Thursday, 28 July 2016

What is bipolar disorder?

How many times have you heard someone say in casual conversation something like: "I'll bet she's bipolar!"  Often the comment is used to describe people who have wide mood swings and erratic behavior.  They can be be very up one moment and very down the next.  While this may have become the casual layperson's version of bipolar, from a clinical, more formal perspective, it does not begin to describe what people with bipolar struggle with and how complex this diagnosis really is.

To begin, for all of us, our moods fluctuate, not just from one day to the next but within the course of a day.  While it is true that people with bipolar disorder demonstrate wide mood fluctuations ranging from very high to very low, these shifts are typically very severe and they are by no means momentary.  The highs and the lows can last for weeks and even months.  Also, in this context, the term "mood" has many more meanings than just feeling up or down. For instance, irritability is often a hallmark of bipolar disorder.  A state of agitation is invariably present which affects both mind and body and can be very uncomfortable and difficult to tolerate.  Bipolar disorder is a serious condition, not easy to diagnose.

Interestingly, 80% of people diagnosed with bipolar disorder are likely to have been diagnosed with depression first.  It is not uncommon to discover when looking at their history that many different kinds of anti-depressant medications were tried without success.  In fact, people with bipolar disorder react very poorly to anti-depressant medication often becoming even more distressed and agitated. Effective medication for bipolar disorder is quite different from the type of medication that is used for just straight depression or what is known as "uni-polar" depression.  This is one instance where diagnosis truly is critical if one is to know what the best course of action is from a medication stand point. Those with a bipolar diagnosis require a mood stabilizer, not anti-depressant medication, in order to feel better.  Our contemporary understanding of depression is changing.  In fact, the most progressive view of depression now sees all types of depression as lying on a single continuum with depression at one end and bipolar disorder on the other.

There have been many recent changes in terminology and in our understanding of bipolar disorder. Manic depression was the original term used to describe bipolar disorder prior to 1980.  An even more recent change in just the last few years was the recognition that bipolar disorder can present in a milder form, the more severe form being referred to now as "Bipolar I" and the less severe kind, referred to as "Bipolar II".  Traditionally, manic depression or what is now called Bipolar I, requires that the person in addition to bouts of depression, experience at least one manic episode in the course of their lifetime. A manic episode is a very serious altered state where the person loses touch with reality.  Symptoms of mania can include a decreased need for sleep for days on end, rapid fire thoughts, pressured speech, delusions of grandeur such as believing one has superhuman powers, excessive behaviors that have a high potential for destructive consequences such as unrestrained buying sprees, sexual indiscretions or foolish business investments,

The most recent version of the Diagnostic Statistical Manual (the DSM-5), published in 2013 and used by psychiatrists and psychologists to assist in determining diagnoses, now states that a milder form of bipolar disorder exists referred to as "Bipolar II".  In this less severe form of bipolar disorder, a more mild form of mania expresses itself called "hypomania".  Hypomania does not involve delusional thinking but it has similar components to mania such as decreased need for sleep, exuberant or elated mood, rapid speech, exaggerated confidence, hyper focus on projects or tasks, greater creativity and productivity, increased energy and sexual drive, reckless behaviors and risky pleasure seeking behaviors.  As was the case with Robin Williams, many people with bipolar disorder are extremely talented and bright and the hypomanic edge when not out of control, may even result in more crisp thinking and greater productivity.  But this should not lead to a romanticized view of the condition.  In both Bipolar I and Bipolar II, the manic and depressive cycles are very painful and difficult to deal with. The depressive cycle of the illness looks very much like the depressive symptoms seen in uni-polar depression although they are often more severe.  When people crash, they really can hit rock bottom. Some of the symptoms present in the depressive phase include: decreased appetite, lack of energy, decreased motivation, difficulty concentrating and remembering things, feelings of hopelessness and pessimism, loss of joy, irritability, feelings of guilt, worthlessness and helplessness. Some people with bipolar disorder experience more the lows than highs and for others, the reverse is true.

We are learning that certain elements are common in those diagnosed with a bipolar condition such as: sleep problems often dating back to childhood; the preservation of sexual drive even in the context of a depressed mood (which does not occur in uni-polar depression); and often a history of failed attempts using standard anti-depressant medications. However, one should not be self diagnosing.  The cluster of symptoms that present themselves can be different for different people and the illness itself is often constantly evolving and can be very unpredictable.  It takes a highly skilled clinician to make the judgement call and even then, it can take an average of 10 years for a correct diagnosis to be made.  This is because the symptoms may be subtle and as time passes, the symptoms change. In other words, not all symptoms happen at once and therefore the picture is not consistent.  Often, you need a skilled psychologist or psychiatrist who has worked a lot with bipolar disorder to be able to diagnose it. Also, you need a doctor or psychiatrist who is willing to hang in with you and who will persist in tracking the symptoms and in trying different medications.

When mood stabilizers work, this is often confirming of a bipolar diagnosis.  Usually, patience is a prerequisite because experimentation is needed to come up with the right type and dosage of mood stabilizer.  Not only the professional but the client has to be willing to stay the course.
Understandably, too many people get frustrated when anti-depressant medication after anti-depressant medication does not work and so they give up.  Persevering, however, is often worth it for the sense of well being that can emerge as a result of proper diagnosis, medication and psychological assistance.  People with this disorder differ in their symptoms, severity, coping strategies, life situations and which treatment plan works the best.  One thing is for certain.  Bipolar disorder is an illness.  It does not define the person and it is not an identity.  You don't want to be talking about someone as being bipolar.  Just as you are not arthritis or diabetes, so no person is bipolar.  Bipolar disorder is a complex condition that requires treatment and a large dose of understanding. Most often, when it is understood and managed properly, the individual can be fully functioning and can experience good quality of life.  We need to be able to be more open in sharing information about this mental health issue.  Shame and having to keep it hidden add incredibly to the stress and difficulty of being able to manage the symptoms with strength and courage.

* For those interested in an excellent resource on Bipolar II, check out the book: "Why Am I Still Depressed" by Jim Phelps.

Thursday, 14 July 2016

Affairs: To tell or not to tell?

It wasn't that long ago that therapists specializing in relationship issues when treating someone who had had an affair, would strongly advise that they disclose the affair to their partner.  A major assumption spurring this recommended action was that secrets act as a wedge between people and that emotional intimacy would be seriously compromised if the affair was not shared and put into the light of day. Therapists, however, have grown in their wisdom and understanding over time and are always learning from their clients. Not surprisingly, more and more, working with people teaches the lesson that there are few absolutes when it comes to what is the best thing to do in a given situation. Therapists are not interested in what is right from a morality point of view.  Rather, they are foremost concerned with implications and outcomes and in this case, what action will best serve the mental health of participants and the future well being of the relationship. One of the unfortunate negative consequences of the view that one should always tell was that too many spouses disclosed prematurely in an effort to off load their guilt.  In other words, disclosure became the way to try to solve the problem rather than the end of a long road of striving for self understanding and taking responsibility.

It is not that we found out as therapists that telling one's partner was the wrong thing to do but rather that therapists realized that to emphasize this was putting the cart before the horse.  What we came to understand was that far more important than disclosure was that the individual who had the affair face and understand their own behavior.  After all, if there is no true understanding of what caused the affair in the first place then what would prevent the same thing from happening again? Furthermore, of equal or greater importance was that the individual take responsibility for their actions.  Here, what was meant was that the individual do some serious soul searching and be willing to take ownership of their own behavior and any of the implications this might have for them and for their partner.  Few people enter a committed, primary relationship planning to break the promise of monogamy.  For many, having an affair is a major breach of their value system and understanding what caused the rupture is critical to reclaiming their integrity.  For those who are religious or spiritual, one might say that an affair needs to be seen primarily as between that person and God or their higher power and only secondarily between them and their partner.  Interestingly, the partner invariably is on board with this emphasis.  Most often, the person who has been betrayed is very invested in their partner digging deeply to understand their own behavior as this is far more reassuring than any apology could ever be.

Relationship therapists view an affair as either being a result of dissatisfaction with one's relationship, unhappiness with oneself, or both.  If the primary problem that has caused going outside the primary relationship is couple dissatisfaction then it is vital to do some work on the couple relationship, ideally with both parties participating. Unfortunately, an affair often creates a primary crisis and until that crisis is dealt with, it is often impossible to begin to probe couple problems that have typically been around for a long time. As any couple therapist knows, there are few events in life that can lead to such deeply felt injury than knowing that one's partner has slept with someone else or even worse, formed an intimate bond with them and it takes much longer than most people think to heal from such an act of betrayal.  This is a major reason why the spouse who has had the affair needs to take responsibility for their actions.  If they have not, then they easily become frustrated and fail to have the patience necessary to provide the understanding and support required for their spouse to be able to work through all the powerful feelings of betrayal, mistrust, anger and disappointment that an affair so often activates.

It would appear that most of us want to know that we are the most important person in another's life. Experimentation with  "open marriage" in the early 70's did not last long.  Too many people thought they could cope with their partner having sexual relationships with multiple other people only to find out down the road that they were not immune to feelings of jealousy, hurt and anger.  The more recent appeal of being polyamorous (i.e., being able to love many partners at one time) will be interesting to observe as it unfolds.  While on one level, it makes sense that one should be able to love more than one person at one time, will this trend also be a passing experiment that dies out because it fails to meet people's deepest needs?

For more information about Dr. Esses, go to

Wednesday, 8 June 2016

Has anyone escaped addiction?

When you think of  "addiction", what comes to mind?  Chances are, your first thoughts are drugs and alcohol.  For the longest time, these were the primary addictions talked about and then gambling became an area of concern and interest, especially with the advent of VLTs and on-line gambling.   In many circles these days, though, the term addiction is being used in a much broader way.  Gabor Mate, M.D., one of the leading authorities on addiction in Canada who worked with heroin addicts on Vancouver's Downtown Eastside, talks about the epidemic of addictions in our society, why we are prone to them and what is needed to liberate us from their hold on our emotions and behaviors.  In his book entitled "In the Realm of the Hungry Ghost: Close Encounters With Addiction",  he defines addiction as a continuum that extends from the homeless, street addict to the workaholic, physician who is addicted to recognition, fame and self-promotion.  He shares his own unique yet painful struggle with compulsive purchasing of classical music, an addiction which he described as having played havoc with his life.  At a recent workshop where I had the opportunity to meet him, he spoke about how his addiction had cost him hundreds of thousands of dollars and had come close to ruining his marriage.  It was inspiring and felt safe to be in a working group with him because he was so very honest and open about his personal problems with addiction. He traced the source of his addiction problem back to his infant days during the Nazi occupation in Hungary when his parents played classical music steadily to calm their fears and raise their spirits.  In his view, his behavior fits the new, more contemporary, definition of addiction in that: 1) it has no brake system once it starts; and 2) it has compromised the quality of his life significantly (i.e., in his case, straining his budget, taxing his marriage and robbing him of precious time).

Drugs and alcohol are not the most serious of addictions.  When the movement to quit smoking began, we learned that cigarettes were more addictive than heroin.  Still there are people, despite deep shame and multiple attempts to quit, who are haunted by this insidious addiction. Then there are those addictions that are terribly damaging but they have been normalized and down played because our society deems them not only acceptable but admirable.  Examples are the "workaholic" and "perfectionist".  As any therapist knows, these are terribly difficult addictions to undo because people not only receive praise for them but develop internal belief systems that are self-reinforcing.  How many times have I heard a perfectionist say:  "If it wasn't for my perfectionism, I would never have achieved the success that I have today."  While such a conclusion defies evidence from psychological research that perfectionism can actually cripple functioning and has serious negative side effects, people may cling to their belief system even when it clearly has ceased to ring true and no longer serves them.  When there are advantages to such addictions, more often than not, the costs out weigh the benefits. For instance, how many successful career people who felt that they had to work endlessly over time, discovered later that they missed out on most of their children's lives?

When the term "addiction" is used more broadly, there is no more of this "us" versus "them" mentality. One realizes that you can end up being addicted to almost anything...worry, shopping, exercise, food, approval, rage, television, technology, on-line dating, etc. and that addiction is rampant in our society. The problem is not in the content but in the process.  It's in the way the behavior controls your mood/behavior and negatively affects your  life that is of significance.  We all need to take a closer look at ourselves, own our own addictive behavior and become aware of what drives it.  Addiction is always a way to escape what ails you.  My own observation as a therapist is that when psychological mechanisms of blocking are no longer sufficient, more powerful mechanisms to numb, shut down and feel better, kick in.  At rock bottom, all of us want the same feel better.  We need to realize this and not criticize or punish ourselves for it but rather recognize that all addictions are fed by the same avoid painful feelings and to try to feel good.  The best way to lessen the hold that an addiction has on you is not to beat yourself up but rather to take a hard look at what is causing you pain and to begin to find those healthy things that can make you feel better.  This can be quite the challenge as once you have become really good at being on the run, it can become difficult to find out what you are running from!  Some have described addiction as "the hole in your soul". Often, being able to feel better requires going back to earlier family-of-origin experiences in order to heal childhood injuries such as feelings of rejection or the fear of abandonment so that they no longer wreak havoc with your contemporary life and relationships.  For many, this has become not only a psychological quest but a spiritual one as well. In Gabor Mate's view:  "Addiction floods in where self knowledge and divine knowledge are missing...spiritual and psychological work are both necessary to reclaim our true nature."

For more information about Dr. Esses, go to

Thursday, 19 May 2016

Do you care too much what people think?





Monday, 2 May 2016

Does illness have to lead to isolation?

We live in an age of technology where people now expect instant feedback and instant connection.   Yet, when you are sick, staying in touch is difficult.  Whether you are ill because of some mental health issue like depression or a chronic medical illness like MS, it is easy to become isolated.  Connection with others can well become compromised.  The unpredictable course of many illnesses such as colitis, bipolar disorder, crohn's disease, rheumatoid arthritis, diabetes and social anxiety means that one day, the ill person has it together and the next day, they do not.  Even the person who is sick may not be able to predict from one day to the next, how she will feel.  As a result, it is hard to keep plans and to stay in touch.  Plans may end up being cancelled last minute, e-mails and texts may go unanswered and phone calls may not be returned for weeks at a time. As one client with chronic fatigue syndrome said, "There is a lot of apologizing that goes with the illness...after so many cancellations, the question becomes should I make plans at all?"  Yet psychological research reveals hands down that social supports play a fundamental role in easing the stress of illness.  How can we get better at supporting those who are suffering out there?

A real difficulty that can result in people with chronic medical illnesses and mental health conditions being misunderstood is that often the symptoms of these illnesses are invisible.  The person looks O.K. and so it is hard for others to fathom why it might be that they are cancelling arrangements one more time.  In truth, however, it just may be that the individual has used up every ounce of energy they have just to get through the day and that they literally have nothing left over to give to anybody. Depending on the type of illness, the fatigue may be too great or the pain may be too disabling or the feelings of anxiety and despair may be too overwhelming to make connection possible.  For many, their lives have become very constricted and so they may feel that they have little to contribute when it comes to conversation.  Sometimes, people who are sick fear becoming a broken record or a burden to others.  Even when friends have been empathetic, after awhile their tolerance may wear thin.  So what can be done about this very real problem of social isolation that tends to accompany illness and often just compounds the stress?

For one, people need to become better educated and more sensitive to the social and emotional fall out that accompanies illness.  The symptoms may be invisible yet many of the conditions mentioned are so very prevalent.  Both sides are vulnerable and the effort to increase understanding is a two way street.  Health professionals and the public at large need to make every effort to listen and learn more about these illnesses and their impact.  Those who are ill, need to be more vocal and forthcoming with information.  When my clients complain about feeling misunderstood, I will often say to them: "People can only understand as much as you are willing to help them to understand." With the availability of technology and the wealth of information that is now available, send them an e-mail that best describes your situation and the nature of your illness.  I had one client with Bipolar Disorder send friends and family a YouTube video that he felt described his manic episodes spot on. Another client with PTSD after years of estrangement from friends and family, wrote a letter describing the devastating impact that this illness has had on her and her relationships.  Granted, some people may not be receptive yet others will be and it is important to steer oneself towards those who want to understand and be supportive. A liability is that keeping illness a secret from those who love and care about you, can fuel shame. The clients I see who seem to fare the best are those who have been able to speak out, talk about their illness, access support groups on-line, be seen and tell people the ways that their condition compromises them.  While not everyone might be empathetic, this is the only way to gain support and be validated.  As one client with MS put it: "The illness may be invisible but that does not mean that you have to be!"

Communication is key.  When someone is ill, do not be shy about asking what is going on.  Do not make the mistake of assuming that they don't want phone contact or company.  This may just fuel their sense of isolation.  Ask them what they need and don't forget to ask as well about their partner and children who may be experiencing isolation as well.  If a friend is not responding to your attempts to initiate, do not assume that they do not want contact or that you have done something to offend them. Check it out.  Only by sharing information about the situation can there be some attempt at forming creative solutions.  Maybe the person who is ill just needs you to accommodate them for awhile by coming over to their place where they can be more comfortable.  Maybe, there simply needs to be a mutual understanding that for a time, connection will be minimal or on hold; maybe brief, spontaneous contact when there is a window of well being can be arranged; or maybe the relationship will be lopsided for awhile with the well person doing the giving and the person who is compromised, receiving and maybe, just maybe, that's not only understandable but it's O.K.  As one wonderful mentor explained to me, giving and receiving is not necessarily tit for tat.  Instead, it is like there is one big pot of resources out there and you take when you need and give back when you can. When I told her that I did not know how I could ever possibly repay her for the help she had given me, she replied:  "One day somebody is going to need the kind of help that I have given you.  All I ask is that you be there for her and pay it forward."   You know what?  Indeed, as life turned out, she was right!

Thursday, 21 April 2016







Monday, 4 April 2016

Are you the child of a narcissistic parent?

Only recently have we begun to understand the impact of having grown up with a narcissistic parent. Parents who are narcissistic carry damage from their own upbringing and as a result, have a difficult time seeing outside themselves and being able to empathize and tune in to their own children's feelings.  Typically, the narcissistic parent's emotional needs were not well met growing up.  As a result, rather than being able to see their children as the unique people they are, parents with such tendencies see their children as extensions of themselves and so unconsciously, superimpose their own needs and wishes onto their children. They unthinkingly assume that it is the child's job to think, feel and behave as they desire.   They believe that it is only correct that the child carry out their dreams and wishes and achieve their version of success.  If this does not occur, the parent may well feel insulted or offended and may interpret their child's behavior as betrayal, resulting in feelings of disapproval, anger and even rage. Typically, this is not a conscious process.  In fact, narcissistic parents often view themselves as very generous and well meaning.  They do not see themselves as self absorbed and fulfilling their own needs at the expense of their children. This does not mean, however, that there are not serious consequences for the child of a narcissistic parent as regards her own personal growth and development.  

From the moment a child is born, the way she learns about herself is through what is called "mirroring" on the part of parents and other primary caregivers.  Mirroring occurs when the parent reflects back to the child in an accurate way what they are feeling and experiencing.  For example, the parent sees signs of fatigue in the child and says: "Honey, you seem tired. Maybe you should lie down for awhile."  Through this feedback, the child learns: "Oh, so this is what it feels like to be tired."  The child comes to understand what she feels and thinks through this process of ongoing feedback from parents.  A narcissistic parent, however, is limited in their capacity to mirror accurately and pick up on the cues that the child is sending.  They are so consumed with their own unmet needs that these consistently over-ride and are superimposed onto the child. Not only are narcissistic parents unable to see their child clearly for who she is but they make the mistake of projecting their own needs onto their child.  For example, the narcissistic parent may so badly need the child to become a successful dancer in order to fulfill their own unfulfilled dreams and desires that they lead the child to believe that this is her true calling and if she does not take this route, that somehow she is a failure or disappointment.

Such parenting makes it exceedingly difficult for the child of a narcissist to come to know who she is and what she really thinks and feels.  She must continually push aside her own personality in an effort to please the parent and provide the mirror image that the parent needs.  The message the child receives is:  "You will only be loved if you are compliant with my wishes".   If she fails to obey the parent's wishes or tries to set her own goals for her life, she may be overtly punished, frozen out or even ostracized for a period of time.  Not only is the child's growth stunted but the child of narcissistic parents internalizes a sense of defectiveness or "not feeling good enough." This is inevitable in light of the fact that as much as she may try to please the narcissistic parent, the child cannot possibly be and fulfill the parent's needs and wants and so she will fail again and again.  The child of a narcissistic parent is incapable of understanding at such a young age that when she is being criticized and disapproved of, that it is the parent's expectations that are impossible and off the mark. Typically, all she is able to understand is that she has somehow failed and has been unable to do it good enough or "right enough".  She inevitably ends up believing that she is deficient in some way for not being able to gain her parent's approval.  Often, she internalizes a deep sense of shame about this failure, turning the anger and frustration against herself.  It can take years into adulthood before she realizes that the type of parenting she received was wrong and that it was the parent who was imperfect, not her.  Having grown up without a sense of goodness, later on in life, she is likely to gravitate toward a partner who is unavailable, critical or withholding, just like the narcissistic parent was.  She is at risk of ending up catering to her partner and trying to keep him happy even when it means squashing her own needs.

One of my earliest mentors used to talk about children of narcissistic parents as "moon children".  I came to believe that this was a wonderful metaphor to powerfully convey the parent-child dynamic when a parent is narcissistic.  Picture one of those diagrams of the solar system where the sun is at the center of the solar system surrounded by the moon and all the planets.  The narcissistic parent is like the sun.  They are the center; the source of light for all that surrounds them.  The child of the narcissistic parent, on the other hand, is best symbolized by the moon.  The moon has no light of her own.  She is totally dependent on the light from the sun.  Her only means of being visible is by reflecting the light of the sun.  And so it is that the child of the narcissist is only acknowledged and seen when she reflects the parent's desires and wishes.  Otherwise, she remains invisible and in darkness.   Therapeutic work can not only shed light on this darkness and help repair the damage by providing corrective, accurate mirroring and empathy but it can also be a powerful vehicle in helping adult children of narcissistic parents to discover their own truth and identity.