Existential Despair and Bipolar Disorder: The Therapeutic Alliance as a Mood Stabilizer

Harvard Medical School, Boston, MA, USA.
American journal of psychotherapy 02/2005; 59(2):137-47. DOI: 10.1176/foc.5.1.111
Source: PubMed


Talking with a manic patient is not easy, but it is also not hopeless. Manic patients are hopeful, ever hopeful, and indeed often too hopeful. But their hopes and dreams, however big, are usually brief and soon damaged by the realities of life. Ultimately, most patients with bipolar disorder become chronically depressed, denied of their hopes by others. Appropriate medication treatment is necessary, but not sufficient, for many such persons. The job of the clinician is twofold initially: first, to seek to existentially be with manic patients and then, to counterprojectively give perspective to those patients about their manic worldview, without completely denying it. This twofold approach then can lead to a healthy therapeutic alliance, which itself has a mood-stabilizing effect. Along with mood-stabilizing medications, this alliance can then lead patients toward full recovery. Put more simply, clinicians need to talk to manic patients about their hopes, to explore the limits of their grandiosity without judging it, to seek out their strengths and to validate them. They also need to go where the patients are, to encounter patients and find the person beneath the illness, to provide a strong relationship, an alliance that cannot be shaken, to conflict with the patient sometimes and not at other times. It is a tall order, and one not infrequently avoided. Yet the times seem to call for a return to actually talking with manic patients, and maybe curing them with such talk. Or perhaps that is grandiose.

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    • "In clinical reports, depressive experience has been observed to involve a pervasive sense of existential struggle and despair—often an experience of grappling with one's future, place in the world and overall sense of life meaning (Addis et al. 1995; Havens and Ghaemi 2005; Yalom 1980). The nature of existential meaning has also been found to be predictive of later depression, with the absence of perceived meaning associated with greater prospective risk and depressive symptomology (Debats et al. 1995; Mascaro and Rosen 2005). "
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    ABSTRACT: Diagnosis of depression has low reliability (kappa = 0.28) due to "covert heterogeneity," making the identification of sub-types a focus of research. Very high rates of moderate or sub-threshold depression among adolescents (35-45 % beyond the 20-25 % with MDD), prompt consideration of a potential sub-type of moderate sub-threshold depression, linked to adolescent development. Previously, developmental depression (DD) has been proposed as sub-type of moderate depression that is a normative developmental process of spiritual individuation, the integration of existential and spiritual experience. DD as a potential sub-type is supported both by clinical observation and by an emerging body of research identifying a common physiology to underlie both depression and spirituality (neurotransmitters, structural MRI and long-term clinical course), as well as research showing a surge of spirituality in adolescence (concomitant with window of risk of depression). We test for unique patterns of comorbidity and neural correlates as support for a sub-type. Based upon existing literature, we propose that DD will be (1) associated with the unique neural correlate of increased volume in the occipital region and (2) co-morbid with symptoms of affected regulation and processing. A sample of 125 adolescents (64 girls and 61 boys; ages 15-19 years) from the larger National Institute of Health Magnetic Resonance Imaging (MRI) Study of Normal Brain Development (Evans in Neuroimage 30(1):184-202, 2006) was assessed using the Cloninger Self-Transcendence Scale to examine correlates of sub-threshold mild to moderate symptoms of depression. Findings lend support to the possibility of a DD. Sub-threshold depression was associated with greater volume in the occipital region, as well as comorbidity with symptoms of affected regulation and processing (mania, ADHD, anxiety). By contrast, in adolescents with a low level of transcendence, sub-threshold depression was associated with conduct disorder and heavy substance use, both of which previous research have found to be associated with low levels of personal spirituality.
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    • "While the women in this study experienced despair as always with them, most referred to its cyclical nature, wave-like pattern, or the " ups and downs " of despair, which is consistent with Kylma's (2005) description of despair as an upward and downward process. Havens and Ghaemi (2007) recognized in their study of persons with bipolar disorder the existence of existential despair. Despair was different from clinical depression because it did "
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    ABSTRACT: While there is a substantive body of knowledge on depression, little is known about the experience of despair. Though the terms depression and despair are often used interchangeably, studies of despair suggest that it is distinguishable from depression as experienced by women. This study explored women's experience of despair through qualitative interviews with 14 women ages 28 to 55 (M = 45) who self-identified as experiencing despair. Three themes emerged: "Crippling and Debilitating," "There's Nothing You Can Do," and ''It'll Never End." The findings lend support to the notion that despair is distinguishable from depression, but this warrants further study. The findings also suggest that while there are common elements of despair among women, there are also unique experiences of despair. While there is a substantive body of knowledge on depression, little is known about the experience of despair. This phenomenological study explored women's experience of despair through qualitative interviews with 14 women ages 28 to 55 (M = 45) who self-identified as experiencing despair. Three themes emerged: "Crippling and Debilitating," "There's Nothing You Can Do," and "It'll Never End." The findings suggest that women desire to have their experiences recognized and validated while simultaneously receiving acknowledgment of their ability to overcome the past and to shape their own destinies.
    Full-text · Article · Jul 2010 · Issues in Mental Health Nursing
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    • "growing number of studies are establishing a direct link between the patient-provider relationship and a variety of outcomes among individuals with bipolar disorder, including primary care attendance, psychotherapy retention, and improved symptoms (Berk et al., 2004; Gaudiano and Miller, 2006; Sajatovic et al., 2005). Given these optimistic findings, the beneficial nature of effective clinical relationships has been aptly coined as an effective " mood stabilizer " (Havens and Ghaemi, 2005) and a critical goal in psychotherapy (Summers and Barber, 2003). Furthermore, in designing appropriate efforts to increase the strength of therapeutic relationships, certain patients may garner particular advantages from positive clinical interactions, such as ethnic minorities who endorse different sets of culturally-based values and treatment perceptions, and might benefit more from their clinical relationships than white patients (Fleck et al., 2005; Tonigan, 2003). "
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    ABSTRACT: The quality of the patient-provider relationship is regarded as an essential ingredient in the treatment of serious mental illnesses, and is associated with favorable outcomes including improved treatment adherence. However, monitoring the strength and influence of provider support in clinical settings is challenged by the absence of brief, psychometrically sound, and easily administered assessments. The purpose of this study was to test the factor structure and examine the clinical and psychosocial correlates of a brief measure of provider support. Participants were recruited from the continuous improvement for veterans in care-Mood Disorders study (N = 429). The hypothesized factor structure exhibited a good fit with the data. At baseline, provider support was associated with higher levels of service access and medication compliance and lower levels of alcohol use and suicidality. Regular monitoring of provider support may provide useful when tailoring psychosocial treatment strategies, especially in routine care settings.
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