The Therapeutic Alliance as a Mood Stabilizer

Existential Despair and Bipolar Depression

What happens to a dream deferred? Does it dry up like a raisin in the sun? Or fester like a sore and then run? Does it stink like rotten meat? Or crust in sugar over like a syrupy sweet? Maybe it just sags like a heavy load? 

Or does it explode? Welcome to the Carlette Psychiatry Podcast, keeping psychiatry honest since 2003. I'm Chris Akin, the editor-in-chief of the Carlette Psychiatry Report. 

And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue. For many patients, bipolar disorder is a story of loss. Loss of marriages, jobs, friendships, physical health, and meaningful roles in society. The kind of dreams deferred that the poet Langston Hughes wrote in his 1951 poem from the start of this podcast. It's not unusual for these patients to complain of depression as these losses stack up. 

But listen carefully when they do. It's not always clinical depression they're speaking of. There are many kinds of depression in bipolar disorder. There's full clinical episodes, the ones that last two weeks and have the full breadth of DSM-5 symptoms. Then there's temperamental depression, what we call dysthymia. This is the kind of low-grade but always eating at you type of depression that patients will tell you they've had all their life. 

Then there's a state that Gary Sacks at Mass General calls roughening, which is when the patient is clearly under stress, possibly getting worse, not fully depressed, but at risk for that. There's premenstrual dysphoria, and this is a tricky one because when it occurs in bipolar disorder, it doesn't warrant a separate diagnosis of premenstrual dysphoric disorder and certainly doesn't warrant jumping into antidepressants that can make bipolar worse. Instead, you might raise the mood stabilizers to treat mood worsening before the menstrual cycle. 

And by the way, mood worsening before the menstrual cycle is somewhat more common in bipolar than in unipolar depression. There's also postpartum depression, winter depression, and atypical depression where you have lead and paralysis, heavy feelings in the arms and legs, tiredness, sleeplessness all day, and high appetite. And all of those three depressive subtypes, postpartum, winter, and atypical features, those are also more common in bipolar than in unipolar disorders. And there's depression caused by substance use or medical problems. 

Chronic medical problems as well as substance use are so common in bipolar disorder that I would see these more as contributing to the depression than causing it. One type of medical depression that we've recently gained more knowledge on is inflammatory depression. We cover that in our January issue and we see it in patients with obesity and chronic medical problems. We'll often see that in bipolar disorder, particularly as the patient gets older. Then there's the manic depressions, which we see in bipolar disorder. These include mixed states and dysphoric mania, where there's a lot of depressive symptoms on top of the mania. But even when mania is not a mixed state, depression is still the most common chief complaint during mania. That's right, mania usually doesn't feel good. 

Or if it does get the euphoric feeling, that rarely lasts longer than a few days. Instead, mania is a state of heightened emotions and they are all heightened, anxiety, depression, irritability, and the occasional good feeling. There's also post-manic depression. That's the depression that comes on right after the mania and it's often with prominent guilt and low energy as if it's the ashes of that manic state. This is where you'd want to avoid antidepressants because they can easily flip the patient back into mania. In our September issue, we brought you unpublished research on a new medication for bipolar depression. 

It's a finding you can use in your practice today. And it can work in most of the depressions I've just listed. But in this supplement to that article, we're going to talk about a different kind of depression you'll see in bipolar disorder. 

One where medications may help, but they're usually not the best answer. It's something Nasser Gami calls existential despair. This is the kind of low-grade, constant depression that builds as life's losses stack up. Now, those losses, divorce, isolation, unemployment, they can cause true clinical depression as well, but they also cause a very real anguish that doesn't fit the DSM description of clinical depression. This despair is a very human response to the painful losses that come with bipolar disorder. Rather than seeing it as a medical problem, this existential despair is probably best seen as a problem of self-hood. In the New York Times magazine in 2013, Linda Logan called on psychiatry to pay more attention to the self when treating bipolar disorder. Or any chronic psychiatric disorder. She spoke from her own experience living with bipolar for several decades, and she suggests that we ask patients about what parts of the self have vanished during their illness and help them come up with strategies to deal with that loss. 

Her story quickly went viral as it touched many patients. She detailed the loss of meaningful roles in her own life over several decades. Motherhood. She felt disconnected from her children and had to pretend to be like other mothers in the schoolyard. 

Teaching career. She wrote, The literature on bipolar disorder is crowded with symptom tallies, genetic assays, behavioral strategies, and brain images. These are all important, but there's a need to touch on the human side of this work as well. Dr. Nassir Gami has written about that throughout his career, and I asked him to read for us today excerpts from a 2005 paper that I particularly like called Existential Despair and Bipolar Disorder, The Therapeutic Alliance as a Mood Stabilizer. It's a rare gem and something he co-authored with the late psychoanalyst, Leaston Havens. Elvin Samrad, the greatest existential teacher of clinicians in the Boston area for many generations, argued that if patients have one relationship in which they feel comfortable, they don't go crazy. We think the same may hold for patients with mania. 

Our colleague Ronald Pies has suggested that the Therapeutic Alliance may be a mood stabilizer, much as medications are. The manic patient is no different from the depressed patient or any other patient in many ways, one of which is that these patients are first and foremost persons. Each has a life, loves, failures, hopes, fears, and something we might call a self. 

The self of each person may be more or less there. It may be riding on their sleeves, easily touched and easily injured, in which case we need to be very gentle in approaching it. It may be hidden deep inside under layers of protection, so absent that even the person rarely sees it. 

In that case, we have to go in search of it. In other words, in therapy, we often need to enter aspects of a person's self that are painful or partly unknown. We need to support the ego at the same time, as we force it to examine feelings that may cause it to feel temporarily weaker. Each person has a self, and we have to meet each other. Our selves as clinicians have to meet our patient's selves, and we meet not as clinician and patient, but as self and self. When we first meet in a clinical setting, it is usually because of a problem. The patient seeks help or is brought to us with a predicament. After recognizing the predicament, both the patient and the clinician are immediately faced with the future in two ways of approaching it, hope or hopelessness. The patient may despair, as may the clinician, but we have to stand for the possibility of a future without imposing that future on our patients as a false hope. The process of bringing about a hopeful future begins by recognizing the strengths of the patient. Yes, the patient's behavior is consistent with a manic episode. Yes, the patient has made many mistakes, but there are some parts of that person which are quite healthy. 

They always are there. So we search for the patient's health. Are they manic but not psychotic? 

Are they manic but not depressed or anxious? Everyone has some virtues. Even those with many vices have some virtues. Sometimes the problem with patients is that they have too much virtue. 

Generosity can lead to bankruptcy, too much courage, to recklessness, too much truth-telling, to gullibility. A strength of humor in particular is an important strength of manic patients. We need to unite with them around what they find humorous. After we meet manic persons, we seek a way to move ahead from the predicament by speaking with them about their strengths and not just their illness. We point the direction to a hopeful future by exploring reasons for hope in the present and the past. And then we work on two fronts, one for treating their illness and one for encouraging their strengths. The patient comes to treatment with assumptions about the doctor and the doctor with assumptions about the patients. These assumptions sometimes doom the treatment before it begins. The most noxious assumption is that doctors can fulfill the feeling of patience that we represent the system, the status quo of power and privilege. We label the patients as sick and resistance to treatment as often a reflection of the patients justifiable if sometimes exaggerated hesitation to enter this process. Harry Stax Sullivan taught us that sometimes it's better to avoid conflict with patients even if they want it. If patients expect us to confront them, we should agree with them instead. In so doing, we disabuse them of assumptions that they hold about us and remove such distortions from the interpersonal field in the interest of relationship building. For instance, we would argue that when a manic patient makes a grandiose statement, it is best to agree with it at least initially. 

Joining with a relation and not just depression is an essential part of forming a human connection with a manic patient. 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 that he cannot connect with a clinician and treatment ends. Relation 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. The 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. But why are we afraid to empathize with grandiosity, or with paranoia, for that matter? 

We in the mental health field are frequently 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. It took the technology of audio taping to reveal the extent of such paranoia in the next few years. But it's very likely that such paranoia is always present. 

There are situations when one cannot be paranoid enough. This concept of man-exciting goes against the grain of much teaching in psychotherapy, where we're usually taught to avoid splitting, not to side with the patient against the world or the world against the patient. Yet, mania is a unique state. The parts of the brain that learn and process information are literally shut down during mania, while psychotherapy is a learning process. 

So usual techniques aren't going to work well here. In the detailed rating scales we use for research on bipolar, we see symptoms of mania like the urge to do something shocking, or to argue for the sake of arguing. Mania in other words is prime to get your goat, and prime for a fight. Confronting the patient in this state can easily spiral downwards, so often it's better just to agree and side with them. But how do you agree without being totally dishonest? The answer is to speak in broad generalities, the kind of talk that you see on bumper stickers. For example, suppose you work in a large medical office and a manic patient comes in complaining that your receptionist is a Nazi. You don't want to throw your receptionist under the bus in those situations, but you don't want to defend your receptionist there either, and risk spiraling down into a destructive argument. 

So you could say something general like, you know, the world could use a lot more kindness. I'll tell you a story of when I failed at Man Exciting. I was in residency at Duke, and an agitated woman came in for her first visit at the clinic. On her t-shirt was an image of Jesus Christ hanging from the cross with the words, dying to know you below. 

Before I could ask what brought her in, she shouted, First, there's something I need to know about you. Are you a Christian psychiatrist? I had been raised a Christian, and I identified as such, but I didn't feel comfortable misleading her into thinking that I agreed with all her beliefs so that I was going to pray during session, so I got kind of perplexed and I hedged. I said, I am a Christian, but that doesn't change how I work with you. 

My work as your doctor is guided by medical science just as any other doctor does. That's all I need to know, she said, and stormed out of the room. She did come back. About five years later, she looked me up and returned to my practice. But because I had failed to side with her in that critical moment, she lost five years of treatment. What would you have said? If I could go back, I would have looked her in the eye with great solemnity, and said, I can tell that question is very important to you, and I want you to know it's very important to me too. 

Yes, I am a Christian. Well, that was before you read Dr. Gamme's article. Tell us about a time when manic siding worked. Well, we can side with patients about their point of view and their beliefs, but when it comes to our own prescriptions, siding can be more uncomfortable. So here's a story about a patient I worked with who is basically in an untreated manic state for several years. The only medication he would take was Valium. He had little insight into the mania. So even when we found a tolerable mood stabilizer that worked, he wouldn't stick with it and would go right back into the mania. Now it was tempting to stop the Valium as it's not appropriate to use on its own in bipolar. And though he didn't abuse it, it was probably rewarding in some ways, and it might have been enabling his avoidance of mood stabilizers. 

But I chose to side with him. From his point of view, Valium did what he needed. It helped the anxious face of the mania, at least. 

It didn't help his functioning at all or treat the mania in any meaningful way. But it also kept him engaged with treatment. And what's most important here is that in siding with his view, he did come to trust me and eventually he was brought into the clinic emergently by his family who's in a manic psychotic state doing dangerous things, totally out of control and wouldn't listen to a thing his family said. But when he sat down with me, there was like this innate trust because we had worked together so long. And he said, Doc, I'm in a terrible state. 

Just tell me what I need to do. And I told him to get back on the mood stabilizer, which he did, and he recovered. So it was a very slow build. But by siding with him in the beginning, it allowed him to stick with treatment that he might otherwise have rejected. A couple years later. It is not enough to psychoanalyze or to diagnose and prescribe. What has been put aside is the relationship. The relationship comes first. Without it, all other diagnostic and treatment efforts are at the very least impaired. 

And at worst, simply wrong. Talking with a manic patient is not easy, but it is also not hopeless. Manic patients are hopeful, ever hopeful, indeed, often too hopeful. 

But their hopes and dreams, however big, are usually brief and soon damaged by the realities of life as they become depressed and denied of their hopes by others. The job of the clinician is twofold, first to existentially be with manic patients and then to give perspective to these patients about their manic world view without completely denying it. This approach can lead to a healthy therapeutic alliance which itself has a mood stabilizing effect. Along with mood stabilizing medications, this alliance can 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, to conflict with the patients sometimes but 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 may be curing them with such talk. 

Or perhaps that is grandiose. Nassir Gharmi is a professor of psychiatry and psychopharmacology at Tufts University School of Medicine. He is the author of over half a dozen psychiatric textbooks. Two that focus on today's subject are a First Rate Madness and On Depression. And this Wednesday, 60 Second Psych is returning and you can expect regular installments every Wednesday and Saturday. You can find our full coverage of the new treatment for bipolar depression online at thecarlatreport.com in our September issue where we have a special discount for our podcast listeners. You can get $30 off your first year subscription with the promo code podcast in all caps. The CarLat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support. 

Existential Despair and Bipolar Depression

from The Carlat Psychiatry Podcast

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Existential Despair and Bipolar Depression

from The Carlat Psychiatry Podcast

Media

Links

Key Points

Summary

Transcript

Disclaimer and Important Information

Derek Harmanli

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Related Posts

Categories