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Introduction

Bipolar disorder is a type of mood disorders characterized by abnormally depressive moods, anxiety and maniac states. However, it is noteworthy that bipolar disorder theory, whether stated explicitly and formally or implicitly and tacitly, makes assumptions about the following dimensions of traumatic impact on the organism: (1) changes in psychobiological state (e.g., disequilibrium, increased catecholamine production); (2) changes in learned behavior through classical conditioning or operant conditioning; (3) changes in cognitive processing, including information processing and belief and value system orientation, as well as the capacity for memory, learning, and concentration; (4) changes in self-structure and object relations; (5) changes in interpersonal relations and orientation to society (e.g., alienation); and (6) the nature of the stressors experienced within the time-space framework of a culture at a historical moment (Basco, 2005). One of the important tasks for future research will be to undertake a comparative analysis of the disparate theories using a common yardstick such as the six dimensions listed above. Such a comparative analysis will not only broaden the possibilities for hypothesis testing but enable higher-order integration of the existing scientific findings into a new, more parsimonious framework.

Case Description

Mr. Thompson is a 42 year old factory worker diagnosed with bipolar disorder. This patient suffers from the depression disorders for 3 years.  Mr. Thompson is a person who presents with apparently non-traumarelated problems such as depression, relationship difficulties, sexual dysfunctions, and family discord. Careful inquiry reveals symptoms of bipolar disorder such as recurrent nightmares or emotional numbing. As the majority of clients, Mr. Thompson falls midway between these two extremes. Most clients typically report a trauma but need extensive inquiry to provide sufficient information for diagnostic decision making and treatment planning (Basco, 2005).

Mr. Thompson is fragile and reacts so adversely to uncovering traumatic memories that probing for details would be inappropriate during assessment. He is so emotionally numb or withdrawn that he cannot convey the severity of what happened to him, even with considerable prompting (Mondimore, 2006). The authors have found it helpful in their work with bipolar disorders to provide a clear explanation regarding the information that will be needed in order to conduct a thorough evaluation. It is made clear to clients at the outset that explicit information will be elicited from them about their traumatic experiences and the ways in which these experiences may have affected them. Also, it is emphasized that they have permission to go only as far as they feel comfortable as they begin to reveal what happened to them (Miklowitz, 2002).

Mr. Thompson frequently suffers from loneliness and social isolation. These effects stem from low self-esteem, depression, and sense of being "deviant" due to the trauma; fears of being "triggered" into a depression or rage reaction due to comments made by others; feeling "tainted" or "cynical" and therefore different and apart from others due to loss of innocence or shattering of spiritual or religious beliefs as a result of the trauma; self-blame for their depressions, rage reactions, or wide fluctuations in mood; self-doubts created by observing their emotional shifts; confusion as to which of their problems are trauma-related and which are not; and fear of intense anger or grief, of losing control emotionally and/or of embarrassing and/or hurting others with intense grief or rage reactions (Mondimore, 2006).

Emotional numbing, the tendency to shut off emotionally, to be reluctant or unable to share on a deep emotional level, or to withdraw from others in other ways, especially intimate partners, creates numerous relationship problems, for example, hurt feelings. During the client's depressive episodes family members and friends might try to "cheer up" the client. Yet their efforts may bring about only further depression. The client feels like a failure because, even though his positive response is desired, the depression is too deep to permit that response. Eventually, family members or friends also become frustrated and depressed. They, too, feel like "failures" because they have not been able to help the client substantially. On one hand, they may truly empathize with the patient. On the other, they may also resent the client for not responding to their efforts, for being a "dead weight," or for being "overly negative." The belief that "nothing will help," that not even human love and comfort can do much to alleviate the suffering caused by the trauma, can create mutual alienation in families (Basco, 2005).

Many misunderstandings and communication problems of Mr. Thompson result from the presence of two sets of symptoms in the home. In this case each individual may not own or understand his psychological problems. Due to lack of treatment, inadequate treatment, or treatment that has not addressed the disorder or depressive state, patients are often confused and dismayed by these symptoms and the intensity of their emotions, as well as of their "non-emotion" or numbing. Mr. Thompson frequently exhibits impaired self capacities (Miklowitz, 2002). Within constructivist self-development theory, there are three self capacities that, taken together, contribute to the individual's ability to regulate self-esteem. The four self capacities are the ability to manage and tolerate strong affect, the ability to maintain an inner sense of connection with others, and the ability to maintain a positive sense of self. A clinical dilemma related to history taking emerges when the individual's self capacities are undeveloped or impaired by traumatic experiences. If the history-taking process evokes intolerable affect, it may result in premature termination, destructive reenactments, self-mutilation, or other behaviors aimed at warding off the overwhelming affect (Basco, 2005).

Treatment Methods

In bipolar disorder cases, the clinician's job is to gather standard information and to begin to form hypotheses about the possibility of a traumatic history. If the therapist worked with the above patient from the perspective of a relational psychology, rather than individual psychopathology, psychotherapy might focus on clarifying the interpersonal contexts of psychological histories, Any psychotherapy would need to begin with external validation of a need to understand and make sense in some fashion of what in fact happened to Mr. Thompson. This patient needs to work through the assumptions shattered by his own history as well as whatever empathic factors (Mondimore, 2006).  To the extent that peer support groups are available, they are likely to be most helpful. Support and education for the patient's spouse and family would also contribute to a successful working-through process. For traumatized people, painful emotions need to be addressed within and between the generations. It is important to remember that such painful emotions are not necessarily evidence of psychopathology. Perpetrators' actions engender painful, paradoxical emotions in patients and those close to the patients (Basco, 2005).

Professionals can understand how the resulting predicaments can be handled, how their implications for basic assumptions can be processed, and how psychological functioning can be preserved to varying degrees, without invoking the notion of psychopathology. Surviving does involve pain, but pain is not the same as pathology. This distinction is important to patients suffered from bipolar disoder (Mondimore, 2006). Anything that unnecessarily adds to the distance between client and therapist, including a silent presumption of pathology in the patient, reinforces the patient's realistic awareness of disconnection, misunderstanding, and a sense of not being accurately heard. This can contribute to the persistence of psychological isolation and disconnection, despite efforts at treatment. The perpetrators' behavior was traumatic for the patient. Facts cannot be undone. Only the subjective experience of human connection and understanding can help time heal the wounds inflicted on patients and their loved ones (Miklowitz, 2002).

It is important to remember that the risk of harm is greatest when theoretical constructs are used to reinforce the human tendency to avoid empathic factors from listening to the patient's descriptions of painful predicaments. The therapist should focus more on clearly defined aspects of "patenting," on basic assumptions, on relational therapeutic psychology, and on peer and social supports to improve understanding of the fundamental mechanisms by which trauma has intergenerational consequences and the techniques by which some deleterious consequences can be minimized (Miklowitz, 2002).

Conclusion

Treating a bipolar disorder, the therapist might acknowledge that, while the individual may feel a need to tell all the details, he may feel frightened or overwhelmed after doing so and therefore need to back off. Talking about how this process might be regulated and controlled by the client, both within the sessions and at home, conveys respect for the client's own sense of timing. The therapist may also convey that the trauma history can be revealed over a period of time, rather than all at once. This assurance gives the person permission to back away from the material in the session, particularly if he is struggling with intense, overwhelming emotions and appears ambivalent about proceeding. The therapist might help Mr. Thompson to maintain a positive sense of self. This capacity, related to feelings of shame, humiliation, and disgust, is most often impaired among patients with bipolar disorder who feel responsible for the events or who make sense of abuse by blaming themselves. Bipolar disorder should be recognized and treated at early stages in order to reduce negative consequences for a patient and his family. 

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