Bipolar 2 From Inside and Out

Posts tagged ‘therapy’

Advances in Schizophrenia Treatment

Schizophrenia is one of the most problematic and least tractable of the Serious Mental Illnesses (SMI). Recently, though, there have been advancements in treatment in terms of medications, therapy, and even virtual reality. Let’s take a look at what’s happening.

Medications

Medications have been the traditional way to treat schizophrenia. In the 1970s, there were drugs such as fluphenazine, chlorpromazine, and clozapine, the first atypical antipsychotic. Among the drawbacks were movement disorders such as akathisia, Parkinsonism, and tardive dyskinesia. Many people stopped taking them because they couldn’t handle the side effects. They were also noted for their sedative effects, and were primarily effective for positive symptoms such as hallucinations and delusions rather than negative ones such as flat affect. But medications weren’t the only possibilities. There were also insulin comas, the much-maligned ECT, and the thoroughly abhorrent frontal lobotomy.

In recent years, there have been advancements in medications for schizophrenia. In 2024, for example, the FDA approved a drug called Cobenfy. It combines two other medications, xanomeline and trospium chloride. Apparently, it reduces psychosis and delusions in schizophrenia without many of the side effects like unwanted movements and weight gain. On the other hand, xanomeline has its own side effects, including diarrhea, nausea, vomiting, and increased heart rate and blood pressure, so there’s that. (It’s also used to decrease symptoms in Alzheimer’s patients. Another new drug, KarXT, which is still experimental, is another combination drug that shows promise. Like Cobenfy, it’s supposed to reduce both psychosis and side effects.

Therapies

In the 70’s, effective therapies for schizophrenia were not really available. Psychoanalysis and family therapy were tried, largely to no avail. (The famous book I Never Promised You a Rose Garden epitomized the psychoanalytical approach, misleading many.) They missed the fact that schizophrenia is a serious brain illness, not really amenable to talk therapies.

Still, some psychosocial therapies are now in use. Cognitive remediation is said to show benefits for social and vocational functioning. Another method, called “Errorless learning,” which focuses on rehabilitation, also targets social and work skills. And Integrated psychological therapy is likewise suggested for improving social skills. None of them applies to the more severe cases of schizophrenia, but can be helpful for those who experience milder symptoms or are fairly well controlled by medication.

Virtual Reality

Virtual or augmented reality devices have also been used to help schizophrenic patients learn coping skills. In particular, they are said to be helpful in transferring these skills from a virtual environment to daily life. It’s also been suggested that such alternative realities can be used for research to assess patients’ reactions to specific environments. Computer-animated humanoid agents are also being investigated for use in encouraging medication compliance. An analysis by Chivilgina, Elger, and Jotterand says that these technologies “pose more questions than answers,” however, and to “to establish safe environments, further examination is needed.”

Treatments for Tardive Dyskinesia

You can’t talk about treatments for schizophrenia without talking about treatments for TD. Along with sedation, it’s one of the side effects that frequently causes patients to stop taking their medication. It’s also one of the more disabling side effects, as TD movements can vary from minor yet noticeable to extreme and debilitating. Unfortunately, many of the treatments for TD have a significant side effects: abnormal movements. So, you get a drug that is supposed to treat abnormal movements—and the result can be abnormal movements.

Guidelines from the American Academy of Neurology say that drug treatments for TD include clonazepam, valbenazine (Ingrezza), deutetrabenazine (Austedo), and clonazepam. Among other treatments for TD, clozapine, vitamin E, levodopa, benzodiazepines, botulinum toxin, reserpine, tetrabenazine, propranolol, and gingko biloba have been tried, as well as less common substances used in Chinese medicine. And there are off label uses of drugs usually prescribed for other conditions. For particularly intractable cases, deep brain stimulation can be tried. If this sounds kind of hit or miss, it is. I would hate to be a patient who had to try each of these therapies in hopes of finding one that works for me.

Still, the outlook for schizophrenic patients seems to be improving, and increasingly researched. As with most psychiatric medications, the trick is finding treatments whose side effects aren’t worse than the disorder they’re prescribed for.

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Our Shadow Selves

You may have heard of the “Shadow Self” or “Shadow Work.” But what does this mean? And is it related to bipolar disorder?

The Shadow Self has been described as the Mr. Hyde to a person’s ordinary Dr. Jekyll. It’s made up of all the parts of ourselves that we want to deny or keep suppressed—our baser impulses, uncivilized or unacceptable emotions, self-talk, beliefs, and antisocial traits that lurk somewhere within our psyches. We all have them. But we hardly ever try to get in touch with our Shadow Self or know what to do about it if we’re aware of those traits and impulses.

According to Carl Jung, the Shadow Self develops from unprocessed childhood events. It also arises when someone internalizes messages they get from family, friends, or society regarding what is acceptable and unacceptable. A person can project their repressed traits onto other people. For example, if you look down on someone because they express rage, there may be rage hidden within your Shadow Self. Or a person may have the belief that being assertive is actually selfish and may be pushed around because of that. They repress a feeling of resentment and feel guilty that they are resentful.

My Shadow Self includes any number of unpleasant aspects. I own that I am obsessive, insecure, and unforgiving. These and other shadow traits result in perfectionism, fear of failure, and self-sabotaging behavior. No doubt there are parts of my Shadow Self that I haven’t recognized yet, or don’t want to.

Of course, some of my shadow traits are almost certainly caused by messages that I haven’t addressed yet. For example, I think my perfectionism was caused by messages I received that making mistakes equaled being bad, something I didn’t want to do. It wasn’t fear of being punished; it was because I didn’t want to be a bad person like some of my relatives who made mistakes involving sex and alcohol.

The Shadow Self isn’t universally bad. It’s a part of everyone. It’s possible to channel the Shadow Self in constructive ways. Million-selling mystery author Sue Grafton referred to hers as “She Who Writes.” Her protagonist was far from a perfect human being, being occasionally given to lying, ignoring rules, and Looking down on others’ faults. Grafton thought she was able to write the character because of her own less-than-noble impulses. It made her detective a flawed human being, but one that readers could sympathize with and, perhaps, see themselves in.

If you try to deny or repress your Shadow Self, it continues to affect you negatively without your knowledge. Identifying it through “Shadow Work” can result in self-acceptance and growth. Therapy is one way to deal with the Shadow Self, though those words may not be used. Trying to do Shadow Work by yourself is also possible, though the help of a therapist may increase your ability to work through difficult emotions like shame and fear. Therapy may include journaling, meditation, artistic expression, and inner dialogue and can help you understand and integrate your shadow traits into your conscious mind. Patience, keeping an open mind, practicing self-compassion, dedicating time to Shadow Work, and reflecting on your progress will help you with the process.

Or help me. I don’t have a therapist at the moment, so if I try to do Shadow Work, I’ll be on my own with it. I don’t know whether I’m brave enough. It’s something I need to consider, though.

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Completing Therapy

In a sense, there’s no such thing as completing therapy, and in another sense, it’s necessary. Right now, I’m trying to balance between the two poles of that spectrum.

I know that, barring any unlikely miracle cures (which I don’t anticipate), my bipolar disorder is something I’ll be dealing with for the rest of my life. On the other hand, I have on occasion achieved periods of stability in which therapy was no longer a necessity.

Sometimes it’s been my therapist who has encouraged me to leave treatment because they didn’t feel that I had symptoms severe enough to require further therapy at that time. I was, if not cured, stable enough to function well without weekly or biweekly boosts of psychological or psychiatric tune-ups. (Once, when I left therapy this way, Dr. L. told me solemnly, “I hope you don’t think I’m rejecting you.” I didn’t, but I thought it was nice of him to bring up the subject.)

Once I quit therapy because it was supremely unhelpful. It was couples therapy, and it wasn’t achieving its goals. The therapist sided with my husband and shredded me. After a few sessions, I refused to go back.

Sometimes, my therapy has quit me. I had a very good relationship with Dr. R., my psychiatrist, who retired and moved across the country. I knew I still needed the services of a psychiatrist as well as a therapist, so I began the long search for another practitioner who could help me, had an opening, and would take my insurance. It’s a process much like interviewing candidates for a job. You need to find a good fit (i.e., one who won’t shred you). At the time I mostly needed someone who could supervise my meds, as I was seeing a therapist for my ongoing psychological issues.

I stayed with that therapist for years. It began to become clear that perhaps I should leave therapy when I needed therapy less often—once every other week instead of every week, then once every three weeks, and eventually every month. Even when we still had sessions, they ran short because I didn’t have immediate issues that needed to be addressed. And her advice consisted of “Look how far you’ve come” and “Keep doing what you’re doing.” When she moved to a new practice, I had one or two more sessions, then ended therapy. I kept her number, though. You never know.

Right now, I am considering leaving therapy with my psychiatrist for purely practical reasons. Dr. G. only sees people on Thursdays and Saturdays till early afternoon. At the moment, my husband works both those days and hours and we have only one working car. I see Dr. G. four times a year for med check, but it’s becoming increasingly problematic for Dan to get time off work to take me to appointments. I suppose I could take a Lyft, but it’s another expense I can’t afford. Perhaps I should look around for another provider closer to me with better hours. If I can find one that doesn’t have a years-long waiting list, I mean. (I’m told that I need to get a referral from my PCP to get one in-network.) Or someone else in Dr. G.’s practice who would be willing to take me on. (I have to go to the office and fill out a form to accomplish that.) Either way, no guarantees.

There have been times in my life when I felt stable enough to go without a therapist or psychiatrist. Right now, though, I’m having issues with anxiety, hypomania, and insomnia, so I need someone at the very least to prescribe or tweak my dosages.

Most of all, though, I hate the process of finding a new psychiatrist—interviewing them to see if we’re a good fit, telling them the Reader’s Digest version of my screwed-up life, getting my records transferred, and the rest of the tap dance involved.

Wish me luck.

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How I Treat My Bipolar Disorder

There are many treatments for bipolar disorder, from SSRIs to EMDR and more. I must admit that I haven’t tried all of them, but I have encountered a few over the years. Some worked well, others not so much. But I’m doing well now, so I thought I’d share what works for me—my roadmap to stability.

Note that I said, “How I Treat My Bipolar Disorder.” That’s because my treatment is up to me. My psychiatrist or therapist can recommend a certain treatment, but whether I take that drug, undergo that procedure, or engage in therapy is ultimately my choice. I look at my providers as people who recommend treatments and help me implement them. But they don’t make the decisions. I do. Most of the time, I take their suggestions—they know more than I do about medications, for example. But I feel free to make suggestions, too, if the medication isn’t working like it’s supposed to or is having side effects I can’t deal with.

Meds

My med journey started (approximately 30 years ago) with the then-ubiquitous SSRI, Prozac. It worked well for me, relieving my depressive tendencies (I hadn’t been diagnosed with bipolar yet). Until it didn’t. That’s when my doctors started throwing drugs against the wall, hoping they would stick. Over the years, I’ve been on at least three different SSRIs, two NDRIs, two SNRIs, and a sedative-hypnotic. Probably other ones, too, that I don’t remember. (One of the side effects for one of them was memory loss.)

My previous psychiatrist experimented with a variety of meds until we hit on a cocktail that worked: an SSRI, a broad-spectrum anti-seizure drug, an atypical antipsychotic, and a benzo. My current psychiatrist mostly tweaks the dosages up or down when I need it. I’ve quit the sedative-hypnotic altogether and only take the benzo as needed. Recently, when I told him that I thought I was having mixed states, he upped the dosage of the atypical antipsychotic. (I don’t like to give the names of the drugs I’m taking because what works for me doesn’t necessarily work for others.)

I see the psychiatrist four times a year for med checks, though I can call if I have any adverse reactions or increased symptoms.

(When I was looking for illustrations to go with this post, I was astounded at the number of images of mushrooms that I saw. I guess it’s trendy now, but I’ve never tried them. There were also pictures of marijuana plants. There’s a medical dispensary in my area, but I’ve never pursued getting a prescription. I have taken CBD gummies, but the only effect they had was to make me foggy and dizzy, which I didn’t like. They did nothing for my moods. They didn’t even relax me; I was too nervous about my balance and the potential of falling.)

Therapy

Individual talk therapy is my go-to form of therapy, though I recently felt I could stop. (I keep the number handy in case I ever need it again.) I guess you could say I weaned myself off therapy. When I started I was going once a week; later, once every other week. When it got to three or four weeks between appointments, I decided it was time to fly on my own. I don’t know what particular kind of therapy I had—CBT or DBT, for example. She never said and I never asked.

I went to group therapy when I was still undiagnosed, but it wasn’t helpful. Once, when my therapist was out of town, I went to a therapy group she recommended but had an adverse reaction to it. Another group just seemed to have a weird format and a book they used like a “bible,” and I didn’t get anything out of that, either. A few times, my husband and I went to couples therapy, and it seemed to help. Another time, we went to a few sessions with a different therapist and I felt shredded. She seemed to think that I was the “sick one” and my husband was the “normal one.”

Treatments

Most of the modern treatments I haven’t tried because medication and talk therapy work so well for me. I had a close brush with ECT, which frankly frightened me, when I went through multiple drugs for several years and nothing seemed to work. My psychiatrist gave me the information and gave me time to think it over and make my own decision. I was almost ready to try it when, miraculously, a different drug brought my mental function under control. But when it comes to TMS, ketamine, EMDR, et cet., I have no experience with them. I don’t believe in reflexology and won’t try herbal remedies because they might interact badly with my meds. Basically, because what I’m already doing works for me, I see no need to explore alternatives.

Self-Care

It’s hard for me to keep up with self-care. I do stick to a sleep schedule and get 8-9 hours a night, with occasional daytime naps. I don’t exercise. It’s hard enough just to walk with my arthritic knees and bad back.

My husband helps me enormously with self-care. He works at a store with a grocery section, and he makes sure I have a variety of food and beverages on hand—fruits and juices, fizzy water, bread, and cheeses, for example—and fixes meals with protein, starch, and vegetables. Left to myself, I would probably subsist mostly on peanut butter sandwiches and breakfast cereal. Back in the day, he used to drive me to my therapy appointments when I was too nervous or depressed to drive myself. Now he picks up my scripts at the pharmacy department in his store.

What’s the takeaway here? I’m not telling you that I have the answer for how you should treat your bipolar disorder. I know what’s worked for me, but you have to find a path that’s right for you. I merely offer my experiences for what they are—mine. You can create your own roadmap, too.

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Baby Steps Toward Healing

Once I attended a weekend photography workshop. One of my photos received praise as being innovative and interesting, one based on a technique I had seen a friend use. The rest of my photos missed the mark. I was frustrated by my lack of progress. The instructor reassured me, advising me that I should take (or was taking) “baby steps.” That photo provided a brief glimpse of what I could do if I kept at it.

My therapist has also reminded me of this numerous times. And she’s been right. Almost all the progress I’ve made in dealing with being bipolar has been gradual and incremental.

The baby steps process was long and arduous, lasting for years. The first step was taking Prozac, which helped me for a while, then didn’t. Most of the progress I’ve made with medication has been in tiny, discrete steps. My prescribing psychiatrists have never done anything quickly, which is in one way a blessing and in another a torment. They would try me on one drug, then wait to see the results, then try a different dose or a different drug altogether. Lather, rinse, repeat until progress at last occurred.

Progress in therapy has likewise been gradual over the years. First there were therapists who diagnosed me with depression, which was certainly true, though not the whole picture. And they helped, or at least a number of them did over the years. I learned a lot about depression in general and how it applied to me in particular. I also learned about relationships, and those insights helped my marriage.

Finally, I was given an accurate diagnosis of bipolar disorder 2 with anxiety. That was where the steps toward reaching some resolution regarding my medication really started. That was also when I started working with the therapist who reminded me about baby steps.

Although I had made steps toward healing in the past, I had taken a deep and protracted plunge into depression before I started going to her. Several years of it had left me immobilized, despairing. At my lowest point, I described myself as “pathetic.” There were going to be a lot of baby steps needed to get me out of that miserable place.

So we went to work. I liked the kind of therapy she practiced – non-directional, non-judgmental. (I had had problems with therapists who weren’t like that in the past. Needless to say, I made no progress with them. In fact, I even took steps backward.) There was a long way to go.

Dr. B. frequently reminded me of the importance of baby steps and, eventually, how far those steps had taken me. I learned coping mechanisms. I learned new ways of thinking. I learned to accept myself with the reality of my bipolar disorder, but without the constant misery. And, by the time my proper medications had kicked in, we were making some even bigger steps. But all my progress was built on a foundation of many, many baby steps along the way.

I think all therapy consists of a lot of little steps. I don’t know anyone who has had a great revelation that instantly moved them further along with their healing. I only got glimpses of what my situation could be like if I persisted. And along the way, I regressed at times, needing to re-learn the lessons I had been exposed to and re-taking the steps I had already accomplished. Progress is like that – two steps forward and one step back – especially with a disorder as cyclical as bipolar.

Anyway, I still go to therapy and still take baby steps toward whatever my future holds. I realize it will take a long time – probably the rest of my life – but I’m dedicated to the process.

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When Your Therapist Tells You What to Do

The classic examples of non-directive therapists are Sigmund Freud and his disciples, who legendarily sat at the head of their couches and made comments like, “Hmm,” “Tell me about your dreams,” and “How do you feel about your mother?”

Freudian psychiatry is, thankfully, now out of vogue. But there are still therapists who believe that their job is to listen, not to instruct.

On the other hand, there are more directive therapists who assign homework. This can be anything from “Listen to this podcast on mindfulness” to “Write a letter to your ex telling him/her what you truly feel.” They probably won’t tell you to kick the bum to the curb, but if you decide to do so they’ll help you prepare for it.

But, although I am far from a Freudian and shy away from those who are (not many these days), I prefer non-directive therapists. I am not averse to doing a little homework or having a therapist ask me in a session to vocalize what I would like to tell a person or even to write a list of the coping mechanisms I’ve developed. My preferred dynamic, however, is to give-and-take with the therapist and then go home to contemplate what was said and how I feel about it.

I have had therapists who have given me homework and I can’t say they were wrong to do so. Sometimes writing something down or throwing teacups against the basement wall (or whatever helps you get your anger out) is a good thing.

My most recent therapist was a combination of the two. She mostly listened while I rambled on about what was happening in my life or what had happened in my past. Then she suggested ways that I could think about the events or pointed out coping mechanisms that I had developed or suggested ways I could put those coping mechanisms to use.

All in all, I felt that our sessions were mostly non-directive. She did suggest that I listen to a podcast on mindfulness, but she never quizzed me on whether I did and only listened when I told her what I got from it. She never told me that I should delve deeper into mindfulness or listen to more podcasts. She left that up to me, if I thought it might be helpful.

I understand that some therapists, particularly those that work in community mental health facilities, are required to file treatment plans and I can see where giving homework can flesh one out more than “talk about feelings.”

Perhaps there is something I’m missing. Perhaps at different stages of therapy, directive psychological interaction is more beneficial. Perhaps my particular problems lend themselves more to non-directive therapy. Perhaps I just have an aversion to being told what to do, especially where it concerns my memories and my feelings.

Of course, everyone has the option not to do the homework. This can be seen as resisting treatment, or disagreeing with the treatment approach, or simply lacking the wherewithal to carry it out. Sometimes it may be more helpful when the therapist sacrifices part of the session to doing the assignment there instead of leaving it to be done at home. In this case, the therapist is being really directive, though of course the client always has the choice not to do the assignment. It’s much harder, though, when the therapist is sitting there waiting for you to make a list of your dreams, your feelings, or your interactions with your mother, or to bash an empty chair with a pool noodle.

What it comes down to, basically, is therapeutic philosophy and therapeutic style. And a client is not bound to pursue whatever style of therapy that is favored. Although it is sometimes difficult to realize, a client has the option to request or to seek a therapist whose therapeutic style matches what the client feels is most helpful.

Remember, your therapist works for you, not the other way around. If you need a more or less directive therapist, it is your right to seek one out. Therapy has been known to stall and a different approach or philosophy may be just what you need.

 

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