Transactional Analysis Journal

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Manic-Depressive Structure: Treatment Strategies

Maxine E. Loomis and Sandra G. Landsman
Transactional Analysis Journal 1981 11: 346
DOI: 10.1177/036215378101100419

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Treatment

Manic-Depressive Structure:
Treatment Strategies
Maxine E. Loomis
Sandra G. Landsman

Abstract Manic Depressed

Describes use of developmental and life You can do But you'll never do
script information in planning and imple- anything it well enough to
menting treatment of clients who mani- please me.
fest a manic-depressive structure-a struc-
ture consisting of two separate and seem-
ingly incompatible parent incorporations Discount Problems can 'I be
along with two sets of Child adaptations. significance solved
A number of general treatment strategies
are described, and relevant precautions in
their use noted. Five distinct stages of
treatment, each with specific issues to be I'll keep running I don'texist
confronted and techniques useful to aid I'm good AC I won'tfeel
and facilitate resolution, are identified I'll show you - ha-ha 1 I'm bad
and discussed in detail. I'lldo(not do) things I'll never make it

Ego State Network in

Introduction
In our October 1980 article we presented
theoretical and clinical material regarding
the assessment and development of the
manic-depressive structure. In this article,
we will describe the use we have made of
developmental and life script information
in our treatment work with this population.
"Manic-depressive structure as used in
our work refers to the general ego state
pathology and life script issues commonly
found in persons experiencing affective
disorders. Included in this discussion are
the diagnostic categories of the American
Psychiatric Association (1980), 296.
"Affective Disorders." (Loomis and
Landsman, 1980). The treatment strategies
presented in this article are a direct means
of correcting the basic messages and
adaptations presented in our previous
article and summarized in the following
diagram:
346
Manic-Depressive Structure
The manic-depressive structure consists
of two separate, and seemingly
incompatible, parent incorporations along
with two sets of child adaptations. The
manic and depressive sides of the structure
are experienced as separate and the
apparent internal contradictions are
maintained through the use of denial. As
long as this internal grandiose and com-
petitive structure is allowed to continue the
person will experience difficulty in solving
problems and continue to discount the
significance of stimuli. The overall goal of
treatment, therefore, is integration.
General Treatment Strategies
Treatment of persons with manic-
depressive structures must be done from a
non-competitive position. This may sound
Transactional Analysis Journal

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simple, however, manic-depressive clients
have grown up and learned to experience
themselves, their relationships, and their
environments within a competitive frame
of reference. They tend to polarize issues
and will argue that normal functions, such
as thinking and feeling, cannot be done
simultaneously. They will attempt to re-
define treatment expectations in
competitive terms with statements such as,
"But you told me to stop working so
hard," as justification for not showing up
for training group or a therapy session. In
this case, the adaptation, "I'll show you -
ha hal" must be confronted, and the pur-
pose for the redefinition of alternatives
explored. Most clients have numerous
options for cutting their busy schedules.
They do not need to cut back on therapy
and in effect run from closeness or contact
with the therapist.
Manic-depressive clients also require a
realistic Nurturing Parent from the
therapist. Since most manic-depressives
operate from the unrealistic assumption
that someday they will be able to obtain
their fantasized nurturing, they are likely to
approach the treatment situation with this
expectation. Again, treatment and the
therapist will be defined as a polarized, all
or nothing, experience. The therapist must
avoid such grandiose expectations with the
message, "I will take care of you in a
healthy manner." While this message may
be heard by the client as "I will take care of
you no matter what," it is important that
the therapist persist in establishing realistic
expectations for herself, the client, and the
group if that is the setting in which treat-
ment is being conducted. Of course there
will be limit testing to assure the client's
young and needy Child of the therapist's
presence, and some clients will use their
grandiose, but unmet expectations of nur-
turing as a means of terminating treatment.
The therapist must remember that it would
not be useful for the manic-depressive
client to hear the message of caring and
nurturing as permission to do anything and
therefore feed into the grandiosity.
Realistic nurturing will contain realistic
limit-setting and mutual contracts for
change.
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MANIC-DEPRESSIVE STRUCTURE
Treatment of manic-depressive clients
also requires a flexible approach. We often
talk of our work with these individuals as
similar to flying a kite in a high wind. One
develops a feel for when to pull back on the
string and when to let it out. Pulling the
string too hard in a gusty wind will cause it
to snap and the kite will take off on its
own. Too slack a string is likely to result in
a careening or crashing kite. Manic-de-
pressive clients change rapidly as they
lower their defenses and give up the denial
and exclusions that have maintained the
structure. The therapist must adjust and
pace these changes.
In general, the therapist needs to give
highest priority to dealing with the
behavioral manifestations of the disorder,
second priority to the developmental and
script issues supporting the behavior, and
finally deal with the structural and integra-
tion issues specific to the manic-depressive
structure. The outline and description
which follows should be regarded as a
general pattern for the course of treatment.
The flexible therapist who works from a
non-competitive and realistic nurturing
position will be able to adapt this frame-
work to her own treatment of manic-
depressive clients.
Stages of Treatment
In our treatment experience with manic-
depressive clients the work progresses in
five distinct stages. At each stage there are
specific issues to be confronted and
techniques to facilitate resolution. The
therapist must pace and lead clients
through this process in a flexible manner,
as mentioned above. The following thera-
peutic tasks are especially relevant at each
of the five stages. Stages one and two may
occur simultaneously.
STAGES OF TREATMENT
1. Lower Defenses
- set basic contracts
- deal with behavioral manifesta-
tions
- achieve and maintain social control
2. Decontamination Work
- confront grandiosity and discount-
ing
347
MAXINE E. LOOMIS AND SANDRA G. LANDSMAN
- emphasize use of Adult for
problem solving
- transactional and game analysis
3. Exclusion Work
- deal with developmental and script
issues
- provide realistic Nurturing Parent
- provide integration messages
4. Integration
- facilitate decision to alter (rather
than adapt) structure
- facilitate decision to give up fan-
tasied Nurturing Parent
- teach increased awareness and con-
trol of energy cathexis
5. Resolutions
- facilitate natural, realistic use of
options for thinking, feeling, and
doing.
The first stage of treatment with manic-
depressive clients involves the lowering of
defenses. Because most of these clients
present themselves with problems of doing
or not doing things, we usually begin
working with them around practical issues
of time structuring. One such client may
need help cutting back on an 80 hour work
week filled with overlapping committee
meetings, while another requires specific
directions about obtaining and maintaining
employment. The expectations are
behaviorally specific, e.g., "Find 10 hours
per week and free up that time," or "I
want you to interview for three jobs this
week," and provide a beginning assessment
of the client's investment in treatment. We
regard the ability to make and keep
contracts as central to our treatment work,
and this expectation is shared from the
outset.
The next step is to set the contracts basic
to working with manic-depressives. Per-
haps most central to the structure is the No
Running Contract. This is essentially an
agreement to stay and deal with issues and
not to run, either physically or
psychologically. The importance of this
contract is illustrated by the high level of
anxiety experienced by most manic-
depressives when informed of their need
for the contract. Without a No Running
Contract, treatment is not likely to
succeed. The complementary messages
348
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delivered by the therapist are that problems
can be solved, your feelings are not so over-
whelmingthat you msut run away, and you
can stay and deal with the issues. Thus, the
beginning alteration of grandiosity and dis-
counting is established.
Closely related to the No Running
Contract is the No Secrets or Lies
Contract. Secrets or lies may occur by
either omission or commission and are the
primary ways manic-depressives have of
psychologically running. Because of their
use of denial and internal structure of
exclusions, these clients may be unaware of
keeping secrets. The message is that they
are expected to maintain all parts of all ego
states in awareness. This contract provides
the foundation for the exclusion work
(Stage 3) and integration work (Stage 4)
that will follow.
Manic-depressive clients often deny the
need for and importance of a No Suicide/
No Homicide Contract. When this occurs,
it is usually because the client is using
denial to contain the homicidal rage on the
manic side or the needy, depressed infant
struggling with existence issues on the
depressive side of the structure. One client
adamantly denied having ever been
depressed, only to "remember" some
months later about a suicide attempt he
made during his senior year in college.
Most of these clients willingly make a No
Suicide/No Homicide Contract in response
to the therapist's concern and obvious
interest in their safety. Only later do they
emotionally understand the contract's
importance. The presence of the contract
enables the client to deal with Child
adaptations on both the manic and
depressivesides of the structure.
One important objective of Stage 1 work
with manic-depressives is to achieve and
maintain social control as a means of
dealing with the behavioral manifestations
of the disorder. Since most of our
treatment work is done without the use of
medication, a high level of commitment
and cooperation is required of the client.
Most accept this challenge to make and
keep contracts, and it becomes a way of
making the competitive frame of reference
work to their benefit.
Transactional Analysis Journal

Social control contracts are made
specific to the needs of the individual
client. For example, one woman who was
picking up energy from the car engine and
radio while driving and had been ticketed
for speeding was restricted to driving no
faster than 55 MPH. She further
contracted to walk or take a cab if she was
too "high" to drive safely. The result was a
self-imposed technique of not using the car
radio and/or pulling off to the side of the
road until she was calm enough to drive,
which got her safely through a manic
escalation. Gradually, the 55 MPH speed
came to have a calming effect, and the
threat of totally restricting use of her car
was never enforced. She now has a car with
cruise control.
The second stage of treatment with
manic-depressive clients involves
decontamination work and may be
occurring simultaneously with the setting
of contracts and maintenance of social
control. During this stage, the emphasis is
on use of the Adult ego state for problem
solving. We spend considerable time and
energy confronting grandiosity and
discounting, and teach our clients to think
about and maintain awareness of the
consequences of discounting the
significance of stimuli. Thus, clients learn
to slow down and assess the signific:anc:e of
all relevant stimuli before doing things by
considering what might happen if they
don't. For example, a business executive
learned to slow his manic Child by
generating internal images of the
consequences of arriving at the airPort
without his briefcase or hastily preparing
an incomplete report for a board meeting.
At this slower pace, he was more able to
adequately determine the significance of
both internal and external stimuli. While he
complained at first of the decrease in Child
spontaneity (excitement generated by
manic Child) as a result of consciously
processing everything through Adult, he
was reassured that this was not a
permanent solution. Later, Natural Child
spontaneity was experienced as his exclu-
sions were resolved and integration was
completed.
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MANIC-DEPRESSIVE STRUCTURE
"Most problems have a solution;" ,'You
are capable of solving problems." These
are the new messages we provide as we
confront manic-depressive grandiosity,
Fears of never getting enough, always
being depressed, driving people away, or
not being able to stand it are common to
this structure. Such grandiosity is the
justification for thinking, feeling, or doing
certain things. While the majority of our
clients have previously engaged in
hypomanic activity to avoid feeling
depressed, we have had several clients who
kept themselves moderately depressed to
avoid the discomfort of becoming manic.
The notion that one must be totally manic
or totally depressed is confronted as
grandiose, mutually exclusive, and
internally competitive in both instances.
When clients persist in not thinking or
solvina problems, we make use of a variety
of techniques for dealing with resistance
and non-thinking behavior.
Within the decontamination work we
pay particular attention to the familiar
transactions and games with which the
dieDt furthers the manic-depressive script
decisions. Our experience so far suggests
that the bottom line within this structure is
to end up all alone and not existing (a
younaer construct than death), This is the
script payoff regardless of whether the
overt behavior appears to be engaging or
rejecting of others. We next move into the
exclusion work to deal with the issue of
existence.
TIw thi!'d stage of treatment with manic-
depressive clients involves dealing with
developmental and script issues-especially
existence. With most clients, these issues
have been excluded from awareness
through use of denial. A great deal of
energy has been invested in maintaining the
defensive internal barriers. Once the client
decides to examine what has previously
been denied, he usually experiences
difficulty in maintaining a constant
cathexis of energy. In some cases, this has
meant rapidly shifting from one ego state
to another or experiencing difficulty
maintaining Adult cathexis. One client who
had driven for years suddenly became
349
MAXINE E. LOOMIS AND SANDRA G. LANDSMAN
frightened of cars on the freeway. Another
client whose work involved business
lunches and dinners was forced to order
foods which she could eat with her fingers
when she became so uncoordinated that
foods such as salad would not stay on her
fork. A number of clients have reported
transient sleep disturbances as frightening
content is worked into awareness through
dreams.
While many of these symptoms fit with
the grandiosity of the structure, each must
be dealt with from a realistic, protective
position. We actively engage our clients in
resolving previously excluded issues in a
healthy manner-one which does not rein-
force the structure and old decisions. For
example, one young woman, during the
course of regressive work, had become
aware of bodily sensations which we
assumed were related to physical abuse as
an infant. For several weeks following this
insight the client reported experiencing
regular pain in the joints of her lower
extremeties, especially while doing
regressive work. She seemed to be
experiencing feelings related to the earlier
trauma which had been previously denied.
A medical examination confirmed that
there was no physical injury. After some
encouragement, the client was able to
figure out how to resolve the current pain
without denying it. She decided to cry
(instead of withdrawing), to take in
physical strokes (instead of blocking
them), and to accept baby aspirin, a warm
blanket and nurturing to relieve the pain.
Over the next several weeks, the pain
gradually subsided. Our assumption is that
the pain was a hysterical symptom designed
to focus energy and resolve an issue
previouslydenied. The client's decision and
cooperation was essential in achieving
resolution.
Regressive work has been helpful in
assisting our clients deal with issues on the
depressive side of the structure. We have
found a common theme of early infant
depression in all of our clients for whom
"being little" is a useful metaphor. Many
of them regress to a very young age (0-3
months), close out external stimuli, and
350
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experience either fear or grief. Some des-
cribe being in a contained space such as a
hole, tunnel or cave where they may protect
themselves in secret from a perceived
hostile environment. Others experience
sensations which can only be described in
terms such as "non-existence," "waves of
sadness, grief, fear, or anger which are all-
consuming." Due to the preverbal nature
of the experience, they have difficulty
articulating the primary process experience
in secondary process terms. It is important
that clients describe these experiences
following the regressive work and
participate in figuring out how to take care
of the baby.
Each manic-depressive brings an
interesting array of developmental events,
however, the script issues are remarkably
similar. Some have been over-nurtured,
some abused, some expected to never win,
and some never to lose, but the key issue is
existence. The manic-depressive has built
an elaborate internal structure of
exclusions, each one of which must be
identified, worked through and integrated.
The fourth stage of treatment with
manic-depressive clients involves dealing
with structural and integration issues. For
manic-depressives who stay in treatment,
there is a point at which they need to decide
to alter their basic structure, not just adapt
it. Clients who have made this integration
decision report a clear difference between
"wanting to make the structure more func-
tional" and "deciding to change the
structure." For them, the whole is more
than just the sum of its parts. They have an
increased awareness and control of energy
cathexis because they have abandoned
denial of thoughts, feelings, or behavior as
an alternative for solving problems.
Grandiosity and discounting are no longer
necessary and they can choose when and
how they willcompete.
It appears that the decision to giveup the
fantasied Nurturing Parent is one which
facilitates the process of integration.
Perhaps this is true because it allows the
client to drop adaptations on both the
manic and depressive sides of the structure
and experience Natural Child more freely.
Transactional Analysis Journal
 MANIC-DEPRESSIVE STRUCTURE

Parenting is then experienced as realistic, they will continue to develop as

and not competitive. With the external
competition thus resolved, C2 feelings and
P 2 incorporations can proceed smoothly
without the previous need for an internally
competitive system of exclusions and
denial. It is at this point. clients report
experiencing an integrated self.
The fifth stage of treatment, resolution,
is one with which we have the least
experience. At the time of this writing, a
number of our manic-depressive clients are
at this stage. They are now able to identify
the difference between "normal"
excitement and their previous manic hights;
the difference between sadness related to
loss and their previous dark, lonely depres-
sions. They report a natural realistic use of
options for thinking, feeling, and doing
things with an excitement and spontaneity
that is fun to share. Our assumption is that
autonomous, flexible, and productive
people.
Maxine E. Loomis, RNCS, PhD, CPTM
is a professor of nursing at the University
of Michigan and a member of clinical and
training staff of Landsman/Foner Asso-
ciates in West Bloomfield, Michigan.
SandraG. Landsman, MA, CSJv, CPTM,
is Clinical Director and Director of Train-
ing, Landsman/Foner and Associates in
West Bloomfield, Michigan.
REFERENCES
American Psychiatric Association. Diagnostic and
statistical manual of mental disorders. (Third
Edition) Washington, D.C., 1980.
Loomis, M.E., & Landsman, S.G. Manic-depressive
structure: Assessment and development. Transac-
tionalAnalysis Journal, 1980, 10(4), 284-29()'

Berne weighed titles and functions judiciously and seldom expressed degree snobbish-
ness. Although he used the word "patient" in the traditional way because of his
medical orientation, he used the word "doctor" in a nontraditional way. In fact,
one of his hospital stories is of psychiatric staff-a group of psychiatrists, psycholo-
gists, and social workers-who had lunch together regularly and joked about them-
selves as being unreal docors in contrast to the surgeons and internists who occa-
sionally joined them and who were considered "real." In Berne's view, "real
doctors could be described as follows:
I. A "real doctor" is specifically oriented throughout his training toward curing
his patients and that is his overriding consideration throughout his practice.
2. A "real" doctor can plan his treatment so that at each phase he knows what he is
doing and why he is doing it.
3. A "real doctor" clearly distinguishes research and experimentation from good
medical or surgical care, and the former is always subsidiary to the latter.
4. A "real doctor" takes sole and complete responsibility for the welfare of his
patients.
-Muriel James, "Techniques in TransactionalAnalysis, "p. 36-37

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