Last week, Dan came to the session and told me he was so frustrated with himself. He slept through class again. Now he is worried and too ashamed to go back to class again.
Dan’s story reminded me how much small events linked with mood regulation can have a big effect on functioning. But it can be hard to see how this works.
When Dan was first diagnosed, his moods (and their effects on his behavior) were very intense. He couldn’t regulate his moods on his own. He couldn’t talk himself out of the intense highs or lows, and no one else could keep him comfortable for long. A doctor had to intervene—with medications and other treatments—to get things back on track.
Once he was on a good course of treatment, his daily moods looked like they were more “in the normal range.” But Dan still has a lot of trouble managing stress, particularly when he thinks he has done something wrong. When he feels upset with himself, he can’t regulate his negative emotions well enough to recover on his own. For Dan, a little extra dose of negative emotion (i.e., shame because he missed class) can overwhelm him and throw him off course. Now he just wants to go to sleep and avoid everyone and everything.
Why is this happening?
In part, these problems arise because we are accustomed to relying on our emotions, both positive and negative, to help motivate us. We think about the kind of person we want to be (i.e., “a responsible person” or a “good student,”), and set goals for ourselves. When our actions are consistent with our goals, we feel positive emotions, like pride or satisfaction. In a way, these positive emotions are a reward for being who we want to be.
On the other hand, when we are not on track, we often use negative emotions—like embarrassment, anxiety or even shame—to prod ourselves to do the right thing. If we are procrastinating about starting our homework, we might get angry and say to ourselves: “Hey, stop being so lazy, get up and do the work!” Once we are back on track, the negative emotion dissipates.
We often think of it as a sign of good character when we can use our own emotions to guide our actions (i.e., to self-regulate). We don’t need to wait for someone or something to push us to act. When we don’t have problems with mood regulation, this makes sense. We can rely on satisfaction and pride to push us forward, and trust little doses of negative emotions will keep us on track.
But in bipolar disorder, the story is different. Problems in mood regulation make it very difficult to use negative emotions as a motivating force. When moods are not fully stabilized, it is difficult to put a brake on negative emotions. And without an effective brake—without the ability to control the intensity or frequency of the feelings—those feelings can spiral out of control. Negative emotions become a barrier to getting back on track.
For Dan, his problems with mood regulation mean that he may not be able to regulate the dose of shame. He fears his negative feelings are likely to spiral downward, shifting his focus to other things he does not like about himself. If it gets really bad, his mood may pull him into a black hole of negativity and self hatred.
Dan wants to be responsible, but he knows he can’t just yell at himself or shame himself into behaving correctly. In fact, the more he does that, the worse it gets. The feelings of shame can end up paralyzing him.
Dan recognizes that he needs some outside support to help him put a brake on the intensity of the feelings. Together, Dan and I put the situation into a more balanced perspective: “It’s still early in the semester. I can go back to class and make up the work. The teacher will not write me off if I can start to do the work. The disabilities office at school can give me help talking to the teacher.”
We agree that I will give him a call tomorrow before he is supposed to leave for class. Maybe this will give him a little extra courage, so he can to go back to class. Dan texts a classmate and gets the class notes and homework assignment. If changing his perspective, getting social support, and starting the homework don’t get him back on track, we will call his psychiatrist and see if a medication adjustment is in order.
Most important, Dan can see that he is building character by getting the help he needs to regulate those negative emotions and get back to class.
Later that week, another patient, Joan, started the session by saying “I feel like I need a kick in the pants to get back to work on this term paper. I know you will push me, but I am ready.” Joan has been very stable for several years now. She can use a little negative emotion—a little guilt—to push herself past the tough parts of her work. She trusts that she can turn that guilt off when she needs to—she won’t start a downward spiral of harsh self-criticism. We talked about her plans for completing her schoolwork, and she got right back to work.
If your moods aren’t yet well regulated, be gentle. Don’t try to turn up the volume on the negative emotions to force yourself to get going. Try to soften the emotion and get help making a new plan for getting back on track.