Introduction

Working in a field in which so many phenomena may be prone to relative interpretations as they relate to human emotions and behavior, a therapist may find comfort in looking for solid grounds for a treatment. As a family therapist, even though I am mostly informed by less behavioral and more experiential theories, I admit to the desire to find concrete maps to recovery. I take comfort in being an integrative family therapist who is willing to learn from multiple approaches. Nevertheless, there have been certain cases in which I have felt the ground beneath me shifting, and one constant in these cases is the diagnosis of Bipolar. The existing literature on Bipolar has so far been discouraging for me as a family therapist attempting to formulate a more systemic intervention for this disorder. A mental illness that is so profoundly coddled by psychopharmacology, and that is looked at more on the level of a person’s biological rather than psycho-social system, seems to have rendered family therapy interventions accessorial. Whether I believe this or not is the story that I am about to tell you. I will, however, begin with a review of the literature that adds some context to my argument, and to my professional struggle with the Bipolar diagnosis and its associated treatment methods.

Bipolar disorder is understood to exist on a spectrum of severity, with hyperthymic and cyclothymic temperament at one end of the spectrum and psychotic Bipolar, or mood-incongruent mania, at the other end of the spectrum (Goodwin & Jamison, 2007, p. 21). There have been numerous attempts to quantify the severity of symptoms on the Bipolar spectrum. For example, Craddock, Jones, Kirov, and Lones (2004) created the Bipolar Affective Disorder Dimension Scale (BADDS), which includes plausible diagnostic criteria for situating mania and depression on a spectrum from mild to incapacitating.

While scales such as BADDS (Craddock et al., 2004) purport to measure Bipolar disorder on a continuous scale sensitive to the spectrum, the scale for the administration of lithium to individuals with Bipolar disorder is more uniform in nature. According to Muzina and Calabrese’s (2005) discussion of Bipolar disorder treatment guidelines, the best practice is to administer lithium such that patients achieved a serum concentration of lithium of between 0.8 and 1.2 mmol/L (p. 471). Thus, as Van Calker and Berghofer (2010) have noted, lithium has a fairly narrow therapeutic range (p. 16).

Lithium has not only a narrow therapeutic range but also a long list of undesirable side effects, including tremors, nausea, and cognitive dulling (Keck & McIlroy, 2010, p. 82). In sufficiently high doses, lithium is toxic (Van Calker & Berghofer, 2010, p. 16). There is thus ample motivation for therapists, physicians, and other healthcare personnel to explore non-pharmacological treatment of Bipolar disorder. In particular, given that there is limited research on the efficacy and risks of lithium for Bipolar patients on the milder end of the spectrum (Van Calker & Berghofer, 2010), it is logical to explore non-pharmacological alternatives to lithium therapy for those who do not suffer what Craddock et al. (2004) described as impairment or incapacitation. Perhaps more controversially, it is also worth exploring the question of whether the relatively low success rate of Bipolar treatment—both pharmacological treatment and existing forms of therapy—is somehow associated with the inability of current treatment approaches to address the systemic features of Bipolar disorder.

A systems approach to Bipolar disorder could, in theory, function in distinct ways based on the observed severity of the disorder. First, for individuals on the milder end of the spectrum, a systems approach to therapy could be a plausible first choice of treatment, to be supplemented with individual therapy and pharmacological therapy should the disorder prove to be resistant to a systems approach. The theoretical argument in favor of such an approach is that, for individuals on the milder end of the Bipolar spectrum, the environmental component of the gene-environment interaction might be more determinative of the disorder. If in fact the environment is a dominant factor in the milder forms of Bipolar disorder, then a systems approach might be a better candidate for therapy. Systems approaches are highly sensitive to understanding and incorporating the environment, particularly the human environment, in treating Bipolar disorder. Second, even individuals on the more severe end of the Bipolar spectrum could benefit from increased attention to their human environments.

Bipolar Disorder: Evolution of Therapeutic Thinking

The existence of what is now known as Bipolar disorder has been attested since ancient times. Aretaeus of Cappadocia noted in 150 A.D. that “melancholy is the commencement and a part of mania” (p. 54). Centuries before Aretaeus, Plato defined mania as a divine affliction in the Phaedrus, relating it to prophecy and inspiration, while, at about the same time, Hippocrates defined melancholy as a condition characterized by fear and sorrow.  By the time of Aretaeus, mania had joined melancholy as part of a discourse of mental health.

Closer to our time, Jean-Pierre Falret (1854) and Jules Baillarger (1854) separately defined Bipolar disease (which Falret called la folie circulaire and Baillarger called la folie a double forme) as a form of mental illness characterized by the succession of manic and melancholic states interspersed with periods of lucidity. Half a century later, Kraepelin’s (1904) case notes firmly established the existence of Bipolar disorder in the context of modern psychiatry.

Kraepelin was seemingly oblivious of the intimate relationship between Bipolar disorder and family circumstances. Introducing the case of one of his patients, Kraepelin (1904) wrote that “the patient comes of a healthy family, but has a son who is insane” (p. 72). Kraepelin’s therapeutic blindness was remarkable; shortly after noting that this patient’s son was insane, Kraepelin diagnosed the patient as having “groundless anxieties” (p. 72), as if the anxieties of a parent with a mentally ill child could ever be groundless. Elsewhere in Lectures on Clinical Psychiatry, Kraepelin counseled that, for Bipolar patients, “simple separation from others is an efficient calmative” (p. 66).

Lectures on Clinical Psychiatry reads like two parallel narratives, with one narrative being a demonstration of the existence of Bipolar disorder and the other narrative being an inadvertent record of the systemic roots of this disorder, roots that Kraepelin ignored.  Kraepelin provided so many details of Bipolar patients’ distressed family circumstances without ever connecting them—etiologically or therapeutically—to the disorder itself.

Bipolar disorder, like so many other forms of mental illness, was first treated in sanatoria (Roberts & Buikstra, 2012). Sanatoria were, of course, places in which the unwell could be segregated for treatment, but with little thought given to how the inciting sicknesses had themselves been generated in society and would once again be subject to the pressures of society. Thomas Mann’s (2005) novel The Magic Mountain epitomized this concept of isolated, non-systemic, and ultimately bourgeois mental health treatment. However, even before the popularity of sanatoria as isolated treatment sites for mental illness, there was a long tradition of non-systemic approaches to Bipolar disorder and its two components of mania and depression. For example, Plato thought of mania as a divinely conferred condition, while Hippocrates described melancholy as biologically determined; in neither case was the possibility of social influence or context admitted. Thus, Kraepelin had many illustrious progenitors who also failed to understand Bipolar disorder and its components as arising from, and therefore at least partly solvable through, systemic contexts.

In Kraepelin’s work, the diagnosis of Bipolar disorder transferred all pathology and therapeutic attention to the individual patient, who, once diagnosed, was subjected to a combination of warm baths, bromide of sodium, social isolation, bed rest, and, in general, “kindly, quiet, non-exciting treatment” (Kraepelin, 1904, p. 66). While such treatment was successful in the rarefied atmosphere of the sanatorium, it did nothing to address the systemic traumas in the lives of Bipolar people. Kraepelin’s patients would eventually have to return to their social circumstances, which, judging by Kraepelin’s case histories, were characterized by traumatized and traumatizing family systems. Kraepelin noted of many of his patients that they had returned to the sanatorium as many as eight times, without ever reflecting on the significance of this pattern. Obviously, Kraepelin’s pharmacologically oriented, individualized, and isolated  treatment of Bipolar disorder did not have a lingering therapeutic effect in the world beyond the sanatorium walls.

Bipolar treatment has advanced since Kraepelin’s day, but some of the same blind spots exist. For example, in Frank, Swartz, and Kupfer’s (2000) work on interpersonal and social rhythms for managing Bipolar disorder, there is an acknowledgement but rapid dismissal of the role of the system: “In our model, life events (both negative and positive) may cause disruptions in patients’ social rhythms that, in turn, perturb circadian rhythms and sleep-wake cycles and lead to the development of Bipolar symptoms” (p. 593). Frank et al.’s acknowledgement of life events, and, by implication, the social systems of which they are a part, was an advance over the historic circumscription of Bipolar disorder to the individual, a circumscription that is just as visible in Hippocrates’ (1822) crude biological determinism as in Cade’s (1949) insistence that mania was a deficiency of lithium. However, Frank et al. conceived of systems as triggers for the expression of genetically predisposed Bipolar disorder, not as part of the disease—or its treatment.

As Frank et al. (2000) pointed out, Cade’s (1949) discovery of lithium as a suppressant of mania inaugurated a long period of pharmacological approaches to treating Bipolar disorder. The availability of lithium and the apparent failure of purely psychotherapeutic methods for treating Bipolar disorder combined to make medication an indispensable part of the treatment plan. In Frank et al.’s approach, medication is combined with two other focal points, namely “helping patients to…lead more orderly lives, and resolve interpersonal problems more effectively” (p. 594), in an effort to address both the biological and psychosocial factors (in particular, psychosocial stressors) underlying Bipolar disorder. While such an approach appears to unite a pharmacological treatment plan with elements of psychotherapy and, at least implicitly, systems thinking, the systems component is once again the weak point, as the following discussion of a case study from Frank’s (2013) book will illustrate.

Misplacing the System: A Case Study

Frank (2013) offered the case study of Tad, a young man from Alabama. At 18, Tad transitioned from his small town, social isolation, and dependence on his mother to life as an art student in New York City. Soon after this transition, Tad began to sleep less, interact excitedly with his classmates, indulge in substance use, and experiment with his art, at one point completing an installation out of stolen women’s underwear. Nothing in Tad’s history, as Frank presents it, is incongruous with the experience of a previously stifled, creative young person exposed to college life in New York, but Frank reaches the alarmingly judgmental conclusion that “Tad was a seriously ill young man” (p. 11). Frank also notes that “Naturally, he at first denied that anything was wrong with him” (p. 11), demonstrating an attitude similar to that of judges in witch trials, for whom both confession and denial were the same.

The course of treatment prescribed to Tad was a form of medication that resulted in trembling hands, effectively ending his career and leading to a course of “psychotherapy focused on grieving for all the dreams he had once had” (Frank, 2013, p. 12). Tad was broken down over a period of 6 years, a time during which he was convinced that his symptoms—which were limited to some drug experimentation and an artistic project that, in the context of contemporary art, can hardly be described as transgressive—merited the sacrifice of his vocation and, frankly, a neutering of his potential. With his trembling hands, internalized self-reproach (as effective as anything doled out in the Cultural Revolution), and foreshortened dreams, Tad has to return to his small town to serve as an art teacher. With disturbing insistence, Frank describes Tad as leading “a stable and satisfying life” (p. 12).

In systems terms, Frank (2013) failed Tad by not trying to distribute his burdens across the two societies of which he was a part, his Alabama system and his New York system. Tad’s initial spree in New York City appears, in substantial part, to be a response to his straitened life in Alabama, a life to which his mother greatly contributed. If Tad were rebelling against his mother, or expressing his freedom in a manner that defied her values, then she should have helped to carry the ledger of pathology that Frank imposed on Tad alone. Similarly, Tad’s experimentation in New York took part in a social context; he was encouraged to experiment, and, when he did, he was pathologized for it, not only by his professor, but also by his therapist. Thus, in both of his social settings, Tad was defined as the unit of trouble and pathology; processes of pathologization, analysis, and healing that ought to have been spread across systems were instead focused to a single, laser-like point and trained on Tad. The danger of such an individualized approach is that, if in fact the Bipolar patient’s symptoms are a response to, or even a product of, the systems setting, the therapist will never know. The kind of treatment visited on Tad is fully comparable to the lobotomization of someone who has been traumatized by others; the lobotomy removes the response to the trauma, but leaves the trauma untouched and in fact punishes the traumatized party.

Clark: A Systems Approach to Bipolar

When my patient Clark was first diagnosed with Bipolar, he had no intention of questioning the doctor’s diagnosis. He went along with it, just as he had gone along with colic, Sensory Processing Disorder, and ADHD earlier. He is the oldest of three children, the only boy among his siblings. His therapist decided that individual therapy wasn’t getting him the help he needed, so he was referred to me to “try family therapy.”

The willingness of the whole family to gather around to “help him” was touching, and clearly help was needed in the family system. Mom and dad were sitting way apart from each other; dad was very hard to hear, while mom was one kind touch away from tears. Clark placed himself in the chair closest to me, perhaps a structural gesture to confirm his identified patient position, his status as the one to be fixed. The girls took up the space between mom and dad, perhaps as buffers.

Oddly, my position as the last remedy for Clark made his chance of surviving Bipolar bleaker than ever.  After all, if all attempts had failed, then what was one supposed to think and feel?  Facing a family constantly referred from one source to another can be hard to digest for a therapist. This was a family that has lost its vision of health in the never-ending search for the removal of illness. As Ackerman (2000) so brilliantly stated, “Unless the patient is able to envisage a new and a better way of living, he will cling to his old way. He will resist exchanging a familiar kind of adaptation for an alternative that he cannot yet perceive or believe in” (p. 42) The family was the jungle Clark was supposed to go back to even after getting the best treatment that was available to him in the comfort of civilization. Whatever the treatment, it needed to be given in the very jungle that Clark called family, and any professionals attempting an intervention needed to ask themselves if they were up for that challenge.

Clark was failing his classes, he was acting hostile towards his sisters, and he had an obsession with knives and sharp objects. His parents had to keep all of their knives in a locked cabinet. He had been hospitalized for severe depression and suicidality. Since then, he has been demonstrating aggression, emotional volatility, and belligerence on a daily basis. He had been physically abusive to his sisters, stolen and hid knives as well as other items, and threatened to cut himself when he was being punished for his behavior. He demonstrated high impulsivity and appeared to be agitated most of the day every day. He struggled a great deal with poor focus and barely passed school. His aggressive behaviors were described as escalating following his release from the hospital, and they only got worse; he was hospitalized a second time the following year.

Clark began the family therapy journey saying that he was the problem. Living up to this evaluation, he would at times screech like a pteranodon or crawl on the floor with buttocks exposed, leaving us all with varying responses. Midway through the year, he stated that it felt good not having to be the only problem in the family, and afterwards he noted a discomfort with his Bipolar diagnosis. Clark’s insights occurred during a year of family therapy that also included couples therapy sessions for his parents.

Our sessions revealed that the father had been physically and sexually abusive with Clark and Kellie, Clark’s middle sister. Clark was exposed to his father’s inappropriate touch two years ago, when he was sleeping in his own room.  Interestingly one of Clark’s so-called symptomatic behaviors as reported to me in the assessment was that Clark had a hard time falling asleep, and the only place he could fall asleep was the sofa in the living room. To his parents’ surprise, he had stopped sleeping in his room. Clark says that his father touched him only once, but the father’s abuse of Kelly had been ongoing for two years.. The chronology of the abuse directly coincided with Clark’s obsession with sharp objects, his suicidality and aggressive behavior, and his hospitalization.

Conclusion: From Bipolar to ‘Whypolar’

Bipolar disorder, despite its roots and antecedents in individual biology, arises and flourishes within systems, particularly family systems.  The symptoms of Bipolar disorder are all too easily mistaken as individual pathology whereas, on examination, they can disclose the contours of family pathology. Similarly, the treatment of Bipolar as an attempt to quash symptoms, particularly through aggressive psychopharmacology, masks the role of the system in the emergence of these symptoms. In Clark’s case, the diagnosis and ostensible treatment of Bipolar failed to ask the question that I have come to designate ‘whypolar.’ To me, the concept of whypolar is a means of extending the net of diagnosis, examination, and treatment around Bipolar to the family and other systems around the identified patient.  To ask ‘whypolar’ is to reject the pat assumption that the Bipolar lifecycle takes place solely within an individual, and to invite the therapist to make a more conscientious effort to understand the role of the underlying systems.  Once the system is named, understood, and engaged, there is a better chance that members of the Bipolar patient’s system can gain their own voices, envision better circumstances, and move from a paradigm of symptom management to existential encounters.

The systems approach to addressing Clark and his family was more successful than previous attempts.  Clark went off his medications and reported no worsening in his mental and emotional states. As he himself put, he “never really noticed any difference anyway” while he was on them. His case, and the existing critique of approaches to Bipolar disorder given earlier in this article, give me good reasons to believe in the efficacy of whypolar.

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