The importance and breadth of psychoanalytic thought in the treatment of Bipolar Disorder.
In 2018, the International Society for Bipolar Disorders & the Canadian Network for Mood and Anxiety Treatments published its guidelines for the management of patients with bipolar disorder. Across the span of 50 pages these guidelines eloquently describe a litany of biological and medical interventions that are essential to the successful treatment of a bipolar disorder. It is striking that out of 50 pages, only 3 pages concern themselves with the role of psychotherapy
The contents of these guidelines represent the status quo of the medical and psychological community regarding the treatment of a debilitating mental health condition. Within the respective three pages, Cognitive Behavioral Therapy and psychoeducation are the constitutive assumption. In a stunning admission, this same paper goes on to say, “it was not possible to identify whether the benefits came from changes in the medications prescribed or the psychosocial treatments.” (2018) Further, the same guidelines mention the primary developmental primitive defense mechanism used by a patient with bipolar disorder, denial, only once over the course of 50 pages. Denial of illness only captures a small part of the reflexive process of denial. Rather reality testing fails through the functional experience of anosognosia.
In a 2013 article, The Lancet, described the position of psychotherapy in bipolar treatment. “Most studies of psychotherapy for bipolar disorder are maintenance trials in which patients receive standard drugs and either an experimental psychosocial intervention or usual care (eg, brief treatment or a supportive treatment of equal frequency and duration.” (Geddes 2013) It seems that in the attempt to treat the discrete symptoms of this disorder, we forget that there is a human being on the other side.
It appears that the psychoanalytic perspective has much to offer as we continue to develop a clinical consensus towards the treatment of bipolar disorders. Nancy McWilliams describes this better than I can, “The validity and reliability of the post 1980s DSMs have been disappointing. The attempt to redefine psychopathology in ways that facilitate some kinds of research, has inadvertently produced descriptions that fail to capture patient’s complex experiences.” (McWilliams 2020)
Otto Kernberg provides a definitional assumption regarding the nature of bipolar disorder that is reflective of the broader psychoanalytic community. According to Kernberg, “the manic-depressive personality is to be understood as a definitionally borderline construction. As this personality organization rests primarily on the primitive defense mechanism of denial.” (1975) Freud was the first to notice that essential to depression was the loss of self. Thus, in Drive Theory, the depressive person was one who had experienced loss at a developmentally inappropriate time. (1917)
I, and many other clinicians, have observed in many a suicidal pre-teen who has presented for treatment, that there is a common reported history regarding the utter desecration of self. Analytical Psychology eventually understood depressive features to contain the content of the disturbing material. Loss, at times inextricably linked to trauma, becomes an introjective or anaclitic feature which is then related to and with. These emotional, psychological affective states, which Sigmund Freud called the “Id” & “superego” or better translated, “it” & “I above,” is thus the content or material that must be denied in a bipolar psychology.
Modern neuroscience has begun to confirm our theoretical presupposition. “The Right hemisphere is the seat of implicit memory. The discovery of implicit memory has extended the concept of the subconscious. Implicit Memory is where the emotional, affective, sometimes traumatic-presymbolic and preverbal experiences of the primary mother-infant relations are stored.” (Schore 2019) Dr. Schore further illustrates the right brain to right brain affective experience occurring between clinician and patient. He explains the biological, emotional reality of transference & counter transference[k1] : “transference-countertransference transactions are expressions of, nonconscious, nonverbal, right brain, mind, body, stressful communication between patient and therapist.” (Schore 2019)
Whether the patient experiences themselves as fundamentally bad (introjective) or chronically inadequate and fated to a life of disappointment, (Anaclitic) the patient is then subject to various mechanisms mediating between the “It” the “I,” & “I above.” Anna Freud defined a defense mechanism as, “unconscious resources used by the ego to decrease internal stress.”
For the bipolar patient, who by nature of the disease, becomes less and less capable of reality testing as the disease progresses, it is imperative that they be grounded in the reality of their condition by clinicians across the medical system. Both the International Society for Bipolar Disorders and Diagnostic & Statisticians Manual-5 report that the severity of manic and depressive states worsen with repeated episodes. Cognitive Behavioral Therapy as such does not provide the theoretical groundwork necessary for treatment. A clinical orientation and relationship from provider to patient that confronts reflexive processes of denial, allows for the bedrock condition of loss to be experienced, mourned, processed and treated is a better solution.
To conclude, as a clinician, I have experienced an incongruence when it comes to theory and praxis. I cannot help but notice an irony that the bipolar patient and the clinicians treating them are often not given the full framework to understand the situation. I hope to contribute an understanding that assists in our understanding and treatment of bipolar disorders.
Salzman notes that denial is a pathologic coping strategy in mania, but he also emphasizes that it is a perfectly normal response to serious illness for a patient with bipolar disorder. We live in an age where our medical understanding of bipolar disorder allows for miracles. It is time for our therapy to do the same.
Nancy Mcwilliams shares that “Because of pharmacology, clinicians are now enabled to work with depressive people at all levels of disturbance and to analyze the depressive dynamics even in psychotic clients. Before Lithium, many patients were so sure of the therapist’s inevitable hatred of them, or so despairing of real devotion, that they could not tolerate the pain of attachment.” (Mcwilliams 2020) I hope to improve theory and praxis for bipolar patients and assist the clinicians spanning medical communities who will treat them.
After all, bipolar disorder is an incredibly intense expression of a fundamentally human need. That is, to know that who we are is better than the most seductive, and grandiose, sense of ourselves that we create in our minds; and that therapy, our lives, our days are imperfect and that that is alright.
References
1. Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O'Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., McIntyre, R. S., … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609
2. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. The Lancet. 2013;381:1672–82.
3. McWilliams, N. (2020). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. The Guilford Press.
4. Kernberg, O. F. (2004). Borderline conditions and pathological narcissism. Rowman & Littlefield.
5. Freud, S., Ellmann, M., & Whiteside, S. (2005). On murder, mourning, and melancholia. Penguin Books.
6. Schore, A. N. (2019). Right brain psychotherapy. W. W. Norton & Company.
7. FREUD, A. T. I. O. P. (2019). Ego and the mechanisms of Defence. ROUTLEDGE.
8. Salzman C. Integrating Pharmacotherapy and Psychotherapy in the Treatment of a Bipolar Patient. AJP. 1998;155:686–8
