On the last track, we discussed various topics I emphasize to educate my Bipolar Adult client to prepare them for the therapy process. We
discussed the symptoms of the disorder; its effect on the client’s relationships;
and the effect of stress on the intensity and timing of manic and depressive
Have you, like I, found that many clients are resistant to accepting the idea
that they have bipolar disorder? Many clients believe that the manic episodes
they undergo are a personality response to a goal or problem. Often, they do
not realize that the excessive energy comes from a disorder. Many times, this is because the client has achieved recognition because of their
hard work during a manic cycle. As a result, he or she does not wish to
believe that the achievements during this period were not the work of themselves,
but of a disorder.
On this track, we will examine three types of resistant
clients: clients who reject diagnosis; the underidentifying; and the over-generalizing
3 Types of Resistant Clients
1. Clients Who Reject Diagnosis
The first type of resistant client is the client who completely rejects the diagnosis. As
we discussed in track 1, many clients believe that a bipolar diagnosis is merely
a misinterpretation of their personality traits. However, this also is a handy
defense mechanism for the client. But by rejecting the problem, the client
also is rejecting treatment that could quite possibly save his or her life.
was a 23 year old bipolar client of mine. Like many of his generation,
Clark had given in to the New Age treatments and believed that my diagnosis was
completely misguided. Clark stated, “I realize that people have bipolar,
and I feel sorry for them. But my problem doesn’t come from some
disorder. I’ve been limiting
my sugar intake and I’ve been seeing an acupuncturist. I can easily
beat this thing.” Because of this, Clark refused to take his medications
which he claimed only heightened his episodes. Clark stated, “My
moods were fine until they gave me Depakote, and now they swing all over the
I was concerned that Clark might harm himself during a depressive episode, I
discussed thoroughly the consequences of rejecting his medicine, the reasons
for my diagnosis, and the many reasons that his mood swings could not possibly
be the result of a sugar imbalance. As I discussed in track 1, educating
the client about this disorder lessens the resistance they exhibit towards diagnosis.
Technique: a 9 Question Self-Administered Quiz
Also, I remembered that one of my clients, Marianne discussed on the previous
track, had found a “Self-Administered Quiz” helpful. I gave Clark a list of questions and asked him to complete them with a yes or no after having read a catalogue
of informative materials on the disorder. Has there ever been a period of time lasting two weeks or more when you were
not your usual self and you experienced five or more of the following:
1. Felt Sad, blue or down in the dumps?
2. Were uninterested in things?
3. Lost or gained more than 5% of you body weight?
4. Slept too little or too much?
5. Felt so good or so hyper that other people thought you were not your normal
6. Were so irritable that you shouted at people or started fights?
7. Felt much more self-confident than usual?
8. Got much less sleep than usual and found you didn’t really miss it?
9. Were much more talkative or spoke much faster than usual?
After completing the quiz, Clark found that he had answered seven of the questions
with a “yes”. He then stated, “Ok, I guess
I understand this Bipolar stuff a little better now, so I’ll give
it a shot your way.”
2. Underidentifying Clients
The second type of client is the underidentifying client. In essence, these
types of clients are in denial about their disorder. Although this may
sound similar to those clients who reject a diagnosis, the underidentifying client
refuses to deal with the emotions instead of completely rejecting the diagnosis.
rejection, underidentifying can be a defense mechanism overlying grief for the loss of a healthy self. If he or she does not recognize the problem, it
cannot exist and will go away. Many clients were once bright and popular people
before they were diagnosed and hope that by pretending nothing has changed, their friends and loved ones will continue to
treat them as they once did and not like a mental patient.
34, had once been a well-liked and charismatic individual before being diagnosed
with bipolar disorder. For weeks after the diagnosis, Cheryl reflected any questions about her health and began to stop taking her medications. In
our sessions together, I addressed the problem directly, “Cheryl,
why have you not taken your medication?” Cheryl stated, “I
don’t know what
you mean.” I then asked her, “Cheryl, I think you know what
I mean. If you had been
taking your medication regularly, you would have needed a refill by now, yet
you have not asked me to write you another prescription.” Cheryl
responded, “I don’t know what to say when I take it. My family
asks me what I need pills for and I just can’t bear to tell them.”
you can see, Cheryl feared telling her loved ones about her disorder. Through
role playing, Cheryl and I came up with likely scenarios that could occur when
she finally discusses her disorder with her parents.
3. Over-Generalizing Clients
In addition to the rejecting and underidentifying client, the third type of resistant
client is the over-generalizing client. Often, these clients
see their own characteristics manifested in those around them and begin to diagnose
their families and loved ones. Francine, a bipolar client of mine, stated, “My
mother really gets on my case about my medications, about my visits to my doctor,
about the men I’m going out with, you name it. She’s always
asking me if I’ve been drinking. She goes behind my back to
try to find out. She’s always been critical and disapproving of me. I
think she’s the one who’s bipolar.”
her assertions were well-founded because bipolar disorder does tend to run in
families and truly some family members might have a moderate form of the disorder. However,
many times this over-diagnosing stems from not wanting to feel alone or isolated. I
asked Francine, “Do you ever feel alone in having this disorder?” She
stated, “Yes, sometimes. I feel like people don’t know what
it’s like to be the
only one around who has this thing.”
I then asked Francine, “Could
your mother’s reactions be actually a manifestation of love and concern
for your well-being?” Francine stated, “Yeah, I know she loves me and
wants me to beat this thing, it’s just so hard when she’s so overbearing.” I
asked Francine, “Have you ever discussed with your mother these feelings? Have
you told it’s harder for you when she acts this way?” She answered, “No,
I know that would help, though. I guess.”
As you can clearly
see, Francine had also exhibited a fear of confronting her loved ones about their
own behavior. Think of your over-generalizing client. Could they
benefit from an interaction with the offending loved one?
On this track, we presented three types of resistant clients: clients who
reject diagnosis; the underidentifying; and the over-generalizing client.
On the next track, we will examine characteristics of clients who come under
the influence of psychosis: delusional thoughts; hallucinations; and paranoia.
Peer-Reviewed Journal Article References:
Mneimne, M., Fleeson, W., Arnold, E. M., & Furr, R. M. (2018). Differentiating the everyday emotion dynamics of borderline personality disorder from major depressive disorder and bipolar disorder. Personality Disorders: Theory, Research, and Treatment, 9(2), 192–196.
Swartz-Vanetik, M., Zeevin, M., & Barak, Y. (2018). Scope and characteristics of suicide attempts among manic patients with bipolar disorder. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 489–492.
Youngstrom, E. A., Egerton, G. A., Genzlinger, J., Freeman, L. K., Rizvi, S. H., & Van Meter, A. (2018). Improving the global identification of bipolar spectrum disorders: Meta-analysis of the diagnostic accuracy of checklists. Psychological Bulletin, 144(3), 315–342.
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