Can Modern Psychoanalysis Cure Bipolar Disorder?

June 26, 2018

Reading Time: 7 minutes

It was Spring, March. I was a student, at the New York Graduate School of Psychoanalysis. It was an emotional time. I was beginning to realize that my parents were separating and that something was gravely wrong with my mom. Meanwhile, I was feeling heartbroken, having discovered that the woman with whom I was falling in love was hooking up with my friend. Fleeing depression, I decided to plan an underground rave. I started taking uppers and hired several open-minded organizers on Craigslist. We spent four crazy days trying our best to get things in order and in that time two of us became manic. Before anything resembling the event I envisioned materialized, I was involuntary hospitalized and diagnosed as bipolar.

Traumatized from six days of containment and forced medication, I was unable to complete the semester. When I was ready to return to my school I was told by its administration that I would have to be cleared as fit-to-attend by a psychiatrist. I refused to see one on principle and out of fear. A proponent of psychoanalysis as an alternative, safe, therapy, I felt quite turned around by the experience of winding up in a psychiatric institution and being asked by the school to see a psychiatrist. It took me several years to sort out my understanding of what happened. It was unclear to me whether I should have been treated by psychiatry, psychoanalysis or both.

Historically, bipolar disorder isn’t among the conditions associated with psychoanalysis. If the early work of Sigmund Freud touched upon manic depression it did so only using the term dementia praecox, which was less a diagnosis than a categorical classification. It suggested a sense of finality, excluding patients whom it described from the psychoanalytically curable diagnoses. The conditions to which it referred were subsequently sorted out, first by Emil Kraepelin (the father of psychiatry) and company, as Alzheimer’s disease, schizophrenia and manic-depressive disorder.

It was not until Freud developed the dual-drive theory—the idea that everyone is born with libidinal and aggressive instincts—in his late work that he realized that the disorders he eventually attributed to the pre-Oedipal phase of psychological development could be cured. It was largely due to his preoccupation with affection (rather than aggression) that people’s faith in psychoanalysis waned near the middle of the century, at the same time that psychiatry discovered and developed anti-psychotic drugs. Before Freud’s psychoanalytic practice could finish its evolution toward treating narcissistic patients—those who experience psychosis—psychiatry rose as the field supposedly capable of understanding and helping such patients; because of this psychiatrists became society’s “experts” in regard to mental health.

Later, modern psychoanalysis was developed by Hyman Spotnitz and his colleagues to treat schizophrenia, an extremely durable condition. “Modern” psychoanalytic strategy consists of transference between the analyst and his or her patients, examination of their earliest relationships, and externalization of their pent-up aggression. While psychiatry is able to temporarily reduce schizophrenic psychosis, psychoanalysis 2.0 is able to cultivate long-lasting progress.

Learning about psychoanalysis’ ability to heal schizophrenia led me to question whether or not it could challenge psychiatry’s treatment of bipolar patients. I discovered that about a century ago and ahead of Freud, Karl Abraham identified the aggressive drive and its importance in the narcissistic conditions. He also realized that something akin to narcissistic transference is essential when treating bipolar disorder:

“By the help of a psychoanalytic interpretation… I succeeded in attaining a greater psychic rapport with the patients… It is usually extraordinarily difficult to establish a transference in these patients who have turned away from all the world. Psychoanalysis, which has hitherto enabled us to overcome this obstacle, seems to me for this reason to be the only rational therapy to apply to the manic-depressive psychoses.”

He perceived a need to rescue bipolar patients from psychiatric care: “therapeutic results in this sphere justify us in the expectation that it may be reserved for psychoanalysis to lead psychiatry out of the impasse of therapeutic nihilism.” In other words, Abraham believed that psychiatric care is a temporary solution to treat episodic symptoms; meanwhile, psychodynamic therapy can heal bipolar disorder.

In terms of nature vs. nurture, psychiatry is associated with the former and psychoanalysis is associated with the latter, but both ideologies fall somewhere on a spectrum. Psychiatry doesn’t deny that environmental conditions affect mental health and psychoanalysis doesn’t deny that genetics play a role. Psychiatrists don’t really concern themselves with the source of symptoms. They care about the “what” and psychoanalysts care about the “why.” Psychoanalysis focuses on the causes while psychiatry focuses on the effects. Psychoanalysis considers the patient’s unconscious to be active in mental and physical illness.

Psychiatry tends to portray bipolar disorder as an affliction, like a bodily disease, to which the patient is the passive victim. In Kraepelin’s time diagnosis was an intellectual pursuit, categorization taken as the first step toward understanding. Medicine was much less malignant. Psychiatric techniques were experimental and led to side effects that ranged from non-existent to mild.

Kraepelin didn’t claim to understand the conditions in which bipolar symptoms arise. However, he established interventions, which relied on environmental manipulation: “the treatment… will be above everything to prevent external stimuli as far as possible”; as such, “quiet friendliness, at a suitable moment… make the patient, who in unskilled hands is dangerous and stubborn, docile and good-natured.”

Kraepelin thought bipolar disorder might be curable but, before crossing that bridge, his diagnostic index was appropriated by psychiatrists whose approach to helping patients for the most part consists of medication.

The American Psychiatric Association uses an arbitrarily numerical index with which to diagnose bipolar disorder. The main criterion for “bipolar l disorder” is one or more manic episodes. “Bipolar ll disorder” is qualified by one or more major depressive episodes. The episodes themselves have a numerical index as well: five or more symptoms lasting two weeks or longer.

The Diagnostic and Statistical Manual of Mental Disorders, often referred to as the DSM, says that depressive symptoms include diminished interest in pleasurable activity, insomnia, lack of appetite, loss of energy, suicidal ideation, and “feelings of worthlessness or excessive or inappropriate guilt (which may be delusional).” A manic episode involves inflated self-esteem, decreased need for sleep, pressure to talk, flight of ideas, increase in goal-oriented activity, and “excessive involvement in pleasurable activities that have a high potential for painful consequences.”

While psychoanalysis agrees for the most part with psychiatry’s diagnostic criteria, it takes diagnosis as the starting point and then proceeds to sort out environmental factors. This is reflected in the way in which the chapter on bipolar disorder in the Psychodynamic Diagnostic Manual (PDM) begins with a diagnostic section similar to that in the DSM but then offers lengthy sections on anaclitic patterns and etiological hypotheses. The PDM describes the way in which the child has certain non-integrated emotions, which he or she cannot regulate.

The PDM suggests that bipolar patients likely experienced disruption in their relationship with their parents, producing punitive self-criticism, fear of loss, desire to be protected, and difficulty with impulse delay. A novel hypothesis is thereafter proposed:

“Bipolar patterns in children can be understood as arising from a unique configuration of antecedents involving sensory processing and motor functioning, early child-caregiver interaction patterns, and early states of personality organization.”

The difference between conditions such as bipolar disorder and what psychoanalysts used to call transference neuroses—i.e., obsession, hysteria, etc.—is that the disturbance behind bipolar disorder occurs in the earliest phase of psychological development.

The most appealing psychoanalytic approach to bipolar disorder, the disorder of two poles, is through dual-drive analysis. According to Abraham’s theories about manic depression, pathological disturbance during infancy prevents certain individuals from learning how to sublimate their internal drives into external relationships. They become narcissistic due to their parenting—too much or too little stimulation. The aggressive drive is stronger than the libido in some of these narcissistic people so, internalizing sadism, they become masochistic.

A bright painting of two naked figures.

Untitled by Ricky Kruger

When all is said and done, can modern psychoanalysis really cure manic-depression? I think so.

Anecdotally, I went through intensive modern psychoanalytic treatment for more than two years. This introspective period in my life uncovered parts of myself that I was not prepared to explore. As such, my first manic episode came a year into treatment and led to psychiatric hospitalization, an experience for which I was also not prepared. My matriculation into psychiatric care (involuntary hospitalization) was not a gentle one and increased the skepticism I already possessed in regard to psychiatry.

I didn’t accept my diagnosis until I experienced my first depressive episode, when I became suicidal. Seven years after I was diagnosed as bipolar I finally started taking psychiatric medication. My resistance faded in light of my desperation to feel better. A few months later, I am doing much better.

Instead of thinking of psychoanalysis as an alternative to psychiatry, I am thinking that it is an effective complementary approach, at least for me. Holistic healing is worth a shot before turning to Western medicine. In regard to mental health, psychiatry is always there as a last resort, like a safety net. The goal of psychiatric treatment is not to cure patients but to render them amenable to psychodynamic therapy or self-healing.

I could not ignore the disorder any longer and attempted to heal myself applying what I knew about psychoanalysis. I finally told my family members that I felt betrayed by them because they didn’t tell me or my sister that my bipolar mother was trying to take her own life (via psychiatric medication) until it was too late—I didn’t find out she was suicidal until I saved her life after an overdose. It was very cathartic to discharge my aggression instead of internalizing it. I think that facing my mommy and daddy issues was very healing, even more than narcissistic transference with an analyst would have been. I also began to practice mindful authenticity through writing therapy, which is helping me identify and dispel delusional thoughts.

I’m not claiming to be cured, but I believe that I’m now on the right track. After avoiding them altogether for five or so years, I feel grateful to my recent psychiatrists—solicited voluntarily in this case—for alleviating my acute depression. That said, I think I owe my progress to modern psychoanalysis because it brought my issues to light giving me a chance to work through them.

Meme: "The goal of psychiatric treatment is not to cure patients but to render them amenable to psychodynamic therapy or self-healing."

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