I sometimes encounter mental health-related blogs and articles which represent the kind of black and white thinking that ends up being more harmful than helpful. An example is a recent internet blog titled "Change Bipolar Disorder by Changing Your Mindset." The author's premise is that bipolar disorder is a creation of the mind and through the process of coming to terms with reality and facing one's past trauma, the symptoms of bipolar disorder can be conquered. The author's perspective is conveyed through statements such as: "The medical society comes from a typical solution of medications, which are drugs... Bipolar Disorder comes from a person not facing reality and their fears... Drugs stop the ability to grow emotionally beyond the basis of past trauma... The manic and depressive episodes are just a signal that you are maladjusted to life and running from reality."
These efforts to espouse hope that cure is within reach is potentially guilt-inducing for those with bipolar disorder who experience the prospect of cure as being beyond their reach. From the author's perspective, those who take prescribed medication are using pharmaceutical treatment to run from their fears! The implication being that if they alternatively chose the right kind of psychotherapy, they could free themselves from drug treatment and from a bipolar future fraught with recurrent relapse.
I know many a bipolar individual who would mightily disagree. I too can't align with this position, though I also can't fully dismiss the implication that unresolved personal issues sometimes do contribute to bipolar symptoms. The important distinction entails knowing when personal issues do exacerbate bipolar symptoms rather than proffering the broad-sweeping and misinformed assumption that unresolved personal issues cause bipolar disorder.
There's also the converse side of the argument, the more predominant medical model, which holds to the view that bipolar disorder is biologically based, chronic and lifelong. Essentially, if you've got it, you're stuck with it and there’s little to no chance of resolution. For most with bipolar disorder this is more familiar territory. If you've been hospitalized or experienced recurrent episodes of moderate to acute instability, then you've likely had a psychiatrist suggest that you need to accept the permanence of your condition and learn to live with it. Generally speaking, I agree with this though I don’t want to discount the possibility that we sometimes see unusual and unexpected outcomes. However, the reality is that most longitudinal studies do support the notion that bipolar disorder is a chronic lifelong condition.
Where this gets tricky is with those on the mild end of the bipolar continuum who are somewhere between 16 and their mid-twenties. Consider the profound transformation that most individuals undergo while going from adolescence to young adulthood; or better, imagine taking a version of yourself at 19 and visiting with him or her when you turn 32. You'd probably feel like you were encountering a very different individual. That's the beauty of maturation - we really do change with time.
When the lifestyle patterns of the late adolescent evolve toward adulthood, we often see the establishment of regular employment routine, healthier sleep hygiene and increased consistency of day-to-day functioning. This is why adolescents are prone to see adulthood as boring!
Similarly, when recreation doesn't entail frequent drug and/or alcohol use and when one becomes more skilled at managing external stressors as well as the impact of complex emotions, then mild bipolar symptoms can sufficiently diminish and no longer meet the threshold for the bipolar diagnosis. I am not saying this commonly occurs, but I can report that anecdotally, I do see it happen from time to time. In other words, sometimes growing up also means smoothing out.
Maturation is one of those things that happens apart from our volition. In fact, the cerebral cortex, a part of the brain involved in judgment, decision-making and impulse control continues to develop into the mid-20s. You don't just wake up one day at age 19 and say I'm going to become grown up today. More accurately, you gradually develop better insight, perspective and impulse control through experience and with continued cortical development over the course of late adolescence and young adulthood. That's where the hope lies for those in their late teens with mild bipolar symptoms.
If you’re much beyond your twenties and looking towards the influence of maturation upon bipolar symptoms, it’s unlikely to occur. That doesn't mean maturation and personal growth don’t continue throughout the lifecycle; but realistically the degree of maturational change we experience begins to level off as we progress into adulthood. So if you can’t bank on maturation, then where do you invest your hope and your efforts to change? My own admittedly biased answer to this is – psychotherapy. Before going there, we need to first consider the important distinction between internal and external influences upon mood.
Let's begin by thinking of bipolar disorder as being akin to the volatile substance, nitroglycerine. When agitated, the substance rapidly changes from being relatively inert to highly explosive. If the substance remains undisturbed explosion can be avoided. There's much in life that can be agitating. Environmental and situational stressors are pervasive: fast-paced employment environments, high academic volume, the approach of work submission deadlines and difficult individuals who don’t always treat us kindly… these are all in the realm of external stress. They’re out there and, short of becoming a recluse who lives off the grid, it’s difficult to avoid this kind of stress within our lives. At the same time I’m not suggesting that we are all doomed to react like a vial of agitated nitroglycerin.
Think of two people with very different temperaments or personality styles. One is usually calm, even-tempered, rarely anxious and mostly has positive self-esteem. The second person, by contrast, approaches most things with apprehension and doubt and often feels that stress undermines his or her capacity to think clearly and make good decisions. These are people who approach life quite differently.
Imagine these two people both experience the same difficult and challenging day. While their external stress may be comparable, these individuals' capacity to manage their day is quite different. For the one with anxiety and deficient self-soothing, their fearfulness and difficulty remaining calm are stressors in and of themselves. In other words, the psyche of the individual absolutely plays a significant role in how the day is experienced. The notion that circumstance or other people make us feel anyway in particular is inaccurate. Life comes at us, but our response is our own creation.
Now let’s loop back to the psychotherapy issue. If self-awareness, stress management, decision making processes and interpersonal skills are all in the realm of things we may have some influence upon, then it only make sense that improvement of these functions could potentially improve one’s overall sense of emotional equilibrium. And if our own internally generated stress or “how we are in the world,” doesn’t lend itself towards stability, then it would also seem self-evident that becoming involved in psychotherapy as a means of improving one’s coping style is a reasonable thing to do.
I don’t want to replicate the perspective that I criticized at the outset of this blog. Psychotherapy won’t likely resolve the symptoms of bipolar disorder. Even the most insightful, self-aware, self-accepting bipolar individual will still experience some mixture of highs, lows and/or irritability that will be difficult to manage. That’s life with bipolar disorder.
I also don’t want to suggest that psychotherapy oriented towards significant personal change is a simple undertaking. There aren’t three easy steps to equilibrium and serenity. It's more the opposite: serious, in-depth, transformative psychotherapy is hard work. Facing unresolved personal issues is something we typically avoid rather than meet head on because the process often involves a fair amount of emotional pain. But if you’re motivated towards therapy and can find a skilled professional to facilitate the process, then meaningful personal change is truly possible.
Living with bipolar disorder is never easy. In fact, if your symptoms are generally on the more severe end of the bipolar continuum, then much of what I'm conveying about psychotherapy and bipolar symptom management may simply not be relevant. But if you're one of the many individuals with bipolar disorder whose symptoms do allow you to maintain reasonably effective functioning, then with effort, you can absolutely look towards improvement. You can ask yourself what are the internal elements of stress that you bring to the table and how might you be able to modify or soften their maladaptive influences. Ultimately, if you can improve upon that which is changeable then you’ve got a higher likelihood of living better with your bipolar disorder.
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Russ Federman, Ph.D., ABPP is Director of Counseling and Psychological Services at the University of Virginia. He is also co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com