The Role of Family and Friends in a Bipolar Person's Life

In trying to support a person with bipolar disorder, how do you make sense of the ups, downs and sometimes downright craziness?

Bipolar in the Family: Difficult on Everyone

When one member of a family has bipolar disorder, the illness affects everyone else in the family. Family members often feel confused and alienated when a person is having an episode and is not acting like him or herself. During manic episodes or phases, family and friends may watch in disbelief as their loved one transforms into a person they do not know and cannot communicate with. During episodes of depression, everyone can become frustrated, desperately trying to cheer up the depressed person. And sometimes a person's moods are so unpredictable that family members may feel that they're stuck on a rollercoaster ride that's out of control.

It can be tough, but family members and friends need to remember that having bipolar disorder is not the fault of the afflicted person. Supporting their loved one can make all the difference - whether it means assuming extra responsibilities around the house during a depressive episode, or admitting a loved one to the hospital during a severe manic phase.

Coping with bipolar disorder is not always easy for family and friends. Luckily, support groups are available for family members and friends of a person with bipolar disorder. Your doctor or mental health professional can give you some information about support groups in your area.

Understanding, Recognizing Symptoms of Bipolar Disorder

Never forget that the person with bipolar disorder does not have control of his or her mood state. Those of us who do not suffer from a mood disorder sometimes expect mood-disorder patients to be able to exert the same control over their emotions and behavior that we ourselves are able to. When we sense that we are letting our emotions get the better of us and we want to exert some control over them, we tell ourselves things like "Snap out of it," "Get a hold of yourself," "Pull yourself out of it." We are taught that self-control is a sign of maturity and self-discipline. We are indoctrinated to think of people who don't control their emotions very well as being immature, lazy, self-indulgent, or foolish. But you can only exert self-control if the control mechanisms are working properly, and in people with mood disorders, they are not.

People with mood disorders cannot "snap out of it," much as they would like to (and it's important to remember that they want desperately to be able to). Telling a depressed person things like "pull yourself out of it" is cruel and may, in fact, reinforce the feelings of worthlessness, guilt, and failure already present as symptoms of the illness. Telling a manic person to "slow down and get a hold of yourself" is simply wishful thinking; that person is like a tractor-trailer careening down a mountain highway with no brakes.

So the first challenge facing family and friends is to change the way they look at behaviors that might be symptoms of bipolar disorder - behaviors like not wanting to get out of bed, being irritable and short-tempered, being "hyper" and reckless or overly critical and pessimistic. Our first reaction to these sorts of behaviors and attitudes is to regard them as laziness, meanness, or immaturity and be critical of them. In a person with bipolar disorder, this almost always makes things worse; criticism reinforces the depressed patient's feelings of worthlessness and failure, and it alienates and angers the hypomanic or manic patient.

This is a hard lesson to learn. Don't always take behaviors and statements at face value. Learn to ask yourself, "Could this be a symptom?" before you react. Little children frequently say "I hate you" when they are angry at their parents, but good parents know that this is just the anger of the moment talking; those are not their child's true feelings. Manic patients will say "I hate you" too, but this is the illness talking, an illness that has hijacked the patient's emotions. The depressed patient will say, "It's hopeless, I don't want your help." Again, this is the illness and not your loved one rejecting your concern.

Now a warning against the other extreme: interpreting every strong emotion in a person with a mood disorder as a symptom. The other extreme is just as important to guard against. It's possible to jump to the conclusion that everything the person with the diagnosis does that might be foolish or risky is a symptom of illness, even to the point where the person is hauled into the psychiatrist's office for a "medication adjustment" every time he or she disagrees with spouse, partner, or parents. A vicious cycle can get going wherein some bold idea or enthusiasm, or even plain old foolishness or stubbornness is labeled as "getting manic," leading to feelings of anger and resentment in the person with the diagnosis.

When these angry feelings get expressed, they seem to confirm the family's suspicion that the person is "getting sick again," leading to more criticism, more anger, and so on. "He's getting sick again" sometimes becomes a self-fulfilling prophecy; so much anger and emotional stress get generated that a relapse DOES occur because the person with the illness stops taking the medication that controls his or her symptoms out of frustration and anger and shame: "Why bother staying well, if I'm always treated as if I were sick?"

So how does one walk this fine line between not taking every feeling and behavior at face value in a person with bipolar disorder and not invalidating "real" feelings by calling them symptoms? Communication is the key: honest and open communication. Ask the person with the illness about his or her moods, make observations about behaviors, express concerns in a caring, supportive way. Go along with your family member to doctors' appointments, and share your observations and concerns during the visit in his or her presence. Above all, do not call the therapist or psychiatrist and say, "I don't want my (husband, wife, son, daughter, fill in the blank) to know that I called you, but I think it's important to tell you that..." There's nothing more infuriating or demeaning than to have someone sneaking around reporting on you behind your back.

Remember that your goal is to have your family member trust you when he or she feels most vulnerable and fragile. He or she is already dealing with feelings of deep shame, failure, and loss of control related to having a psychiatric illness. Be supportive, and yes, be constructively critical when criticism is warranted. But above all, be open, honest, and sincere.

Bipolar Mania, Depression, Suicide and Family Safety

Never forget that bipolar disorder can occasionally precipitate truly dangerous behavior. Kay Jamison writes of the "dark, fierce and damaging energy" of mania, and the even darker specter of suicidal violence haunts those with serious depression. Violence is often a difficult subject to deal with because the idea is deeply embedded in us from an early age that violence is primitive and uncivilized and represents a kind of failure or breakdown in character. Of course, we recognize that the person in the grip of psychiatric illness is not violent because of some personal failing, and perhaps because of this there is sometimes a hesitation to admit the need for a proper response to a situation that is getting out of control; when there is some threat of violence, toward either self or others.

People with bipolar disorder are at much higher risk for suicidal behavior than the general population. Although family members cannot and should not be expected to take the place of psychiatric professionals in evaluating suicide risk, it is important to have some familiarity with the issue. Patients who are starting to have suicidal thoughts are often intensely ashamed of them. They will often hint about "feeling desperate," about "not being able to go on," but may not verbalize actual self-destructive thoughts. It's important not to ignore these statements but rather to clarify them. Don't be afraid to ask, "Are you having thoughts of hurting yourself?" People are usually relieved to be able to talk about these feelings and get them out into the open where they can be dealt with. But they may need permission and support in order to do so.

Remember that the period of recovery from a depressive episode can be one of especially high risk for suicidal behavior. People who have been immobilized by depression sometimes develop a higher risk for hurting themselves as they begin to get better and their energy level and ability to act improve. Patients having mixed symptoms - depressed mood and agitated, restless, hyperactive behavior - may also be at higher risk for self-harm.

Another factor that increases risk of suicide is substance abuse, especially alcohol abuse. Alcohol not only worsens mood, but it also lowers inhibitions. People will do things when drunk that they wouldn't do otherwise. Increased use of alcohol increases the risk of suicidal behaviors and is definitely a worrisome development that needs to be confronted and acted upon.

Bottom Line

Making peace with the illness is much more difficult than healthy people realize. But the harder lesson is learning that there is no way that anyone can force a person to take responsibility for his or her bipolar disorder treatment. Unless the patient makes the commitment to do so, no amount of love and support, sympathy and understanding, cajoling or even threatening, can make someone take this step. Even family members and friends who understand this at some level may feel guilty, inadequate, and angry at times dealing with this situation. These are very normal feelings. Family members and friends should not be ashamed of these feelings of frustration and anger but rather get help with them.

Even when the patient does take responsibility and is trying to stay well, relapses can occur. Family members might then wonder what they did wrong. Did I put too much pressure on? Could I have been more supportive? Why didn't I notice the symptoms coming on sooner and get him or her to the doctor? A hundred questions, a thousand "if only's," another round of guilt, frustration, and anger.

On the other side of this issue is another set of questions. How much understanding and support for the bipolar person might be too much? What is protective, and what is overprotective? Should you call your loved one's boss with excuses as to why he or she isn't at work? Should you pay off credit card debts from hypomanic spending sprees caused by dropping out of treatment? What actions constitute helping a sick person, and what actions are helping a person to be sick? These are thorny, complex questions that have no easy answers.

Like many chronic illnesses, bipolar disorder afflicts one but affects many in the family. It's important that all those affected get the help, support, and encouragement they need.