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Section 24
Therapy and Bipolar Disorder

Question 24 | Test | Table of Contents

It is commonly thought that one cannot talk to manic patients, or at least one cannot do therapy with them (Baruch, 1997). In this paper, we seek to explain why we think this perspective need not be the case. In our judgment, there are two aspects to talking with the manic patient. First, one must meet the patient. This involves empathic connection. There needs to be a meeting on a common existential ground (Jaspers, 1998). In this work, the therapist must struggle to avoid theorizing or judging, but rather should seek simply to think, feel, and experience what is happening as the patient is thinking, feeling, and experiencing it. The second step, after connecting with the patient, is to help the patient put perspective on his/her experiences (Semrad, 1984). Therapists try to achieve this perspective through different methods.
Perhaps the majority use some variation of psychoanalytic theory, trying to help patients gain insight into the deeper wishes or feelings that might be driving their behavior. Some therapists use cognitive-behavioral theory and focus on how patients' interpretations of their situations may produce their emotions or behaviors. Both of these common approaches are quite limited with manic patients, however. In this paper, we want to suggest that the best alternative for communicating with these patients is to use "counterprojective" techniques, derived from the work of Harry Stack Sullivan (Sullivan, 1954; Havens, 1983). (These methods have also been termed "paradoxical intention" in family/systems models, or "siding or joining the resistance" in relational and some psychoanalytical models). Sullivan, perhaps, has most focused his therapeutic work and writing on these methods, which are too often ignored in modern psychotherapeutic practice.

The Therapeutic Alliance
In her autobiography (1995) Kay R. Jamison, a researcher and psychiatry professor who has bipolar disorder, commented that her psychotherapy was invaluable to her survival. She said that it was not so much what her therapist said that was important; it was what he did not say. Sometimes talking with patients entails not talking with them. This is especially the case with a manic patient. Hypervigilant, aroused, overactive, the manic patient cannot tolerate much talking on the part of the clinician. On the other hand, s/he might need a very good listener. In the era when psychoanalytic models predominated, some clinicians claimed that persons with bipolar disorder often has superficial relationships with other persons in their lives (Ablon, Carlson, & Goodwin, 1974). For instance, people with bipolar disorder would not have long-lasting intimate relationships, and frequently experienced multiple divorces. However, clinicians in the psychoanalytic era sometimes noted that patients with bipolar disorder might have one intimate relationship with someone else, often their therapist, and the therapist could chart the course of that person's illness by the vicissitudes of that relationship. Whether as cause or effect, the relationship of a therapist with a person who has bipolar disorder may be a clinically important aspect of the course of the illness.

Counterprojection
The patient comes to treatment with assumptions about the doctor, and the doctor with assumptions about the patient. These assumptions sometimes doom the treatment before it begins. The most noxious assumption that doctors can fulfill is the feeling by patients that we, their doctors, represent the "system," the status quo of power and privilege. We will label the patient as sick, and then send him through a rigamarole of diagnosis and treatment that will end up with his extrusion as a "patient," often without an active and productive role in society or a strong sense of self-worth. The resistance of patients to treatment is often a reflection of their justifiable, if sometimes exaggerated, hesitation to enter this process. Harry Stack Sullivan (1954) taught us that sometimes, contrary to our comments on the encounter, it is better to avoid conflict with patients, especially if they want it. If patients expect us to confront them, we should agree with them instead. In so doing, we are disabusing patients of their assumptions about us and removing such distortions from the interpersonal field, again in the interest of real valid relationship-building. The basic idea of this counterprojective position is that sharing feelings reduces them (Havens, 1983). So, in perhaps the most controversial perspective of this paper, we would argue that when a manic patient makes a grandiose statement, it is (more often than not) best to agree with it, at least initially. Joining with elation, and not just depression, is an essential part of forming a human connection with the manic patient. In the old days, especially in the Boston area, any young manic patient worth his salt would aspire to be like that other Boston Irishman who made it big: (patients used to say, and truly believe, that they were) John F. Kennedy. He has fallen a bit out of favor these days, but whether it is Kennedy or Christ (who never seems to fall out of favor), our manic patients deserve at least some acknowledgment of their worthiness as human beings. If someone says, "I'm Jesus Christ," one might respond: "Well, I was hoping to meet him some day." Or perhaps: "Please don't tell anyone else, because you know what they always do to the Messiah. They crucify him. And I don't want that to happen to you." The world is full of people who think they are the Messiah. But then again, didn't Jesus Christ think he was the Messiah? A person's aspirations should not be discouraged or pathologized. This usually produces the opposite reaction: the manic person realizes s/he cannot connect with the clinician, and treatment ends. Or perhaps the manic patient accepts treatment, but at the price of giving up all his or her hope. That chronic depression, which seems to be the most common course of patients with bipolar disorder despite our current best treatment (Judd et al., 2002), may reflect such loss of hope.

Elation is seen not only in manic pathology. We should be able to find aspects of our own experience that allow us to empathize with it. Take New Year's Eve celebrations, for instance. In some ways, what a foolish idea such celebrations are: Why would the events of the next year be any better than those of every year past? And yet, we celebrate the New Year with renewed hope and renewed ambitions. Encouraging grandiosity diminishes it. The best reaction to a grandiose
comment is to say: "How wonderful! I wish I could feel more that way myself." Once a patient meets a clinician who actually believes in him/her, who takes seriously all of his/her wildest dreams, s/he then begins to dream a bit more realistically. Then s/he might be able to listen to the clinician when the discussion turns later to realistic goals. This failure of clinicians to appreciate grandiosity is concerning to us. Clinicians are not afraid to engage depression empathically. We know that an empathic approach to depression reduces the depressive burden, which is passed on to the therapist. But why are we afraid to empathize with grandiosity, or paranoia for that matter? Many grandiose manic patients also become paranoid, because they find that everyone disbelieves them, even the mental health professionals who are paid to be with them. If everyone had a low opinion of you, you might indeed be prone to paranoid thoughts. If a paranoid patient says something like, "Doctor, you are poisoning me," one might respond: "Oh, you're finding that out, are you?" Such a response can put a smile on the patient's face, and add another brick to our therapeutic alliance edifice. One of our old mentors, a director of a major mental hospital and a full professor at a prestigious university, used to claim that he was the most paranoid person in the building. As his students, we felt more secure with our paranoid leader, because we knew he would never be surprised. So we also need to celebrate paranoia. We in the mental health field are frequently quite naive about how the world works. There are, in fact, plenty of destructive forces out there, and persons in positions of power often experience a quite realistic sense of paranoia in relation to the efforts of their enemies to ruin them. It took the technology of audiotaping to reveal the extent of such paranoia in the higher levels of power during the Nixon years, but it is very likely that such paranoia was quite present in years past but never recorded, and it will continue to play an important political role in the future. There are situations when one cannot be paranoid enough.

Summary
Talking with a manic patient is not easy, but it is also not hopeless. Manic patients are hopeful, and indeed often too hopeful. But their hopes and dreams, however big, are usually brief and soon damaged by the realities of life. Ultimately, most patients with bipolar disorder become chronically depressed, denied of their hopes by others. Appropriate medication treatment is necessary, but not sufficient, for many such persons. The job of the clinician is twofold initially: first, to seek to existentially be with manic patients and then, to counterprojectively give perspective to those patients about their manic worldview, without completely denying it. This twofold approach then can lead to a healthy therapeutic alliance, which itself has a mood-stabilizing effect. Along with mood-stabilizing medications, this alliance can then lead patients toward full recovery. Put more simply, clinicians need to talk to manic patients about their hopes, to explore the limits of their grandiosity without judging it, to seek out their strengths and to validate them. They also need to go where the patients are, to encounter patients and find the person beneath the illness, to provide a strong relationship, an alliance that cannot be shaken, to conflict with the patient sometimes and not at other times. It is a tall order, and one not infrequently avoided. Yet the times seem to call for a return to actually talking with manic patients, and maybe curing them with such talk. Or perhaps that is grandiose.

Havens, L., & Ghaemi, N. Existential Despair and Bipolar Disorder: The Therapeutic Alliance as a Mood Stabilizer. American Journal of Psychotherapy, 59(2), 137.

Personal Reflection Exercise #10
The preceding section contained information about communicating effectively with bipolar clients in a manic phase.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
A Meta-Analysis of Group Cognitive Behavioral Therapy and Group Psychoeducation for Treating Symptoms and Preventing Relapse in People Living with Bipolar Disorder

Tan, M. K., Chia, E. C., Tam, W. W., McIntyre, R. S., Zhang, Z., Dam, V. A., Nguyen, T. T., Do, H. T., Ho, R. C., & Ho, C. S. H. (2022). A Meta-Analysis of Group Cognitive Behavioral Therapy and Group Psychoeducation for Treating Symptoms and Preventing Relapse in People Living with Bipolar Disorder. Healthcare (Basel, Switzerland), 10(11), 2288. https://doi.org/10.3390/healthcare10112288


Peer-Reviewed Journal Article References:
Fredman, S. J., Baucom, D. H., Boeding, S. E., & Miklowitz, D. J. (2015). Relatives’ emotional involvement moderates the effects of family therapy for bipolar disorder. Journal of Consulting and Clinical Psychology, 83(1), 81–91.

Lamers, F., Swendsen, J., Cui, L., Husky, M., Johns, J., Zipunnikov, V., & Merikangas, K. R. (2018). Mood reactivity and affective dynamics in mood and anxiety disorders. Journal of Abnormal Psychology, 127(7), 659–669.

Martins, M. J. R. V., Castilho, P., Carvalho, C. B., Pereira, A. T., Santos, V., Gumley, A., & de Macedo, A. F. (2017). Contextual cognitive-behavioral therapies across the psychosis continuum: A review of evidence for schizophrenia, schizoaffective and bipolar disorders. European Psychologist, 22(2), 83–100. 

Mneimne, M., Fleeson, W., Arnold, E. M., & Furr, R. M. (2018). Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder. Personality Disorders: Theory, Research, and Treatment, 9(2), 192–196.

Sauer-Zavala, S., Cassiello-Robbins, C., Woods, B. K., Curreri, A., Wilner Tirpak, J., & Rassaby, M. (2020). Countering emotional behaviors in the treatment of borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

QUESTION 24
According to Havens, what is the main idea behind the counterprojective therapeutic approach? To select and enter your answer go to Test.

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