Thursday, April 17, 2014

Bipolar Disorder in Psychotherapy

Individuals with bipolar disorder struggle with a sense of internal damage so pervasive they feel there's no realistic hope for improvement, leading to a search for "magical" solutions instead. This article will provide a case illustration of this dynamic: a young man in his 20s who might have been considered "cyclothymic" rather than receiving a full diagnosis of bipolar disorder, though his mood swings demonstrate the same high/low dynamics.

Jeffrey was an extremely bright and talented young man, recently graduated from college, who aspired to be a writer. He came to me because of depressive episodes so severe he felt barely able to function. He managed to hold down a clerical job to support himself despite his depression, attempting to write in the evening after work and on weekends. If he were feeling deeply depressed, he couldn't write a word. After work, he'd often collapse into a state of inertia, barely able to feed himself, watching mindless TV. He suffered from extreme insomnia and often slept but a few hours.

Jeffrey badly wanted to have a relationship but felt completely worthless, as if everything about his adult functioning self was a facade, and that as soon as anyone got close to him, they'd find out he was a fraud. He would describe himself as a loser, "damaged goods," or "a worthless piece of shit." The issue of "shittiness" often came up in our work. He had a recurrent dream that the toilet in his bathroom would back up and his apartment would be flooded with feces. Or sewer pipes in the ceiling would break. In these dreams, he'd feel completely helpless to do anything about the broken plumbing or sewer problem. The damage felt insurmountable.

In our work together, I would talk about these dreams in two different ways. The overflowing sewage represented both his "backed up" emotions which he felt unable to tolerate or process, as well as the hopelessness he felt about his internal damage. We returned to this issue again and again, particularly his fear that our work together was pointless because (a) I couldn't possibly tolerate all his "shitty" feelings either, and (b) the damage was simply too vast.

Periodically, the depression would lift and he'd enter a hyper-industrious phase, writing for many hours at a time and throughout the weekend. He'd come up with a "brilliant" new idea for a novel and write 10, 20 or 30 pages at a time. He wouldn't stop to reread or revise but simply kept on with a manic drive in the hope of completing the book within a few weeks, selling it to a publisher and advancing to an idealized life in which he'd be a wealthy, famous and critically acclaimed author. He felt increasingly anxious during these periods; although he came to his sessions, he felt difficult to reach and became suspicious and hostile if I tried to examine his drive to write. Eventually the manic phase would pass and he'd slip back into depression, discarding the partial manuscript as "worthless".

During the manic phase, he clearly felt in the grip of magical thinking; underneath, he feared that he was only passing off shit as if it were something of great value. When he was in his hyperactive writing phase, he unconsciously felt it as a kind of evacuation, too, as if he were magically ridding himself of all the bad intolerable feelings. He couldn't go back and revisit his work or revise it because to do so might deflate the manic triumph of his creation as well as bring him back into contact with the bad feelings he'd tried to evacuate.

My job was to show him, again and again, that he felt hopeless to do anything realistic to improve, either in terms of his writing or his internal damaged world; only magic could solve his problems. Over and over, we had to return to those shitty bad feelings, try to understand them and help him to tolerate his own emotional experience. It was the work of years. Eventually he completed and sold a novel but continually struggled to wrest his writing from the realm of magic.

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