Disclaimer: This post reflects the personal experiences and perspectives of the author, and do not represent the position of Tava Health.
After nearly a decade in private practice, I've worked with several individuals who entered our work with a Bipolar Disorder diagnosis. Most found working with me confusing at first, as I never used the term “bipolar” nor focused on the symptoms associated with it. As they all seem to have identified closely with Bipolar, it might be like neglecting to talk about how being male, gay, or biracial plays a role in someone's context.
There are matters of over-identification:
As a contextual behaviorist, I'm simply not interested in disorders, but rather look at symptoms through the lens of behavioral repertoires, or more plainly, ways in which people learn to respond to various situations and their own thoughts and feelings. “Symptoms” are actually responses to environments perceived as dangerous, confusing, “bad,” or painful.
The BPD diagnosis describes symptoms that include periods of a sense of grandiosity with all kinds of behaviors like staying up for days at a time, having lots of sex with many partners, spending all or most of their money, and so on. Periods of feeling hopeless, lost, and avoidant can follow. In other words, maintaining a degree of instability and chaos is confusingly “safe.”
Most clients have found me after more serious manic or depressive episodes have led to intensive in-patient and out-patient care (which is where they get the diagnosis), but it seems to me that only a few have ever experienced such difficult cycles that the Bipolar label fits more like a glove. Otherwise, I hear about exaggerated ups and downs, disproportionate to the situation, letting me know that my client lacks a workable way of navigating these situations, and therefore relies on almost childlike reactivity, which makes sense given that most people with Bipolar disorder endure some kind of childhood-adverse life event.
Bipolar does seem to be passed down in a family, but “genetically predisposed” rarely matters in my case conceptualizations as much as a learned response does. People working with Bipolar issues often describe having chaotic relationships with people they're close to, but who are volatile. Likewise, romantic relationships tend to enter a revolving door. People seem to fall in love and lust hard, becoming “too much” for their partner. Relationships oscillate between codependent and distant.
They talk about smoking a lot of pot and drinking a lot of alcohol, and having difficulty managing things like bills, a schedule, and maintaining a clean house. With all this, moods will shift dramatically, and people will go from feeling hopeful and happy to hopeless and miserable. My clients learned to treat relationships this way from Mom, who copes with her anxiety through drugs and spending money, marries and divorces several inattentive men. Grandma was not good at asking Mom how she was feeling, what she needed, and was inconsistent in her responses: for example, going over to a man's house for dinner was a wonderful idea, while tomorrow Grandma is throwing a fit about Mom loving the man more than her own mother! So Mom feels most comfortable in these kinds of relationships, chaotic as they are, and so she recreates them with her own daughter, who is now my client. In that way, Bipolar moves through generations.
People whose parents neglected helping their child become a whole, self-knowing individual often create adults who are void of a sense of who they are outside of these volatile relationships. My therapeutic approach with “Bipolar” clients is to start asking the questions Mom should have asked, but couldn't, while struggling with her own identity:
In behavioral terms, my patient’s episodes are avoidant responses to developing a stable sense of self, which is scary and difficult to do. Instead, the behaviors maintain a coherent sense of self, a child seeking positive reinforcement from primary caretakers who are unable to provide consistent reinforcement. My patient learned how to respond to inconsistency, so as an adult, she finds more positive reinforcement by living well with inconsistency. If it gets too stable, Cindy has to blow it up in order to maintain this sense of self.
The therapy is to put behaviors that maintain this sense of self on extinction (have them lessen), and reinforce ways of responding to chaos and order that are more workable.
Eventually, clients come into contact with a stable and yet flexible sense of who they are. The “symptoms” either disappear or get less frequent and intense. At the same time, I challenge them to resist the chaos and try living in accordance with the “You” we've worked on together. We might also learn about how Mom and Grandma did not get to do this “selfing” work, and we can perhaps meet the pain of childhood with more compassion and understanding. That sense of self strengthens. If my patient keeps up this kind of self-attention, she will likely not qualify for a BPD diagnosis.
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