Bipolar Disorder and Tough Love

Some patients are easy and some patients are difficult. With the easy ones, so little effort seems to be required that I often ask myself if I am needed. Not with Peter. He was as difficult as they come.

Initially, Peter’s mother visited me in my office, in tears, not knowing what her 19-year-old son’s problem might be. She was not only perplexed by his behavior but worried sick he might kill himself.

After listening to her, I suspected she had every reason to worry. Her description of her son indicated he may be suffering from some form of bipolar disorder, a condition once called manic depression. Suicide occurs in 10 to 15 percent of individuals with certain forms of bipolar disorder.

By taking the family history, I surmised that Peter’s father must also be bipolar even though he was described as a mere depressive who chronically took antidepressants on his own accord.

Bipolar disorder is largely biologically based, with pharmacological intervention the mainstay of treatment. However, these patients often do not take their medication, so psychotherapy is needed for them to comply with treatment.

It took a whole year after meeting his mother for Peter to come to therapy. He agreed to weekly sessions with me and more sporadic ones with the psychiatrist I referred him to and who put him on an antidepressant and mood-stabilizing medication. He reassured me that, apart from the occasional joint, he was not abusing drugs or alcohol.

Just like many others suffering from bipolar disorder, Peter did not have any insight into his behavior. He was not aware that the interpersonal difficulties he experienced were largely related to his being bipolar. Things were always someone else’s fault. He often fought with his family and was short-fused in public. He could not hold a job.

Peter often cried in therapy because of perceived injustices. While depressed, he exhibited feelings of worthlessness, hypersomnia, indecisiveness, suicidal ideation and a lack of concentration. In more elevated moods, he experienced grandiosity, distractibility, psychomotor agitation and irritability. There was also excessive involvement in pleasurable activities with a high potential for painful consequences, such as engaging in unrestrained shopping sprees, sexual indiscretions and substance abuse, which included smoking pot and snorting cocaine. He was inconsistent with his medication and counseling sessions.

Unfortunately, Peter’s parents gave him excessive amounts of money without him earning it. No limits had ever been placed on him. A couple of months into therapy, he confessed that he speeds and drives while under the influence of alcohol. While driving home one night stoned, he almost fell asleep at the steering wheel.

I told him I would have to follow through with what I had told him the first day we met, which was that whatever was discussed in therapy was strictly confidential, and that I would break that confidentiality only if I thought he was putting his or someone else’s life in danger. Therefore, I would be calling his parents.

Recklessness is common bipolar behavior, and so is substance abuse. I called his mother and requested a joint session with her and Peter’s father because a more forceful intervention was necessary. Peter needed to be more closely monitored in a clinical setting. His mother said she would get back to me. She never did.

Peter never showed up for our next scheduled appointment. My repeated calls to him and his family went unanswered. To this day I still wonder if Peter’s family stopped enabling his destructive behavior and whether they ever provided the tough love he so desperately needed.

Peter is not the patient’s name. Some details have been changed to protect his identity.

First published by Loula Koteas in The Athens News.