Case Study: James Experiences Bipolar Disorder (Individual Psychotherapy)
James is a 55-year-old biracial (Hawaiian and Caucasian) executive who lives alone following the death of his wife seven years ago. He has one adult daughter who has a family of her own.
Presenting Problem: James presents in a manic stage of bipolar disorder, having had a number of previous episodes. James’s maternal uncle and grandfather also had bipolar illness. This episode involved James discontinuing his lithium use, traveling to Los Angeles in the hopes of becoming an actor, spending thousands of dollars on extravagant merchandise, and finally being arrested for drunk and disorderly conduct at a nightclub. James was hospitalized in an inpatient unit briefly and is now seeking outpatient treatment.
Key Biopsychosocial Factors:
• Biological: There is a family (genetic) history of bipolar disorder as well as research supporting a biological basis of bipolar disorder. Medication is an essential treatment component.
• Psychological: James’s lack of compliance with his lithium regimen, denial regarding chronicity of his bipolar disorder, enjoyment of the manic high, need for control and independence, emotional losses pertaining to wife’s death, and a severe chronic psychiatric condition all play a role in his illness.
• Social: Family and cultural traditions that (in James’s family) distrust Western medicine and cultural and general social isolation also are likely to impact his illness.
Treatment Goals and Plan: James requires medication management in addition to individual therapy in order to achieve several immediate and long-term goals. After an initial consultation and assessment period with James, the following treatment goals were determined. First, James will seek to work through the various impediments to his reliable use of lithium medication. These involve not only his need to be in control and not dependent on drugs (or others), but his family of origin’s negative feelings about Western medicine. Second, James finds that when he becomes depressed, he longs for the “high” associated with mania. Therefore, the causes of his depression will be determined as well as improved coping skills. Third, James is lonely, misses his wife, and feels isolated from the Hawaiian heritage he cherishes. Thus, treatment will also address his interpersonal, social, and cultural needs.
The treatment plan involves the following components:
- Collaboration with James’s physician regarding his lithium regimen.
- Behavioral contracting, which involves James’s commitment to maintain his lithium regimen for at least the first six weeks of psychotherapy.
- Exploratory work to understand James’s disdain for dependence and impediments to developing a more satisfying interpersonal life.
- Psychoeducational materials regarding bipolar illness, lithium, and traditional Hawaiian healing techniques and rituals to aid James in understanding the similarities, differences, and potential virtues and liabilities of both traditions.
- Problem solving regarding increasing social contacts and cultural identification.
- Developing improved awareness and skills for combating depression and curtailing future manic episodes.
- Examination of the transference relationship between James and his psychologist to better understand James’s interpersonal issues as well as his need for control and independence.
This case example illustrates how personality and culture impact compliance with medical regimens such as medication, and the need to work through a variety of intrapsychic and social issues in managing a major psychiatric problem such as bipolar illness. The treatment by necessity is multidimensional and mindful of the biopsychosocial influences on human functioning.