevant for patients with bipolar disorder. A coping-oriented group therapy approach consists of psychoeducation, stress identification and management, health behavior, and family psychoeducation. The group members identify a stressful situation, and the group works to understand the stress and develop appropriate coping strategies by using a problem-solving approach. They discuss healthy behavior—ways in which to structure their day and their leisure time to expand their horizons and avoid injuring those they care about. The group members practice these strategies in real-life situations and later discuss their experiences in the group.
Obviously, patients with bipolar illness, like all patients, will at times experience and misperceive their psychiatrists in ways that reflect their relationships with significant others from their past. When patients are in their turbulent manic states, grandiose, narcissistic, and dependent drives may grossly distort reality. A seemingly positive therapeutic alliance can disintegrate, leaving the therapist feeling impotent.
Salzman (7) describes the complex and therapeutically important task of remaining attuned to the possibility that a patient's reaction, which may at first blush appear to be a manic distortion, is in fact a transference distortion. He describes a patient and the seeming dissolution of an alliance, which was replaced by "disappointment, hostility, and denigration. I was not only ridiculed as a 'drug-manipulating mechanic' like previous psychiatrists, I was also branded as an incompetent, not very bright therapist."
Salzman initially blamed hypomania for the patient's anger but in time realized that the patient was recapitulating her feelings about her father's control over her independence. Some of her anger toward her therapist was connected with earlier feelings toward her father. Talking about this "enabled her to acknowledge the contradictory currents of love and anger elicited by the important men in her life." Salzman writes, "These shared realizations helped diminish her anger and my frustration."
The countertransference reactions that occur in working with bipolar patients are truly complex. The engaging and amusing nature that many patients exhibit may initially seduce the therapist into joining with them in entertaining flights of fancy. Like patients with borderline personality disorder, patients with bipolar disorder may give the appearance of being more in control of their thoughts and actions than they really are—or, conversely, they may appear to be more out of control than they actually are. These affective fluctuations require a stable environment in which to organize the patients' thoughts and behaviors. The clinician in many ways acts as a containing force. In a clinic setting it is also often the clinic itself that serves this purpose.
Both the therapeutic work and the bipolar illness are always challenging. It is imperative to use both psychopharmacologic means and psychotherapy to stabilize these patients and enable them to minimize the damaging effects of this difficult and chronic illness.
Dr. Goin, who is editor of this column, is clinical professor of psychiatry and behavioral sciences at the Keck School of Medicine at the University of Southern California in Los Angeles. Send correspondence to her at 1127 Wilshire Boulevard, Suite 1115, Los Angeles, California 90017 (e-mail, firstname.lastname@example.org).