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PERSPECTIVES
exciting treatment” (p. 66). While such treatment was successful in the rarefied atmosphere of the sanatorium, it did nothing to address the systemic traumas in the lives of bipolar people. Kraepelin’s patients would eventually have to return to their social circumstances, which, judging by the case histories, were characterized by traumatized and traumatizing family systems. Obviously, this pharmacologically-oriented, individualized, and isolated treatment of bipolar disorder did not have a lingering therapeutic effect in the world beyond the sanatorium walls.
Bipolar treatment has advanced since Kraepelin’s day, but some of the same blind spots exist. For example, in Frank, Swartz, and Kupfer’s (2000) work on interpersonal and social rhythms for managing bipolar disorder, there is an acknowledgement but rapid dismissal of the role of the system: “In our model, life events (both negative and positive) may cause disruptions in patients’ social rhythms that, in turn, perturb circadian rhythms and sleep-wake cycles and lead to the development of bipolar symptoms” (p. 593). Frank et al.’s (2000) acknowledgement of life events, and, by implication, the social systems of which they are a part, was an advance over the historic circumscription of bipolar disorder to the individual, a circumscription that is just as visible in Hippocrates’ (1822) crude biological determinism as in Cade’s (1949) insistence that mania was a deficiency of lithium. However, Frank et al. (2000) conceived of systems as triggers for the expression of genetically predisposed bipolar disorder, not as part of the disease—or its treatment.
As Frank et al. (2000) pointed out,
Cade’s (1949) discovery of lithium as a suppressant of mania inaugurated a long period of pharmacological approaches to treating bipolar disorder. The availability of lithium and the apparent failure of purely psychotherapeutic methods for treating bipolar disorder combined to make medication an indispensable
part of the treatment plan. In Frank
et al.’s (2000) approach, medication
is combined with two other focal
points, namely “helping patients to... lead more orderly lives, and resolve interpersonal problems more effectively” (p. 594), in an effort to address both
the biological and psychosocial factors (in particular, psychosocial stressors) underlying the disorder. While such
an approach appears to unite a pharmacological treatment plan with elements of psychotherapy and, at least implicitly, systems thinking, the systems component is once again the weak point.
From bipolar to “whypolar”
Bipolar disorder, despite its roots and antecedents in individual biology, arises and flourishes within systems, particularly family systems. The symptoms of bipolarity are all too easily mistaken as individual pathology, whereas upon examination, they can disclose the contours of family pathology. Similarly, the treatment of bipolar as an attempt to quash symptoms, particularly through aggressive psychopharmacology, masks the role of the system in the emergence of these symptoms. In Clark’s case (see case vignette on next page), the diagnosis and ostensible treatment of bipolar failed to ask the question that I have come to designate “whypolar.” To me, the concept of whypolar is a means of extending
the net of diagnosis, examination, and treatment around bipolar to the family and other systems around the identified patient. To ask “whypolar” is to reject the pat assumption that the bipolar lifecycle takes place solely within an individual, and to invite the therapist to make a more conscientious effort to understand the role of the underlying systems.
Once the system is named, understood, and engaged, there is a better chance that members of the patient’s system can gain their own voices, envision better circumstances, and move from a paradigm of symptom management to existentialencounters. u
Alev Ates-Barlas, MS, MA, LMFT, holds an MS in communications and an MA in marriage and family therapy. She is currently
practicing as a family therapist at a not-for-profit, multi-service agency in Upstate New York. Ates-Barlas is a Pre- Clinical Fellow of AAMFT.
References
Baillarger, J. (1854). De la folie a double forme. Annalles Medico-Psychologiques, 6, 367-391.
Cade, J. (1949). Lithium salts in the treatment of psychotic excitement. Medical Journal of Australia, 2, 349-352.
Craddock, N., Jones, I., Kirov, G., & Jones, L. (2004). The Bipolar Affective Disorder Dimension Scale (BADDS)—a dimensional scale for rating lifetime psychopathology in bipolar spectrum disorders. BMC Psychiatry, 4(1), 1-10.
Falret, J.-P. (1854). Memoire sur la folie circulaire. Bulletin de l’Academie Imperiale de Medecine, 19, 382-400.
Frank, E., Swartz, H. A., & Kupfer, D.J. (2000). Interpersonal and social rhythm therapy: Managing the chaos of Bipolar disorder. Biological Psychiatry, 48(6), 593-604.
Goodwin, F. K. & Jamison, K.R. (2007). Manic-depressive illness: Bipolar disorders and recurrent depression. New York: Oxford University Press.
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Keck, P.E. & McElroy, S. L. (2005). Lithium and mood stabilizers. In D. J. Stein, D. J. Kupfer, & A. F. Schatzberg (Eds.), The American psychiatric publishing textbook of mood disorders (pp. 281-290). New York: American Psychiatric Publishers.
Kraepelin, E. (1904). Lectures on clinical psychiatry. (T. Johnstone, Trans.). New York: William Wood & Company.
Mann, T. (2005). The magic mountain. New York: Random House.
Muzina, D.J. & Calabrese, J. R. (2005). Guidelines for the treatment of bipolar disorder. In D. J. Stein, D. J. Kupfer, &
A. F. Schatzberg (Eds.), The American psychiatric publishing textbook of mood disorders (pp. 463-484). New York: American Psychiatric Publishers.
Roberts, C. A. & Buikstra, J. E. (2012). The bioarchaeology of tuberculosis: A global view of a reemerging disease. Gainesville, FL: University Press of Florida.
Van Calker, D. & Berghofer, A. (2010). Lithium. In I. Stolerman (Ed.), Encyclopedia of psychopharmacology, volume 2 (pp. 713-718). New York: Springer.
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