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Section 2
Diagnostic Accuracy

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In this section, we discussed various topics I emphasize to educate my Bipolar Adult Client to prepare them for the therapy process.  We discussed the symptoms of the disorder; its effect on the client’s relationships; and the effect of stress on the intensity and timing of manic and depressive episodes.

Have you found that many clients are resistant to accepting the idea that they have bipolar disorder?  Many clients believe that the manic episodes they undergo are a personality response to a goal or problem. Often, they do not realize that the excessive energy comes from a disorder. Many times, this is because the client has achieved recognition because of their hard work during a manic cycle.  As a result, he or she does not wish to believe that the achievements during this period were not the work of themselves, but of a disorder. 

In this section, we will examine three types of resistant clients:  clients who reject diagnosis, the under identifying, and the over-generalizing client.

3 Types of Resistant Clients

♦ 1. Clients Who Reject Diagnosis
The first type of resistant client is the client who completely rejects the diagnosis.  As we discussed in section 1, many clients believe that a bipolar diagnosis is merely a misinterpretation of their personality traits. However, this also is a handy defense mechanism for the client.  But by rejecting the problem, the client also is rejecting treatment that could quite possibly save his or her life. 

Clark was a 23 year old bipolar client of mine.  Like many of his generation, Clark had given in to the New Age treatments and believed that my diagnosis was completely misguided.  Clark stated, "I realize that people have bipolar, and I feel sorry for them.  But my problem doesn't come from some disorder.  I’ve been limiting my sugar intake and I’ve been seeing an acupuncturist.  I can easily beat this thing."  Because of this, Clark refused to take his medications which he claimed only heightened his episodes.  Clark stated, "My moods were fine until they gave me Depakote, and now they swing all over the place." 

Because I was concerned that Clark might harm himself during a depressive episode, I discussed thoroughly the consequences of rejecting his medicine, the reasons for my diagnosis, and the many reasons that his mood swings could not possibly be the result of a sugar imbalance.  As I discussed in section 1, educating the client about this disorder lessens the resistance they exhibit towards diagnosis.

Technique:  a 9 Question Self-Administered Quiz
Also, I remembered that one of my clients, Marianne discussed on the previous section, had found a "Self-Administered Quiz" helpful.  I gave Clark a list of questions and asked him to complete them with a yes or no after having read a catalogue of informative materials on the disorder. Has there ever been a period of time lasting two weeks or more when you were not your usual self and you experienced five or more of the following:
1. Felt Sad, blue or down in the dumps?
2. Were uninterested in things?
3. Lost or gained more than 5% of your body weight?
4. Slept too little or too much?
5. Felt so good or so hyper that other people thought you were not your normal self?
6. Were so irritable that you shouted at people or started fights?
7. Felt much more self-confident than usual?
8. Got much less sleep than usual and found you didn’t really miss it?
9. Were much more talkative or spoke much faster than usual?
After completing the quiz, Clark found that he had answered seven of the questions with a "yes".  He then stated, "Ok, I guess I understand this bipolar stuff a little better now, so I’ll give it a shot your way."

♦ 2. Under Identifying Clients
The second type of client is the under identifying client.  In essence, these types of clients are in denial about their disorder.  Although this may sound similar to those clients who reject a diagnosis, the under-identifying client refuses to deal with the emotions instead of completely rejecting the diagnosis. 

Like rejection, under-identifying can be a defense mechanism overlying grief for the loss of a healthy self.  If he or she does not recognize the problem, it cannot exist and will go away. Many clients were once bright and popular people before they were diagnosed and hope that by pretending nothing has changed, their friends and loved ones will continue to treat them as they once did and not like a mental patient. 

Cheryl, age 34, had once been a well-liked and charismatic individual before being diagnosed with bipolar disorder.  For weeks after the diagnosis, Cheryl reflected any questions about her health and began to stop taking her medications.  In our sessions together, I addressed the problem directly, "Cheryl, why have you not taken your medication?"  Cheryl stated, "I don’t know what you mean."  I then asked her, "Cheryl, I think you know what I mean.  If you had been taking your medication regularly, you would have needed a refill by now, yet you have not asked me to write you another prescription."  Cheryl responded, "I don’t know what to say when I take it.  My family asks me what I need pills for and I just can’t bear to tell them." 

As you can see, Cheryl feared telling her loved ones about her disorder.  Through role playing, Cheryl and I came up with likely scenarios that could occur when she finally discusses her disorder with her parents.

♦ 3. Over-Generalizing Clients
In addition to the rejecting and under identifying client, the third type of resistant client is the over-generalizing client.  Often, these clients see their own characteristics manifested in those around them and begin to diagnose their families and loved ones.  Francine, a bipolar client of mine, stated, "My mother really gets on my case about my medications, about my visits to my doctor, about the men I’m going out with, you name it.  She’s always asking me if I’ve been drinking.  She goes behind my back to try to find out.  She’s always been critical and disapproving of me.  I think she’s the one who’s bipolar." 

Francine believed her assertions were well-founded because bipolar disorder does tend to run in families and truly some family members might have a moderate form of the disorder.  However, many times this over-diagnosing stems from not wanting to feel alone or isolated.  I asked Francine, "Do you ever feel alone in having this disorder?"  She stated, "Yes, sometimes.  I feel like people don’t know what it’s like to be the only one around who has this thing." 

I then asked Francine, "Could your mother’s reactions be actually a manifestation of love and concern for your well-being?"  Francine stated, "Yeah, I know she loves me and wants me to beat this thing, it’s just so hard when she’s so overbearing."  I asked Francine, "Have you ever discussed with your mother these feelings?  Have you told it’s harder for you when she acts this way?"  She answered, "No, I know that would help, though.  I guess." 

As you can clearly see, Francine had also exhibited a fear of confronting her loved ones about their own behavior.  Think of your over-generalizing client.  Could they benefit from an interaction with the offending loved one?

In this section, we presented three types of resistant clients:  clients who reject diagnosis; the under identifying; and the over-generalizing client.

In the next section, we will examine characteristics of clients who come under the influence of psychosis:  delusional thoughts; hallucinations; and paranoia.
Reviewed 2023

Peer-Reviewed Journal Article References:
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.

Youngstrom, E. A., Egerton, G. A., Genzlinger, J., Freeman, L. K., Rizvi, S. H., & Van Meter, A. (2018). Improving the global identification of bipolar spectrum disorders: Meta-analysis of the diagnostic accuracy of checklists. Psychological Bulletin, 144(3), 315–342. 

QUESTION 2
What are three types of resistant clients? To select and enter your answer go to Test.

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