Psychotherapy Issues Arising from Bipolar Disorder Symptoms

In this video, I use the film ‘Limitless’ to illustrate some of the clinical issues addressed in this post:

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[NOTE: IF YOU HAVE BEEN DIAGNOSED WITH BIPOLAR DISORDER, BEFORE YOU CONSIDER TAKING PSYCHIATRIC MEDICATIONS, PLEASE EDUCATE YOURSELF ON THE DANGERS OF SUCH DRUGS AND LOOK INTO ALTERNATIVE FORMS OF TREATMENT. I’ve written a series of posts concerning (1) the dubious theory that mental illnesses such as bipolar disorder and bipolar ii disorder result from an imbalance in brain chemistry, (2) the fact that widespread use of antidepressants and other psychiatric medications can be linked to an explosive increase in the length and severity of many mental illnesses, and (3) the false claim that psychiatric drugs correct chemical imbalances in a way analogous to taking insulin for diabetes. Another post discusses the role of psychiatric medication in the increase of the symptoms of bipolar disorder in our culture.]

In an earlier post, I discussed the core problem in bipolar disorder or manic-depressive illness:  a feeling that the internal damage is so pervasive that there’s no realistic hope for improvement, leading to a search for “magical” solutions instead.  IN this post, I’d like to give a case example, a young man in his 20s who might have been considered “cyclothymic” rather than receiving a full diagnosis of bipolar disorder, though his mood swings demonstrate the same high/low dynamics.  If you haven’t read it already, you might want to take a look at my post on hopeless problems and perfect answers before reading on.

Jeffrey was an extremely bright and talented young man, recently graduated from college, who aspired to be a writer.  He came to me because of depressive episodes so severe he felt barely able to function.  He managed to hold down a clerical job to support himself despite his depression, attempting to write in the evening after work and on weekends.  If he were feeling deeply depressed, he couldn’t write a word. After work, he’d often collapse into a state of inertia, barely able to feed himself, watching mindless TV.  He suffered from extreme insomnia and often slept but a few hours.

Jeffrey badly wanted to have a relationship but felt completely worthless, as if everything about his adult functioning self was a facade, and that as soon as anyone got close to him, they’d find out he was a fraud.  He would describe himself as a loser, “damaged goods,” or “a worthless piece of shit.”

The issue of “shittiness” often came up in our work.  He had a recurrent dream that the toilet in his bathroom would back up and his apartment would be flooded with feces.  Or sewer pipes in the ceiling would break.  In these dreams, he’d feel completely helpless to do anything about the broken plumbing or sewer problem.  The damage felt insurmountable. In our work together, I would talk about these dreams in two different ways.  The overflowing sewage represented both his “backed up” emotions which he felt unable to tolerate or process, as well as the hopelessness he felt about his internal damage.  We returned to this issue again and again, particularly his fear that our work together was pointless because (a) I couldn’t possibly tolerate all his “shitty” feelings either, and (b) the damage was simply too vast.

Periodically, the depression would lift and he’d enter a hyper-industrious phase, writing for many hours at a time and throughout the weekend.  He’d come up with a “brilliant” new idea for a novel and write 10, 20 or 30 pages at a time.  He wouldn’t stop to reread or revise but simply kept on with a manic drive in the hope of completing the book within a few weeks, selling it to a publisher and advancing to an idealized life in which he’d be a wealthy, famous and critically acclaimed author.  He felt increasingly anxious during these periods; although he came to his sessions, he felt difficult to reach and became suspicious and hostile if I tried to examine his drive to write.  Eventually the manic phase would pass and he’d slip back into depression, discarding the partial manuscript as “worthless.”

During the manic phase, he clearly felt in the grip of magical thinking; underneath, he feared that he was only passing off shit as if it were something of great value.  When he was in his hyperactive writing phase, he unconsciously felt it as a kind of evacuation, too, as if he were magically ridding himself of all the bad intolerable feelings.  He couldn’t go back and revisit his work or revise it because to do so might deflate the manic triumph of his creation as well as bring him back into contact with the bad feelings he’d tried to evacuate.

My job was to show him, again and again, that he felt hopeless to do anything realistic to improve, either in terms of his writing or his internal damaged world; only magic could solve his problems.  Over and over, we had to return to those shitty bad feelings, try to understand them and help him to tolerate his own emotional experience.  It was the work of years.  Eventually he completed and sold a  novel but continually struggled to wrest his writing from the realm of magic.

Over the years of my practice, many clients have brought in similar dreams — broken sewer pipes, backed up toilets. If you’ve had such dreams, it might concern feelings you find overwhelming and intolerable, emotional sewage you can only hope to evacuate.

Many people have an issue with follow-through, whether it’s in a creative endeavor or something as mundane as housework.  Often it’s because they begin in manic states of mind where they intend magically to do everything, all at once.  If you have such a problem, it might be a symptom of a larger difficulty, and a fear that nothing realistic can be done — step by step, little by little — about your internal world.

In bipolar disorder, these are the core issues:  intolerable emotions and internal damage felt to be so vast you can only hope to evacuate it, and in the process magically turn feces into gold.

UPDATE (April 10, 2013):

I’d like to present some additional clinical material to demonstrate the ways that manic-depressive issues may also arise with clients who would never receive a diagnosis of bipolar disorder or even bipolar ii disorder. In every respect, the client I’m going to describe was high-functioning, dynamic, verbal, intelligent and successful. She had suffered only one depressive episode in her entire life. It occurred about six months before the beginning of treatment when her husband had lost his job, found a new one in a different city and left her behind to take care of selling their house.

Bethany and her husband had lived in that house less than a year and although she had formed no close friendships during that time, she had put down emotional roots and hoped to spend the rest of her life there. Most people in her situation would feel unhappy and quite possibly depressed; Bethany managed to pack up and transfer their household but shortly after arriving in a new and unfamiliar city, she found it almost impossible to function. This depression terrified her. Although she rationally understood it wouldn’t come to pass, she was afraid she’d fall apart and never recover. The acute depressive episode passed after a few weeks and she began to build a life for herself in this unfamiliar place.

Shortly after Bethany and I began working together, she brought me a dream. She was in a car traveling at very high-speed; she wasn’t the driver and didn’t know who was behind the wheel. From behind, a motorcycle began to pursue and catch up with her. She felt threatened by the motorcycle driver, although in her associations to the dream, he reminded her of me. I suggested she was trying desperately to keep “ahead” of something internal — some feelings or memories we didn’t yet know about — and felt threatened that therapy would bring her into contact with those feelings. She accepted this interpretation although it had little effect at the time.

As I came to know my client better, I recognized a pattern in her behavior: she always had a new and exciting project underway. An entrepreneur in her own right, she had started several businesses and continually came up with new ventures and co-ventures. Some were successful; others lost her interest after a month or two and she’d move on to something new. Then, after almost a year in this new town, Bethany’s husband again lost his job and she was faced with the prospect of yet another move. This time, however, she seemed unworried about the prospect. (As we were working by Skype, the end of treatment wasn’t an issue.)

During session, Bethany remarked on this absence of anxiety — it surprised her. Perhaps because she’d already been through a prior move, she had “adapted” and no longer found it a threat. Then, she went on to relate yet another new business scheme that had occurred to her. She was quite tired in that session because she had stayed up half the night developing a new business plan. Normally, she told me, it would take her months to implement such a plan but she felt driven to get this new business going in record time.

I suggested to Bethany that this new project was her way of warding off a whole set of painful emotions about the coming relocation. I reminded her of the dream from months before and also brought up the almost paralyzing depression she’d felt during the last move. Through her manic, sped-up business plan, she was trying to stay “ahead” of her feelings; she was afraid that if they “caught up” with her, they’d overwhelm and immobilize her and she’d never get moving again. I sensed the rise of sadness along with some fear, but her response was short-lived and we came to the end of the session.

I’m sure you can see the similarities between Bethany’s process and Jeffrey’s more serious issues. Even in high functioning clients who would never receive a serious diagnosis, bipolar issues may arise where “manic” or magical solutions are pursued in order to escape depressive feelings that are felt to be unbearable or overwhelming.

By Joseph Burgo

Joe is the author and the owner of, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.


  1. Hi

    Thanks for this post. I’m really interested to know whether finally publishing a book helped with his low self esteem?

    1. In some ways. The difficulty was helping him sort out the facts — he had succeeded because of hard work over a long period of time, what he could and should feel good about — and the fantasy that in fact it was magic and now EVERYTHING would change.

  2. Good piece, Joseph. I have found it fascinating as well that so many of my clients over the years have had similar “plumbing” dreams that have manifested during the course of our work together. Ruptured septic tanks, backed up toilets, flooded basements, etc. are wonderfully clear metaphors for what the client is experiencing in the home, the most basic symbol of the psyche. I also find there is a distinction to be made as to which home the person is dreaming about. Typically plumbing issues surrounding childhood homes are due to a stuckness or shittiness regarding the more deep seated, developmental issues as opposed to current homes pointing more to a progressed state of development or stuckness, even progress if the plumbing has been repaired or addressed!

  3. I got diagnosed almost a year ago, and was doing well with medication, but feel like I’m back at square one. Are meds the best way out?

    1. First of all, I believe the diagnosis of “bipolar disorder” is over-used. As for medication, I’m a cynic. I think most psychotropic meds do very little; the scientific evidence that supports their effectiveness shows a “statistically significant” improvement, but that doesn’t necessarily mean it’s a large or lasting improvement. The drug companies stand to make huge amounts of money from these drugs and so they market aggressively to physicians and the public. Since people are desperate for some kind of help, they usually leap on board when their physician or psychiatrist recommends medication but from my limited experience, I see no lasting benefit. With some of these drugs, the side effects are worst than the supposed benefits.

      1. I agree with you that the side effects of drugs are often worse than the benefits. I was diagnosed with cyclothymia and major depression at age 55 and then bipolar disorder at age 56 (nearly 57) by a different psychiatrist. Both psychiatrists pushed drugs as a solution. My present psychiatrist is very drug oriented in treatment but he is wonderful in that he will talk with me about anything I ask him. He will spend an hour with me instead of the scheduled 15/20 minutes if I need to discuss something with him. What irks me is that I was never told that my own efforts could lead me down the path to wellness. In the beginning, I thought drugs were supposed to make me well–that is what I was told would be the goal of treatment. I felt worse. At one point, I couldn’t feel anything at all, except occasionally anger. I had been hospitalized twice, had taken every drug and combination thereof imaginable, had 6 ECTs and still I cycled every week to 2 weeks–sometimes full cycles only took two or 3 days. That was when I put my foot down and insisted certain drugs be changed, doses drastically reduced and some drugs even be dropped. I finally realized I had to take control and take responsibility for my behavior by learning how to face the cycles, accept them for what they were and learn how to react to them in a healthy manner. I told my psychiatrist that to do this, I had to be on as few drugs as possible and on low doses so I could feel the swings and learn from them. He was upset–worried actually, and advised me against pursuing my plan. I thought he would drop me as a patient. To his credit, he stuck by me. I’ve worked very hard towards wellness and I am now feeling and doing better than I have ever felt in my life and I am now down to only taking low doses of 3 meds, soon to be only 2. My doctor is amazed and very happy for me. My goal is to be meds free if possible but if I find I still need one or the 2, I will still be happy–my hard work paid off–the high doses of drugs and extremes of treatment did not. I thank God my psychiatrist stuck by me–he still finds it hard to believe my way worked, but he can’t deny the evidence in my mood chart, our talks, the decrease in prescribed meds, and the records he’s kept concerning my journey to wellness. I have recently discovered that there are other people with experiences similar to mine. There is even an author who has written about his journey calling it Bipolar In Order. That’s how I feel too, that I’ve finally gotten my bipolar in order and I feel good and function normally–finally.

        1. That’s an impressive story and I admire your courage. It’s unfortunate that our profession and our society has become so drugs-oriented that you had top push your own psychiatrist to help you.

      2. I really agree with this comment. I was diagnosed bipolar 2 at 18. I took drugs for 14 years. After losing a promising career, all my money.. basically everything, i got desperate and wanted to see what life is like off epilim (depakote) and citalopram. After tapering down over four months and five weeks off the drugs completely i can say a number of things very confidently. I feel way more ‘rational’ and clear headed and present in life. I still feel anxiety and depression sometimes but feel more responsible for managing my thoughts and feelings. I no longer see popping a pill and chanting ‘see no evil hear no evil’ as realistic. Incidently i held down a menial job during going off. Nothing of what i was told would happen actually happened. Apparently its impossible to function normally off drugs in the long term if you are bipolar. I just don’t believe it! Personally, from my long medicated experience i would prefer to take the times of just feeling like me and dealing with the turbulence of anxiety and depression at others than feeling ineffectual, tired, flat, easily confused etc from taking the meds (particularly Epilim). Thankyou Joseph for going against popular opinion on this issue. It needs to be debated.

        1. You’re very welcome. The problem — as I’m sure you have experienced — is that we get almost no support anywhere for the idea of simply struggling along and trying to deal with anxiety and depression. Instead, you’re told that a pill will rectify your chemical imbalance and you can’t possibly function without it. We live in a society that is hostile to the idea of “bearing with” pain. I’m really glad you wrote in and talked about your experience. I hope other people will read it and see that there’s an alternative to psychiatric medication.

  4. thanks for the info im kind of been stuck in a rut my entire life going from job to job i would just get bored with the job i started my own buisiness in land scapeing over 6 years ago but im getting that boreing feeling again i dont no what to do im 46 now starting to get scared of my finacial future i dont want to take meds how can i fix this for myself or can i that is my question thank you Jesse i do think i have add also ok thanks again if u could give me any answers at all

    1. Jesse, if you spend much time here, you’ll see that I don’t believe in “answers”, only in process and hard work. Medication is certainly not the “answer” for you (or for anyone else). I’ll be putting up another post today or tomorrow about parenting issues that might be useful to you.

  5. I agree about meds not necessarily being the answer. I’ve been biopolar all my life (47 years) and didn’t know it until I took antidepressants that sent me into mania and then extreme depression. It’s done a lot to destroy my life, and I really wish I had just dealt with the depression the way I’ve been doing for years–without meds.

  6. Still working my way through your blog (thanks for responses to my comments). I have always been afraid I have bipolar disorder at root, though diagnosis is complex PTSD. I am afraid of the control of people with bipolar disorder diagnosis, so always hide these symptoms from mental health professionals. However, I totally identify with this case study. I would also have recurrent dreams of filthy sewers, being trapped in horrifically dirty public toilets etc. When a therapist did an exercise with me where he took me into a house, supposed to be my psyche or something, all I could see (honestly; didn’t say so as didn’t trust therapist enough, it was the first or second session and he let me down badly later) was blood, excrement on the walls, darkness so I couldn’t even see the structure of the house. That is how I feel internally, though never tell a therapist this (due to fear/shame, more fear than shame?). One problem I have is that I tend to have dulled a lot of my positive emotions for so long that when they come back at all – joy, excitement – I am so afraid I’m becoming manic I try to dull them down quickly. I would have periods of trying to write my autobiography – not for publication, just to get it out, usually working on it for hours and hours every day, on holiday once (alone) I wrote about 10,000 words per day. I’ve never re-read what I wrote though I did have periods of flashbacks afterwards as I’d got closer to my memories in writing. I would LOVE to be able to heal this bipolar dynamic in myself, I just don’t know that I will ever be able to trust anyone to help me do this. I’ve never been able to trust a therapist despite over ten years of therapy, enough to tell them how I feel. On occasion I have begun to tell, via dreams etc, the therapist has quit therapy (twice). This only reinforces my sense of it being too broken. When I rationalize this, I think it’s my trust in people that is most broken, due to my father being an extremely ‘clever’ psychopath who probably continues to rape and murder children to this day – the only way I really know to continue with my life is to ‘cover it up’ as I am sure I would lose my mind/ connection with the world if I returned to my childhood feelings which were utterly suicidal. It’s very hard, I believe I am committed to healing but it probably doesn’t sound like it from what I write here.

    1. I think your commitment to healing DOES comes across; I think it has to be through shame, though, and confronting all those painful feelings of being damaged. The sad truth is that most therapists can’t go there with you, for various reasons. Keep looking!

  7. As a bipolar type 1 person I admire that Jeffery was able to complete his book. I trust that he we get the satisfaction such a noteworthy achievement deserves over time.

  8. I went through similar phases, but went through stages of not wanting to exercise (depression) to suddenly the heights of an elite athlete (my manic phase). I’ve been off medication for 6 months after being on them for 7 years, and have spiralled back down into a depression. Although I can think more clearly than I ever could, I can also feel more physical pain and don’t have the motivation to exercise. If exercise made me happy, but not with this much pain, should I consider anti depressants again?

    1. If you can avoid going back on anti-depressants, then don’t. You should read up on the long-term side effects of these medications. They’re quite serious and can lead to permanent forms of damage.

      1. Is it possible that all I am feeling an accumulation of all that pain I could hardly feel while training with antidepressants? I feel like they are my only option, besides frequent chiropractic and osteopathy sessions to relieve this constant pain.

        1. Just because you “feel like they are” you only option, that doesn’t mean it’s true.

  9. I can readily agree that anti-depressants are over prescribed. However, after years of struggling with suicidal depression and occasional episodes of what I now know where hypomania, and a year and a half of excellent psychotherapy, I was medicated with tri-cyclics, and discovered a world I did not know existed. I did not know that I had been living in a sink-hole. For the first time, I felt like a “normal” person.

    To my mind, the anti-depressants were a tremendous gift. I grant you that scientists do not know exactly how they work. I grant you any number of things. I grant you the right to sound a cautionary note about the indescrimate use of anti-depressants.

    I do not grant you the right to take away the possiblility that anti–depressants do an important job for people who have an unfortunate illness. I come out of a milieu of religious people who flap their wings over the use of such medications inasmuch as they perhaps think that hours of prayer will relieve all unpleasant symptoms.

    In my case, hours of prayer did no such thing. Anti-depressants were far more effective at restoring a sense that I was, as we all are, “damaged goods”, but more importantly good and worthy and capable of worthy things.

    I see an excellent psychiatrist as well as an excellent psychologist. One does the best one can with the life one has been offered. On the whole, there is a lot to be thankful for. Amongst the many things I am thankful for, effective anti-depressants are one.

  10. Wow you are describing my mother. In the past my therapist has suggested she could be bi-polar although he is of course not certain as he is only going on what I’ve told him. My brother and I have often wondered. We thought she may be histrionic/narcissistic however I guess she could show these traits like symptoms of the bi-polar. It is so clearly what she is struggling with. She just can’t see it. I can’t imagine the progress she (and we) could make if she could willingly and successfully accept help and a diagnosis.

    Really hard for me to process my past pain and manage a ‘healthy’ relationship with her when the personal growth and effort is purely one sided.

    Once again thank you for sharing your wealth of knowledge and insight Dr.

    1. It’s important to remember that those diagnostic labels are artificial, to a degree, and there’s a lot of overlap between these “distinct” categories. Lots of borderline individuals have feature of bipolar disorder.

  11. Do you feel that the “magical solution” idea is the root cause even in extreme mania that presents with full psychosis? A dear family member has been struggling with Bipolar I for the last 15 years. When I asked about his most severe episode (which resulted in arrest, felony charges and 8 weeks of hospitalization), he did allude to “doing something outrageous because there was nothing else he could do to stop his suffering”. He was in and out of consciousness during week of the event as he had little memory to all that happened in the days before and after, but his admission always stood out in my mind.

    He’s had several episodes since then (about 1 hospitalization an year and 2 or so hypomanic episdoes each year as well). Antipsychotics do seem to bring him out of the psychosis, but he never stays on them for long and continues to cycle over and over again. I have taken psych meds before and quite frankly I don’t blame him for not taking them! Do you think such a severe case can be helped with psychotherapy alone? In a case like this, do you really think it is just an emotional issue and not a brain malfunction?

    1. Yes, I do. Unfortunately, with such a severe condition, he’d have to be in analysis several times per week for a number of years, and that’s beyond the financial reach of most people.

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