Manic depression: when elation takes control
Aine Tubridy and Michael
Corry don't like the term ‘bipolar disorder' as applied to manic
depression. Here, they advance a different view of what is happening
in this experience
There is a line in the sand between those who
experience manic depression and the more common-or-garden forms of
mental distress. Much mystique surrounds the experience of elation, and this is understandable. How is it possible that
an individual in the prime of their life, with all the external
trappings of normality in place, suddenly find themselves
experiencing a superhuman amount of energy, which drives them
relentlessly, without sleep, like a person on a mission, insatiable
for social contact and avenues for their escalating ideas, to
contrive fantastical ‘big picture' projects which they feel
convinced will jet them to fame and fortune or, at the very least,
to present to the world the ‘grand solution' to many of its
problems?
Within weeks, such
a person finds themself in a psychiatric hospital, doped up to the
eyeballs, unable to string two thoughts together, their life in
shreds, and with their family, friends and colleagues shaking their
heads. The future has taken an entirely different depressing flavour
— gone is the confidence, the powerful energy, the grandiosity, the
great plans of the preceding weeks. And most depressing is the fact
that there is huge collateral damage to repair, the swathe of
destruction wreaked during their manic episode.
In addition, they
have to absorb the feedback they get from their doctors that they
are suffering from a mental illness, a disease of their brain, which
will require a lifetime on medication with no guarantee that it can
prevent further episodes occurring. How can they engage with a
future with such uncertainty in it, where overnight their entire
identity, both to themselves and others, has evaporated, only to be
replaced by some alien ‘patient' identity come to inhabit them? This
rock-bottom state is the stuff of a serious emotional
crisis.
Tragically, within
the current psychiatric repertoire of treatment, this state is
related to as merely the inevitable tail-end of the manic process.
Because this end-state depression and the mania which preceded it
are seen as going hand and glove, inseparable processes which are
the ultimate result of a disease of the brain, no attention need be
given to any other possible initiating causes. Caught in the terrain
of the sick-brain model, no-one pays attention to the primary cause,
the emotional triggers preceding the mania, which are a reflection
of a stress or predicament placing a strain on the
personality one has in place. Instead the focus is on biochemical
shifts, defective genes and medication regimes, all of which are
secondary phenomena.
Would it make
sense to repair a series of crashed cars, driven by the same driver,
over and over, without ever asking why he keeps crashing them?
Relevant questions such as: Is the driver drinking? Has he passed
his driving test? Is he driving too fast? Trying to kill himself?
Does it always occur on exactly the same spot in the road? One point
is clear. The car is not the source of the problem but the
consciousness behind the wheel.
This broken
machine model clearly cannot work, since it marginalises the unique
contribution of each person's mindsets, value systems, life
experiences, vulnerabilities, special gifts and talents,
socio-economic status, levels of responsibility, support systems,
relationships, and the place at which they find themselves along
their life plan as mind/body/spirit organisms. In short, while there
is some commonality with respect to symptoms, no two manic
depressives are the same as far as causality goes, which is always
exquisitely personal to each.
Manic
responses
Certain stressful contexts contain the ingredients to
provoke the manic response in some individuals.
Defence against failure
For some, mania can be seen as an unconscious defence against
an imminent failure, a manoeuvre to essentially
avoid, deny and escape from the feelings of setback, disappointment
and failure which are so much a part of everyday life for most of
us. Feeling ordinary, vulnerable and out of control are not part of
this person's everyday mindset. They prefer to be extraordinary,
invulnerable and on top; they are uncomfortable with the down
position and distort any evidence that it is on the horizon, instead
overcompensating in the opposite direction. Their last-ditch efforts
to ‘pull it off' in the face of all objective evidence to the
contrary are legendary. This behaviour is akin to rearranging the
deckchairs on the sinking Titanic, encouraging the dance band
to play their hearts out while they keep the champagne
flowing.
Richard, a 38-year-old, highly
successful property developer, with a reputation for arrogance and
risk-taking, lived a high-flying palatial life. He owned homes in
many fashionable parts of the world, and lived in a magnificent
mansion with stables in Kildare. He was part of the hunting and polo
set, he moved with the rich and famous. The golden boy in a family
of girls, he had gone to the best schools, achieving some acclaim as
a sportsman and debater, then made his entrepreneurial debut at a
young age, taking up the mantle from his father. He lacked his
father's tact and political savvy, throwing his weight around and
refusing to compromise and play the political game. In this way he
made enemies in high places.
He
did not see his Waterloo coming when he overextended himself on a
huge property deal and the banks threatened to foreclose. Loathe to
take any advice, and make the obvious financial steps, he instead
took off to the Epson Derby with a party of friends where he backed
a number of winners. Convinced now that his luck had turned he hit
the town. Fielding frantic calls from his wife and business
associates, he took up residence in the Ritz. He started
entertaining round the clock, set up business meetings and planned a
merger with one of the biggest property developers in London, who
owned hotel chains across the world, believing that if he pulled
this deal off his troubles at home would be sorted. The way forward
was now clear — he would move his offices to London, and relocate
his family. Newly inspired, he partied on, full of energy, and
getting no sleep.
He
became a charicature of himself, pompous, loud and aggressive, and
filled with an air of triumphalism. Following a series of complaints
from other guests about the noise in his suite, he had an ugly
showdown with the hotel manager in the foyer, insisting that he his
consortium was in the process of buying the hotel and that he would
be fired that day. When the police arrived he was standing on the
reception desk inviting other guests to the bar where, as the new
owner the drinks were on him. He was eventually taken to the
Maudsley Hospital where he was involuntarily detained.
The
‘eureka!' experience
Some individuals,
consumed by an intensely intellectual project or piece of research,
working marathon hours, their brain turbo-charged and exhilarated by
the implications of their findings, without the brake that downtime
provides, enter into a phase of sleep deprivation which opens the
door to an altered state — mania. They now become mind-blown by the
immense importance of their work, seeing its interconnectedness to
the wider world, and how it could influence the future of mankind
for the better. Obsessed now by the implications of their
‘discovery', they are high and think of nothing else, talking to
anyone who will listen, and soliciting support from the influential
and powerful. Criticism is brushed off and condescendingly
interpreted as ignorance. Seeing themselves now as a messenger of
great good, they feel divinity and righteousness to be on their
side.
Sylvia, a 25-year-old PhD student in
sociology, was completing her thesis on an aspect of group dynamics.
She was behind schedule and it was now absorbing her totally, day
and night. Particularly exciting to her was notion that in any group
certain members had a predisposition to feel and express the
thoughts and feelings unconsciously held by other members. This, she
felt, had huge implications on the world political stage for those
in leadership roles and in the area of conflict resolution. She
formed a theory that if leaders could be made conscious of this
fact, their power to influence people would be unlimited. This
insight directed her towards a study of famous political and
religious leaders. Day after day, holed up in her apartment, unable
to sleep with excitement, eating little, and not communicating with
anybody, she read voraciously, spent hours on the net, and made
copious notes.
Her
first outing in months was to be bridesmaid at her sister's wedding.
She arrived bursting with energy, engaging people vivaciously, but
her over-the-top excitement was passed off as wedding-related.
Finally, unable to contain herself any longer, she used her
bridesmaid's speech as an opportunity to launch on the stunned but
receptive guests her Theory of Mass Influence. She was reluctant to
stop speaking, in spite of interventions by the family. When the
best man instructed the band to begin playing she grabbed the
microphone from the singer and continued on passionately insisting
on her message reaching as many people as possible as it had
implications for world peace. Arguing, screaming, and wrestling with
anyone who tried to stop her, she was bundled into a side room and a
doctor was called, who had her admitted to a psychiatric hospital.
The
spiritual opening
The spiritual
experiences of the past, undergone by ascetics, monks, prophets, and
other religious devotees in monasteries, caves and mountaintops,
followed a consciously sought ‘communing with God' breakthrough.
This was facilitated by long periods of fasting, meditation,
isolation and sleep deprivation. The state they reached was, in
essence, a psychotic experience, an altered state of consciousness
of a transcendental nature. The cultural context at the time was
accepting of their revelations, genuinely seeing them as divine
messengers, if not divinity itself. Let's not forget that the big
names in spirituality such as Buddha, Jesus, and Mohammed,
experienced their ‘visions', and insights as to their life purpose,
in such deliberately created settings.
Nowadays, some individuals suffering from mania
experience spiritual openings in environments where the focus is on
their inner journey, such as during meditation retreats and
intensive personal development workshops. It is not uncommon for
ordinary people to return from places like Medugordje, Machu Pichu,
Lourdes and other apparent vortices of concentrated spiritual energy
with an expanded sense of their place in the grand scheme of things,
and in a state of manic elation.
David, a 41-year-old managing director
of a public relations company, joined his wife in Medugordje, where
she had gone with their only child Sarah, aged 12, who was suffering
from muscular dystrophy and had been in a wheelchair for one year.
Being a non-practising Catholic for many years, and really only
there in solidarity with his wife, he was surprised to find that the
energy of the place inspired him. He embraced every ritual with
great enthusiasm, from night-time candlelit vigils to prayer
meetings and the outdoor celebration of masses, and hours spent in
silent prayer.
In
the church where the Blessed Virgin is believed to appear regularly,
during a mass he became aware of a golden light filling the church
and auras like halos of different colours around members of the
congregation. Waiting in line to receive communion, with his
daughter in her wheelchair, he suddenly felt drawn to place both his
hands on the crown of her head. As if like a bolt of lightening, he
felt a huge force coming through his head, down his arms, and into
his hands.
He
began to shake uncontrollably and could not remove his them. He
became frightened but was relieved to find that his daughter was
enraptured by the experience, and had a beatified smile on her face.
The entire event lasted a minute, and afterwards he asked his wife
to take over and left the church feeling very confused and
disorientated. Reluctant to risk a repeat of the experience, he did
not attend any more ceremonies and couldn't sleep, wandering the
town at night.
On
his return to Ireland, still not sleeping, and finding it hard to
re-engage with work, he took a few weeks off, and began to spend
more time with his daughter, who he felt had benefited by the entire
experience in Medugordje. One morning he decided to bring her to
mass in the neighbourhood church where, once again, as he was
waiting in line, he experienced a bolt of energy running through
him. Later, at home, in an excited state he informed his wife and
daughter that these high energy experiences meant that he was a
spiritual healer, with the power of Jesus Christ acting through him.
He told them that he would be leaving his job to pursue this
important mission. For the next couple of weeks was rarely seen at
home. Living rough and walking in his bare feet through the streets
of Dublin, he was eventually found, penniless, having given away his
money and credit cards to the homeless. This precipitated his first
admission to hospital.
Drug-induced mania
Over 30% of
individuals diagnosed with manic depression follow on from the use
of street drugs such as amphetamine, cocaine, crack, and some
hallucinogenic substances. (Anti-depressant medications, because of
their stimulant effect, are also capable in some individuals of
triggering an episode of mania.)
Sophie, a 22-year-old aspiring model,
hung around the edges of the ‘It' crowd, partied every weekend, and
started to use cocaine regularly. She found that it gave her energy,
suppressed her appetite, enhanced her libido, and made her extrovert
and confident. She became the darling of the designers and
fashionistas, and her career took off. Enjoying her new-found
celebrity status, she appeared at every premiere, attended all the
parties, and became the trophy every man wanted to be seen with. In
such circles she found the supply of cocaine unlimited, but started
to stockpile her own in case her source ever dried up. Day and night
blurred, and weekend party bashes began to spill over into the
working week. Now she was consuming up to six grams of cocaine a
day, which she needed in order to function. Because she was such a
successful model verging on the supermodel status, allowances were
made for her petulant cantankourousness, frequent late starts, and
her flippant approach to her work.
At
a weekend country house birthday party hosted by a rock musician,
cocaine was falling like snow and she snorted more than usual.
Suddenly she experienced a rush of unprecedented energy and power
and became imbued with the sense that she was the diva of all divas,
the re-incarnation of the sex goddess Marilyn Monroe herself.
Monopolising the dance floor, she openly began a seductive
titillation of the male company, seeking particularly to impress her
host with her ‘Happy Birthday Mr Rock Star' song.
Finding that he had been solicited away by a young
wannabe model, she stormed off the floor in search of him, burst
into his bedroom, and attacked the girl viciously, striking her with
her stiletto heel. After being pulled away, she ranted around the
house breaking windows with anything that she could find. Bundled
into a car, she rapidly found herself being delivered home to her
apartment in the early hours of the morning. She immediately called
every newspaper, and media contact that she had, informing them that
she would hold a press conference later that day at which she would
tell the world that she was in fact Marilyn Monroe. Her agent
arranged her hospitalisation.The sick brain model of mania focuses on the effect
(the symptoms) rather than the causal context, particularly in the
first three of these types. It can be no other way once the cause is
understood as a disease process, a defect in the hardware of the
brain. Within such a model the treatment would be the same for all
four; psychotherapy would not be thought relevant, nor personality a
factor to be addressed, notwithstanding all the other existential
issues in a person's life.
A portrait of mania
For the purposes of
understanding the natural timeline of a manic episode, we have
decided to focus on the classic type, which forms the largest group,
namely the defence against failure.
The predicament on the
horizon
The pre-manic years are relatively trouble free. No
shrinking violets, mania sufferers are more often high achievers,
socially skilled, confident, proactive, competitive and familiar
with success. They are good all-rounders and some may well be voted
by their class as being the ‘most likely to succeed'. Because of
this apparent headstart, they enter the world of work full of
promise. The first sign of a psychological hiccup can come therefore
as a total shock to patient and family alike. Their game plan for
the future was one of continued success. To return to the analogy of
the Titanic, their predicted life seemed unsinkable and Plan
B — the lifeboats — was never dreamt of.
How they look to
others is important to them: the public gaze, material things,
getting ahead, and the need for power and approval is crucial to
their identity. They are often larger than life, the life and soul
of the party, and are well liked. Their bonhomie and extrovert
nature attracts people to them. When it comes to having their own
needs met, they expect doors to be opened for them and see no reason
why they should not be facilitated.
They expect others
to give their all and share enthusiastically in their dreams and
visions. If challenged on practicalities they become annoyed,
impatient and frustrated. Familiar with the ‘high horse' position,
they can if obstructed ride rough-shod over colleagues, family and
friends. A setback is not on their agenda. At all costs they are
survivors.
When a setback
occurs, the predicament it throws up will elicit an exaggerated
response in this pre-manic group. While others may sympathise with
them, few appreciate the depth and intensity of their newly-felt
vulnerable feelings as their ego is challenged for the first time.
Typical setbacks might include missing a promotion, a failed
business investment, or any experience where losing face in public
occurs. What would be experienced as a minor obstacle to others
becomes an earthquake to them, in psychological terms. It's as
though they have put everything, even their very personhood, on the
line. The reverberations are huge, and the setback proves too much
for their system to integrate.
Rather than
experience feelings of failure, the incoming evidence is rejected
and distorted by the mania mindset, and the blame for setbacks is
located elsewhere. They contrive explanations which free them from
any personal responsibility. They cook the books. Reasons and
rationalisations are dragged up to offload responsibility for the
failure. This has the unfortunate consequence that the core problem
is never addressed and the slide downwards continues. A point is
inevitably reached where denial can no longer hide the reality of
the situation, and they are forced to acknowledge that a failure is
imminent. When the dam burst occurs and the truth of the situation
is no longer avoidable, the personal lie starts to break
down.
There are
recognisable phases to the manic process akin to the launching of a
rocket into space, its orbiting and its return, re-entry,
crash-landing and fall out.
The launch
pad
Staring failure in the face, mania-sufferers move rapidly in
the opposite direction, back to the success end of the
success-failure spectrum. In this way they impress upon themselves
and try to impress upon others that they are still in control,
proving this by overcompensating.
There is a
noticeable speeding up of thoughts and behaviours. Subjectively,
they feel a surge of energy, power and invincibility. It's as if
they have become the Greek character Sisyphus, but who has suddenly
found the extra strength to push the boulder over the ridge of the
mountain and down the other side, finally freeing himself from
repeated failures. There is an air of triumphalism: anything is
possible!This is the stage
where the psychotic break has not yet occurred but is about to. It
is an exaggerated and magnified version of themselves in top form, a
caricature. As they move closer to the launch pad, the possibility
of aborting the mission rapidly fades.
Launch
pad symptoms
Unstoppable rapid-fire speech, full of inflated high sounding
rhetoric. They are incapable of listening.
'Eureka'
ideas. They
get light-bulb insights, which they are convinced would provide a
blanket solution for past misjudgments and mistakes. They set up
meetings, make phone calls, and send faxes and e-mails towards this
end. An example might be attempting to recruit the support of Bill
Gates in person to invest in and to save their company from
liquidation.
The Holy Grail and other quests. They may become
passionate adventurers, heading off, for example, to the Pyramids of
Egypt, to white-water raft in New Zealand or to find a guru in
India.
Sleeplessness. Their mind is never still, racing thoughts and flights
of ideas are the order of the day, and night. This, coupled with
enhanced energy, interferes with their sleep pattern, reducing it to
one or two hours a night. ‘I have too much to do to waste my time
sleeping.' This can reach the stage where they literally don't shut
an eye for days at a time, in some cases for weeks.
Time
urgency. They
get impatient at the pace at which things move and want everything
to be done yesterday.
Short fuse. There is an anger and irritability
when challenged and criticised about their behaviour. They don't
suffer fools easily, are impossible to reason with, and strenuously
resist the restraints of normal life.
On the
town. There
is a sense that ‘I deserve the best.' Money is spent on clothes,
presents, nights on the town, champagne, a new car, a brief trip to
Rio.
God's gift to women and men. Both sexes who are on the launch pad
can become sexually disinhibited and engage in amorous one-night
stands.
Political incorrectness. This can range from
telling the wrong jokes to the wrong people, making sexual passes at
people they would never in their wildest dreams have any interest
in, such as their neighbour, an in-law or the boss's wife. This form
of promiscuity has no gender difference.
Lifting off
into orbit. The dice are
rolling. An unstoppable energetic and chemical shift is under way.
Their metabolism is turbo-charged and their consciousness is so
single-minded, passionate and goal-orientated that it will not be
deflected. They feel fantastic and ‘over the moon', hence the
association with the term elation (which comes from the Latin efferre, meaning to lift up, inspire with pride, lift the
spirits of, or to feel exalted and lofty). Lift-off is
recognised by a total loss of contact with consensus reality, as
they assume an alternative persona. This role usually has a
grandiose quality to it, giving sufferers a sense of power, success,
confidence, and a feeling that everything is going really well and
that they are in full control. They become super-fixers with godlike
powers, and believe that they are the custodians of the solutions
that humanity has been waiting for, such as Third World economic
programmes, global conflict resolutions, scientific discoveries, and
breakthroughs in medical science. Others believe
that they have extraordinary talents in the area of music, acting,
film, as yet undiscovered by the entertainment world. Like a good
method actor they take on the persona that most fits the furthest
out dimensions of their prior personality and live this role around
the clock. They have entered the megalomaniac stage (from the Greek
word megas, meaning great or very large)
Lift-off
symptoms
Increasing distance. The gap widens between their
reality and that held by those around them. This gives rise to
reciprocal frustration, irritability, angry outbursts and a total
breakdown of normal communication and relationships.
The
lossof a
personal censor. Anything goes. ‘I will not be stopped, and no
one is going to stand in my way.' There is a refusal to be censored
by the outside. Threats such as loss of job, collapse of
relationship, suspension of credit and legal interventions all fall
on deaf ears.
Hostile behaviours. With the combination of time
urgency, grandiosity and their conviction that the end justifies the
means, support is extorted to validate their views which are
patently obvious to others as ludicrous.
Conspiracy theories
abound. This
provides a logical explanation to them as to why they are not being
facilitated with urgent meetings, financial support and public
acclaim. ‘Those that are not with me are against me.'
Hitting
the wall. As
in the old proverb, they have given themselves enough rope to hang
themselves with and the noose begins to tighten. Spouses, children,
friends withdraw. Financial resources dry up and all credibility
collapses. Lack of sleep, excessive substance abuse, inadequate
diet, erratic routines, emotional turmoil from ongoing conflict,
begin to take their toll on their energy reserves.
Hospitalisation.
Inevitably, there comes a time when the long-suffering relatives
reach their limit, and decide that in the individual's own interest,
to prevent further damage, the best thing that could happen to them
is something akin to a shot from a tranquillising gun. There is
general agreement among onlookers that the cycle has to stop. This
may mean that they are coerced or involuntarily committed into a
psychiatric institution.
Re-entry and
crash-landing: post-elation depression
Sufferers undergo
energy bankruptcy. Metabolically, they no longer have the reserves
to deal with the overwhelming demands at this time. The batteries
are now flat and biochemically they are in a state of metabolic
burnout. Sleep deprivation, lack of food, substance abuse and the
relentless, chaotic activity has created a toxic state from which
the individual now needs to recuperate.
Psychoactive
medication is used to bring the manic phase to a close. It does so
by slowing the metabolism, reducing the manic thoughts and the
hyperactivity. Essentially, the initial phases of medication act as
sleep therapy. The restoration of sleep reduces the hypersensitivity
of the nervous system to the aminergic family of mind-brain
chemicals (adrenaline and serotonin, the struggle/striving
hormones). This allows the cholinergic family (acetylcholine, the
hormone of balance and maintenance) to catch up and restore
normality.
In the words of
Shakespeare, ‘Sleep is nature's balm'. While medication is essential
to end the destructive manic flight, functioning like a
pharmacological strait-jacket, it creates a state of suspension or
twilight zone, where normal psychological and emotional responses
are slow to return. This phase can be extremely distressing for
relatives, particularly children, who find parents zombie-like and
unresponsive.
Symptoms
Wounded
pride. Pride comes before a fall. A
free-falling manic topples from a great height, and the impact
reflects that. As they return to everyday consciousness and their
previous identity, they are faced with a scene equivalent to the
post-battle scenario, much like a defeated general reflecting on the
number of lives needlessly lost, and the futility of the cause
fought for with such blinkered single-mindedness.
Disillusionment. As the medication is gradually decreased and awareness
starts to percolate through, many become deeply depressed by the
outlook, making problem-solving an additional overwhelming burden.
One of the primary dis-illusionments is that, in spite of their
‘great escape', on their return they are still facing the
predicament of impending failure from which they took flight, now
seriously compounded by the visible debris resulting from the manic
episode itself. This can include severed relationships, financial
ruin, loss of others' confidence and trust, the jeopardising of a
good work record and promotional possibilities. In some cases, there
are even more serious consequences, such as legal proceedings as a
result of car accidents, broken contracts, violent behaviour,
barring orders, protection orders, paternity suits, all of which
demand urgent attention at a time when sufferers are at their
lowest.
Suicidal thinking. For some this seems like the only reasonable solution, so
great is their shame. There is no way out. Their flight into mania,
which was an unconscious effort at a solution, has inevitably
created more problems that it has solved. So deep is the feeling of
despair, desolation and hopelessness that the pain of it dictates an
action which will end it. In this sense it is a form of
self-administered euthanasia.
The medication see-saw. Manic patients, having been brought back to consensus
reality by high doses of sedative medication may now find
themselves, particularly if they are deeply depressed and suicidal,
being prescribed psychic energisers (antidepressant medication) to
provide a mood elevation. Often as a result, the mood will elevate
to such a point that another manic episode is feared, and corrective
sedative medication is prescribed to dampen it. This ‘relapse' can
be a further blow to patient and family, so soon after the manic
episode. Alternating mood swings of this kind, highs and lows, can
give rise to the diagnosis of a ‘bipolar' disorder (manic
depression) and the goal becomes one of ‘balance' — balancing out
the sufferer's mood.
The career patient. Having left hospital, many sufferers become
professionally trained mood watchers. They may lose their
sense of perspective as to what are acceptable normal levels of joy
and excitement, or their opposites, having an off day. Juggling
doses of medication can become the sole focus of out-patient
consultations, reinforcing the notion that ‘relapses' are caused
purely by ‘chemical shifts' and unrelated to any other factors in
the person's life. In this way medication is seen as ‘corrective'.
Unfortunately, this balancing act can become a life-long process. To
break this disempowering cycle, psychotherapy is vital to make sense
of the beginning, middle and end of the manic experience, and the
multitude of factors, both external and internal which influence
that.
Psychotherapy: first calm down, then find the way back
Strictly speaking, the question is not how to get
cured, but how to live.
— Joseph Conrad
Psychotherapy
derives from the Greek psyche, meaning ‘soul', and therapeia, meaning ‘attendance'. If psychotherapy was ever a
critical component in the management of a psychological distress, it
has to be in manic depression.
What arrives in
the door of the psychiatric hospital is an exploding bomb which
requires emergency measures to defuse it. Any effort at logical
conversation has no place at this stage: the furious firestorm in
the mind needs to be urgently dealt with and this has to be done
with high doses of major tranquillisers. It can take days and weeks
for the madness to clear and normality to return. During this phase
the individual not only requires sedation, but a nursing input with
full medical backup, bordering on intensive care protocols, to
restore health to a body depleted of its nutritional resources, and
often so compromised in its immune system that infections have taken
root. A matter of additional urgency is the process of
detoxification where substance misuse has led to addiction.
In a sense, those
who experience mania have travelled to another world, like Saturn,
and back, such is the extra-ordinarily unique nature of their
experience. Consequently, once normality and perspective has
returned, they need the vital input of a psychotherapist
specifically trained in this area. This process, once started,
should continue following discharge until the causal factors have
been deconstructed and medication terminated.
The inevitable
burnout, and the trail of destruction left in the wake of a manic
episode, is quite rightly called depression. However it makes more
sense if it is called Post-elation Depression and not part of
some bipolar disease.
In its own right,
this is the appropriate natural emotional response to
feeling sapped of all energy, realising that you have been the cause
of so much chaos, hurt and ruin to yourself and others, and newly
aware of the awesome task pressing down on top of you of rebuilding
your life. If this perspective is not taken, this depression is in
danger of being made into a purely chemical disease process, as all
depressions within the current, dominant biomedical model are. In
such a framework, in addition to the cocktail of major
tranquillisers (anti-psychotics), lithium, and anti-epileptic
medication, now anti-depressants are added. The individual is
related to as a ticking timebomb, with all those around them
anxiously awaiting the next explosion.
Richard
Keynote: ‘Failure? I don't do
failure!'
This case is the
stereotypical manic story, where its exponent takes the elevator
approach: on beginning to become aware of a scenario which is not to
his liking, nor in his emotional repertoire to handle, he
metaphorically presses the button to remove himself to a more
pleasing and manageable scenario on another floor. When this
in turn begins to contain ingredients which offend, he repeats the
manoeuvre again until he runs out of floors and ends up, stark
raving mad, on the rooftop. One manic, having gained insight during
psychotherapy, described the dilemma in these words: “It was as if I
was running from a war party of Apaches who were rapidly gaining
ground. I felt I had to keep running because if I stopped and turned
to look at them, I would get a hundred arrows in the
face.
The goal of
psychotherapy in Richard's case is directed towards helping him
acquire the emotional maturity and skills to deal with setback.
Ordinary people experience setbacks, they see them coming, and have
accumulated along the way a repertoire of strategies to use in such
situations. A person who can only be extra-ordinary, as a way of
being, cannot readily do this, and this is what Richard needs to be
helped to learn. He has always spoken only the language of success
(Texas-speak, as it were), and now has to get his tongue and his
mind around the dialect of the common man, and ultimately live a
‘smaller' life with equanimity.
If on the
other hand he is treated within the sick brain model — 'you have a
chemical imbalance and must keep taking the pills' — this
conversation will never occur and no learning will ever take place,
and a window of opportunity is missed. Evidence painfully shows that
if personal responsibility is not taken, that is, learning how to
manage one's life in a psychotherapeutic (soul-attending) way, that
no amount of medication will prevent a further episode and future
admissions become a way of life. A career patient has been
created.
Sylvia
Keynote: ‘Einstein, Hawking: move
over!'
Sylvia has one
vulnerability. She so enjoys the world of her intellect that she has
a tendency to indulge it as if it were her entire life. She has
willingly forfeited meaningful relationships, sporting activities,
pleasurable pursuits and contact with nature. She had a brilliant
academic record and was known even since her early schooldays as a
‘brainbox'. Her recent immersion in her PhD project was the most
exciting period of her life. It allowed her to lock herself away,
disconnect from social contacts and live like a hermit. In such a
climate no reality testing was occurring and, as we saw, her inner
world took over.The
psychotherapeutic work here is to help her gain awareness of her
tendency towards imbalance, excessively favouring her inner world to
the negation of healthy connections outside. Her task is obviously
simpler than Richard's, and is merely one of maintaining the right
lifestyle balance.
David
Keynote: ‘May the Force be with
you'
David's case
reflects a rare ability or gift to experience phenomena in the
non-physical realms, of a spiritual and energetic nature. The
problem arose for him because he had never had such transcendental
experiences before and was at a loss as to how to interpret or
contain them. He would therefore require a very different kind of
therapist, one familiar with transpersonal and energetic phenomena.
Dr. Stanislaus Grof, a psychiatrist and leading pioneer of
transpersonal psychology, would regard David's case as a spiritual emergency. As countless clairvoyants and healers
will testify, their initiation into the non-physical or energetic
world was far from smooth. David ultimately has to learn to manage
his energy, appreciate its limits and stay grounded.
Sophie
Keynote: Lining up for
stardom
This is a
straightforward case of addiction with the added dimension that some
addicts have an energetic tendency to experience altered states more
easily than others. Let's not forget that her drug of choice, which
she was abusing for years, is an ‘upper', designed to lift the mood
and create an over-expansive sense of self. Sophie, like all
addicts, needs to develop her own inner strengths, finding the
‘buzz' in a balanced lifestyle and attending regular Narcotic Anonymous
meetings.
Final
comments
The depression
following a manic episode is as much an emotional reaction as any
other, and we would advocate that it be called Post-elation
Depression. As such, it is not a ‘disease', but a normal
response to a horrendous experience, and is best integrated and
healed through the process of psychotherapy which provides a
de-briefing opportunity in which the entire experience can be
understood.
The manic episode
itself is the result of an unconscious attraction towards being
extra-ordinary. The climax of mania — the psychotic phase — is a
medical emergency, and can only be reversed through the use of
sedative medication, which in most cases is only possible within a
hospital environment. This phase is transitory, like the need for
morphine in a case of a broken leg, and once consensus awareness has
returned, should be phased out and replaced with a psychotherapeutic
approach which has as its primary aim a search for the unconscious
triggers, and conscious preventive measures put in
place.
We
believe that psychiatry has lost its way, that its reliance on
excessive use of medication, its revolving door hospitalisation
practices, and its ultimate fallback, electro-shock therapy,
urgently need to be chllenged.
Could this have anything to do with
the fact that over 99% of psychiatrists practising in this country
do not have a registered university qualification in psychotherapy?
If your only tool is a hammer, everything looks like a
nail.
— Ludwig
Wittgenstein
This is an edited version of the chapter on
elation and mania in Depression: An Emotion, not a Disease
