Currently, medication is the go-to treatment for bipolar depression, a practice that is not without controversy.  As a psychologist, I was trained to focus foremost on the patient’s vast experiences that influence their way of being in the world.  Only after kicking and screaming have I come to accept the enormous value of pharmacological intervention.   I've come to believe that for some patients medications such as Lithium are critical in helping them to hold onto their jobs, repair broken relationships, and prevent destruction in their lives.    

Yet medication is no cure-all.  The biggest trouble reported in treating bipolar depression is that patients don’t stay on their meds.  The result?...rehospitalization, the loss of jobs and relationships, and worse.  Something isn’t working.  I suggest what's necessary is an inquiry into the psychological context of taking medication.  Is there respect and acknowledgment of the patient’s ultimate freedom to take or not take what is prescribed.  Has there been an exploration and understanding of the significance of the patient’s mania.  And Is there a positive alliance between the patient and all treating professionals?   By addressing these inquiries, the patient is far less likely to impulsively stop their meds.

Mania is not simply a biochemical reaction.  It occurs in a psychological context. Mania can be understood as an attempt to break free from what a patient perceives as an intrusive and oppressive force in one’s life.  For the patient, the practitioner may represent that oppressive force.  It is a very reasonable impulse for a professional to take the following protective attitude toward patient:  “How do I get her to stay her meds?”  However well meaning, such an intention may backfire and be perceived as coercive, particularly if trust has not been developed.  If the patient believes their free will is being intruded upon, they may take flight and stop the meds. The bipolar individual has a vitality that refuses to submit to what may feel like an impinging authority. 

It is critical to hold and reflect in the broadest sense possible the things the patient cares most about.  It appears as immanent that the patient would like success in love and work.  But just as important, the patient has a need to experience mania.  Feelings of euphoria, omnipotence, invincibility, limitlessness and expansiveness are cherished by the patient.  With medication the patient may have to give up the experience of some of these feelings. The therapist can help a patient find less extreme avenues of expression when on medication.  But to the extent that the medication has quelled manic expression, there is a loss that needs to be mourned.  Otherwise, the expression may manifest as the patient stopping their meds.

More than anything else, adhering to a medication plan requires a positive therapeutic alliance.  Whether the therapist is the prescribing doctor, or whether the therapist and prescribing doctor are collaborating together, the patient needs support, encouragement, and recognition from all parties.  The patient must not be distanced from the practitioner as an “other,” a disturbed individual in contrast to the healthy professional.   On the contrary, the therapist must dwell together with the patient in their common suffering, from one human being to another.  Trust must develop.  The therapist should engage in careful and authentic admiration of the patient’s strengths and potential.  Slowly, a base is created for greater freedom.  The patient can begin to feel secure and hopeful without the need to flee into mania.   In a strong and trusting therapeutic relationship, the patient can more easily accept losses.  And also accept what is to be gained—an acceptance of medication as a way of taking care of oneself, renewed connections with friends and family, and the ability to thrive in daily life.

It is easy to see how psychotherapy can work to support the effectiveness of medication for bipolar depression.  When we become seduced by the promise of medication as a cure-all, it is easy to forget the very humanness of the difficulties we’re treating.   Working together, medication and psychotherapy give the treatment of bipolar depression a more hopeful prognosis.  

For more on bipolar depression:  http://www.stephenlsalter.net

About the Author

Stephen L Salter, Psy.D

Stephen L. Salter, Psy.D., runs a private psychotherapy practice in Beverly Hills, California.

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