Tag Archives: bipolar

Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Bipolar Resiliency Program” with John Duggan (HT056)

Webinars (aca.digitellinc.com/aca)

  • “Depression/Bipolar” with Carman S. Gill

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Reads recommended by counselors: Psychotic Rage!: A True Story of Mental Illness, Murder and Reconciliation

Review by Judith A. Nelson & Richard E. Watts December 27, 2015

Psychotic Rage!: A True Story of Mental Illness, Murder and Reconciliation is the gut-wrenching, yet fascinating, account of the Malone family and their struggle with severe mental illness. The author, Benny Malone, now retired, was a mental health professional in schools and in the community throughout her career. In this book, she provides readers with a detailed account of living with a mentally ill family member and the journey through the medical, mental health and judicial systems as she and her husband tried desperately to help their son overcome a severe mental illness.

At age 14, Benny’s son, Chris, was diagnosed with bipolar disorder. By the time Chris was 21, his diagnosis had expanded to include schizoaffective disorder. The book details the roller coaster ride of Chris’ 18 hospitalizations due to self-harm or suicidal ideation between the ages of 14 and 24. During this 10-year period, Chris had relationships as a patient with nine different psychiatrists, PsychoticRageworked with two therapists and was prescribed 25 different medications. He was hospitalized for a total of 295 days during these years.

In Benny’s words, “Psychosis became our new family member following the schizoaffective diagnosis, and my son’s health significantly deteriorated despite continual psychiatric treatment.” Despite Benny and her husband’s dedication to their son’s psychiatric treatment, Chris’ health deteriorated until the situation spiraled into an unbelievably tragic event.

In their quiet suburban neighborhood on a warm summer day in 2005, Benny and her husband were chatting at their kitchen table when Chris, now 24, had a major psychotic break, attacking Benny and killing his father. In spite of all the help they had provided Chris and the years of ups and downs with his illness, nothing could have predicted such a tragic outcome.

Benny details the entire account of the murder, including the 911 call, the sirens, the ambulance and the police cars. The scene at the house was chaotic, and even Benny’s visit to the hospital for her injuries is disturbing given the compassionless treatment of the emergency room personnel.

Chris was arrested the same day as the murder. In November 2011, following 6 1/2 years awaiting trial for murder, he was ultimately found not guilty of murder by reason of insanity. Benny recounts this long span of time prior to the trial in which Chris was transferred back and forth four times between a county jail and a state hospital, resulting in his spending a total of 39 months in jail and 38 months in the state hospital. These delays occurred because he was deemed not competent to stand trial for most of this time period.

After years of trying to manage Chris’ severe mental illness, Benny and her family didn’t anticipate the many additional years of burden they would experience struggling to navigate the criminal justice system. Readers are given a vivid sense of how the struggles of families dealing with severe mental illness seem unending.

Benny ends her story by explaining her understanding of her son’s inability to control his illness and her ability to forgive him for his erratic behavior that resulted in her husband’s murder.

This well-written account of living with a family member with a severe mental illness is intended for a variety of audiences. Psychotic Rage provides hope and encouragement to families such as Benny’s. She makes it clear that severe mental illness happens to all kinds of families, even those with a mother who is a mental health professional. Mental illness crosses all economic, social, racial, ethnic and faith lines and often attacks youth first.

The book is also meant for mental health professionals and those in training. It will help them better understand the complexity of severe mental illness and the ramifications for affected family members.

Psychotic Rage is also for policymakers and mental health advocates who need this important information to make informed decisions about the difficult legal aspects of patients and families facing serious mental illness.

To conclude, Psychotic Rage is a must-read for anyone who is interested in a compassionate understanding of the struggles of families who have a member with severe mental illness.

Benny Malone was the recipient of the Professional Writing Award at the most recent Texas Counseling Association Annual Professional Growth Conference.

 

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Have a book that you’d like to recommend to other counselors? Contact us at ct@counseling.org.

 

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Judith A. Nelson is associate professor of counselor education (retired) at Sam Houston State University in Texas and a past president of the Texas Counseling Association. She and Bunny Malone, the author of the book being reviewed, were former colleagues in a suburban Houston school district.

Richard E. Watts is a Sam Houston State University distinguished professor of counseling, the immediate past president of the North American Society for Adlerian Psychology and a fellow of the American Counseling Association.

Counseling the highly creative population

Olga Gonithellis September 1, 2013

ArtsMaybe it’s because I live in New York, a city that offers daily encounters with artists from all walks of life, or perhaps it’s because I have years of songwriting and performing experience myself. Regardless of the reason, I have often sought out (mostly unsuccessfully) clinical research or counseling practices focused on the “creative population.”

In searching for a relevant bibliography and attempting to locate resources that address mental health and artists, I have found a limited number of studies, theories and clinical work examples that explain or highlight issues unique to artists, performers and other creative individuals. As might be expected, there has been the occasional study on why “artsy teens are more likely to be depressed,” such as the one published by Laura N. Young of Boston College, or how “writers are often diagnosed with bipolar disorder,” such as in a Swedish study by Simon Kyaga (both studies are from 2012). In addition, some books, such as Christopher Zara’s Tortured Artists and Barry Panter’s Creativity & Madness: Psychological Studies of Art and Artists, have attempted to draw a connection between early childhood trauma and the need for artistic expression.

Nonetheless, studies dedicated to the unique counseling needs of clients who are highly creative have received relatively little attention, either from research institutions or the mainstream media. In addition, there is often a great deal of controversy regarding whether a causal connection exists between creativity and psychopathology. This article does not attempt to prove or disprove such a connection. Rather, it aims to illustrate why, when it comes to artists who seek help for mental health concerns, a need exists to have a deeper theoretical and clinical understanding of issues involving creativity and performance. It also provides some examples that showcase the importance of establishing artists as a subgroup.

After several years of experience as a mental health counselor to the general public in a variety of settings (private, state-funded and community), I decided to narrow my focus to clients whose mental health concerns affect, or are affected by, an important component of their identities: working as visual or performing artists and/or spending a significant part of their lives devoted to creative self-expression through art. Through my encounters with these clients, I have found that artists feel more comfortable and understood when talking to someone who spends time exploring what role creative expression and the “artistic lifestyle” plays in their lives. Furthermore, these clients benefit from specific counseling interventions and approaches.

Diagnosis as an integral part of identity

I once worked with a young woman who had been diagnosed with bipolar disorder and had a history of hospitalizations. She had been on various medications over a period of four to five years and had attended numerous counseling sessions. She was also a visual and performing artist.

During the period in which I saw her, she spent most of her time designing and painting, singing in bands and brainstorming ideas for a documentary she was hoping to shoot in the near future. A mental health professional might have described her as exhibiting “racing thoughts,” “labile affect,” “increased energy” and “grandiose plans.” She struggled with her mood and anxiety and would go through periods of numbness and isolation. These were contrasted by intense, long periods of high energy, passion, creativity and dedication to her art. She was prolific, innovative and talented — very talented.

One of the primary issues that arose in our work together was her acceptance of and degree of comfort with the term bipolar disorder. She wondered out loud, “Why should I be labeled as having bipolar every time I have a burst of creativity or every time I reflect upon life’s struggles? I’m just a different and unique individual!”

Moreover, from her perspective, feeling low and depressed often seemed to provide her the creative flow necessary to bring her ideas to life through the energy boost of a manic state. In other words, we have an example of a client whose psychiatric diagnosis was an integral part of her individual identity as an artist. She did not want to eliminate “manic episodes” or work on reducing her depression or regulating her mood. Rather, she was searching for a means of integrating her “highs and lows” into her sense of self as a creative being. She needed help recognizing her emotions, making use of them and channeling them appropriately through artistic mediums to produce a result that would make her feel confident and fulfilled.

Driven by the underlying assumption that her affective experiences were valuable for her professional and artistic identity, we began to focus on observing patterns of shifting moods. If, for example, she knew that she tended to feel particularly “expansive and energetic” every three to four weeks or whenever she was approaching a performance, we would keep track and prepare for the possibility of such mood changes. We also arrived at an agreement: During those times, she would be “allowed” to work on her art by welcoming the creativity that accompanied her manic symptoms. In exchange, she would commit to maintaining a proper self-care routine, including getting adequate sleep and setting time aside to relax, following each burst of intense creative work. This way, by working with the symptoms of bipolar disorder rather than against them, she was able to experience greater Rogerian congruence between her ideal and actual selves.

Performance anxiety

Other mental health concerns pertaining to artists may result from the perceived criticisms and evaluations related to the nature of performing. One example comes from a discussion I recently had with a young woman dedicated to her work as a songwriter and recording artist. She spent countless hours producing songs and adding the right instruments and vocal lines. However, during our discussions about her work, she would downplay her talent and often end her sentences by saying, “I don’t know what I’m doing” or “Everything I do sounds terrible.”

One day, as we were discussing her general life and career goals, she reported having ruled out a future as a stage performer because of her discomfort in front of others. She stated her plan to focus exclusively on becoming a recording artist and to avoid live performances. It was obvious that low self-esteem, performance anxiety and high levels of negative self-talk were affecting this young woman and determining her creative path from the very beginning.

The goal of working with this client might be to establish and strengthen her identity as an artist and to understand why she initially chose a profession based on self-expression, only to shy away from expressing herself in front of others. A counselor might also assist her with her debilitating performance anxiety by helping her to identify and challenge automatic negative thoughts. Although such an approach would seem to encroach on cognitive behavioral territory, it still requires a counselor who can connect with the motivational drive that pushes the client to create and express.

In this particular case, the focus of the sessions was twofold. On the one hand, many of our discussions centered on meaning-making. Put simply, we explored what this client found meaningful about singing and what it would mean to her to have others hear her voice and lyrics. By looking at her performing as an extension of her personality, we worked on empowering her sense of entitlement to expose and share these personality traits.

Furthermore, it became apparent that when this client performed in front of others, she would “blank out,” panic and occasionally feel depersonalized. We quickly realized that she needed a set of easily accessible relaxation and visualization tools that she could use when her body reverted to the familiar sensation of anxiety.

Relationship issues

A final example illustrates the difficulties that touring performers may face in forming and maintaining meaningful, long-lasting relationships. I worked with a comedian who was away from home for months at a time, traveling and meeting new people on the road, while also having to wear the mask of the “funny performer” every night. As the initial excitement wore off, he found himself feeling depressed and isolated. Of the hundreds of connections he was making with other people, few had any permanence, and none made him feel like an authentic version of himself. Although it was obvious to him that his work was contributing to his relational problems and feelings of depression, performing onstage was an essential component of his job, and he did not want to relinquish the experience of making others laugh.

In this situation, the counseling process might involve addressing feelings of depression through behavioral modification and cognitive behavior therapy, managing conflicting goals (“I choose to spend most of my time being someone else, yet I am in distress due to not being able to feel like myself”) and working on developing meaningful, albeit long-distance, relationships.

One of the goals we established was to work on the skill of “turning off” the character this client had to portray during his shows. We discussed the idea that conflicting personality traits can exist between one’s stage persona and one’s actual self, and that there is nothing wrong with that. We explored the client’s social interactions and how he might have been unintentionally presenting a character that did not accurately represent or satisfy his interpersonal needs. We then worked on recognizing which parts of himself he wanted to hold on to during his personal interactions and which parts he desired to leave onstage.

Final thoughts

Actors may face daily rejections from auditions. Writers with depression may face creativity blocks and low motivation. Dancers and athletes may face an increased risk of eating disorders in an environment obsessed with body shape. There are many examples that speak to a need for counselors who specialize in this particular population. This is not to say that nonartists don’t experience similar problems, or that a counselor who specializes in treating anxiety cannot help an anxious writer. However, a counselor who specializes in how anxiety affects writers and other highly creative individuals will be able to effectively work with a large group of people whose mental health diagnoses may be uniquely tied to their creative and artistic identities.

Finally, many questions arise from focusing on creativity and mental illness. Do individuals with mental illnesses choose highly creative careers because of the preconceived stereotype of the “tortured artist”? Is artistic expression a form of “self-treatment” for artists? Can artist-clients better connect to counselors who understand the importance of creativity to their perception of the world? Why are there so many iconic artists with a documented history of psychiatric conditions?

I eagerly anticipate an increased interest in understanding the potentially bidirectional relationship between mental illness and creativity, as well as a greater emphasis on training counselors regarding issues commonly presented in artists and performers. By trying to understand how the creative mind works, we will open ourselves to a fascinating field with great potential for growth and to the possibility of tailoring treatment to the needs of a large and unique group of people.

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Olga Gonithellis is a licensed mental health counselor who works in her private practice and a substance abuse day treatment program in New York City. She has received training in advanced creativity coaching for writers, visual artists and performers, and also received a certificate in performance psychology through the Zur Institute. In addition to her membership in the American Counseling Association, she is a member of the Performing Arts Medicine Association and the Creativity Coaching Association. Contact her at olgagonithellis@gmail.com or visit creativityandperformance.com.

Letters to the editor: ct@counseling.org