You may be reading this chapter as a “significant other” (S.O.) of some sort, or just looking for hints on how to get your loved ones to assist you. Here are some guidelines on how S.O.’s can help with someone whom they think has “bipolarity”. Remember, this site is primarily about Bipolar II and other “soft” bipolar variations. Bipolar I, with the potential for full manic episodes and a complete lack of insight on the part of the patient, presents some very different challenges. Here we’ll focus on the difficulties you might face when a person has repeated episodes of depression, and additional symptoms such as irritability, agitation, impulsive decision-making, and other features of hypomania, in addition to depression.
First, for the perspective of people who’ve “been there”, see the website for BiPolar Significant Others, www.bpso.org . The organizers have done a superb job of presenting resources and connecting people. Their website offers you an “expertise” I cannot even try to match. (If your version or that of your loved one is a “soft” bipolar disorder, far from Bipolar I, then some of the resources online may not feel quite right to you, as they often emphasize Bipolar I. Remember, until the last few years, Bipolar I was the only version of bipolar disorder widely recognized.) Secondly, there is nothing better than to learn a lot about what you’re facing. That’s what my book, and this website, are supposed to help you with. I hope you’ve found them useful.
From there, let’s take a look at the approach of a therapist and medication prescriber like me — because in some respects, your role and your challenges are similar to mine; and because most of these ideas are unusual, if not downright paradoxical, so that you would probably not think this up on your own. Experience might teach you — but maybe I can save you a few steps.
Think about it: you have a desire to help; and you must maintain a relationship in the process; and, most likely, in the long run you’d really like to see the mood disorder get better and fade into the background. You probably understand by now that it is not something you should be expecting to go away, but rather something that will require management over time, yet may be so well managed that symptoms are no longer interfering with your loved one’s ability to function — including in your relationship! Many of these connections to your loved one are shared by a therapist or psychiatrist or other health professionals who get involved in her treatment: we want to help; we know we’ll be doing so over a period of time; and we want the symptoms to become so mild that we can have a different relationship (namely, in my case, being unnecessary! In your case, hopefully you can go back at that point to the joys and challenges found in all intimate relationships).
So our challenges are similar, and therefore, some of the techniques and perspectives that we use may be useful for you.
First, Do No Harm
They taught us this in medical school. In many cases, you may not be able to help much, they said; but at least, while you’re trying, don’t make things worse. How might you significant others be at risk for making things worse? Here is one very common way: judging. This is a normal, natural thing for humans to do; our brain is built for it. We see things and think “that shouldn’t be so” (like having invaded Iraq under false pretenses), or see people and think “that’s a strange way to act”, and indeed, we watch ourselves, don’t we, and think “I shouldn’t have done that”. You can recognize these thoughts from the words in which they appear: should/shouldn’t, must/must not, best/worst, bad/good, and so forth.
Our brains add these judgements to events which simply are what they are. The judgment is supposed to motivate us to act in a particular way in accordance with our value system. And yet we make mistakes with these judgements all the time: we fail to notice some detail that changes everything, for example, like the fact that there was no detergent left, when John did not run the dishwasher as he said he would. If we don’t know about the detergent (neither did John, at first!), then we might think “John is so irresponsible” or “lazy” or “unreliable”.
So, here is my caution to you: watch out for judging thoughts about your loved one. Ah, wait a minute. If I’m right, you might just then have had a thought, or an irritated feeling: “who is this guy, telling me to avoid judging? He has no idea of what’s been going on around here. If he could just see what I have to put up with, why he wouldn’t be giving me this advice, that’s for sure”–or something like that. You might have felt like I really didn’t understand what you’re dealing with, or worse, that I was accusing you of judging, and hey, I don’t even know you!
I’m guessing this because it’s what the theory says will happen (as well as having seen this come true many times in my office): when someone offers a thought that can be perceived as judging, the reaction is anger and resentment and resistance. Therefore I’m doing now what I do in my office when I know I’ve made a mistake, or when I can see someone has been stung by something I just did or said: Quick, name the experience they are having, and demonstrate thereby that I understand it and am not judging it, indeed I am accepting it. And then, go one step further: take responsibility for having possibly caused that feeling, and indicate this was not my intent.
Aw, come on, you might think: I can’t be doing that in real life. Phelps might be able to do that with a client, but I can’t be doing that when Christopher has not done his homework yet again and now he’s upset because I told him he had to do it! Quite right. This is not a plan for every situation. But you might be able to do this much: you might, if you thought about this paragraph while staring at Christopher, be able to say something like “now there may be some very good reasons I don’t know about as to why your homework is not done. When we have time, perhaps we can look into them. For right now, it’s clear there’s one thing to do: homework” and see what happens.
Everything I’m telling you here is just a hypothesis to be tested. Will this help? Try it, or something close, and see what happens. And do not judge yourself for “not doing it right”, either, okay? (You can see I’m just repeatedly applying this principle, even as I write this: What is the reader likely to be thinking, after that sentence? Might it be a rejection? Better anticipate that and deal with it–using my principle: listen for judging, rephrase to something more neutral.) But here are at least two problems with this principle you’re going to test: first, how does one know when the time has come to use it (or do you have to live like this all the time?) And secondly, how do you find “neutral”, when you’re upset? Let’s take these problems one at a time.
When to Listen For Judgement
No, you don’t have to live like this all the time, listening for judgement — although that’s an interesting idea to consider, as indeed this process is an important part of some eastern philosophies. But for us Westerners, here is one time when we should definitely consider applying this principle: when we’re angry. The hardest part of this maneuver is not in applying the principle; it’s in recognizing that we’re angry! Neck muscles tense, thoughts focused on the problem (and not on the beautiful day outside, or the rose in the vase, or the comfortable feel of the clothes on your skin, or the nice things Christopher did for you this morning): sound familiar?
With some practice you can see it coming, especially if you learn, from experience, that you have a new technique which can help you navigate angry moments. But isn’t anger a good thing sometimes? Perhaps. Just try the “go to neutral” approach a few times and see what you think. Then, if you still think anger is useful, read a wonderful book by a Tibetan Buddhist (different from other kinds of Buddhism), called Working With Anger. As my buddy Dr. Teresa pointed out to me, the book starts and ends with a chapter which is more about Buddhism; but the middle of the book is just one technique after another for dealing with anger (check out the list of all these tools, an appendix at the back: it’s great to know that there is such a large number of them).
How do you find neutral, when you’re upset? I’ll offer you a psychiatrist’s technique in the next section. For now, try this: listen to yourself before you speak (this is not easy, thus that well known advice, “Count to Ten”). Do your thoughts sound like judging? Listen for those judging words: good/bad, best/worst, should/shouldn’t, etc. If so, hold off on opening your mouth (like yelling at John about the dishes) until you are certain you have all the information you’d need to fairly arrive at that judgement. The older I get, the longer it takes for me to become certain (perhaps because I can see more and more mistakes I’ve made thinking I knew what was going on!). And as a therapist, I’ve discovered I actually get much better results from very deliberately avoiding judgement. People feel much more comfortable, they tell me more about what is going on inside them, and lo, we discover all sorts of things that make them look less judge-able.
You might be one of those people whose mind is just wired to arrive at judgements. Your mind is really good at coming up with them. But your S.O. might be one of those people with bipolar disorder who can do some very unwise things, which even she recognizes as such–later. And thus trying to take it easy on judging can be very difficult, and challenging, and a repetitive sport. Yet when I try to maintain that non-judgmental stance with my patients even after they’ve done something very regrettable, I still get better outcomes, so I still think it is worth using this technique even in the most extreme circumstances. The technique is about preserving the relationship with this person, exactly as you would wish to do, while still “getting traction” on the problem–using the technique described next, perhaps. ( A short book full of tools for balancing the need for change with the need for preservation of the relationship is a simple book on negotiating skills: Getting to Yes, one of my all-time favorites.)
As with all the suggestions in this chapter, you may find them easier to follow if you find yourself a therapist and ask for some help.
Don’t Just Do Something, Sit There
How do you get more information, about whether a judgment is called for, for example; or about what is really going on for your loved one? This is another technique I learned in Psychiatry training: sit there.(Subject of all sorts of jokes, I know, but hear me out, it’s not just sitting there…) You know the phrase “Don’t sit there, do something!” Doing is usually happens when your loved one is feeling badly, and you want to make that stop: you try to calm him, try to tell him everything will be all right, try to point out the good side of things, try to help him shift his attention elsewhere. But as a therapist I was taught to let those feelings stay right there so that they could be examined and considered in detail; and even more importantly, so that my client would feel that having these feelings is acceptable, understandable, not as scary as they seem, and that while holding them right there, as bad as they are, they can become more manageable, more okay to just have.
One of my teachers put it this way: pain + struggle = suffering. The struggle not to have what you have (in one way or another, e.g. alcohol, gambling, fast driving, or perhaps even writing websites and books?) makes pain turn into suffering. Sometimes the pain is just going to be there–the pain of knowing you’re stuck with a complex mood disorder, for example, or living with someone who’s got one. But the struggle with this pain, trying to make it go away when it cannot really go away, is what makes for suffering. Thus in treatment we often shift our attention to the struggle, rather than working on making the pain go away. Then both the therapist and the patient are applying the maxim: “Don’t Just Do Something, Sit There.”
You desire to help your loved one will tempt you to action. Sometimes that is very appropriate, and you will get good outcomes with your helping behaviors. But if you are not getting such outcomes, you may need to consider a different approach, like this one. The hard part is to sit there with your feelings: when you watch your S.O. in pain, you want to make it stop, in part so that you won’t feel so badly. Tricky, isn’t it, having to admit that? Remember, suffering = pain + struggle. You too might be trying not to have something that you just have to have. This trying often makes things worse, both for you and your loved one. When you try to make her pain stop, you send several messages you don’t want to send:
- Don’t have those feelings. Stop having them now.
- You shouldn’t be having those feelings. Have some different ones.
- (Here’s the clincher) I can’t handle it when you have those feelings.
Message #1: You may be teaching your S.O. to struggle with her pain: “try not to have what you have”. This can lead to more suffering than the pain alone.
Message #2: You shouldn’t be having those feelings.” See the judgement word. This can lead to anger and resentment and resistance, as discussed above. But the third message is in some ways the worst, especially if your loved one loves you in return. When you send the message “I can’t handle it when I see you hurt”, he may respond, out of love for you, by trying to keep you from seeing it. He may shove those feelings down where they won’t bother you. For some people, this may not be terribly harmful; but for others, this “stuffing” of feelings can keep them from being able to accept what they have. Instead, they may pursue other coping strategies: exercise, that would be fine, but in excess perhaps injurious; or work, likewise okay in moderation but potentially a problem if it is being used to cope with pain; alcohol, definitely a problem; and so forth.
So, the idea is, “just sit there”. But this is not a passive position, as the words might imply. We therapists, if we are doing our job well, “sit” very actively (now there’s a funny concept). We do “active listening”, a term now so commonplace it’s a bit tarnished, I fear, and I hesitate to drag you through an explanation. Suffice to say that this is a very active process of conveying “I’m understanding you” in several different ways, as you listen.
There are whole books written about this, but you’ll do pretty well if you just:
1. Listen, hey, pretty basic: the key is to really want to understand what the person is saying. If you don’t, you’ll be faking it, and they’ll know. So, don’t worry about technique if you don’t really care to hear what they have to say.
2. Make it clear that you’re listening. Most people can do this without saying a word, through facial expression. But if you aren’t that facially expressive (some aren’t), then you’ll need to practice grunting. Grunting? Okay, we could call it “minimal verbal encouragers” if that would make you feel better. You know what I’m talking about: this is the well-timed “mmmhmmm” we psychiatrists are famous for. There are lots of variations: “mmm”, is one of my favorites, and “mmm-mmm”. And I really like “uhmhmm”. And you’re not taking me seriously now, I trust. Just make some noise when you get what they’re saying, okay?
3. Paraphrase now and then. If you aren’t a natural at this, try jumping in periodically with “So what you’re saying is….” and then summarize what you just heard briefly. This will work a lot better if you were really listening, obviously. The most important thing to get in your summary is any emotion she or he is feeling, that you can recognize: “looks like you’re feeling pretty hurt about Sara’s cancelling your plans”; or that phone call from Jack really made you angry?” . I never use the one people think we psychiatrists use all the time: “How did you feel about that?” Duh. If you have to ask, then you’re not really getting what your loved one is saying, are you? You should be apologizing for not getting it, rather than asking this dumb question– that is, if you really care about what they’re saying.
This technique may be easier to learn if you’ve hired a therapist to work on one of the other techniques here, as she/he ought to be doing it with you (hard to beat that for a learning opportunity).
A few more general guidelines
Ask, Don’t Tell: Collaborating
You want a certain behavior to increase or decrease, but every time you push, you just get push back. There is a different way, which emphasizes collaboration, and begins with learning what your loved one is trying to achieve with these behaviors; and comparing what you are hoping for. If some common ground can be found, it will be much easier to work together. For example, placing the emphasis on decreasing irritability, rather than on taking a particular medication, can put you on the same team.
You want to stay in this relationship for the long haul. Therefore you’d better make sure your approach is sustainable. Imagine doing what you’re doing for years. Can you keep it up? Can you be the good listener for all that suffering? Can you be the “first responder” to every crisis? Consider the “patchwork quilt model”:
you are one square among many, and thus if you occasionally unavailable, your loved one is still warm. We also consider my mentor’s maxim: “never worry alone”, and look at developing safety plans for those who need them — before they need them.
The Problem of Insight
Information is fine for people who know there’s something wrong with their moods. What about those who don’t? How are you supposed to cope with repeated episodes of irritability and destructive behavior which your SO does not recognize as such; or with someone who simply refuses to get help?
There is a book on this issue for severe mental illness, I’m Not Sick, I Don’t Need Help. This may sound like a really useful book, and if you’re in this circumstance, you should probably read it. But it’s not a great solution. It just helps to know that others have “been there.” A couple of resources to check out:
- if you have an active chapter of the National Alliance for the Mentally Ill (NAMI), you’ll find a lot of other folks who understand what you’re going through. You may be able to help them too; and you can all work on national advocacy, one of the missions of NAMI.
- consider getting your own therapist for support and for help navigating the tricky channels
- Learn about “Stages of Change“. The general idea is to recognize the person’s willingness to change (everybody has at least a tiny, tiny bit) and tailor your strategies to that degree of readiness.
Dealing With The Doctor
Finally, what do you do if your loved one’s doctor does not encourage your involvement? At minimum, provide information. Many people don’t know that you can leave information for the doctor anytime. It’s getting information that requires a “Release of Information.” So if you think your son won’t tell the doctor about problems he’s been having, you can leave a voicemail or write a note. If you’re desperate and can’t get through, try sending your note as a fax (much harder to ignore; but because of that, this may be experienced as arm-twisting).
Be careful about how you do this. Remember this one too is a relationship that must be managed for the long-term. If in doubt, ask to be told if you’re doing something the doctor might not appreciate. Remember, if you make yourself useful, an efficient resource (lots of information she can use, not much time or effort to get it), you’re more likely to find an open channel for communication.