Bipolar Disorder: A Therapist’s Guide

Regardless of what brought you here, I am glad you are here. Some of us find ourselves exploring bipolar disorder because a clinician like me or maybe your primary care provider happened to mention it to you, and it feels like it has been nagging at you ever since. Some of us arrive here because we lived through a few, “what the hell was that?” moments in our lives; the kind of moments that make you question your own choices, decision making ability, and if those decisions were authentically yours in the first place. Others may have a family member or friend that is struggling with bipolar disorder and is actively looking for some information to assist in their support of said person.

Whatever your reasoning for being here, my goal for this guide is to help with all of the above. Just because I have to mention this, this guide is not a diagnostic tool, and it can never replace seeing a clinician, but it can start to give you some language, questions to ask, and practical next steps to take if you are trying to figure out where you stand in reference bipolar disorder.

Defining Bipolar Disorder

Clinically, bipolar disorder is a mood disorder in which people experience recurring episodes of mania or hypomania (which we can think about as highs) and depression (which we can think of as lows), that often have stretches in between that may seem completely “normal” to the untrained eye. The first thing I want to draw your attention to is the episodic nature of bipolar. Bipolar disorder is not just bad days, feeling moody, or having more energy than normal… Bipolar disorder begins to make more sense when there are sustained, consistent changes in mood and a person’s behavior that are markedly different from their usual baselines.

Secondly, there needs to be some awareness surrounding the multifaceted nature of the diagnosis. For the sake of the nature of this article, I will only touch on bipolar 1, and bipolar 2. Lets break those down in order. Bipolar 1 can be categorized as the following (paraphrasing and simplifying the DSM-5’s language):

• One fully developed and observed manic episode (needs at least 3 or more from, below):

  • Highly increased self-esteem or a sense of grandiosity (“I’m on top of the world!”)

  • Decreased need for sleep

  • Much more talkative than usual

  • Racing thoughts and ideas

  • Very easily distracted

  • A sharp increased in goal-directed activity (“I am gonna do this, then get this accomplished, then read these 10 books…”)

  • Excessive involvement in high-risk activities.

• One fully developed major depressive episode (needs 5 or more from below during a consecutive 2-week period):

  • Majority of time spent in a depressed mood (sad, empty, or feeling hopeless, etc.)

  • Noticeable diminished interest in activities you usually enjoy and participate in

  • Significant weight loss, or weight gain.

  • Insomnia, or hypersomnia.

  • Having a really hard time moving/using your body the way you usually can.

  • Feeling really tired almost every day.

  • Feeling that you are worthless or really guilty about something.

  • Feeling like you have a large change in your ability to concentrate, get tasks done, make decisions, or think clearly.

  • Reoccurring thoughts about death or dying.

  In contrast to bipolar 1, bipolar 2 has a slight variance in its symptomology. Instead of having a clearly defined manic episode, bipolar 2 has hypomanic episodes in combination with major depressive episodes instead. Here is a more clear breakdown below:

• Hypomanic Episode:

  • A clearly defined, and persistent state of elevated, expansive, or irritable mood.

  • Abnormally high and persistent state of increased energy or activity.

  • Lasts at least 4 days in a row consistently.

  • During the above states, at least 3 or more of the below have been going on:

    • Inflated self-esteem

    • A decreased need for sleep or rest

    • More talkative than usual

    • Racing ideas and thoughts

    • Highly distractable

    • Increase in goal-directed behavior

    • A huge increase in your participation in activities

Now that we have a little more baseline information regarding Bipolar Disorder, let’s talk about it more intuitively. Now, we obviously cannot diagnose ourselves from an article, but this can be a good place to start thinking about if any of these examples starts to sound like you and your circumstances.

If you begin to look at your patterns in life, and begin to see things like periods of feeling really, really good for a week or so, and then crash, recognizing that you have only been sleeping a couple hours a night, yet feel completely rested, or maybe that people keep on telling you that you are acting weird, and not really like yourself, bipolar may be present.

If you find yourself often looking back on your decisions with regret, or shame regarding the lack of impulse control, or a feeling of acting completely out of your character, or maybe you were making huge life decisions super fast, without truly thinking things all the way through… Bipolar might be present.

Another thing that I always encourage people to look at is their family history. Does anyone in your family deal with these issues, diagnosed or not? Are there any stories about your family members that are starting to sound a little too close to this? There may be genetic predispositions present to increase your likelihood of developing bipolar disorder.

I Have Bipolar Disorder, Now What?

We use the diagnosis as a piece of organizational material to fold into our understanding of ourselves so that we can live a healthier, happier life. Hopefully, some things in your life are now starting to make a little more sense, and there is some more context for where these feelings may be coming from. However, it is not lost upon me that this also comes with a host of negative feelings, stigma, shame, etc. My goal for this article is to begin to address those pieces, and try to frame this disorder as one in which does not leave you powerless, but is just another point of information we can use to get ourselves closer to an authentic, happy life.

How I encourage everyone struggling with bipolar disorder to start thinking about it is that, with everything in the mental health world, needs to be an ongoing plan of treatment to better your life. There are several ways we can start to do that, and I want to give an introduction to a few ways I encourage people start with.

Firstly, medication management is usually the number one intervention for bipolar disorder. Not everyone is going to be thrilled with that answer, but the reality is, if it was a physical issue with your heart or joints, we wouldn’t have the same amount of stigma. Regardless, here is why medication can be helpful to you. Medications can help you with mood stabilization, reducing your symptoms intensity, and reducing your symptoms frequency as a whole. Now, I also get anxious when approaching this topic, so let me give you a few permissions prior to any sort of medication management appointment; you’re allowed to ask all of the questions you want/need, you’re allowed to get second opinions, you’re allowed to be curious about the side-effects of the medications they are recommending, and you are allowed to voice your emotional responses with that provider, and if they are dismissive, go somewhere else… period.

Secondly, therapy and psychoeducation are extremely helpful (yes, I am biased). Therapy can help you with things like, making sense of the diagnosis (and going through the diagnosis step-by-step), untether yourself from any associated shame, learn how your symptoms present so that you can catch them as early as possible, work through any attachment damage, and finally, work through any associated issues that are usually present (trauma, anxiety, & substance use to name a few).

Let me harp for a moment. Because of the nature of the disorder, your routines need to be productive in that they allow you an easier time navigating anything emotionally related. You need to get good sleep, and it needs to be planned and consistent. You need to do your best to avoid any mind-altering substances. The reason being is that bipolar disorder will cause enough fluctuation on its own, we do not need to help it along, and make it worse, or more often. Lastly, it is my highest recommendation that you give yourself enough structure to condition yourself to what healthy feels like, that way, when things get hard, you will be pulled to do your usual patterns (that you have made healthy).

Someone I love Has Bipolar Disorder, What Can I Do?

If you were one of my interns, or a new clinician under my supervision, I would tell you the same thing, which is that you are not a solo crisis unit. You cannot expect yourself to be able to intervene at all times, through all situations. I have been a therapist for a long, long time at this point, and I do not expect to be one either. Take that burden off of yourself. If someone you love is struggling with bipolar disorder, you can make a profoundly positive impact, and you can help in huge degree, but you cannot keep anyone else alive or healthy.

With that being said, here are a few things to keep in mind: open yourself to the concept that sometimes things just feel like an extremely strong sense of “can’t.” In a severe state of mania or depression, the person you love may authentically feel like they cannot even get close to assessing risk accurately, understand the consequences of their choices or be able to prioritize their sleep, wellness, and medication adherence. In these states, you need to understand that is not your fault, and there is only so much impact you can have on other’s decisions. At the end of the day, you have to take care of yourself, and if some of these things are too much, then they are. Please try your best to understand that during a manic or major depressive episode, it doesn’t always reflect how that person truly feels about you. Try your best not to take it to heart, and understand that these abnormal states don’t choose when they show up, even if they are showing up at seemingly the worst times.

You most likely already know much more than you are currently giving yourself credit for. Pay attention to what your gut is telling you, and begin giving some voice to those feelings. The reason is that when you start naming these feelings, and walking yourself through them out loud, you can begin to truly observe and assist with certain patterns and shifting emotional states. One major thing to keep in mind is that you are using these to help, never throw them in the person’s face in the middle of an argument, or when things are not going well. If they are on board with the idea, it may be helpful to bring them into the observational journey alongside you, to better understand their patterns as well.

Navigating a loved one’s bipolar disorder cannot be played as a multiplayer, competitive game. This requires cooperation, empathy, patience, and a healthy dosage of love. There are plenty of things that you can do alongside the person struggling. What I usually recommend are things like psychoeducational groups surrounding bipolar disorder, family therapy sessions, offering physical help to your loved one (like driving them to appointments, helping them with medication management, and in some severe cases, things like managing their money and accounts). One of the most important things you can do for everyone is to create a strong structure and sense of love within your environments so that no one is having to guess at things, least of all you.

Summary

To wrap all of this up, there are a few key things I want everyone to leave with. Those things are the following: bipolar disorder is treatable and manageable with the correct amount of care and attention. Many people with bipolar disorder live completely full, meaningful lives despite the diagnosis. Having questions regarding whether or not you have this disorder is not abnormal or dramatic, it makes you an intelligent human that cares about their health. Any diagnosis, even this one, is not an imprisonment within a poor life, it is just something to plan around, navigate and be honest with yourself and those around you about.

If you find yourself thinking that you could be experiencing bipolar disorder, go seek out treatment and begin asking the questions out loud, make it real. You will never be your diagnosis, it is only one small part of your life.