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Manic depression: when elation takes control

Aine Tubridy and Michael Corry don't like the term ‘bipolar disorder' as applied to manic depression. Here, they advance a different view of what is happening in this experience


There is a line in the sand between those who experience manic depression and the more common-or-garden forms of mental distress. Much mystique surrounds the experience of elation, and this is understandable. How is it possible that an individual in the prime of their life, with all the external trappings of normality in place, suddenly find themselves experiencing a superhuman amount of energy, which drives them relentlessly, without sleep, like a person on a mission, insatiable for social contact and avenues for their escalating ideas, to contrive fantastical ‘big picture' projects which they feel convinced will jet them to fame and fortune or, at the very least, to present to the world the ‘grand solution' to many of its problems?

Within weeks, such a person finds themself in a psychiatric hospital, doped up to the eyeballs, unable to string two thoughts together, their life in shreds, and with their family, friends and colleagues shaking their heads. The future has taken an entirely different depressing flavour — gone is the confidence, the powerful energy, the grandiosity, the great plans of the preceding weeks. And most depressing is the fact that there is huge collateral damage to repair, the swathe of destruction wreaked during their manic episode.

In addition, they have to absorb the feedback they get from their doctors that they are suffering from a mental illness, a disease of their brain, which will require a lifetime on medication with no guarantee that it can prevent further episodes occurring. How can they engage with a future with such uncertainty in it, where overnight their entire identity, both to themselves and others, has evaporated, only to be replaced by some alien ‘patient' identity come to inhabit them? This rock-bottom state is the stuff of a serious emotional crisis.

Tragically, within the current psychiatric repertoire of treatment, this state is related to as merely the inevitable tail-end of the manic process. Because this end-state depression and the mania which preceded it are seen as going hand and glove, inseparable processes which are the ultimate result of a disease of the brain, no attention need be given to any other possible initiating causes. Caught in the terrain of the sick-brain model, no-one pays attention to the primary cause, the emotional triggers preceding the mania, which are a reflection of a stress or predicament placing a strain on the personality one has in place. Instead the focus is on biochemical shifts, defective genes and medication regimes, all of which are secondary phenomena.

Would it make sense to repair a series of crashed cars, driven by the same driver, over and over, without ever asking why he keeps crashing them? Relevant questions such as: Is the driver drinking? Has he passed his driving test? Is he driving too fast? Trying to kill himself? Does it always occur on exactly the same spot in the road? One point is clear. The car is not the source of the problem but the consciousness behind the wheel.

This broken machine model clearly cannot work, since it marginalises the unique contribution of each person's mindsets, value systems, life experiences, vulnerabilities, special gifts and talents, socio-economic status, levels of responsibility, support systems, relationships, and the place at which they find themselves along their life plan as mind/body/spirit organisms. In short, while there is some commonality with respect to symptoms, no two manic depressives are the same as far as causality goes, which is always exquisitely personal to each.


Manic responses

Certain stressful contexts contain the ingredients to provoke the manic response in some individuals.


Defence against failure
For some, mania can be seen as an unconscious defence against an imminent failure, a manoeuvre to essentially avoid, deny and escape from the feelings of setback, disappointment and failure which are so much a part of everyday life for most of us. Feeling ordinary, vulnerable and out of control are not part of this person's everyday mindset. They prefer to be extraordinary, invulnerable and on top; they are uncomfortable with the down position and distort any evidence that it is on the horizon, instead overcompensating in the opposite direction. Their last-ditch efforts to ‘pull it off' in the face of all objective evidence to the contrary are legendary. This behaviour is akin to rearranging the deckchairs on the sinking Titanic, encouraging the dance band to play their hearts out while they keep the champagne flowing.


Richard, a 38-year-old, highly successful property developer, with a reputation for arrogance and risk-taking, lived a high-flying palatial life. He owned homes in many fashionable parts of the world, and lived in a magnificent mansion with stables in Kildare. He was part of the hunting and polo set, he moved with the rich and famous. The golden boy in a family of girls, he had gone to the best schools, achieving some acclaim as a sportsman and debater, then made his entrepreneurial debut at a young age, taking up the mantle from his father. He lacked his father's tact and political savvy, throwing his weight around and refusing to compromise and play the political game. In this way he made enemies in high places.

He did not see his Waterloo coming when he overextended himself on a huge property deal and the banks threatened to foreclose. Loathe to take any advice, and make the obvious financial steps, he instead took off to the Epson Derby with a party of friends where he backed a number of winners. Convinced now that his luck had turned he hit the town. Fielding frantic calls from his wife and business associates, he took up residence in the Ritz. He started entertaining round the clock, set up business meetings and planned a merger with one of the biggest property developers in London, who owned hotel chains across the world, believing that if he pulled this deal off his troubles at home would be sorted. The way forward was now clear — he would move his offices to London, and relocate his family. Newly inspired, he partied on, full of energy, and getting no sleep.

He became a charicature of himself, pompous, loud and aggressive, and filled with an air of triumphalism. Following a series of complaints from other guests about the noise in his suite, he had an ugly showdown with the hotel manager in the foyer, insisting that he his consortium was in the process of buying the hotel and that he would be fired that day. When the police arrived he was standing on the reception desk inviting other guests to the bar where, as the new owner the drinks were on him. He was eventually taken to the Maudsley Hospital where he was involuntarily detained.


The ‘eureka!' experience
Some individuals, consumed by an intensely intellectual project or piece of research, working marathon hours, their brain turbo-charged and exhilarated by the implications of their findings, without the brake that downtime provides, enter into a phase of sleep deprivation which opens the door to an altered state — mania. They now become mind-blown by the immense importance of their work, seeing its interconnectedness to the wider world, and how it could influence the future of mankind for the better. Obsessed now by the implications of their ‘discovery', they are high and think of nothing else, talking to anyone who will listen, and soliciting support from the influential and powerful. Criticism is brushed off and condescendingly interpreted as ignorance. Seeing themselves now as a messenger of great good, they feel divinity and righteousness to be on their side.


Sylvia, a 25-year-old PhD student in sociology, was completing her thesis on an aspect of group dynamics. She was behind schedule and it was now absorbing her totally, day and night. Particularly exciting to her was notion that in any group certain members had a predisposition to feel and express the thoughts and feelings unconsciously held by other members. This, she felt, had huge implications on the world political stage for those in leadership roles and in the area of conflict resolution. She formed a theory that if leaders could be made conscious of this fact, their power to influence people would be unlimited. This insight directed her towards a study of famous political and religious leaders. Day after day, holed up in her apartment, unable to sleep with excitement, eating little, and not communicating with anybody, she read voraciously, spent hours on the net, and made copious notes.

Her first outing in months was to be bridesmaid at her sister's wedding. She arrived bursting with energy, engaging people vivaciously, but her over-the-top excitement was passed off as wedding-related. Finally, unable to contain herself any longer, she used her bridesmaid's speech as an opportunity to launch on the stunned but receptive guests her Theory of Mass Influence. She was reluctant to stop speaking, in spite of interventions by the family. When the best man instructed the band to begin playing she grabbed the microphone from the singer and continued on passionately insisting on her message reaching as many people as possible as it had implications for world peace. Arguing, screaming, and wrestling with anyone who tried to stop her, she was bundled into a side room and a doctor was called, who had her admitted to a psychiatric hospital.


The spiritual opening
The spiritual experiences of the past, undergone by ascetics, monks, prophets, and other religious devotees in monasteries, caves and mountaintops, followed a consciously sought ‘communing with God' breakthrough. This was facilitated by long periods of fasting, meditation, isolation and sleep deprivation. The state they reached was, in essence, a psychotic experience, an altered state of consciousness of a transcendental nature. The cultural context at the time was accepting of their revelations, genuinely seeing them as divine messengers, if not divinity itself. Let's not forget that the big names in spirituality such as Buddha, Jesus, and Mohammed, experienced their ‘visions', and insights as to their life purpose, in such deliberately created settings.

Nowadays, some individuals suffering from mania experience spiritual openings in environments where the focus is on their inner journey, such as during meditation retreats and intensive personal development workshops. It is not uncommon for ordinary people to return from places like Medugordje, Machu Pichu, Lourdes and other apparent vortices of concentrated spiritual energy with an expanded sense of their place in the grand scheme of things, and in a state of manic elation.


David, a 41-year-old managing director of a public relations company, joined his wife in Medugordje, where she had gone with their only child Sarah, aged 12, who was suffering from muscular dystrophy and had been in a wheelchair for one year. Being a non-practising Catholic for many years, and really only there in solidarity with his wife, he was surprised to find that the energy of the place inspired him. He embraced every ritual with great enthusiasm, from night-time candlelit vigils to prayer meetings and the outdoor celebration of masses, and hours spent in silent prayer.

In the church where the Blessed Virgin is believed to appear regularly, during a mass he became aware of a golden light filling the church and auras like halos of different colours around members of the congregation. Waiting in line to receive communion, with his daughter in her wheelchair, he suddenly felt drawn to place both his hands on the crown of her head. As if like a bolt of lightening, he felt a huge force coming through his head, down his arms, and into his hands.

He began to shake uncontrollably and could not remove his them. He became frightened but was relieved to find that his daughter was enraptured by the experience, and had a beatified smile on her face. The entire event lasted a minute, and afterwards he asked his wife to take over and left the church feeling very confused and disorientated. Reluctant to risk a repeat of the experience, he did not attend any more ceremonies and couldn't sleep, wandering the town at night.

On his return to Ireland, still not sleeping, and finding it hard to re-engage with work, he took a few weeks off, and began to spend more time with his daughter, who he felt had benefited by the entire experience in Medugordje. One morning he decided to bring her to mass in the neighbourhood church where, once again, as he was waiting in line, he experienced a bolt of energy running through him. Later, at home, in an excited state he informed his wife and daughter that these high energy experiences meant that he was a spiritual healer, with the power of Jesus Christ acting through him. He told them that he would be leaving his job to pursue this important mission. For the next couple of weeks was rarely seen at home. Living rough and walking in his bare feet through the streets of Dublin, he was eventually found, penniless, having given away his money and credit cards to the homeless. This precipitated his first admission to hospital.


Drug-induced mania
Over 30% of individuals diagnosed with manic depression follow on from the use of street drugs such as amphetamine, cocaine, crack, and some hallucinogenic substances. (Anti-depressant medications, because of their stimulant effect, are also capable in some
individuals of triggering an episode of mania.)


Sophie, a 22-year-old aspiring model, hung around the edges of the ‘It' crowd, partied every weekend, and started to use cocaine regularly. She found that it gave her energy, suppressed her appetite, enhanced her libido, and made her extrovert and confident. She became the darling of the designers and fashionistas, and her career took off. Enjoying her new-found celebrity status, she appeared at every premiere, attended all the parties, and became the trophy every man wanted to be seen with. In such circles she found the supply of cocaine unlimited, but started to stockpile her own in case her source ever dried up. Day and night blurred, and weekend party bashes began to spill over into the working week. Now she was consuming up to six grams of cocaine a day, which she needed in order to function. Because she was such a successful model verging on the supermodel status, allowances were made for her petulant cantankourousness, frequent late starts, and her flippant approach to her work.

At a weekend country house birthday party hosted by a rock musician, cocaine was falling like snow and she snorted more than usual. Suddenly she experienced a rush of unprecedented energy and power and became imbued with the sense that she was the diva of all divas, the re-incarnation of the sex goddess Marilyn Monroe herself. Monopolising the dance floor, she openly began a seductive titillation of the male company, seeking particularly to impress her host with her ‘Happy Birthday Mr Rock Star' song.

Finding that he had been solicited away by a young wannabe model, she stormed off the floor in search of him, burst into his bedroom, and attacked the girl viciously, striking her with her stiletto heel. After being pulled away, she ranted around the house breaking windows with anything that she could find. Bundled into a car, she rapidly found herself being delivered home to her apartment in the early hours of the morning. She immediately called every newspaper, and media contact that she had, informing them that she would hold a press conference later that day at which she would tell the world that she was in fact Marilyn Monroe. Her agent arranged her hospitalisation.The sick brain model of mania focuses on the effect (the symptoms) rather than the causal context, particularly in the first three of these types. It can be no other way once the cause is understood as a disease process, a defect in the hardware of the brain. Within such a model the treatment would be the same for all four; psychotherapy would not be thought relevant, nor personality a factor to be addressed, notwithstanding all the other existential issues in a person's life.

A portrait of mania
For the purposes of understanding the natural timeline of a manic episode, we have decided to focus on the classic type, which forms the largest group, namely the defence against failure.

The predicament on the horizon
The pre-manic years are relatively trouble free. No shrinking violets, mania sufferers are more often high achievers, socially skilled, confident, proactive, competitive and familiar with success. They are good all-rounders and some may well be voted by their class as being the ‘most likely to succeed'. Because of this apparent headstart, they enter the world of work full of promise. The first sign of a psychological hiccup can come therefore as a total shock to patient and family alike. Their game plan for the future was one of continued success. To return to the analogy of the Titanic, their predicted life seemed unsinkable and Plan B — the lifeboats — was never dreamt of.

How they look to others is important to them: the public gaze, material things, getting ahead, and the need for power and approval is crucial to their identity. They are often larger than life, the life and soul of the party, and are well liked. Their bonhomie and extrovert nature attracts people to them. When it comes to having their own needs met, they expect doors to be opened for them and see no reason why they should not be facilitated.

They expect others to give their all and share enthusiastically in their dreams and visions. If challenged on practicalities they become annoyed, impatient and frustrated. Familiar with the ‘high horse' position, they can if obstructed ride rough-shod over colleagues, family and friends. A setback is not on their agenda. At all costs they are survivors.

When a setback occurs, the predicament it throws up will elicit an exaggerated response in this pre-manic group. While others may sympathise with them, few appreciate the depth and intensity of their newly-felt vulnerable feelings as their ego is challenged for the first time. Typical setbacks might include missing a promotion, a failed business investment, or any experience where losing face in public occurs. What would be experienced as a minor obstacle to others becomes an earthquake to them, in psychological terms. It's as though they have put everything, even their very personhood, on the line. The reverberations are huge, and the setback proves too much for their system to integrate.

Rather than experience feelings of failure, the incoming evidence is rejected and distorted by the mania mindset, and the blame for setbacks is located elsewhere. They contrive explanations which free them from any personal responsibility. They cook the books. Reasons and rationalisations are dragged up to offload responsibility for the failure. This has the unfortunate consequence that the core problem is never addressed and the slide downwards continues. A point is inevitably reached where denial can no longer hide the reality of the situation, and they are forced to acknowledge that a failure is imminent. When the dam burst occurs and the truth of the situation is no longer avoidable, the personal lie starts to break down.

There are recognisable phases to the manic process akin to the launching of a rocket into space, its orbiting and its return, re-entry, crash-landing and fall out.


The launch pad
Staring failure in the face, mania-sufferers move rapidly in the opposite direction, back to the success end of the success-failure spectrum. In this way they impress upon themselves and try to impress upon others that they are still in control, proving this by overcompensating.

There is a noticeable speeding up of thoughts and behaviours. Subjectively, they feel a surge of energy, power and invincibility. It's as if they have become the Greek character Sisyphus, but who has suddenly found the extra strength to push the boulder over the ridge of the mountain and down the other side, finally freeing himself from repeated failures. There is an air of triumphalism: anything is possible!This is the stage where the psychotic break has not yet occurred but is about to. It is an exaggerated and magnified version of themselves in top form, a caricature. As they move closer to the launch pad, the possibility of aborting the mission rapidly fades.


Launch pad symptoms
rapid-fire speech, full of inflated high sounding rhetoric. They are incapable of listening.
'Eureka' ideas. They get light-bulb insights, which they are convinced would provide a blanket solution for past misjudgments and mistakes. They set up meetings, make phone calls, and send faxes and e-mails towards this end. An example might be attempting to recruit the support of Bill Gates in person to invest in and to save their company from liquidation.
The Holy Grail and other quests. They may become passionate adventurers, heading off, for example, to the Pyramids of Egypt, to white-water raft in New Zealand or to find a guru in India.
Sleeplessness. Their mind is never still, racing thoughts and flights of ideas are the order of the day, and night. This, coupled with enhanced energy, interferes with their sleep pattern, reducing it to one or two hours a night. ‘I have too much to do to waste my time sleeping.' This can reach the stage where they literally don't shut an eye for days at a time, in some cases for weeks.
Time urgency. They get impatient at the pace at which things move and want everything to be done yesterday.
Short fuse. There is an anger and irritability when challenged and criticised about their behaviour. They don't suffer fools easily, are impossible to reason with, and strenuously resist the restraints of normal life.
On the town. There is a sense that ‘I deserve the best.' Money is spent on clothes, presents, nights on the town, champagne, a new car, a brief trip to Rio.
God's gift to women and men. Both sexes who are on the launch pad can become sexually disinhibited and engage in amorous one-night stands.
Political incorrectness. This can range from telling the wrong jokes to the wrong people, making sexual passes at people they would never in their wildest dreams have any interest in, such as their neighbour, an in-law or the boss's wife. This form of promiscuity has no gender difference.
Lifting off into orbit.
The dice are rolling. An unstoppable energetic and chemical shift is under way. Their metabolism is turbo-charged and their consciousness is so single-minded, passionate and goal-orientated that it will not be deflected. They feel fantastic and ‘over the moon', hence the association with the term elation (which comes from the Latin efferre, meaning to lift up, inspire with pride, lift the spirits of, or to feel exalted and lofty). Lift-off is recognised by a total loss of contact with consensus reality, as they assume an alternative persona. This role usually has a grandiose quality to it, giving sufferers a sense of power, success, confidence, and a feeling that everything is going really well and that they are in full control. They become super-fixers with godlike powers, and believe that they are the custodians of the solutions that humanity has been waiting for, such as Third World economic programmes, global conflict resolutions, scientific discoveries, and breakthroughs in medical science. Others believe that they have extraordinary talents in the area of music, acting, film, as yet undiscovered by the entertainment world. Like a good method actor they take on the persona that most fits the furthest out dimensions of their prior personality and live this role around the clock. They have entered the megalomaniac stage (from the Greek word megas, meaning great or very large)


Lift-off symptoms
Increasing distance. The gap widens between their reality and that held by those around them. This gives rise to reciprocal frustration, irritability, angry outbursts and a total breakdown of normal communication and relationships.
The lossof a personal censor. Anything goes. ‘I will not be stopped, and no one is going to stand in my way.' There is a refusal to be censored by the outside. Threats such as loss of job, collapse of relationship, suspension of credit and legal interventions all fall on deaf ears.
Hostile behaviours. With the combination of time urgency, grandiosity and their conviction that the end justifies the means, support is extorted to validate their views which are patently obvious to others as ludicrous.
Conspiracy theories abound. This provides a logical explanation to them as to why they are not being facilitated with urgent meetings, financial support and public acclaim. ‘Those that are not with me are against me.'
Hitting the wall. As in the old proverb, they have given themselves enough rope to hang themselves with and the noose begins to tighten. Spouses, children, friends withdraw. Financial resources dry up and all credibility collapses. Lack of sleep, excessive substance abuse, inadequate diet, erratic routines, emotional turmoil from ongoing conflict, begin to take their toll on their energy reserves.
Hospitalisation. Inevitably, there comes a time when the long-suffering relatives reach their limit, and decide that in the individual's own interest, to prevent further damage, the best thing that could happen to them is something akin to a shot from a tranquillising gun. There is general agreement among onlookers that the cycle has to stop. This may mean that they are coerced or involuntarily committed into a psychiatric institution.


Re-entry and crash-landing: post-elation depression

Sufferers undergo energy bankruptcy. Metabolically, they no longer have the reserves to deal with the overwhelming demands at this time. The batteries are now flat and biochemically they are in a state of metabolic burnout. Sleep deprivation, lack of food, substance abuse and the relentless, chaotic activity has created a toxic state from which the individual now needs to recuperate.

Psychoactive medication is used to bring the manic phase to a close. It does so by slowing the metabolism, reducing the manic thoughts and the hyperactivity. Essentially, the initial phases of medication act as sleep therapy. The restoration of sleep reduces the hypersensitivity of the nervous system to the aminergic family of mind-brain chemicals (adrenaline and serotonin, the struggle/striving hormones). This allows the cholinergic family (acetylcholine, the hormone of balance and maintenance) to catch up and restore normality.

In the words of Shakespeare, ‘Sleep is nature's balm'. While medication is essential to end the destructive manic flight, functioning like a pharmacological strait-jacket, it creates a state of suspension or twilight zone, where normal psychological and emotional responses are slow to return. This phase can be extremely distressing for relatives, particularly children, who find parents zombie-like and unresponsive.


Wounded pride. Pride comes before a fall. A free-falling manic topples from a great height, and the impact reflects that. As they return to everyday consciousness and their previous identity, they are faced with a scene equivalent to the post-battle scenario, much like a defeated general reflecting on the number of lives needlessly lost, and the futility of the cause fought for with such blinkered single-mindedness.

Disillusionment. As the medication is gradually decreased and awareness starts to percolate through, many become deeply depressed by the outlook, making problem-solving an additional overwhelming burden. One of the primary dis-illusionments is that, in spite of their ‘great escape', on their return they are still facing the predicament of impending failure from which they took flight, now seriously compounded by the visible debris resulting from the manic episode itself. This can include severed relationships, financial ruin, loss of others' confidence and trust, the jeopardising of a good work record and promotional possibilities. In some cases, there are even more serious consequences, such as legal proceedings as a result of car accidents, broken contracts, violent behaviour, barring orders, protection orders, paternity suits, all of which demand urgent attention at a time when sufferers are at their lowest.

Suicidal thinking. For some this seems like the only reasonable solution, so great is their shame. There is no way out. Their flight into mania, which was an unconscious effort at a solution, has inevitably created more problems that it has solved. So deep is the feeling of despair, desolation and hopelessness that the pain of it dictates an action which will end it. In this sense it is a form of self-administered euthanasia.

The medication see-saw. Manic patients, having been brought back to consensus reality by high doses of sedative medication may now find themselves, particularly if they are deeply depressed and suicidal, being prescribed psychic energisers (antidepressant medication) to provide a mood elevation. Often as a result, the mood will elevate to such a point that another manic episode is feared, and corrective sedative medication is prescribed to dampen it. This ‘relapse' can be a further blow to patient and family, so soon after the manic episode. Alternating mood swings of this kind, highs and lows, can give rise to the diagnosis of a ‘bipolar' disorder (manic depression) and the goal becomes one of ‘balance' — balancing out the sufferer's mood.

The career patient. Having left hospital, many sufferers become professionally trained mood watchers. They may lose their sense of perspective as to what are acceptable normal levels of joy and excitement, or their opposites, having an off day. Juggling doses of medication can become the sole focus of out-patient consultations, reinforcing the notion that ‘relapses' are caused purely by ‘chemical shifts' and unrelated to any other factors in the person's life. In this way medication is seen as ‘corrective'. Unfortunately, this balancing act can become a life-long process. To break this disempowering cycle, psychotherapy is vital to make sense of the beginning, middle and end of the manic experience, and the multitude of factors, both external and internal which influence that.


Psychotherapy: first calm down, then find the way back


Strictly speaking, the question is not how to get cured, but how to live.
— Joseph Conrad


Psychotherapy derives from the Greek psyche, meaning ‘soul', and therapeia, meaning ‘attendance'. If psychotherapy was ever a critical component in the management of a psychological distress, it has to be in manic depression.

What arrives in the door of the psychiatric hospital is an exploding bomb which requires emergency measures to defuse it. Any effort at logical conversation has no place at this stage: the furious firestorm in the mind needs to be urgently dealt with and this has to be done with high doses of major tranquillisers. It can take days and weeks for the madness to clear and normality to return. During this phase the individual not only requires sedation, but a nursing input with full medical backup, bordering on intensive care protocols, to restore health to a body depleted of its nutritional resources, and often so compromised in its immune system that infections have taken root. A matter of additional urgency is the process of detoxification where substance misuse has led to addiction.

In a sense, those who experience mania have travelled to another world, like Saturn, and back, such is the extra-ordinarily unique nature of their experience. Consequently, once normality and perspective has returned, they need the vital input of a psychotherapist specifically trained in this area. This process, once started, should continue following discharge until the causal factors have been deconstructed and medication terminated.

The inevitable burnout, and the trail of destruction left in the wake of a manic episode, is quite rightly called depression. However it makes more sense if it is called Post-elation Depression and not part of some bipolar disease.

In its own right, this is the appropriate natural emotional response to feeling sapped of all energy, realising that you have been the cause of so much chaos, hurt and ruin to yourself and others, and newly aware of the awesome task pressing down on top of you of rebuilding your life. If this perspective is not taken, this depression is in danger of being made into a purely chemical disease process, as all depressions within the current, dominant biomedical model are. In such a framework, in addition to the cocktail of major tranquillisers (anti-psychotics), lithium, and anti-epileptic medication, now anti-depressants are added. The individual is related to as a ticking timebomb, with all those around them anxiously awaiting the next explosion.


Keynote: ‘Failure? I don't do failure!'


This case is the stereotypical manic story, where its exponent takes the elevator approach: on beginning to become aware of a scenario which is not to his liking, nor in his emotional repertoire to handle, he metaphorically presses the button to remove himself to a more pleasing and manageable scenario on another floor. When this in turn begins to contain ingredients which offend, he repeats the manoeuvre again until he runs out of floors and ends up, stark raving mad, on the rooftop. One manic, having gained insight during psychotherapy, described the dilemma in these words: “It was as if I was running from a war party of Apaches who were rapidly gaining ground. I felt I had to keep running because if I stopped and turned to look at them, I would get a hundred arrows in the face.

The goal of psychotherapy in Richard's case is directed towards helping him acquire the emotional maturity and skills to deal with setback. Ordinary people experience setbacks, they see them coming, and have accumulated along the way a repertoire of strategies to use in such situations. A person who can only be extra-ordinary, as a way of being, cannot readily do this, and this is what Richard needs to be helped to learn. He has always spoken only the language of success (Texas-speak, as it were), and now has to get his tongue and his mind around the dialect of the common man, and ultimately live a ‘smaller' life with equanimity.

If on the other hand he is treated within the sick brain model — 'you have a chemical imbalance and must keep taking the pills' — this conversation will never occur and no learning will ever take place, and a window of opportunity is missed. Evidence painfully shows that if personal responsibility is not taken, that is, learning how to manage one's life in a psychotherapeutic (soul-attending) way, that no amount of medication will prevent a further episode and future admissions become a way of life. A career patient has been created.


Keynote: ‘Einstein, Hawking: move over!'


Sylvia has one vulnerability. She so enjoys the world of her intellect that she has a tendency to indulge it as if it were her entire life. She has willingly forfeited meaningful relationships, sporting activities, pleasurable pursuits and contact with nature. She had a brilliant academic record and was known even since her early schooldays as a ‘brainbox'. Her recent immersion in her PhD project was the most exciting period of her life. It allowed her to lock herself away, disconnect from social contacts and live like a hermit. In such a climate no reality testing was occurring and, as we saw, her inner world took over.The psychotherapeutic work here is to help her gain awareness of her tendency towards imbalance, excessively favouring her inner world to the negation of healthy connections outside. Her task is obviously simpler than Richard's, and is merely one of maintaining the right lifestyle balance.


Keynote: May the Force be with you'


David's case reflects a rare ability or gift to experience phenomena in the non-physical realms, of a spiritual and energetic nature. The problem arose for him because he had never had such transcendental experiences before and was at a loss as to how to interpret or contain them. He would therefore require a very different kind of therapist, one familiar with transpersonal and energetic phenomena. Dr. Stanislaus Grof, a psychiatrist and leading pioneer of transpersonal psychology, would regard David's case as a spiritual emergency. As countless clairvoyants and healers will testify, their initiation into the non-physical or energetic world was far from smooth. David ultimately has to learn to manage his energy, appreciate its limits and stay grounded.


Keynote: Lining up for stardom


This is a straightforward case of addiction with the added dimension that some addicts have an energetic tendency to experience altered states more easily than others. Let's not forget that her drug of choice, which she was abusing for years, is an ‘upper', designed to lift the mood and create an over-expansive sense of self. Sophie, like all addicts, needs to develop her own inner strengths, finding the ‘buzz' in a balanced lifestyle and attending regular Narcotic Anonymous meetings.


Final comments


The depression following a manic episode is as much an emotional reaction as any other, and we would advocate that it be called Post-elation Depression. As such, it is not a ‘disease', but a normal response to a horrendous experience, and is best integrated and healed through the process of psychotherapy which provides a de-briefing opportunity in which the entire experience can be understood.

The manic episode itself is the result of an unconscious attraction towards being extra-ordinary. The climax of mania — the psychotic phase — is a medical emergency, and can only be reversed through the use of sedative medication, which in most cases is only possible within a hospital environment. This phase is transitory, like the need for morphine in a case of a broken leg, and once consensus awareness has returned, should be phased out and replaced with a psychotherapeutic approach which has as its primary aim a search for the unconscious triggers, and conscious preventive measures put in place.

We believe that psychiatry has lost its way, that its reliance on excessive use of medication, its revolving door hospitalisation practices, and its ultimate fallback, electro-shock therapy, urgently need to be chllenged.

Could this have anything to do with the fact that over 99% of psychiatrists practising in this country do not have a registered university qualification in psychotherapy?


If your only tool is a hammer, everything looks like a nail.
— Ludwig Wittgenstein


This is an edited version of the chapter on elation and mania in Depression: An Emotion, not a Disease



Manic depression


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