Gestalt Therapy and Bipolar Disorder

Background

I started my career as a medical doctor in general practice where, from the very start, I struggled with the

potential as well as the limitations of the medical model. In general practice, patients and doctors are more

often than not confronted with multi-causal and complex sufferings. The medical model I had learned had

not prepared me well enough for this confrontation.

Although I was introduced to Gestalt therapy accidentally, I found it a model for dealing with the

complexity I experienced in my practice. Since then I have been intrigued by the idea of a possible

integration of the two models, Gestalt therapy and the medical model. A consequence of this interest was

research which I did at Erasmus University, Rotterdam (EUR), the Netherlands, and later at Norsk

Gestaltinstitutt (NGI) Oslo, Norway, the work resulting in some articles o ne was “Spontaneous Regression

of Cancer: A Clinical and Psycho-Social study” (van Baalen et al., 1987) It is a quantitative study among

clinical proven mortally ill patients, who survived despite their diagnosis, and without medical treatment.

The results of our study suggested that there might be significant differences between the psychological

history of patients having a spontaneous regression of cancer and other cancer patients. Another paper

was “Gestalt Diagnostiek” (van Baalen, 1998; 2000), in which I suggested a “Gestalt diagnostic system”,

which can possibly support Gestalt therapists in their work and their communication with medically oriented

health workers.

Bipolar disorder aroused my interest by accident as well. A client of mine, Anne, developed a typical

bipolar episode. She became psychotic, hyperactive and sleepless in a period I was on holiday. She was

hospitalized and medicated. After being short in hospital she was referred back to me. Consequently, I was

confronted with a medical diagnosis, while practising as a Gestalt therapist. As far as I recalled from my

medical training, a medical diagnosis of bipolar disorder meant having a lifelong mental illness with manic-

depressive episodes, the only treatment being lithium and/or anticonvulsive drugs. What was I to do?

Continue Gestalt therapy? And if so, how?

In an attempt to answer these questions, I turned to a review of more recent literature on the subject

.Then I will present a case. I will discuss some examples from the case and compare my findings with the

literature reviewed.

1
Literature review

A personal and poetic experience of Kate Redfield Jamison (1995 ) shows the drama of the disorder:

Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of

rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its

origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring

advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not

infrequently, suicide. (...) I am fortunate that I have not died from my illness, fortunate in having

received the best medical care available, and fortunate in having the friends, colleagues, and family

that I do. (p.6)

Epidemiological studies emphasize even more the need to explore the drama:

 two to four new cases occur per 100,000 people per year for bipolar affective disorders

 the above means that about 1 in 200 people will suffer from a hypo manic episode at some time in

their lives

 peak age at first diagnosis of bipolar disorder is 25-30 years, but many patients have had affective

episodes in adolescence or early adulthood

 15-20% of patients with the disorder commit suicide, acute depressive and mixed episodes being

the periods of greatest danger.

(Drug and Therapeutics Bulletin, 2005; 43(4):28-31)

Hakkaart-van Rooijen et al. (2004) discuss the high costs in the Netherlands for persons diagnosed with

bipolar disease. Both the quality-of-life scores and the self-perceived health status of the study participants

were lower than those of the general population. They think that receiving appropriate treatment would

lower the costs.

The study of Morgan et al. (2005) suggests that quality-of-life of bipolar is compromised due to the

disruptive impact of the illness. Their results also point to important gaps in health care that may be

overcome by ameliorating the access to support services.

2
L.V. Kessing (2006) points out that younger adults have a different bipolar profile from older patients.

Young bipolar patients are more prone to manic psychotic symptoms, while elderly outpatients over 65 are

at a higher risk of severe depressive episodes with psychosis.

The interest for bipolar disorder is also shown by the yearly international conferences on bipolar disorder,

the first in 1999. The seventh international conference was held in June 7-9, 2007, at the University of

Pittsburgh. Issues discussed were:

● Medical risk prevention and intervention

● Psychoeducation and psychotherapy

● Advances in neurobiology and genetics

● Classifying bipolar disorders

Bipolar I - Mania and major depression

Bipolar II - Hypomania and major depression

Bipolar III - Cyclothymia

Bipolar IV - Antidepressant induced hypo/mania

Bipolar V - Major depression with a family history of bipolar disorder

Bipolar VI - Unipolar mania

● Treatment of bipolar depression

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder (my italics) that causes

unusual shifts in a person’s mood, energy, and ability to function. In contrast to the normal ups and downs

that everyone goes through, the symptoms of bipolar disorder are severe. Bipolar disorder causes dramatic

mood swings - from overly “high” and/or irritable to sad and hopeless, and then back again, often with

periods of normal mood in between. Severe changes in energy and behaviour go along with these changes

in mood. The periods of highs and lows are called episodes of mania and depression. Episodes of mania

and depression typically recur across the life span. Between episodes, most people with bipolar disorder

are free of symptoms, but as many as one third have some residual symptoms. (The National Institute of

Mental Health, 2007)

3
The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar

I disorder. Some people, however, never develop severe mania but instead experience milder episodes of

hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or

more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar

disorder. Some people experience multiple episodes within a single week, or even within a single day.

Rapid cycling tends to develop later in the course of illness and is more common among women than

among men.

People with bipolar disorder can lead healthy and productive lives when the illness is treated effectively.

Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person

may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those

experienced when the illness first appeared. But in most cases, proper treatment can help reduce the

frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Which correlations are to be found in the disorder? In the following I use

the word correlations on purpose, not to be misinterpreted as cause and effect relations.

It appears likely that many different genes act together, in combination with other factors of the person or

the person’s environment, to cause bipolar disorder. Many factors seem to act together to produce the

illness. For example: Kieseppä et al. (2005) show in a nation wide twin study (USA) that bipolar disorder

tends to run in families. There was high concordance of bipolar I disorder in a nationwide sample of twins.

Wals et al. (2006) show that children of bipolar parents are at increased risk of developing mood disorders.

Kessing’s (2006) discussion referred to above, stressing that younger adults have a different bipolar profile

from older patients, shows that age is of some importance.

Friedman et al. (2006) conclude that seasonal affects may indeed vary by region and bipolar subtype. High

creativity and bipolar disorder seem to correlate in families, according to Simeonova et al. (2005).

Christensen (2003) found a gender difference in the course of bipolar affective disorder, women having a
4
significantly higher number of depressive episodes than men, and men having a higher number of manic

episodes than women. In bipolar patients with long duration of the disease a significant number of

depressive episodes in women were preceded by negative life events. Somatic health problems and

conflicts in the family were significant factors preceding new depressive phases.

Rasgon et al. (2005) discuss a different mood pattern reported by women and men. The presented

observations support a gender-variable approach to the management of bipolar disorder.

Noaghiul and Hibbeln made cross-national comparisons of seafood consumption and rates of bipolar

disorders, and indeed they found a significant relationship between greater seafood consumption and lower

prevalence rates of bipolar disorders throughout the countries studied. Although the results from this study

do not provide the direct proof that sufficient seafood intake can prevent bipolar disorder, they support the

hypothesis from other studies that low dietary intake of seafood increases the risk of affective disorders.

What happens in the brain? Frangou et al.

(2006) state that there is evidence from studies that the brains of people with bipolar disorder may differ

from the brains of healthy individuals. Because of the same oligodendrocyte dysfunction in schizophrenia

and bipolar disorder, schizophrenia and bipolar disorder may share malfunctioning genes. Bipolar and

schizophrenia patients differ in fronto-temporal dysfunctions. The results, though, suggest that in both

disorders the tasks involving cingulo-frontal networks are impaired, with more severe cingulate dysfunction

in schizophrenia.

Prognoses Most people with bipolar

disorder - even those with the most severe forms - can achieve substantial stabilization of their mood

swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-

term preventive treatment is strongly recommended and almost always indicated. A strategy that combines

medication and psychosocial treatment is optimal for managing the disorder over time. A comprehensive

treatment programme pays off in bipolar mania; systematic care was associated with a significantly greater

reduction in mean level of mania symptoms. Patients with clinically significant mood symptoms at baseline

appeared to benefit the most, according to Simon et al. (2006).

5
Treatment

Medications known as “mood stabilizers” are usually prescribed to help control bipolar disorder. Examples

are lithium and anticonvulsant drugs (The National Institute of Mental Health).

The publication of J. Garnham (2007) shows that less than one third of patients treated with lithium

achieved remission; the effectiveness of other treatments in this naturalistic sample was even lower.

Psycho education or psychosocial interventions tend to enhance pharmacotherapy outcomes in bipolar

disorder. Doctors are to apply a combination of pharmacological and psycho educational treatment for the

long-term benefit of these patients.

Bernhard et al. (2005) describe the impact of cognitive-psycho educational intervention in bipolar patients

and their relatives. Cognitive-psycho educational interventions can generate positive changes in both

patients and their relatives, and this should be considered together with standard medical treatment.

Reinares et al. (2006) come to a similar conclusion in a study “What really matters to bipolar patients'

caregivers”. Addressing caregivers’ needs via psychosocial interventions can possibly impact the long-term

outcome of bipolar disease.

Fleck et al. (2005) describe treatment strategies that could target at minimizing the self-perceived stigma

associated with taking psychiatric medication, and alleviating the fears of becoming addicted. These can be

effectuated by:

 discussion of compliance with the patient, possibly using rating scales as to assess compliance

 cognitive behavioural treatment and behaviour modification techniques, teaching patients about the

disease, and

 adaptation of medication.

Fagiolini et al. (2004) justify long-term clinical support based on high risk of suicide in bipolar disorder.

According to Baethge et al. (2005) patients with bipolar disease have high risk of drug and alcohol abuse.

Swann et al. (2004) advise intervention at a very early stage in bipolar disease in order to limit the

6
patients’ abuse of drugs or alcohol. Development of bipolar disease and recovery was better for patients

who used none or just one substance. Goldstein et al. (2006) recommend bipolar patients to abstain from

drinking any alcohol. Almost half of all bipolar patients are suffering from alcoholism during their life. The

number of emergency department visits and the number of mood episodes were higher in patients who

drank only a few drinks per week in comparison with patients who did not drink alcohol

Young people with bipolar disorder are vulnerable to developing alcohol related disorders according to

Fleck et al. (2006). These patients are more likely to develop alccohol related disorders correlated with the

development of bipolar symptoms.

Bhugra et al. (2005) discuss why bipolar disorder is often treated too late. Bipolar disorder is characterized

by alternating episodes of depression and mania or hypomania and is therefore often not recognized as a

disorder by the patients themselves. Only 50% of the persons affected by this disease in the USA receive

appropriate treatment on time and in follow up. This article reviews the literature on the factors that prevent

persons affected with bipolar disorder from receiving appropriate treatment. Important factors of not

receiving appropriate treatment were wrong medication and lack of psychotherapy and/or psycho-education

opportunities.

Simon et al. (2006) conclude that comprehensive treatment programmes including psycho education pays

off in bipolar mania. Systematic care was correlated with a significantly greater reduction of mania

symptoms. Patients with clinically significant mood symptoms at baseline appeared to benefit the most,

parameters of depression were not significantly improved by the programme. Miklowitz et al. (2007)

maintain that psychosocial interventions should be part of a treatment package that most patients with

bipolar disorder receive.

Even in the prestigious British Journal of Psychiatry Scott et al. (2006) conclude that: -For stable, lower-risk

population, early in their history of bipolar recurrences, CBT should be considered as an adjunctive

treatment. -For high-risk, complex cases, other forms of therapy

should be considered, such as those targeted at medication adherence or relapse prevention, before

considering CBT. These recommendations are consistent with the results from published meta-analyses

7
and other findings on psychological therapies in bipolar disorders. According to Miklowitz et

al. (2003) examples of psychotherapies and/or psycho-educations in such comprehensive programs are:

1. Prodrome Detection, Perry A. et al (1999), Randomised controlled trial of efficacy of teaching

patients with bipolar disorder to identify early symptoms of relapse and obtain treatment.

2. Psychoeducation, Colom F, et al. (2003) Randomized trial on the efficacy of group

psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission.

3. Cognitive Therapy, Lam DH, et al. (2005) Relapse prevention in patients with bipolar disorder:

cognitive therapy outcome after 2 years.

4. Interpersonal/Social Rhythm, Frank E, et al. (1999) Adjunctive psychotherapy for bipolar disorder:

effects of changing treatment modality.

5.Family-Focused Therapy,Miklowitz DJ,(2003) A randomized study of family-focused

psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder.

Miklowitz et al. (2003) conclude in their study that intensive psychosocial treatment as an adjunct to

pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar

depression. Most of these psychosocial interventions have a strong educational component. Most of them

emphasize looking for, and planning for, signs of relapse, and they also include some way of looking at

“illness acceptance”. Several include some emphasis on regular rhythms of sleep and activity. One

emphasizes involving the family very directly. All the five examples of psychotherapy and/or psycho-

education mentioned above have solid evidence demonstrating their effectiveness.

The Harvard programme “treatment contract” (revised 2007; original 2003) is another example of psyocho-

education not mentioned in the summary by Miklowitz et al. It makes extensive use of written plans, with a

separate plan for each of the following: Building a Support team, Depressive Symptoms, Personal Triggers

of Depression, Coping with Depression, Personal Triggers of Mood Elevation, Mood Elevation Symptoms,

Coping with Mood Elevation.

On the basis of this review I conclude that treatment of the disorder is evidently needed! Out of two

8
hundred persons one will suffer from this disorder, of which 15% will commit suicide. The disorder is seen

as a potential life long disease, and medication alone does not prevent new episodes. Psychotherapy, i.e.

cognitive therapy and psycho-education for patient and caretaker can possibly impact the long-term

outcome of bipolar disease. Special stress, life events, alcohol consumption and discussion of compliance

are mentioned as areas complementary for psychotherapy besides medication.

Gestalt therapy was not mentioned in the literature reviewed. Nor did I find publications about the disorder

in the Gestalt literature.

One of the biological findings of Thase et al. (2000) is significant. They have shown that people with bipolar

disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment

with antidepressant medication. This strikes me as significant because bipolar disorder patients can easily

be misunderstood and diagnosed as depressive, as I have experienced in my own clinical practice, leading

to mistreatment with antidepressant medication.

Striking to read was that “less than one-third of patients treated with lithium achieved remission; the

effectiveness of other treatments in this naturalistic sample was even lower” (Garnham, 2007). When only

one-third or even less achieve a remission with pharmacotherapy and when psychosocial interventions

have been shown to enhance pharmacotherapy outcomes in bipolar disorder (Moklowitz, 2007), then

psychotherapy is in fact indicated.

My original questions become even more relevant after this review. They were: What was I to do? Continue

Gestalt therapy? And if so, how? At this stage I would like to reformulate my original questions, because I

did continue Gestalt therapy with this client: How can Gestalt therapy impact the treatment of bipolar

disorder?

Case study

Anne was at the start of therapy a divorced woman, living alone. She has a daughter born in a former

relationship. She is educated as an artist and works as such in her own atelier, is rather successful, and

can live from that. She is of European offspring and has lived for more then 15 years in Norway.

As a teenager (16) she had a sexual relationship with an art teacher, a relationship that confused her.
9
She had been diagnosed with postnatal depression seven years before entering therapy. Her mother was

probably suffering from mild depressions (my conclusion), and her brother is diagnosed with schizophrenia.

She is a tall elegant, good-looking charming woman. Coming in my office for the first time, I am aware of

her charisma.

Anne chose me as her therapist because of her interest in Buddhism and because she knew that one of my

former teachers in Gestalt therapy was known to be a practising Buddhist. She had been attending

meditation courses for some years and had heard that Gestalt therapy has a root in Buddhism. Moreover,

Anne and I are both immigrants in Norway.

Five years ago Anne became my client, and at the start we saw each other once a week for an hour, later

more or less frequently, depending on Anne’s life situation.

Initially she expressed two issues she would like to work on: First, her interest in Buddhism and the

Buddhist view on spiritual development, and secondly a hope that the creative processes she went through

while working as an artist could become less demanding. The creative processes often starteed with a new

commission for an art product. She described experiences at the onset of such a new project as empty,

dark, “I will never make it,” “I am not good enough,” and meaningless. She told me she would often sit for

hours in despair in her atelier, without any result. (Depressive episodes, is my conclusion.)

Anne, as I then experienced, expected a lot of me concerning Buddhism as well as art. Having had a

general intellectual and philosophic education during my training in medicine and later as a

psychotherapist, I have no particular skills in art or in Buddhism. I soon became aware of being eager to

hide that art and Buddhism were not my thing. I started to feel insufficient, unable to fulfil her expectations.

“Produce, be good,” were words coming up in me.

From the beginning of our sessions I remember her beautiful large questioning eyes, making me feel

insufficient, not knowing what she wanted, not knowing what to do. Later in the session her eyes would turn

10
inward, become empty, making me feel lost, and then suddenly become dark and angry, accusing me of

not being of any help.

My experience of being inadequate, lost and accused surprised me, since I initially was not aware of the

parallelism between my experience and her description of her creative processes in her atelier.

Especially whenever we made a new appointment, I expected not being good enough for a next meeting

and was pleasantly surprised when she showed up the next session. I brought this up carefully in a

session, whereupon she assured me that what we did was just fine, which I of course was not able to

believe.

Gradually our awareness increased and figure became expectations, not being good enough, frustrations

and despair. Together we could carefully begin to see parallels between the experience in the sessions and

her creative process.

Her interest in Buddhism brought her another cause of frustration. Values as non-attachment, equanimity

and patience, values which she practised during her meditation training, gave her periods of relaxation in

the training hours. However, coming home she experienced herself once more as very impatient, losing her

temper, especially with her daughter. She asked herself why her meditation did not help her to practise her

values in her daily life. Once more “produce and be good” was figure.

Besides her sessions with me she started Akido classes, where she after a year found her present partner.

Here was a clear life event! (As I realized later.) She was thrown into turmoil of happiness and doubts. We

practised classical work with the empty chair. Dialogues with her new lover projected in the empty chair

diminished her turmoil. For example she said: ” I am not worth being loved.” In the empty chair she

answered as him: “I love you, you are intriguing.” As herself, she then said: ”Intriguing? No I am difficult to

live with!”

Three years ago she had a manic episode directly after a Zen Buddhist retreat, a retreat with long hours of

meditation, lasting a week. Later she referred to this situation as meaningful to begin with, with vivid

awareness and exquisite sense experiences, visually as well as audibly. For instance she described lying

11
on her back one evening, looking at the clear night sky and having an experience of being part of the

universe and knowing. On her way back from the retreat she walked through a forest and saw and heard

things she had never seen or heard before. She felt excited and happy. At the same time she could not

sleep and was frustrated at not being able to share her experience in words with others, especially not with

her partner.

This period was in the summer and during my holidays, therefore she was seen on the instigation of her

partner by a colleague, a Gestalt therapist, who saw her as psychotic, with hallucinations, delusions, gross

behavioural disturbances and exhausted. She was hospitalized and put on medication, an anticonvulsive

drug. After ten days she became an outpatient, regularly seen by a psychiatrist, who regulated her

medication. She then continued seeing me, in co-operation with the psychiatrist.

The contract between her, the psychiatrist and me was that I was not to interfere with the medication. I

would just continue our sessions. Her diagnosis was Bipolar disorder 1, with a psychotic episode. Her post-

natal depression could have been a misdiagnosed depressive episode of her bipolar disorder.

After the manic episode, because of medication, her weight increased, her moods were less expressive

than I was used to. Over our relation loomed the doom of her diagnosis, life long medication, always the

risk of another episode, and on the advice of the psychiatrist, no more meditation retreats. Being a medical

doctor, trained in psychiatry, I forgot to think as a Gestalt therapist and was caught in the medical model,

seeing no cure, only life long medication for a chronic disease, actually no good reason for continuing

Gestalt therapy. Her partner, informed by the psychiatrist, understandably insisted on her continuing the

medication. Anne thought that his fear of another manic episode was the cause of their emotional

discussions; she could not see his care for her in this and saw only control. Her work as an artist became

difficult as well, she could not stand being in her atelier as she felt depressed and lonely there. What had

been a relatively good place for her now brought agony.

The doom as I called it, looming over our sessions and her private and professional life, made me feel that

we had come to a deadlock. I once more felt inadequate, this time not because of the challenge she had

been, but because of the limitations of the medical model, where I did not see possibilities for recovery.

12
Again, I did not see the possible parallelism between our relationship and her diagnosis. I did not see that

“we” were depressed after a manic episode and emotionally flattened by medication. Awareness of all this

came gradually, first of how my body felt bent down, hanging in my chair, my breathing superficial, and an

hour felt long. Becoming aware of this I noticed Anne’s eyes looking down. Also, her breathing was flat and

her body posture was collapsed. I did not dare to mention this or ask her to experiment with her body

posture and breathing, being afraid that she would only hear criticism.

However, awareness of emotional flatness kept growing and became figure. During a session I

experimented with myself, trying flat breathing even more, consciously and carefully exaggerating my body

position. To my pleasant surprise, parallel with this experiment, Anne said: “I feel calmer today in this

session.”

The next session as I saw Anne walking into my office I noticed something in her body and her facial

expression, and awareness became “up”, my mood went up as well. I stated: “Anne, I am aware that your

shoulders are up, your eyebrows are up, and you breath is high in your chest, while I feel loosening up and

enthusiastic.” After some time she answered: “Yes, I feel sort of up and am afraid that I will become manic

again.” Now I did not feel afraid of asking her to experiment and said: “Can you experiment with your

“upness”, by searching for up- and downness in your breath, your shoulders and your eyebrows?” After

experimenting on her own for a while Anne answered: “I am not sure.” Not being satisfied with her answer, I

invited her to find an exercise with me where she could experiment with sinking down; she called it “to yield

into the floor.” She lay down, letting herself as it were sink into the floor. She said: “It feels as if I’m lying on

a beach, curling in the sand.” Then she said: “Yes, I can do this, and I am aware that I can regulate myself

more down, I can go down when I’m up.” In the same session we experimented further with what could

bring her down.

Anne was interested and went on experimenting at home and reported the next session that she could

keep herself down to a certain degree when she felt too high up. She lost a little of her initial fear of another

manic episode.

13
A few weeks later Anne said: “Now I am down, and afraid of becoming depressed.” I just took some time for

awareness to build up and saw that Anne was dressed in black and black only: a black skirt, a black

sweater, black shoes and stockings. Even her facial expression was dark, as she was hiding her face

behind her long dark hair.

Remembering that Anne in fact often wore black, I asked her if we could experiment with colours. I gave

her a colourful shawl and waited to see what happened.

Anne draped the shawl around her shoulders and walked around a little feeling the shawl, then started to

move slowly and elegantly through the office. After a while she reported: “ Interesting, I move a little from

down to up.” She experimented more, making some dance movements and said: “This is interesting, I can

regulate my mood with this as well.” She continued: “Often in the morning when I am down I don’t have the

energy for clothes and just put on what is there.” I answered: “Yes, I’m aware that you often wear black,

however sometimes with a colourful streak. Could you also experiment with what makes you go up, when

you are down?” The next session she reported: “Yes I can, however I really have to pull myself together to

do so, but once I do, my mood indeed goes up. Colourful dressing helps, so does physical exercise such as

a walk. When I want to, I can regulate my down mood up.”

The following period Anne and I experimented, reported and discussed our findings with up and down.

Anne carefully started to use make-up, which she had never used before. We then experimented with going

even further down when she felt down, the way I had done earlier with myself only. She reported: “Strange,

going down on purpose makes me less afraid of going down, it gives me a feeling of mastering my moods.”

Inspired by this effect we then also experimented with going even more up when she felt up. Anne

enthusiastically reported the same effect. She was at the same time still medicated and under her

psychiatrist’s supervision. Together they decided to gradually reduce and eventually stop the medication.

Only in a period where she once more became sleepless did she use same anticonvulsive drug for a week

and consequently restored her sleep rhythm (as suggested by her psychiatrist). Anne and I continued

working together, and other issues came up.

14
One remarkable episode worth mentioning was when Anne invited me to see some of her art work in a park

close to my office. Remarkable since Anne had only once shown me a little piece of work, probably as a

test to see how I reacted. Remarkable also because I had never asked her to show me anything, certainly

being caught with her in the figure “produce and be good” and afraid of not being able to comment on her

work without her feeling critized.

We went for a walk together to visit her work in the park; she seemed to enjoy both our walk (which I

enjoyed as well) and my pleasant surprise created by seeing her work. We both seemed to be able to

endure the tension of intimacy created by the exposure of her art work and the walk, without going too

much up or down or being caught in “produce and be good”.

Anne also started to experiment with co-artwork. She invited individuals to her atelier to work on a piece of

art together. She received a grant and a commission for a co-product with a colleague. Anne and her

colleague worked in a prestigious atelier offered by the local community and here she did not suffer the way

she had done in her own atelier, she did not feel alone or empty or dark. “We maybe will make it,” “We are

good enough.” She experienced their meetings as meaningful.

The relationship between Anne and her partner became strained because of different opinions about

Anne’s medication. Anne wanted to stop; her partner wanted her to continue. He obviously felt insecure

after Anne’s last manic episode. When the couple had a conflict, he explained their disagreement and the

ensuing strong emotions with her illness and saw it as a reason for continuing the medication. Whether he

was right or wrong, it certainly upset Anne.

Anne and I worked on this issue with classical projection work, “the empty chair”.

By being him in the empty chair she found that her partner was afraid of new episodes and wanted to

protect her. This insight calmed her down, and afterwards their relationship was slightly improved. Anne

and I discussed the option of couple therapy, done by a colleague. We gave up the discussion when her

partner refused, saying: “I am not ill.” I did meet her partner however, the first time at an exhibition of

her work.

15
Anne and her partner had bought a large old sailboat, where they did reconstruction work last summer.

Anne reported, once they had started, to enjoy the work and also working together with her partner. They

are both skilled in craft. Here Anne could enjoy her craftsmanship in relation with her partner, without being

self-critical as she easily becomes when working on a commission. Moreover, this had a positive effect on

their relationship. With this boat the couple visited me once. What the visit did for their relationship, I do not

know, however it created potential ethical dilemmas.

Recently Anne and I made an appointment to visit her own atelier. She still had problems working there.

Her atelier was cold, and I was overwhelmed by the disorder. Everywhere there were boxes and

cupboards, full of stuff, tables with large heaps of materials, only a small space where she could work. I had

come with a feeling of expectations, which immediately disappeared after entering. I told her: “ I am not

surprised that you can’t work here.” She was surprised and relieved that I as a visitor immediately

understood that she could not work there in its present state. She told me that she had tried several times

to clear away the mess and create a sort of order, never making it. I suggested that she had a dialogue with

the room, where she could also answer as the room. Room: “I am cold and do not want to be filled up with

more than I already have, leave me alone.” Anne cried and answered: ”I’m so sorry to have put so much

into you, I have tried to clear you up.” The room answered: “You have tried it so often, you won’t make it,

you need movers to do the job.” After this dialogue Anne decided to ask friends to help her “move” stuff out

of her atelier.

Discussion: Comparing the findings with the literature reviewed

Polarity work

Experimenting with “up” and or “down” and obtaining control over too much of up and/or down made Anne

lose some of her fear of a new manic-depressive episode. She also managed to regulate her emotional

state more and felt more capable in case of new possible episodes. Typical of Gestalt therapy is staying in

16
what “is”, as Yontef (2005) explains: “the goal of a phenomenological exploration is awareness, the

exploration works systematically to reduce the effects of bias through repeated observations and inquiry”

We experimented not only with “what is”, but also exaggerated “what is” as discussed by Korb et al.

experimenting with going even further down and further up when she felt down and or up. Anne could also

feel the effect of her awareness experiments. Earlier I had been the only one with awareness of the

situation of the two of us, experiencing it in my body. Now she could experience it as well, having more

body awareness. Moods and affects are not something a person has, but of a multi-person system

(Wheeler 1991; 1999). Her tendency to become victim of her moods, developed by former manic-

depressive episodes, also diminished when being with someone else. “Exploration works systematically to

reduce the effects of bias through repeated observations and inquiry” (Yontef, 2005) According to (Melnick

et al., 2005) “An experiment can also be conceived as a teaching method that creates an experience in

which a client might learn something as part of their growth.

The above mentioned experimenting with “up and down” is also typical of Gestalt therapy, as Polster E. and

Polster M. (1973) point out: “Any psychological tension has its potential pole, as in thesis and anti thesis,

potential leading to synthesis, which is then the new thesis” (p. 39). In this case down can be seen as

thesis, up as antithesis, and synthesis as managing to regulate her emotional state to make her more

capable in case of new possible episodes.

Relational work

According to Zwanikken et al. (1990) manic-depressive behaviour has a function in a relational system.

With pleasing and denigration the manic-depressive patient manipulates the experience of the others. They

test boundaries and try to change them.

An example of avoiding this testing was my decision not to be involved in the medication of Anne. On the

other hand, my experience of being insufficient, lost and accused, could be seen as an example of being

“tested”. Practicing staying in “the middle mode” (Perls et al., 1951, pp. 421-428) was a way to deal with

testing.

17
Anne’s lover refused to go to couple’s therapy with her, but dialogues with him projected in an empty chair

diminished her turmoil of happiness and doubts.

Our walk to visit her

work in the park and seeing her work, where we both were able to endure the tension of intimacy created

by the exposure of her art work and the walk, was an example of what Perls et al. (1951) describe as “Self

as an emergent function” organizing the situation.

Or as Brian O`Niell says: “The whole determines the parts…..” (Perls, Hefferline and Goodman, 1951.p. xi)

This encourages us as therapists to move beyond the individual, reductionist nature of current psychology

and medicine (italics my adds) that sees only the separate nature of the therapist and client contact. To

move beyond this point is to develop an awareness of the “self” of the therapist/client dyad. ( Brian O`Niell

GR V 12 no. 1 2008)

Examples were the figure formations “awareness of emotional flatness and ups and downs”. My awareness

and experimenting with that awareness are the awareness and experimenting of the dyad. Knowing that I

am part of the dyad makes it possible to raise awareness of the dyad. Not trying to change, on the contrary

to be and eventually exaggerate create change. This according the “paradoxical theory of change” from

Arnold Beisser (1970)

Possibly as result of this relational work Anne started to experiment with co-artwork. With the sailboat

reconstruction Anne enjoyed her craftsmanship in relation with her partner, without being self-critic, as she

easily becomes when working on a commission. Clearly (re)-establishing relationships with important

relatives and colleagues, not only with her close family, seemed to have a stabilizing effect.

To be an artist

Anne seems to illustrate the findings of Simeonova et al. (2005) that there may be a correlation between

high creativity and bipolar disorder.

Drugs, alcohol and nutrition

I do not know whether drug abuse is involved in this case. However the findings of Goldstein et al. (2006),

pointing out that almost half of all bipolar patients suffer from alcoholism, is a reminder for me to consider

the possibility.

18
I did not know that seafood consumption had a possible influence on the development of bipolar disorder,

as Noaghiul et al. (2003) have discovered. It could be interesting to discuss diet with Anne.

For three years Anne has had no disorder episodes, two years without medication, while having regular

therapy sessions. She is still a passionate woman, a passion much appreciated by me, and not always

easy for her, her intimates and me to live with.

Conclusion

The psychosocial interventions mentioned by Miklowitz et al. (2003) and referred to in the literature review,

did not play an important part during Gestalt therapy with Anne. Admittedly, looking for and planning for

signs of relapse can possibly be illustrated by our phenomenological exploration and polarity work. We did

not deal with illness acceptance. Some emphasis on regular rhythms of sleep was included in our work:

When she had to deliver something as an artist, her sleep rhythm was disturbed and then restored by

means of resuming medication for a period. Involving her family was done by “empty chair” work only.

Gestalt therapy seems to be a modality of psychotherapy that clients with a bipolar disorder can benefit

from. In our case we practised being in the "middle mode” polarity work and phenomenological exploration,

and we experimented with the “empty chair” (projection work). All the time, our approach was relational,

and we also worked on her relation to her lover, daughter, colleagues - and to her atelier.

Is Anne cured in the medical sense? If her diagnosis, bipolar 1, was correct, then the medical theory of this

disorder must be reviewed, and Gestalt therapy would be the first choice of treatment.

We need more qualitative research focusing on bipolar disorder and Gestalt therapy. An important aspect

in this connection is the cost-effectiveness of Gestalt therapy interventions. Intensive treatment such as

Gestalt therapy seems to be effective in hastening recovery from episodes, maintaining stability, and

delaying recurrences, but it is costly. Treatment-associated costs must be carefully balanced against the

potential gains for patients when it comes to functioning and quality of life, and possible reductions in rates

of hospitalization or polypharmacy.

19
References

Arehart-Treiche J., Psychiatric News October 17, 2003, Volume 38 Number 20,2003 American Psychiatric

Association p. 24; Lancet 2003; 362:798 - 805.

Arndt S., DelBello M.P., Strakowski S.M. Concurrent tracking of alcohol use and bipolar disorder

symptoms. Bipolar Disord 2006;8:338–344.

Baalen van, D. C., de Vries, M. (1987), “Spontaneous” regression of cancer”, a clinical and psycho-social

study, Dep. Of Gen Pathology Medical Faculty. EUR,

Baalen van, D.C.(1998), Gestalt Diagnostiek, Tijdschrift voor Gestalttherapie, nu. 5, p 33.

Baalen van, D.C. (2000), Gestalt et diagnostic, Gestalt ,no. 18, p 141.

Baethge C., Baldessarini R.J., Kaur Khalsa H.M., et al. Substance abuse in first-episode bipolar disorder:

indications for early intervention. Am J Psychiatry 2005;162:1008-1010.

Beisser Arnold (1970) Paradoxical theory of change in Gestalt Therapy now, Fagan and Shepard, Harper

Colophon book

Bernhard B., Schaub A., Kümmler P., et al., European psychiatry 2006; 21:81-86

Bhugra D., Flick G.R.. Pathways to care for patients with bipolar disorder. Bipolar Disord 2005;7:236-245

Christensen E.M., Gjerris A., Larsen J.K., Bendtsen B.B., Larsen B.H., Rolff H., Ring G., Schaumburg E.

Bipolar Disord. 2003 Oct;5(5):356-61.

Colom F., Vieta E., Sánchez-Moreno J., et al. Psycho education in bipolar patients with comorbid

personality disorders. Bipolar Disorders 2004;6:294-298

20
Colom F., Vieta E., Martinez-Aran A., Reinares M., Goikolea J.M., Benabarre A., Torrent C., Comes M.,

Corbella B., Parramon G., Corominas J. Randomized trial on the efficacy of group psychoeducation in the

prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry.

2003;60:402-407.

Drug and Therapeutics Bulletin 2005; 43(4):28-31.


Fagiolini A.,Kupfer D.J., Rucci P., et al. Suicide attempts and ideation in patients with bipolar I disorder. J

Clin Psychiatry 2004;65:509-514

Fleck D.E., Keck P.E., Corey K.B. and Strakowski M. Factors associated with medication adherence in

African American and white patients with bipolar disorder. J Clin Psychiatry 2005;5:646-65

Frangou S., Dakhil N., Landau S., Kumari V. Fronto-temporal function may distinguish bipolar disorder from

schizophrenia. Bipolar Disord 2006;8(1):47-55.

Frank E., MallAnner A.G., Thase M.E., Weaver E.V., Kupfer D.J. J Abnorm Psychol. 1999 Nov;108(4):579-

87.

Friedman E., Gyalai L., Bhargava M., et al, show seasonal changes in clinical status in bipolar disorder: a

prospective study in patients. Acta Psychiatr Scand 2006;113:510-7.

Garnham J. Journal of Affective Disorders 2007;104(1-3):185-90).

Morgan V.A., Mitchell P.B., Janblensky A.V. The epidemiology of bipolar disorder: sociodemographic,

disability and service utilization data from the Australian National Study of Low Prevalence (Psychotic)

Disorders. Bipolar Disorders 2005;7:326-337.

Goldstein B.I., Velvys V.P. and Parikh S.V. The association between moderate alcohol use and illness

severity in bipolar disorder: a preliminary report. J Clin Psychiatry 2006;67:102-106.

Hakkaart-van Rooijen L., Hoeijenbos M.B., Regeer E.J., et al. The social costs and quality of life of patients
21
suffering from bipolar disorder in the Netherlands. Acta Psyichatr Scand 2004;110:383-392

Harvard program "treatment contract" PsychEducation.org (home), Psychotherapy for Bipolar

Disorder 
(revised 5/2007; original August 2003)

Hayward P., Watkins E.R., Wright K., Sham P. Relapse Am J Psychiatry. 2005;162:324-329.

Kessing L.V., Diagnostic subtypes of bipolar disorder in older versus younger adults. Bipolar Disord

2006;8:56-64.

Kieseppä T., Partonen T., Haukka J., et al. Am J Psychiatry 2004;161:1814-182

Lam D.H., Hayward P., Watkins E.R., Wright K., Sham P. Am J Psychiatry. 2005;162:324-329.

Melnick, J., March Nevis, S. Gestalt therapy methodology in Gestalt Therapy, History, Theory, and

Practice. (2005) Ansel Woldt & Sarah Toman (eds). London, UK: Sage Publications

Miklowitz, D.J, Otto M.W., Frank E., Reilly-Harrington N.A., Wisniewski S.R., Kogan, J.N., Nierenberg A.A,

Calabrese, J.R., Marangell, L.B., Gyulai, L., Araga, M., Gonzalez J.M., Shirley, E.R., Thase, M. E.,

Sachs,G.S., Arch Gen Psychiatry. 2007;64:419-426.


Miklowitz D.J., George E.L., Richards J.A., Simoneau T.L., Suddath R.L, A randomized study of family-

focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch

Gen Psychiatry. 2003;60:904-912.

Morgan VA, Mitchell PB, Janblensky AVBipolar Disorders, 7: pp 326-337 (2005)

Brian O`Niell Relativistic Quantum field TheoryGR V 12 no. 1 p 21(2008)

Noaghiul S, Hibbeln JR. Am J Psychiatry 2003;160: 2222 - 7

22
National Institute of Mental Health (NIMH) http://www.nimh.nih.gov/health/publications/bipolar-

disorder/complete-publication.shtml#pub1

Perls, F. and Hefferline R. and Goodman P.(1977) Gestalt Therapy, Excitement and Growth in the Human

Personality. Bantam Books, New York

Perry A. (1999), Tarrier N., Morris R., McCarthy E., Limb K., BMJ 1999;318:149-153 ( 16 January )

Polster E.and PolsterM., Gestalt integrated, p. 39, 1973

Rasgon N, Bauer M, Grof P, et al. Sex-specific self-reported mood changes by patients with bipolar

disorder. Journal of Psychiatric Research 2005;39:77-83

Redfield Jamisom K., An Unquiet Mind, 1995, p.6

Reinares M., Vieta E., Colom F., et al. Journal of Affective Disorders 2006;94:157-16.3

Scott J. et al The British Journal of Psychiatry (2006) 188: 488-489. doi: 10.1192/bjp.188.5.488© 2006

Simeonova D.I., Chang K.D, Strong C., et al. Creativity in familial bipolar disorder. J of Psych Research

2005 9:623-631.

Simon G.E., Ludman E.J., Bauer M.S., et al. Long-term effectiveness and cost of a systematic care

program for bipolar disorder. Arch Gen Psychiatry 2006;63:500-8

Swann A.C., Dougherty D.M., Pazzaglia P.J., et al. Impulsivity: a link between bipolar disorder and

substance abuse.Bipolar Disorders 2004;6:204-212.

Thase M.E., Sachs G.S. Bipolar depression: pharmacotherapy and related therapeutic strategies.

Biological Psychiatry, 2000; 48(6): 558-72.

The National Institute of Mental Health USA govn. 2007

23
Wals M., Reichart C.G., Hillegers M.H.J., et al. Prediction of change in level of problem behaviour among

children of bipolar parents. Acta Psychiatr Scand 2006;113:23-30.

Wheeler, G. (1991, 1998): Gestalt Reconsidered. New York: Gestalt Institute og Cleveland Press.

Yontef G. Gestalt therapy theory of change, in Gestalt Therapy, History, Theory, and Practice. (2005)Ansel

Woldt & Sarah Toman (eds). London, UK: Sage Publications

Zinker J. 1977, Creative Process in Gestalt Therapy 1977 Vintage Books, New York

Zwanikken G.J., Fischer A.A. and Zitman. F.G.

Psychiatrie, Utrecht, Wetenschappelijke Uitg. Bunge, 1990

24