Even Keeled:
A Practical Approach to Living with Someone with Bipolar II Disorder
by: Philip Neal

 Principles are usually simple enough to understand, though applying them can be challenging. They are fundamental, thus universally applicable. Psychological principles are supremely attractive in that they provide a solid foundation from which to increase understanding of human behavior.

Bipolar II disorder (hereafter referred to simply as bipolar) can be better understood and addressed by applying appropriate psychological principles. One such principle is that, on a very basic level, emotion is neither good nor bad. It is however, the expressed reaction of the mind to its environment. From this perspective, emotion is very useful. Emotionality often gets a bad rap as with bipolar since the person with bipolar often experiences intense varied emotions. Yet, emotion can serve as a window into the inner workings of the mind as long as it is seen as a reaction to one’s environment. If you live with someone who has bipolar, you may find this principle a bit difficult to apply – don’t give up. Unconditional love, reasonable expectations, and consistency are three key guidelines to understanding and coping with bipolar.

Accurately identifying bipolar can be tricky business, even for experienced clinicians, since there are numerous disorders with similar symptoms, and sometimes, “unrelated” symptoms appear together to mimic bipolar. Briefly, the characteristics of bipolar II disorder are major depressive episodes accompanied by at least one hypomanic episode. A hypomanic episode exhibits symptoms that are, in intensity, just below a manic episode yet still cause significant social or occupational distress. Some typical hypomanic symptoms are inflated self-esteem, decreased need for sleep, pressure to continue talking, and racing thoughts. In addition, it should be noted that major depressive episodes are often followed by several days of euthymia (elevated mood in the “normal” range) that should not be confused with hypomanic episodes though it may appear hypomanic because of the dramatic contrast between this state and that of major depression. The key to remember is that if it doesn’t interfere with functioning, it’s not hypomania.

Which leads to another useful principle: psychopathology, or mental illness, is often some aspect of typical human behavior exaggerated to a level that is dysfunctional. What might otherwise fall within the spectrum of normal behavior may be categorized as abnormal when it manifests itself inappropriately. Have you ever heard symptoms read from a list and thought, “Oh, I think I have that!“ only to find later you weren’t even close to having it? That’s because you manifest these symptoms “appropriately”. Knowing that pathology is often a description of typical behavior gone awry can have a normalizing effect. It can also increase our ability to distinguish normal from abnormal behavior.

Integral to the treatment of bipolar are the concepts of constancy and consistency. In all things, the body and mind need a foundation, a point of reference, a place to regroup. For many of us, we can stand on this foundation when we feel loved and understood. From here we can see the world more clearly. The typical person possesses psychosocial tools that help them find this foundation and act as an internal keel for even the strongest emotions. The person with bipolar does not have a sufficiently developed internal keel to help them endure strong emotions. A central goal then is to strengthen the internal emotional keel partly by establishing healthy expectations and adhering to them. This will likely take a significant amount of time and exertion from all parties concerned, but the payoff will be well worth the effort.

Nature and nurture work together to create and continually shape our personalities. A distinguishing factor is that we cannot immediately enhance our genes, but we can enhance our environment. It stands to reason then, if we can enhance our own environment, we can also enhance the environment of others. If you live with a person who has bipolar, especially a child or teenager, you may want to employ this concept to the fullest. Water extinguishes fire. In the same sense, a person with bipolar needs constancy and consistency in their life to act as an external keel and supplement to their own internal keel.

Of primary importance is that the person with bipolar feel and know they are loved. Loving them only if they behave or perform to a certain standard will contribute to emotional instability. They must know they are loved because they need to be loved, as we all do; it has nothing to do with behavior. We need love no matter our condition. It is an innate human need that cannot be denied without severe consequences. Love is unconditional or it is not love. The way we are love by those most dear to us shares our personal value and sense of self-worth. A healthy sense of worth will tend to help the person with bipolar separate their emotions from their sense of self. In turn, emotion will be increasingly viewed as reaction to the current environment and not an internal force that is an unstoppable and inseparable part of the personality. The person with bipolar can learn to separate their emotions from their sense of identity. They can learn to see emotions as interpretive tolls and the spice of their experiences – that instead of being controlled by emotions, emotions are subject to their control. This is not likely to happen if they do not have a healthy sense of self, which in turn is not likely to happen if they are not loved by those most important to them.

Although the person with bipolar should always be accepted, their behavior may not always be acceptable. Set clear expectations based on sound reasoning and principles and make sure they understand them adequately. Keep expectations simple and few. Whether or not they adhere to it, they need to know what the standard is and why it is the standard. Although there may be standards they do not necessarily want to uphold, if they are presented in the light of reason and principle, they cannot be refuted. Extreme opposition to an expectation is a red flag suggesting it may be too high an expectation for an already struggling individual. Motive is always a good indicator for a standard or expectation. Ask yourself why the standard should be upheld. If the answer has much to do with what is good or easy for you and not much to do with what is good for them (or people in general), it suggests the expectation is inappropriate. An act of love practically never falls in the path of least resistance but is quite often the most personally demanding.

Finally, consistency is critically important. The person with bipolar must consistently feel loved and consistently be held accountable to the standards set forth. Never set a standard you are unwilling to enforce, and never threaten. Administer positive and negative reinforcements from the perspective of love, and the person on the receiving end will be more likely to see value in what you are requiring. Remember the five-to-one ratio for positive and negative reinforcement. Though this may not always work out in perfect proportion, make it your goal. No matter what uncontrollable happening is currently taking place in their life, the person with bipolar needs someone they see as an anchor that can stabilize them amid the storm of their experiences. This sense of external stability will translate to increased internal stability, in time. We learn mostly by example. For this reason the example received from every significant person is especially important. The actions of others need to make sense to the person with bipolar, and they need to make sense all the time. We all make mistakes so don’t be afraid of them or too embarrassed to do the right thing. If you make a mistake, correct it by apologizing and making amends. By doing so, you will provide a good example of what others need to do when they make mistakes.

There are also medicines that may be appropriate for the treatment of bipolar disorder in some individuals. With your help, your psychiatrist and psychologist can make this decision. Good psychotherapy is also useful in treating and coping with bipolar disorder. Find a psychotherapist whose beliefs and practices are based on sound principles and who comes highly recommended by someone you trust. Word of mouth is one of the best ways to find a good psychotherapist. The principles and ideas mentioned here are not meant to be a cure but a foundation from which to better understand and cooperate with those who have the disorder, but they apply to everyone and every relationship. Use them within the context of love, and you will be rewarded.

This article was published in “Exceptional Parent” magazine, vol. 38, issue 9.