Tag Archives: bipolar

A time to make dreams come true

By Caitlin C. Regan April 21, 2021

So many people dream of fame, fortune, fast cars and fancy homes. For so long now, I have dreamed of freedom — freedom to be my full true self without judgment, shame or ridicule.

So, who am I, do you ask? I am a 33-year-old female mental health counselor (and former teacher) who also has a mental health condition. I have bipolar II, and for as long as I can remember, I have had to hide part of myself because so much of society stigmatizes, judges and condemns those who have mental health conditions.

It is not that I need to wear a sign around my neck reading “Bipolar II right here,” announcing it to every stranger I meet, but do I want to live in a world where, if that was my choosing, I could do so without being judged or shamed into the darkness. I imagine that many discriminated parties understand where I am coming from and might even be saying, “At least you do get to hide it.” But that is just it — I am tired of hiding. I have spent my life living in the shadows and playing a part the world can accept.

Many people in my life are aware of my condition and accept me — for all of me. I am greatly appreciative of all the support I have received, but it is no longer enough. I want, I demand, more! I want to be able to go to work and say I have bipolar II and not have the room go silent in fear or lack of understanding. I do not want a bad day, simply because I am human and have bad days, to turn into whispers of “Is she manic?” or “Is she depressed?”

For my entire working life, I have kept my condition to myself out of fear of persecution, out of fear of my judgment being called into question because of my condition. In all those years, never once have I put a student in jeopardy (as a counselor, I am placed in a school as well) because I am fully self-aware and manage my condition as I would any other medical condition. On days when I am in a depressive episode or manic episode and am not feeling well enough to do my job, I take a sick day, just as anyone with any other medical condition would need to do.

Those with mental health conditions can thrive if they receive proper care and treatment management. In fact, there are many who have thrived throughout the ages despite having less availability to treatment than is available in the 21st century. Beethoven, Michelangelo and Abraham Lincoln (to mention only a few) all reportedly had mental health conditions, and they accomplished amazing, history-altering feats. Why then is there still such stigma surrounding mental health disorders?

Admittedly, things are better today. In the 1800s, people who were even suspected of hysterics (mostly women) were locked away. In the 21st century, we have many people who openly speak about having mental health disorders and various organizations (the National Alliance on Mental Illness, the Depression and Bipolar Support Alliance, county mental health boards, the Substance Abuse and Mental Health Services Administration, etc.) that work tirelessly to support those with mental health conditions and their loved ones. Even what I do, serving as an intervention therapist, was not heard of as recently as the 1990s and early 2000s when I was in school. 

My beginnings

When I began my journey, at 12 years old, no one knew how to help me. I was consistently described as a “freak” in my school, by students and adults alike. My parents tried to help, going to every medical doctor they could think of to discern why I was randomly fainting. It was not until years later that I was told I had conversion disorder (one’s system converts psychological symptoms to physical symptoms) and not until I was 23 that a psychiatrist diagnosed me with bipolar II. And I was 29 before receiving proper treatment that truly turned my life around.

Ironically, it was not a professional who discovered my miracle treatment. It was me, as a counseling graduate student, doing a paper on electroconvulsive therapy (ECT). Now, coming up on my four-year anniversary of receiving ECT, I am at a new place in my treatment.

I am a mental health professional myself now and experiencing lengths of stability not previously known to me. Even when I do have an episode, they are far shorter and less severe than they ever were before. Most important, I love who I am and am damn proud of myself. It is at this juncture that I want more — not for myself, but for the world of mental health. I am using my newfound stability and happiness to ask, “How can I make a difference?”

I recognize how blessed I am to have found a treatment plan and team that have helped me become the best version of myself, but I want the same thing for all who have mental health conditions, and I want it without bias. As well as I am, I still cannot go into work, sit at the lunch table and talk about my week being difficult because of a medication change for my bipolar. Well, I could, but the ramifications would be costly. For those who doubt my claim and say there are laws against that, let’s be honest. Yes, on paper, there are laws against discrimination and bias. But that does not mean that cases of discrimination and bias no longer take place on a daily basis against every “protected” group.

The fact is, in America, if you are not the “norm,” there are many who look to remove your rights as a citizen, as a person, as a human being. This can no longer be the case, and mental health needs to join the movements rising up. Those of us living with mental health conditions need to demand our right not to be judged and not to be deemed anything less than ALL of who we are. It is true that we need help, but no one goes through life without needing help. With proper treatment and active participation in that treatment, there is no reason that we cannot thrive.

Recognition and moving forward

I have rarely said this out loud. Only a chosen few have heard what I am now going to publish willingly. I think it is in part due to my bipolar that I am so creative. There is something that happens that I truly do believe stems from my condition that allows me to think at the speed I think and write while envisioning my final product (this certainly didn’t hurt during pursuit of the three master’s degrees and one bachelor’s I have earned). It also creates an empathy that allows me to place myself in the moment with people and feel with them, for them, as them.

It is true that this empathy, when I was young and did not understand what seemed an overwhelming amount of feelings, caused me a lot of pain. In return, I caused much pain to myself. But through the receipt of empathy from others and the receipt of caring treatment, I have learned how to hone those feelings and use them in my career as a counselor. I have turned my empathy into my very own “superpower” to help others who are in pain. I receive no greater joy than the work I perform as a counselor for adolescents. First as a teacher and now as a counselor to adolescents in a school, I am privileged to get to turn all I have been through into something truly meaningful.

Again though, it is not enough. Change needs to happen in this society, and I want — no, I need — to be a part of it. Not for political reasons but for humane reasons. I am a human being hurting because I do not have the ability to be my full true self. I have come to a place where I am now proud of who I am, but still I feel I cannot go into society and share my true self — and I want to.

No one should feel they have to hide a part of themselves because it does not fit the accepted “norm.” Now is the time to come together and demand change. Not just for the mental health world, but for all who feel they have to live in the shadows. Support change not because of your political party but because it is the right thing to do for all human beings.

 

Related reading: ACA Virtual Conference Experience keynote speaker Bassey Ikpi also shared her journey with bipolar II disorder. Read more in our coverage of her keynote address.

 

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Caitlin Regan is a 33-year-old living with bipolar II disorder. She was diagnosed in 2012 and has been living successfully in treatment. She receives electroconvulsive therapy and participates in cognitive behavior therapy as her treatment plan. She is a residential therapist in an adolescent addiction treatment facility. Contact her on her mental health support Instragram account: @caitlins_counseling_corner.

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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.

Bassey Ikpi shares her gradual journey toward a healthy relationship with therapy

By Lindsey Phillips April 19, 2021

Bassey Ikpi, a spoken word poet, writer and mental health advocate, opened the third week of the American Counseling Association’s 2021 Virtual Conference Experience by sharing details from her own mental health journey. She recalled that her first encounter with mental health awareness happened in elementary school. An avid reader, she consumed whatever she could get her hands on, including her mother’s psychology textbooks and subscription to Psychology Today.

In particular, Ikpi remembers how Psychology Today’s May 1986 cover story on Howard Hughes shaped her relationship to mental health. The article discussed Hughes’ struggle with obsessive-compulsive disorder, describing in detail how he locked himself naked in a hotel room, refused to brush his teeth or cut his hair and nails, and wore Kleenex boxes on his feet.

That image would be startling to most anyone, let alone a 9-year-old, but what stood out the most to Ikpi was how no one helped Hughes. “I told myself that if I ever needed help, I’d find a way to get it,” Ikpi related to the audience for her keynote. “I never wanted to get to the point where I was wearing Kleenex boxes on my feet.”

Finding help

Ikpi, author of the bestselling memoir I’m Telling the Truth, But I’m Lying, first had serious bouts of depression during college. She said that she vacillated between being unable to sleep and unable to get out of bed, and she maxed out her credit card.

Even though Ikpi felt OK at the time, she was concerned enough to seek out the counseling services on campus. The counselor sat across from her and just scribbled in her notepad the entire session, Ikpi recalled, which left Ikpi feeling unheard and unseen. “I had walked in nervous but hopeful, and walked out discouraged and determined never to return,” she told the audience. “If this was counseling, I thought, ‘I’m good.’”

A few years later, however, Ikpi found herself in distress again when, during a hypomanic episode, she took a spontaneous trip to New York City and ended up dropping out of college and moving to Brooklyn. She hoped the move would keep her moods at bay, but it didn’t work. Ikpi sought help, but like her first experience, the therapist mainly wrote notes on a legal pad and asked clinical, nonpersonal questions. Once again, Ikpi left feeling that seeking therapy had been a waste of time.

After joining the Tony Award-winning Broadway show Def Poetry Jam, Ikpi found that her previous coping methods no longer worked, and she started to deteriorate quickly. She was losing weight, not sleeping and withdrawing. After having a breakdown backstage, the stage manager told her, “If you don’t get help, Bassey, you’re going to die.”

Ikpi left the tour the next day with a list of doctors, determined to get help. “Because of my past experiences with counseling, I walked in with an agenda. I wanted to be helped, but only as far as I would be able to accept,” she said. Her goal was to get enough help that she could return to her job.

After receiving several misdiagnoses, Ikpi walked into the office of the last doctor on her list. This therapist didn’t have a notepad. She instead had a conversation with Ikpi, and for the first time, Ikpi felt heard.

“That meeting was what began my journey toward a healthy relationship with therapy. It taught me the kind of therapy that works best for me,” she told the audience. This therapist also introduced her to another psychiatrist who gave a name to what Ikpi was experiencing — bipolar II disorder.

Overcoming the shame of mental health

Ikpi admitted that her first instinct was to keep quiet about her diagnosis out of a fear that it would change the way others perceived her. But she noticed that the shame also meant she wasn’t able to fully take care of herself.

Shortly after being diagnosed, Ikpi was watching an episode of the TV series Girlfriends in which one of the characters finds out her biological mother had bipolar disorder. Ikpi remembers thinking, “They’re going to have a conversation about bipolar disorder. That’s going to make it so much easier for me to have this conversation when I need to have it.” But the series dropped the ball, Ikpi said, because when the character asks a friend if she has inherited the disorder, the friend quickly dismisses the possibility, saying that the character is amazing, not “crazy.”

“The juxtaposition between ‘crazy’ and ‘amazing’ was trying to dispel all these things that I knew to be true about myself and my experience and my diagnosis,” Ikpi said.

Frustrated by this experience, she wrote about her diagnosis on her blog. She acknowledged to the keynote audience that this was in part a selfish act because she didn’t want to feel alone anymore and hoped to find someone else living with a bipolar disorder.

That blog post was the beginning of Ikpi finding ways to create “space for other people to name what they were experiencing, get encouragement from people and then do something about it.” Ikpi, founder of the Siwe Project, a nonprofit aimed at promoting mental health awareness in the Black community, started the global movement #NoShameDay to encourage people of African descent to share stories about mental health issues without shame and to seek help if needed.

She credits the success of #NoShameDay with the fact that “people are given permission to deal with this out loud as opposed to quietly where you can talk yourself out of it or … where you can ‘other’ yourself in a way that makes it uncomfortable to live in your own brain.”

Ikpi also told the audience it’s no coincidence that #NoShameDay falls on the second Monday in July, which is Minority Mental Health Awareness Month. While #NoShameDay day exists for everyone, it’s especially for the Black community because they are the ones who are consistently penalized for their mental health, she noted. “Our mental health is criminalized; our mental health is legislated in ways that others aren’t so [this movement] … bring[s] attention to that,” she said. The movement humanizes mental health by making “it about people’s lived experiences and their stories and not a collection of texts or a list of diagnoses.”

Growing through therapy

Ikpi compared living with an untreated mental health diagnosis with “living in a run-down house in a bad neighborhood,” where she learned how to survive and cope with what she was given. Continuing this analogy, she said that medicine allowed her to move to a better neighborhood, and therapy taught her how to traverse this new neighborhood.

“Your instinct … is to fall back on the habits that worked before. Therapy teaches me a new way to navigate when the old ways are no longer working or no longer serving my needs,” she explained.

Ikpi also shared that some people have aligned her diagnosis with her artistic ability, telling her that if she didn’t have bipolar disorder, she wouldn’t be the writer that she is. To which she responds, “I would rather not be a writer. I would give it all up. I don’t write because of bipolar disorder. I write despite it.”

“Having bipolar disorder isn’t who I am; it is what I have,” she told the audience. “It doesn’t define me anymore than being short or wearing glasses. It’s just a part of what … I have to navigate the world with.”

Ikpi concluded by reminding mental health professionals of how important their job is. “It’s a service that I don’t think is rewarded enough,” she stressed. “I would not be here — literally would not exist — if it wasn’t for the people who have made it their job to care about people like me.”

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This keynote address is part of a month of virtual events, including hundreds of educational sessions and three additional keynotes, that lasts through April 30.

Find out more about the American Counseling Association’s 2021 Virtual Conference Experience at counseling.org/conference/conference-2021

Registration is open until April 30; participants will have access to all conference content until May 31.

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

Challenging the inevitability of inherited mental illness

By Lindsey Phillips August 29, 2019

With a family history that famously includes depression, addiction, eating disorders and seven suicides — including her grandfather Ernest Hemingway and her sister Margaux — actress and writer Mariel Hemingway doesn’t try to deny that mental health issues run in her family. She repeatedly shares her family history to advocate for mental health and to help others affected by mental illness feel less alone.

And, of course, they aren’t alone. Mental health issues are prevalent in many families, making it natural for some individuals to wonder or worry about the inherited risks of developing mental health problems. Take the common mental health issue of depression, for example. The Stanford University School of Medicine estimates that about 10% of people in the United States will experience major depression at some point during their lifetime. People with a family history of depression have a two to three times greater risk of developing depression than does the average person, however.

A 2014 meta-analysis of 33 studies (all published by December 2012) examined the familial health risk of severe mental illness. The results, published in the journal Schizophrenia Bulletin, found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a 1 in 3 chance of developing one of those illnesses by adulthood — more than twice the risk for the control offspring of parents without severe mental illness.

Jennifer Behm, a licensed professional counselor (LPC) at MindSpring Counseling and Consultation in Virginia, finds that clients who are worried about family mental health history often come to counseling already feeling defeated. These clients tend to think there is little or nothing they can do about it because it “runs in the family,” she says.

Theresa Shuck is an LPC at Baeten Counseling and Consultation Team and part of the genetics team at a community hospital in Wisconsin. She says family mental health history can be a touchy subject for many clients because of the stigma and shame associated with it. In her practice, she has noticed that individuals often do not disclose family history out of their own fear. “Then, when a younger generation person develops the illness and the family history comes out, there’s a lot of blame and anger about why the family didn’t tell them, how they would have wanted to know that, and how they could have done something about it,” she notes.

Sarra Everett, an LPC in private practice in Georgia, says she has clients whose families have kept their history of mental illness a secret to protect the family image. “So much of what feeds mental illness and takes it to an extreme is shame. Feeling like there’s something wrong with you or not knowing what is wrong with you, feeling alone and isolated,” Everett says. Talking openly and honestly about family mental health history with a counselor can serve to destigmatize mental health problems and help people stop feeling ashamed about that history, she emphasizes.

Is mental illness hereditary?

Some diseases such as cystic fibrosis and Huntington’s disease are caused by a single defective gene and are thus easily predicted by a genetic test. Mental illness, however, is not so cut and dry. A combination of genetic changes and environmental factors determines if someone will develop a disorder.

In her 2012 VISTAS article “Rogers Revisited: The Genetic Impact of the Counseling Relationship,” Behm notes that research in cellular biology has shown that about 5% of diseases are genetically determined, whereas the remaining 95% are environmentally based.

The history of the so-called “depression gene” perfectly illustrates the complexity of psychiatric genetics. In the 1990s, researchers showed that people with shorter alleles of the 5-HTTLPR (a serotonin transporter gene) had a higher chance of developing depression. However, in 2003, another study found that the effects of this gene were moderated by a gene-by-environment interaction, which means the genotype would result in depression if people were subjected to specific environmental conditions (i.e., stressful life events). More recently, two studies have disproved the statistical evidence for a relation between this genotype and depression and a gene-by-environment interaction with this genotype.

Even so, researchers keeps searching for disorders that are more likely to “run in the family.” A 2013 study by the Cross-Disorder Group of the Psychiatric Genomic Consortium found that five major mental disorders — autism, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia — appear to share some common genetic risk factors.

In 2018, a Bustle article listed 10 mental health issues “that are more likely to run in families”: schizophrenia, anxiety disorders, depression, bipolar disorder, obsessive-compulsive disorder (OCD), ADHD, eating disorders, postpartum depression, addictions and phobias.

Adding to the complexity, Kathryn Douthit, a professor in the counseling and human development program at the University of Rochester, points out that studies on mental disorders are done on categories such as major depression and anxiety that are often based on descriptive terms, not biological markers. The cluster of symptoms produces a “disorder” that may have multiple causes — ones not caused by the same particular genes, she explains.

Thus, thinking about mental health as being purely genetic is problematic, she says. In other words, people don’t simply “inherit” mental illness. A number of biological and environmental factors are at play in gene expression.

Regardless of the genetic link, family history does serve as an indicator of possible risk for certain mental health issues, so counselors need to ask about it. As a genetic counselor, Shuck, a member of the American Counseling Association, admits that she may handle family history intake differently. Genetic counseling, as defined by the National Society of Genetic Counselors, is “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” It blends education and counseling, including discussing one’s emotional reactions (e.g., guilt, shame) to the cause of an illness and strategies to improve and protect one’s mental health.

Thus, Shuck’s own interests often lead her to ask follow-up questions about family history rather than sticking to a general question about whether anyone in a client’s family struggles with a certain disorder. If, for example, she learns a client has a family history of depression, she may ask, “Who has depression, or who do you think has depression?” After the client names the family members, Shuck might say, “Tell me about your experiences with those family members. How much has their mental health gotten in the way? How aware were you of their mental health?”

These questions serve as a natural segue to discussing how some disorders have a stronger predisposition in families, so it is good to be aware and mindful of them, she explains. Discussing family history in this way helps to normalize it, she adds.   

Everett, who specializes in psychotherapy for adults who were raised by parents with mental illness, initially avoids asking too many questions. Instead, she lets the conversation unfold, and if a client mentions alcohol use, she’ll ask if any of the client’s family members drink alcohol. Inserting those questions into the discussion often opens up a productive conversation about family mental health history, she says.

Environmental factors

Mental disorders are “really not at all about genetic testing where you’re testing genes or blood samples because there are no specific genetic tests that can predict or rule out whether someone may develop mental illness,” Shuck notes. “That’s not how mental illness works.”

Shuck says that having a family history of mental illness can be thought of along the same lines as having a family history of high blood pressure or diabetes. Yes, having a family history does increase one’s risk for a particular health issue, but it is not destiny, she stresses.

For that reason, when someone with a family history of mental disorders walks into counseling, it is important to educate them that mental health is more than just biology and genetics, Shuck says. In fact, genetics, environment, lifestyle and self-care (or lack thereof) all work together to determine if someone will develop a mental disorder, she explains.

One of Shuck’s favorite visual tools to help illustrate this for clients is the mental illness jar analogy (from Holly Peay and Jehannine Austin’s How to Talk With Families About Genetics and Psychiatric Illness). Shuck tells clients to imagine a glass jar with marbles in it. The marbles represent the genes (genetic factors) they receive from both sides of their family. The marbles also represent one’s susceptibility to mental illness; some people have two marbles in their jar, while others have a few handfuls of marbles.

Next, Shuck explains how one’s lifestyle and environment also fill the jar. To illustrate this point, she has clients imagine adding leaves, grass, pebbles and twigs (representing environmental factors) until the jar is at capacity. “We only develop mental illness if the jar overflows,” she says.

Behm, an ACA member, also uses a simple analogy (from developmental biologist Bruce Lipton) to help explain this complex issue to clients. She tells clients to think of a gene as an overhead light in a room. When they walk into the room, that light (or gene) is present but inactive. They have to change their environment by walking over and flipping on a switch to activate the light.

As Everett points out, “Our experiences, drug use, traumas, these things can turn genes on, especially at a young age.” On the other hand, if someone with a pervasive family history of mental disorders had caregivers who were aware and sought help, the child could grow up to be relatively well-adjusted and healthy in terms of mental health, she says.

In utero epigenetics is another area that illustrates how environment affects our genes and mental health, Douthit notes. The Dutch Hongerwinter (hunger winter) offers an example. In 1944-1945, people living in a Nazi-occupied part of the Netherlands endured starvation and brutal cold because they were cut off from food and fuel supplies. Scientists followed a group who were in utero during this period and found that the harsh environment caused changes in gene expression that resulted in their developing physical and mental health problems across the life span. In particular, they experienced higher rates of depression, anxiety disorders, schizophrenia, schizotypal disorder and various dementias.

Why is this important to the work of counselors? If, Douthit says, counselors are aware of an environmental risk to young children, such as the altered gene expression coming from the chronic stress and trauma associated with poverty, then they can work with parents and use appropriate therapeutic techniques such as touch therapy interventions in young infants and child-parent psychotherapy to reverse the impact of the harmful
gene expression.

Behm uses the Rogerian approach of unconditional positive regard and “prizing” the client (showing clients they are worth striving for) to create a different environment for clients — one that is ripe for change.

Counseling interventions that change clients’ behaviors and thoughts long term have the potential to also change brain structure and help clients learn new ways of doing and being, Behm continues. “It’s the external factors that are making people anxious or depressed,” she says. “If you get yourself out of that situation, your experience can be different. If you can’t get yourself out of it, the way you perceive it — how you make meaning of it — makes it different in your brain.”

The hope of epigenetics

Historically, genes have been considered sovereign, but genetics don’t tell the entire story, Behm points out. For her, epigenetics is a hopeful way to approach the issue of familial mental illness.

Epigenetics contains the Greek prefix epi, which means “on top of,” “above” or “outside of.” Thus, epigenetics includes the factors outside of the genes. This term can describe a wide range of biological mechanisms that switch genes on and off (evoking the prior analogy of the overhead light). Epigenetics focuses on the expression of one’s genes — what is shaped by environmental influences and life experiences such as chronic
stress or trauma.

Douthit has written and presented on the relationship between counseling and psychiatric genetics, including her 2006 article “The Convergence of Counseling and Psychiatric Genetics: An Essential Role for Counselors” in the Journal of Counseling & Development and a 2015 article on epigenetics for the “Neurocounseling: Bridging Brain and Behavior” column in Counseling Today. In her chapter on the biology of marginality in the 2017 ACA book Neurocounseling: Brain-Based Clinical Approaches, she explains epigenetics as the way that aspects of the environment control how genes are expressed. Epigenetic changes can help people adapt to new and challenging environments, she adds.

This is where counseling comes in. Clients often come to counseling after they have struggled on their own for a while, Behm notes. The repetition of their reactions to their external environment has resulted in a certain neuropathway being created, she explains.

Clients are inundated with messages of diseases being genetic or heritable, but they rarely hear the counternarrative that they can make changes in their lives that will provide relief from their struggle, Behm notes. “Through consistent application of these changes, [clients] can change the structure and function of [their] brain,” she adds. This process is known as neuroplasticity.

Behm explains neuroplasticity to her clients by literally connecting the dots for them. She puts a bunch of dots on a blank piece of paper to represent neurons in the brain. Then, for simplicity, she connects two dots with a line to represent the neuropathway that develops when someone acts or thinks the same way repeatedly. She then asks, “What do you think will happen if I continue to connect these two dots over and over?” Clients acknowledge that this action will wear a hole in the paper. To which she responds, “When I create a hole, then I don’t have to look at the paper to connect the dots. I can do it automatically without looking because I have created a groove. That’s a neuropathway. That’s a habit.”

Even though clients often come in to counseling with unhealthy or undesirable habits (such as responding to an event in an anxious way), Behm provides them with hope. She explains how counseling can help them create new neuropathways, which she illustrates by connecting the original dot on the paper with a new dot.

Of course, the real process is not as simple as connecting one dot to another, but the illustration helps clients grasp that they can choose another path and establish a new way of being and doing, Behm says. The realization of this choice provides clients — including those with family histories of mental illness — a sense of freedom, hope and empowerment, she adds.

At the same time, Behm reminds clients of the power exerted by previously well-worn neuropathways and reassures them that continuing down an old pathway is normal. If that happens, she advises clients to journal about the experience, recording their thoughts and feelings about making the undesirable choice and what they wish they had done or thought differently.

“The very act of writing that out strengthens the [new] neuropathway,” she explains. “Not only did you pause and think about it … you wrote about it. That strengthened it as well.”

In addition, professional clinical counselors can help bring clients’ subconscious thoughts to consciousness. By doing this, clients can process harmful thoughts, make meaning out of the situation, and create a new narrative, Behm explains. The healthy thoughts from the new narrative can positively affect genes, she says.

Protective factors

When patients are confronted with a physical health risk such as diabetes or high blood pressure, they are typically encouraged by health professionals to adjust their behavior in response. Shuck, a member of the National Society of Genetic Counselors and its psychiatric disorders special interest group, approaches her clients’ increased risk of mental health problems in a similar fashion: by helping them change their behaviors.

Returning to the mental illness jar analogy, Shuck informs clients that they can increase the size of their jars by adding rings to the top so that the “contents” (the genetic and environmental factors) don’t spill over. These “rings” are protective factors that help improve one’s mental health, Shuck explains. “Sleep, exercise, social connection, psychotherapy, physical health maintenance — all of those protective factors that we have control of and we can do something about — [are] what make the jar have more capacity,” she says. “And so, it doesn’t really matter how many marbles we’re born with; it’s also important what else gets put in the jar and how many protective factors we add to it to increase the capacity.”

Techniques that involve a calming sympathetic-parasympathetic shift (as proposed by Herbert Benson, a pioneer of mind-body medicine) may also be effective, Douthit asserts. Activities such as meditation, knitting, therapeutic massage, creative arts, being in nature, and breathwork help cause this shift and calm the nervous system, she explains. Some of these techniques can involve basic behavioral changes that help clients “become aware of when [they’re] becoming agitated and to be able to recognize that and pull back from it and get engaged in things that are going to help [them] feel more baseline calm,”
she explains.

In addition, counseling can help clients relearn a better response or coping strategy for their respective environmental situations, Behm says. For example, a client might have grown up watching a parent respond to external events in an anxious way and subconsciously learned this was an appropriate response. In the safe setting of counseling, this client can learn new, healthy coping methods and, through repetition (which is one way that change happens), create new neuropathways.

At the same time, Shuck and Douthit caution counselors against implying that as long as clients do all the rights things — get appropriate sleep, maintain good hygiene, eat healthy foods, exercise, reduce stress, see a therapist, maintain a medicine regime — that they won’t struggle, won’t develop a mental disorder, or can ignore symptoms of psychosis.

“You can do all of the right things and still develop depression. It doesn’t mean that somebody’s doing something wrong. … It just means there happened to have been more marbles in the jar in the first place,” Shuck says. “It’s [about] giving people the idea that there’s some mastery over some of these factors, that they’re not just sitting helplessly waiting for their destiny to occur.”

Shuck often translates this message to other areas of health care. For example, someone with a family history of diabetes may or may not develop it eventually, but the person can engage in protective factors such as maintaining a healthy body weight and diet, going to the doctor, and getting screened to help minimize the risk. “If we normalize [mental health] and make it very much a part of what we do with our physical health, it’s really not so different,” she says.

Bridging the gap

Shuck started off her career strictly as a genetic counselor. As she made referrals for her genetics clients and those dealing with perinatal loss to see mental health therapists, however, several clients came back to her saying the psychotherapist wasn’t a good fit. Over time, this happened consistently.

This experience opened Shuck’s eyes to the existing gap between the medical and therapeutic professions for people who have chronic medical or genetic conditions. Medical training isn’t typically part of the counseling curriculum, often because there isn’t room or a need for such specialized training, she points out.

Shuck decided to become part of the solution by obtaining another master’s degree, this time in professional counseling. She now works as a genetic counselor and as a psychotherapist at separate agencies. She says some clients are drawn to her because of her science background and her knowledge of the health care setting.

Behm also notes a disconnect between genetics and counseling. “I see these two distinct pillars: One is the pillar of genetic determinism, and the other is the pillar of epigenetics. And with respect to case conceptualization and treatment, there aren’t many places where the two are communicating,” she says.

Douthit, a former biologist and immunologist, acknowledges that some genetic questions such as the life decisions related to psychiatric genetics are outside the scope of practice for professional clinical counselors. However, helping clients to change their unhealthy behaviors and though patterns, deal with family discord or their own reactions (e.g., grief, loss, anxiety) to genetically mediated diseases, and create a sympathetic-parasympathetic shift are all areas within counselors’ realm of expertise, she points out.

An interprofessional approach is also beneficial when addressing familial mental health disorders. If Behm finds herself “stuck” with a client, she will conduct motivational interviewing and then often include a referral to a medical doctor or other medical professional. For example, she points out, depression can be related to a vitamin D deficiency. She has had clients whose vitamin D levels were dangerously low, and after she referred them to a medical doctor to fix the vitamin deficiency, their therapeutic work improved as well.

Another example is the association between addiction and an amino acid deficiency. Behm notes that consulting with a physician who can test and treat this type of deficiency has been shown to reduce clients’ desires to use substances. Even though counselors are not physicians, knowing when to make physicians a part of the treatment team can help improve client outcomes,
she says. 

Another way to bridge the gap between psychotherapy and the science of genetics is to make mental health a natural part of the dialogue about one’s overall health. “Mental illness lives in the organ of the brain, but we somehow don’t equate the brain as an organ that’s of equality with our kidneys, heart or liver,” Shuck says. When there is a dysfunction in the brain, clients deserve the opportunity to make their brains work better because that is important for their overall well-being,
she asserts.

Facing one’s fears

Having a family history of mental illness may result in fear — fear of developing a disorder, fear of passing a disorder on to a child, fear of being a bad parent or spouse because of a disorder.

“Fear is paralyzing,” Shuck notes. “When people are fearful of something … they don’t talk about it and they don’t do anything about it.” The aim in counseling is to help clients move away from feeling afraid — like they’re waiting for the disorder to “happen” — to feeling more in control, she explains.

Some clients have confessed to Everett that they have doubts about whether they want or should have children for several reasons. For instance, they fear passing on a mental health disorder, had a negative childhood themselves because of a parent who suffered from an untreated disorder, or currently struggle with their own mental health. For these clients, Everett explains that having a mental health issue or a family history of mental illness doesn’t mean that they will go on to neglect or abuse their children. “With parents who have the support and are willing to be open and ask for help … [mental illness] can be a part of their life but doesn’t have to completely devastate their children or family,” she says.

Shuck reminds clients who fear that their children could inherit a mental illness that most of the factors that determine whether people develop a mental disorder are nongenetic. In addition, she tells clients their experience with their own mental health is the best tool to help their child if concerns arise because they already know what signs to look for and how to get help.

Even if a child comes from a family with a history of mental illness, the child’s environment will be different from the previous generations, so the manifestations of mental illness could be less or more severe or might not appear at all, Douthit adds.

The potential risk of mental illness may also produce anger in some clients, but as Shuck points out, this can sometimes serve as motivation. One of her clients has a family history that includes substance abuse, addiction, hoarding, anxiety, bipolar disorder, OCD, depression and suicide. The client also experienced mental health problems and had a genetic disorder, but unlike her family, she advocated for herself. When Shuck asked her why she was different from the rest of her family, the client confessed she was angry that she had grown up with family members who wouldn’t admit that they had a mental illness and instead used unhealthy behaviors such as drinking to cope. She knew she wanted a different life for herself and her future children.

Defining their own destiny

Everett doesn’t focus too heavily on client genetics because she can’t do anything about them. Instead, her goal is to encourage clients to believe that they can change and get better themselves. She wants clients to move past their defeated positions and realize that a family history of mental illness doesn’t have to define them.

Likewise, Behm thinks counselors should instill hope and optimism into sessions and carry those things for clients until they are able to carry them for themselves. To do this, counselors should be well-versed in the science of epigenetics and unafraid of clients’ family histories, she says. Practitioners must believe that counseling can truly make a difference and should attempt to grow in their understanding of how the process can alter a client’s genes, she adds.

From the first session, Behm is building hope. She has found that activities that connect the mind and body can calm clients quickly and make them optimistic about future sessions. For example, she may have clients engage in diaphragmatic breathing and ask them what they want to take into their bodies. If their answer is a calming feeling, she tells them to imagine calm traveling into every single cell of their bodies when they breath in. Alternately, clients can imagine inhaling a color that represents calm. Next, Behm asks clients what they want to let go of — stress or anxiety, for example — and has them imagine that leaving the body as they exhale.

Hope and optimism played a large role in how Mariel Hemingway approached her family’s history of mental illness. She recognized that her history made her more vulnerable. Determined not to become another tragic story, Hemingway exerted control over her environment, thoughts and behaviors. Today, she continues to eat well, exercise, meditate and practice stress reduction.

Hemingway’s story illustrates the complexity of familial history and serves as a good model for counselors and clients, Douthit says. “Whether it’s genetic or not, it’s being passed along from generation to generation,” Douthit says. “And that could be through behaviors. It could be through other environmental issues. It could be any number of modifications that occur when genes are expressed.”

Shuck says she often hears other mental health professionals place too great an emphasis on the inheritance of mental illness. A family history of mental illness alone does not determine one’s destiny, she says. Instead, counselors and clients should focus on the things they do have control over, such as environmental factors and lifestyle.

“We have to emphasize wellness [and protective factors] much more than the idea that ‘it’s in my family, so it’s going to happen to me,’” she says. “We have to look at those things we can do as an individual to enhance those aspects of our well-being to make [the capacity of the mental illness] jar bigger.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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.

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.