Therapy of bipolar disorders

Hierarchy of the goals during various phases of the illness

For the treatment of bipolar patients, there is generally a hierarchical order of the goals. During different phases of the illness, varying goals become unequally important. They are not independent of one another nor are they entirely separate, although they do not have the same priority at each point in time. This distinction can be expressed or unspoken, unilaterally or bilaterally significant; it is profitable, and, at a common point in time, to argue and to dispute concerning this situation. The following list does not claim to be complete, but should help only for the concrete negotiation of such goals (see also Bock & Koesler, Bipolare Störungen. Psychiatry-Verlag, Germany).

Assuring your existence

In very acute phases, assuring one's existence is the primary objective, and here with somewhat different accentuation related to either depression or mania: What is the danger of suicide? How far do the risk and carelessness extend? The goal here is to clarify the danger and to explain to those affected, as far as possible, that they must communicate. Hereby, one must understand the feelings and impulses that are responsible for this extreme condition and support them emotionally as far as possible. At the same time, one can have no doubts concerning one's own willingness to provide treatment: In the event of such doubts, the therapist/physician (must) also decide against their own will and, for instance, also admit the patient to a clinic, even if this goes against one's declared wishes. This decision will not be delegated by the therapist/physician, but will instead be made directly by them so that this can subsequently be explained and understood. Helpful, if possible, is to carry out mutual discussions beforehand concerning when such measures might prove to be necessary.

Assuring the basic needs

Depression and mania can lead to a substantial and dangerous neglect of fulfilling one's basic needs. Eating and drinking are neglected or also carried out to extremes. The sleeping-waking rhythm can be disturbed considerably – even though the psychological stress may seem to be quite varied. On the other hand, the respect for one's own basic needs is rudimentary.

Social security

This initially involves the direct assurance of one's social existence and the social relationships. Included here are getting a sick certificate in time, regulating one's means of subsistence, the care of children and support of relatives, and, in a somewhat broader sense – if possible – also the (preventive) protection of personal properties, assets and inheritance (eventually with legal assistance). However, this is not only a matter of social law, but primarily also involves the direct awareness and integration of the relatives.

Self protection and preservation

One's self is not lost, but it is instead put in danger; the responsibility to take care of yourself is not generally fully overridden, but it is in need of stabilisation. Very elementary activities, contacts, rhythms and tasks can be a part of this self-preservation: Which spontaneous activities, e.g. related to hygiene, are still possible? Which types of contact are still discerned (e.g. emptying the mailbox, answering a telephone call)? Which minimal everyday structures must persist (e.g. getting the daily newspaper)? Which of the smallest of tasks are still to be fulfilled so that the feeling of self esteem does not disappear entirely (e.g. watering flowers, walking the dog)? How can all of these concrete goals be defined to such a small extent that the success will be ensured? That is to say, the course of the depressive dynamics – to establish goals in such a manner that it is already inevitable that they will fail – as well as the manic mechanism, whereby every function is immediately interpreted as subjugation, must both be evaded.

Acceptance of the illness

In depression and mania, the acceptance of one's self-esteem can no longer be safeguarded against. Life is momentarily rejected and devaluated, or considered to be worthless. Doubts arise concerning the value of one's own self – during a depression, explicitly and directly, while certainly more indirectly during a mania. What decisions and what information can act as a relief here? During a depression, it could be the recognition of one's own illness. Primarily, however, the therapeutic relationship can help, at least in part, to break through the emotional loneliness by recognising and understanding the subjective distress and by helping one to refrain from giving up one's view concerning the conformance to the phases of life and thereby giving up the hope which is thereby related to this. Important, at the same time, is to learn and to respect the concept of the illness as seen by the patient.

In mania, the relief does not generally function through a reasonable concept in regard to the illness, or merely indirectly. For the close relatives and acquaintances, it can be very relieving to obtain clear information concerning whether or not the current action is being determined by mania or not. In the interest of the patient, it can thereby be important to protect relationships in order to then, in more quiet times, to mutually evaluate what, aside from the illness, actually initiated the conflict and which difficulties in the relationship were accentuated as a result of the mania and, even independent of these, continue to exist. In the mania as well, and in order to develop an appropriate concept of the illness, it can be important to refrain from accepting a one-sided, ideological guideline.

Self responsibility

This struggle does not only affect the more or less relieving concept of the illness. Also in the treatment itself, a struggle will take place as a replacement concerning who has to say what to whom and who has control of the power or powerlessness, which leeway is allowed for whom and how, etc. Here, there is no strategy which always applies for everyone. Some depressive patients are able to clarify the guidelines of their physician/therapist thankfully, without later considering his/her exercise of power resentfully. Others first consider themselves to be taken seriously when the therapist reveals his/her helplessness and has recognised that depression is the worst situation that is to be expected. Some manic patients even react to such minor influences allergically, while others are actually able to accept certain guidelines after longer struggles. According to our experience, true struggles and denial of too rapid regulation prove to be more lasting.

Perception of burdens and conflicts

As early as possible, it is important to not only consider the phases as a catastrophe, but also as a chance to understand how to work against special dynamic mechanisms which counteract the bipolarity: Which unfulfillable demands intensify the depression, which unfulfillable wishes accentuate the mania? Which weaknesses or which strengths become visible? How is it possible to obtain a better balance between burdens and desire? How can one differentiate between important and unimportant tasks and plans, and whose judgement is still to be judged or not? How are one's individual guidelines to be developed or supported in order not to be too much at the mercy of others? And how can the possible limitations influenced by the illness be considered?

Interaction with feelings

Depression cannot be considered equivalent to sadness and mania is not the same as luck. Both phases can be more or less intensively embossed as a feeling of emptyness. Experiencing sadness or being in high spirits, sensing one's self more intensively and obtaining support from other people or, if necessary, from a therapist, generally represent the way to proceed out of the acute phase. The perception and allowance of feelings at the proper time can work against the development of future phases. Sometimes, it is necessary, also as a retrospective view of earlier experiences, to realise one's suppressed feelings and to integrate them.

Social rhythms

People who are torn between mania and depression learn to understand the range of human sensations more intensively than others are able to. At the same time, you occasionally have substantially little esteem for small rhythms, for small regularities and changes. Here, developing more attention can help to weaken or even avoid the acute phases. Maintaining social rhythms and the establishment of a stable and routine daily structure can have a stabilising effect on the biological rhythms as well as on the balance of feeling and energy. According to our experience, many sub-depressions and hypomanias can be averted if, for example, regular sleeping, physical activity, routine daily structures, stable times of relaxation and activity, contact to nature and a good balance to closeness with and retreat from others is maintained during critical times. Consequently, alterations in the social rhythm can also be used as an early warning sign. Here, however, care must also be taken: Constantly looking for these early warning signs can cause one to concentrate too intensively on the illness, which can disturb the sensitive quality of life and then itself become an early warning sign.

Expand one's self concept

A kernel goal in the treatment of bipolar individuals is the development of a stable self concept. By working out the model of the illness through the therapy, which does not only involve the explanation of a metabolic disturbance but places the illness in a biographical relationship, it can come to relief and to an understanding which helps support one's self acceptance. In the relationship with the therapist, the patient can have the experience of a deep sense of value. Also experiencing one's own resources and capabilities has a stabilising effect. Furthermore, the stabilisation of one's self concept, which is made up of both manic and depressive portions (also convictions, desires and fears which have initially been rejected by the patient during acute phases), also involves a re-integration of one's self concept. Such contemplation can occasionally result in a new insight and a sensual context concerning one's self.

(Source: T. Bock, A. Koesler, Bipolare Störungen, Psychiatrieverlag, Germany)

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