Bipolar Disorder -- more work in process

The green grass hills seemed to stretch forever, limited only by the bright blue horizon. It was not hard to imagine those hills covered with bison while eagles circled overhead. Through the dissolving morning mist, we could still an eagle gliding on the heat currents above us, though no bison would appear. We had come to Nick Standing Bear’s spread for sun dance. One year ago I had brought Anna to see Nick. She had never left. I looked forward to seeing her again, having kept in touch by letter, and having seen her twice during the year at other ceremonies.

Anna had come to me in Pittsburgh. She was part black, part Cherokee, a product of slavery times in the Deep South. Anna had been hospitalized every two years for as long as she could remember. She had been tried on every medication known to psychiatry. All gave her side effects, some life-threatening.

Anna had what we call bipolar disorder. This used to be called manic-depression. The term implies extreme ranges of mood, from elation to the deepest of depression. Unfortunately for them, bipolar patients spend 85% of their time being depressed. And, unfortunately, when they became elated, they can become sufficiently bizarre to become hospitalized or jailed. The elation is not without its associated consequences. Anna became paranoid and hypervigilant, ever searching for threat. She felt pressured to talk, but would reveal too much, making everyone uncomfortable around her. When her mania became extreme, she would become psychotic, misinterpreting the world around her and its intentions so severely that she would end up in restraints in a psychiatric hospital. She bitterly described her trauma of being tied up and secluded. The mental health care system was brutal to her. She came to me because she wanted an alternative. She felt herself getting paranoid, she knew something had to be done. She didn’t want more medication. Her past doctors had been encouraging a drug called Clozaril,

Anna illustrates an important narrative principle also spoken by indigenous knowledge keepers – that knowledge is the outcome of interactions and relationships between the inquirers and participants. Here is the radical difference in views – that there is no a priori,pre-set way to “treat” bipolar disorder; there is only a conversation among specific people that generates knowledge about how things work for those people. The biomedical paradigm diagnoses bipolar disorder through applying a set of criteria in cookbook fashion. Then it generates a list of medications to be applied, also in cookbook fashion. Narrative approaches, on the other hand, generate action plans unique to the people creating them. Biomedicine takes DSM-IV-TR as real and essential. A narrative approach does not avoid it, but, rather, recognizes it as one way of specifying similarities and differences among people, which is somewhat arbitrary, and which can be replaced by multiple other ways. Applying DSM is a process like applying any other categorization system. I personally prefer three-dimensional SPECT scans as generating a more reliable story about which medications might be useful. On the other hand, it is within my repertoire of stories, to recognize that the social environment can radically change the brain and that patterns of neuronal activity, even as found on a SPECT scan, are socially constructed. Without relationship, we would have a useless brain for it would not have matured. Our social relationships can change dendritic connections within the nervous system, can change regional blood flow and metabolism, and can transform the story we tell about who we think we are.

Social Psychologist A.T. Abma (2000) writes that our “interactions and relationships are shaped by dynamic socio-political processes and go through conflicts and impasses.” Thus, the relationships of conventional psychiatrists and people labelled as having bipolar disorder are different from those of us on the periphery – in the outskirts of culture, in the margins where social change begins. I would go as far as to say that our people who get labelled as bipolar quickly become different from their people as a result of the social interaction. The quality of what we learn and come to know depends on the quality of the relational process through which we learn it. .

Conflict is inevitable in relationship, especially with those who have earned the bipolar label. Conflict is more th the absence of consensus but rather the negation or exclusion of "otherness. " I want to tell a story about coming to that realization with a family.

Erin (change name before completion) was a thirty-five year old woman who had lived a fairly ordinary life (with the exception of what was called a manic episode in her 20s that resolved) until two years ago when she abruptly ended a 10 year relationship to be with a man she met on the internet who turned out to be married and have two children. The family’s story about Erin was that she realized too late that this man was unavailable and broke down over the pain of loss of the past relationship and her anticipated future relationship. She had been hospitalized and diagnosed with bipolar disorder. She had been started on medications meant to “treat” this disorder, and none had worked. Erin’s psychiatrist sent her to me when she took maternity leave, but I gathered from subtle hints in her notes (between the lines, so to speak) that she was glad to pass Erin along, since Erin wasn’t responding to her ministrations.

At first, I liked the family’s interpretation of Erin’s story, but I slowly became aware that Erin detested this interpretation. She felt it trivialized her struggles and her pain. She believed that she had been meant to be the Vampire Queen, to ascend to sit at the right hand of God as his Queen. At the last minute, she had been punished by being made to live among the undead (the rest of us) due to her selfishness. When the time came to be called, she had been too selfish and had been tossed aside. She was waiting for an angel to come to take her to her rightful place in the cosmos, which involved dying to eternal life. I thought of Jukka Altoonen at first, and how he would work so hard to bring this story around to one that was more ordinary. I tried that approach, but Erin was insulted by it and accused me of conspiring with her family to torture her. That was when I realized that we had to respect and work within Erin’s story. A colleague suggested that we begin with the notion of time. Perhaps Erin’s sitting by the front window, watching through the glass for her angel, was unrealistic. Perhaps Erin’s sense of time was off. Perhaps she would have to busy herself to make her prison better since angels might not come for 20 years. Since she didn’t want to have an accidental death (to choke or drown or otherwise die through non-ascension), she would have to look toward her physical world for a while. This was a better strategy. It also revealed the family conflict. Everyone (including me at first) was trying to deny the reality of the “otherness” of Erin. We wanted her to make sense in our world of ordinary soap opera drama. We wanted to bring her down from her Wagnerian operatic world into our sordid high schoolish dramas. She refused to be dislodged.

When we acknowledged Erin’s otherness, what emerged was the exhaustion of family members from the work of trying to change her. Within the consultation group in which this family presented itself, the recommendation was to surrender, to stop trying to change Erin, to leave her alone unless she became imminently dangerous to herself. Then the proper course of action would be to call the police to intervene. Otherwise, we were to accept her edict – that she is God and therefore is in control of her destiny. Members of the consultation group offered to pray for Erin and for the family. A suggestion was made for everyone to write letters to God; that they could be given to Erin as origami hangings, like Sodaka’s thousand cranes for world peace in Hiroshima, Japan. A member of the group told about praying for her daughter for 20 years before her daughter found a way out of alcohol and drug problems. “God works slowly,” she said. “Maybe 20 years is not long to God,”she added, reinforcing what we had told Erin – that she might need to revise her timeframe for angelic ascension. We encouraged the family to get their life back and to acknowledge Erin’s fundamental differentness from them. She was not speaking in metaphor or parable. She was telling her story as she experienced it.

My desire to become a psychiatrist began with reading R. D. Laing while still in high school. Laing illuminated the world of madness for me by showing its meaning. For him, psychiatrists and psychotherapists should facilitate the individual, family, and society becoming more aware of emotional, experiential, and existential needs in a way that increased meaning and authenticity. Psychotherapy should improve quality of life and allow individuals to live within families and societies in a life-affirming manner. Madness was a creative response to living within insane conditions and impossible families and cultures. Life within these contexts was ubearable. Madness allowed that unbearable emotion to leak out and be expressed even if cryptically and in gibberish. Laing explained why madness was often found in the more intelligent patients. They were able to comprehend the impossibility of their lives, generating all the more suffering and desire to communicate their condition. The goal of his psychotherapy and psychiatry was to legitimatize and validate experience, allowing his patients to reconstruct and recathect a sense of worth and meaning for their lives within a more sane context.

Experience is important in the life of an individual. How we use our own self and our humanity is an important aspect of diagnosis and treatment. Treatment must manage the anxiety arising from empathy. It must stay afloat upon the tumultuous seas of the shared experience of intense, profound human emotion. Laing’s psychiatry emphasized the use of self instead of biochemicals, the use of one’s own authenticity in a community healing effort.

During medical school, as I began to study my Native American heritage, I discovered that traditional medicine people treated insanity very much like R.D. Laing, but with one essential difference. Their treatment was much more compassionate and supportive than Laing who seemed to sometimes leave his patients adrift in their unmanageable emotions with little direction and few guideposts.

Through the philosophy of the seven directions, a safe path for life could always be found. Through the intervention of the Spirits and the Divine, impossible affect could be contained. Through their reliance upon the Sacred, medicine people could work miracles, quietly disclaiming responsibility, achieving a kind of transparency so that the credit for their work passed through them and on the Spirits who stood behind them.

Native American medicine people seemed more able to work within the domain of intense emotions experienced by those suffering profound mental disorders. These are the profound emotions of major life experiences and transitions. They are the profound emotions stirred up and activated by ceremonies. These emotions profoundly affect the entire family and community, and, are the fuel driving therapeutic change.

Intense life events open portals into the intense emotional world which we humans are capable of entering yet so rarely do. It is the same profound emotional experience that occurs whenever intense and exhuastive work gives birth to a new sense of integration.

In Coyote Medicine I wrote about my introduction to obstetrics through the birth of my daughter, Sorrel. My anxiety about home birth catalyzed a search and discovery that birth is one of the most intense emotional experiences humans can encounter. The power and intensity of birth are unequaled. Then I found a passage from Laing about midwives making the best mental health workers. Whenever possible, Laing recruited midwives to live and work in his London homes for people with schizophrenia and other psychoses. He believed that midwives were best prepared to handle the intense emotions part and parcel to recovery from insanity.

Having experienced birth, this now made sense. During the hours of labor, women live through intense sensations, perceived as pain by many, coupled with intense emotions, sometimes of fear and panic. My wife, Morgaine, a most artful midwife, showed me how she transformed these many possible negative feelings and sensations into a positive and successful birth experience, one that is immensely gratifying to the women and families involved. This skill is the same as what is required to sit with the insane as they reconstitute a self. It is the skill necessary to lead the lost soul through the descent into Hades, to steal that soul back from the dead, and to re-create a life in the living present. What differs is the intermittent nature of birth contractions and its finite length compared to the constant duration of the unbearable affect of psychosis and its potentially infinite duration.

It is this intense emotionality that we as a society so often defend against by delegating institutions, such as hospitals, to deal with life’s profound transitions of birth and death. It is the reclamation of emotional experience that both facilitates a positive birth and allows the mad to become whole again.

Experiencing the natural processes of life, such as birth, is a way of experiencing ourselves as human beings, becoming aware of our own strength within the meaning of life which lies in the primacy and intimacy of personal experience, and personal responsibility for our experience.

Birth, death, and rebirth are classic themes for humanity. To be aware of this is to increase our ability to use these energies to facilitate our own growth and expansion as individuals, families, and societies. Birth and psychosis both present incredible opportunities for psychological growth and development that we should not avoid.

I had wanted to become a psychiatrist to lead patients through the Purgatory of madness. Instead I found myself more often, in my early medical career, working with pregnant women. Through my clinical experience and research, I discovered that women’s powerful emotions of fear or anxiety affected their body’s physiological process of giving birth. Powerful emotions could stop labor or prevent it from starting. Cathartic or healing emotional experience could remove those blocks and allow the process to continue. The family within which the birth occurred have much bearing on how labor would proceed. The more constricted and repressed the family, the more difficult labor could be. Context affected physiology, just as it affects the brain and its neurochemicals and transmitters in schizophrenia.

Birth and labor are particularly intense emotional experiences of magnificent focus which unfold in the unique style of the individual woman giving birth. This style is constructed from the woman’s life attitudes and beliefs about herself. These beliefs and attitudes exist within the context of family relationships,the couple’s relationship where one exists, and any active support systems. Each woman gives birth differently and originally. No two births are alike. Just as each woman is unique and lives life in her own style, so is she in how she births her children.

Similarly no two madnesses are the same, despite DSM-IV. The meaning of madness cannot be found in chemicals or diagnostic nomenclature. Each madness has its own unique meaning which can only unfold within the context of the person’s life who lives that madness, and only becomes understandable by seeing the person against the backdrop of his family and community. Just as each woman gives birth in her own style, each individual recovers from insanity in her own manner. The midwife is more the shepherdess of the energy of healing, keeping the process moving, than deciding where it shall go. Though it is also her responsibility to make sure the flock arrives at a destination and does not fall off the cliff on the way. These are the Native American metaphors of working with insanity: the idea of leading the sheep to greener, higher mountain pastures in the summer, of bringing them down from the high country before the first snows of winter. The Navajo or Dineh shepherd is one of our best teachers of the art of psychotherapy.

Birth is an event to which a laboring woman relates intimately and uniquely, weaving a learning experience all her own. For a woman, birthing itself can be delicately balanced point in time of terrific impact couched within the developing framework of motherhood.

Psychosis and its recovery is often similarly a unique time in which a person shatters and can put together the pieces, learning how to be an entirely different self. Psychosis often occurs at times of developmental shifts, such as the adolescent transition to adulthood or the child’s transition to adolescence. Recovering these periods and shepherding the person through this developmental epoch is like taking them through labor.

Through birth a woman travels from mothering on a purely biological and cellular level, relatively free of conscious effort, while nurturing a developing fetus, to mothering on a conscious, deliberate level of raising a newborn to adulthood. The point of birth is a meeting place of intuitive body knowledge and conscious, logical, mind process. The body knows how to give birth, the mind learns from it, and with the aid of body hormones, a woman proceeds to mother a child consciously and deliberately. After birth, the mother may still need to feed the baby with nutrients from her body, but she does so by deliberately putting the baby to the breast, rather than unconsciously through her placenta, as in pregnancy. This meeting of body and mind during birth creates and releases enormous energy for growth, as it is an opening through which a new soul is born and new relationships are begun. These family relationships continue to expand personal possibilties for infinite variations of psychologial growth, change, and development.

When severe mental illness hits just as when birth breaks down and Cesareans and other interventions become necessary, this meeting of intuitive body wisdom with affect and memory becomes disturbed. Physiology fails to function adequately. The uterus will not contract rhythmically and forcibly. The neurotransmitters falter and dissipate. In each case our interventions are just as brutal -- Cesareans, forceps, vacuum extractors, and intravenous hormone drips versus the chemical straight jackets of the phenothiazines.

Over 20 years ago neuroscientists at the Langley Porter Neuropsychiatric Institute of the University of California at San Francisco, convincingly showed in a random assignment study at a state mental hospital (Agnews State Hospital in San José), that new onset schizophrenia could be effectively treated without medication. The unmedicated patients remained in the hospital longer (up to 6 months), but less than 10% had future breakdowns that required re-hospitalizaiton. The medicated patients left the hospital sooner, but 90% had future breakdowns that resulted in chronic rehospitalization and disability.

Similarly, my colleages and I, showed in a number of studies that hypnosis, psychotherapy, and other techniques of behavioral medicine, could be used to help women at risk have normal births.