Moving From Bipolar Disorder To Bipolar IN Order
Everyone has up and down times. It is a natural part of life. If we observe our lives over time we might say there are two poles that we have; some days we feel on top of the world and other days perhaps on the bottom. That is the basis for the word bipolar and the reason I say that everyone is bipolar. Some may argue that there are people who are unipolar and only experience the up or down side, but even they have a range of experience with a “pole” on each end.
Unfortunately, the word bipolar is generally used to describe a subset of people who have adverse reactions when they go to far toward the high and low poles. Although related to how far from center one is, there is no distance from center that guarantees one would necessarily react to it in an adverse way. It really depends on how far we are from our comfort zone. One person might be perfectly comfortable and highly functional at a certain point from center while another could be so uncomfortable that he/she is literally in danger of suicide. I see the comfortable person as keeping life in-order, while the person in danger of suicide has lost control and is in dis-order. Using bipolar as a term to describe the dis-ordered person is an over-simplification that goes too far. We should at least distinguish the difference between having Bipolar Dis-Order or Bipolar In-Order.
But life is not even that simple. If I just won a marathon, for example, I might be very high emotionally yet completely drained and low physically. To really see where we are on the spectrum from high to low we need to consider all of the aspects of our lives: physical, mental, emotional, spiritual, social, and career/financial. It is probably more accurate at any given time to say that we are really in a “mixed state” instead of somewhere on a straight line between the two poles, so we must see even the expansion of bipolar to Bipolar Disorder and Bipolar IN Order as just a convenient simplification of a much more complex topic.
There are six distinct stages of bipolar: Crisis, Managed, Recovery, Freedom, Stability, and Self-Mastery. The first three are considered Disorder, while the last three are clearly IN Order once you understand the difference.
We are in Crisis when the intensity of our high or low state overwhelms us. On the down side, commonly called depression, we either cannot function or we can function only enough to attempt suicide. On the up side, commonly called mania, we lose our ability to control our behavior and may put ourselves and others at great risk.
But, even the most disordered of us are not in crisis all the time. The majority of people considered to have Bipolar Disorder spend most of their time in Managed Stage. They use various tools to keep the intensity from reaching a Crisis level, yet still experience times when it is clearly uncomfortable. They struggle to minimize the intensity with the goal of getting to Recovery.
Recovery, as defined by the National Institute of Mental Health (NIMH), means the manias and depressions have been removed. The recovery movement might challenge such a definition, but I have yet to hear anyone define recovery as moving further toward the two poles. At the least, recovery means to decrease the intensity of mania and depression to the point where we are in control of our behaviors.
The NIMH has determined Recovery to be an unstable state in their landmark STEP-BD study: “According to the researchers, these results indicate that in spite of modern, evidence-based treatment, bipolar disorder remains a highly recurrent, predominantly depressive illness.” Therefore, one is still considered to have Bipolar Disorder even when in temporary remission.
The medical model that only sees bipolar as a disorder or an illness is not working. The assessments, tools, and goals are all based on the idea that bipolar is a disease that must be managed toward reduction if not completely eliminated. It is a system that has been proven not to work by their own studies and is unacceptable given that we have already produced much better outcomes.
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One of my earliest memories is of learning to ride a bike. I remember the fear, exhilaration, and hyper-awareness, along with the tension in my body and how my breath became both more rapid and shorter. I was outside of my comfort zone and challenging myself to grow. It was also a blast!
My father had a wisdom common with most dads. He didn’t push me down a steep hill and hope I survived; he ran along next to me making sure I was not too far outside of my comfort zone as to be incapable of handling it. He taught me one of the most important lessons that day about what it is to be human. We need to challenge ourselves to grow, while at the same time making sure we don’t go too far outside of our comfort zone.
The thrill of learning something new and challenging myself to grow has been a constant companion ever since my first bike ride. On too many occasions, I took on challenges far outside of my comfort zone and was either debilitated by the fear and lack of skills, or took risks that caused more harm than the potential reward from succeeding.
I learned an even more important lesson when I was 28 years old. I ran a retirement home and learned that the ones who stopped challenging themselves were the ones who died the earliest. Those who continued to step outside their comfort zone were the ones who thrived. I was fortunate to see first hand that growth is what keeps us alive.
Humanity is defined by our need to learn and grow and our wisdom to make the right decisions about how far to go in challenging our limits. It is also defined by continuing to face challenges until our last breath. To succeed at being human, we need to balance our need to step outside of our comfort zone with staying close enough to survive.
Most of us have had a similar experience in learning to ride a bike or in learning something new for the first time. We had someone who cared about us helping us to be safe while encouraging us to take a risk. We were outside of our comfort zone and experiencing fear, exhilaration, tension, and the other feelings that come with facing a challenge.
Our fathers could not imagine us riding our bikes on a cyclocross course on the same day as our first ride. They hope that we will develop skills and practice them on safer ground before embarking on such foolish ventures. But, our judgment is not well developed and we don’t yet understand the risks involved when making decisions.
Most of us have gone too far and found ourselves at a point beyond our ability, many of us more times than we can count. We have taken risks that were too dangerous for our current skills and have pushed the limits of safety. While we often get away with such behaviors, we sometimes pay the price for getting too far outside of our comfort zone.
Sometimes, when we get way outside of our comfort zone, we need intervention to heal the injuries that we cause. Depending on how dangerous the behavior and the extent of the injuries, that intervention can be major. We can end up in the hospital or worse. Some behaviors can even end in our death and injury or death for those around us.
One way to understand the power of the idea is to break it into four zones: way outside, not so far out, a little out, and finally, inside of our comfort zone. This model helps us to see the relationship between how far outside the comfort zone we can go and what the risk of intervention is at each level. We can use this model to help us to understand the importance of managing the distance we go from the comfort zone before choosing an intervention.
We are in great danger when we find ourselves way outside of the comfort zone. The likelihood of needing major intervention is very high. For our safety, and for the safety of others, we should avoid this danger zone at all costs.
If we learn to become more aware of our comfort zone and our relation to it, we can begin to catch ourselves before we get so far outside of it. While still in need of intervention , we can avoid the greatest risks and the consequent major intervention necessary to repair our injuries. While definitely preferable to being way outside of our comfort zone, this “not so far out” zone is still in the danger zone and should be avoided.
The sweet spot is when we are just a little outside of our comfort zone. When we become keenly aware of the line that separates our comfort zone from the growth zone, we can learn to go a little out and then back in again. As we practice crossing the line in both directions, we grow in both understanding and skills. We may not want to live on the edge all of the time, but need to cross the line at least some of the time to grow. Finding the sweet spot is finding our humanity.
The current mainstream belief about depression, mania, hallucinations, and delusion is that the more intense if is, the further outside of our comfort zone it takes us. This makes perfect sense and is proven by our experience. The higher our mania or deeper our depression, the greater intervention is needed to bring us back into our comfort zone.
High mania, deep depression, intense hallucinations, and strong delusions are a great danger. It takes major intervention to suppress the experience and bring us back to “normal.” This major intervention often includes hospitalization with massive medications in an effort to stop the symptoms.
If we can learn to recognize our condition earlier, we might be able to get back to “normal” without such a major intervention. We might just need to talk with our therapist, adjust medication, or some other treatment that keeps us in control. While still in danger, we can take steps that bring us back to “normal” that are less intrusive. This has the benefit of creating less trauma as well as having less negative side effects.
It is also believed, and with good reason, that even elevated or low energy states are a danger and in need of intervention. Too often, such lessor states have spiraled out of control and rapidly escalated into high mania or deep depression. Although the intervention may be more subtle, we nonetheless need to rein in the state before it gets out of control.
The reality is that our behavior is what makes us need intervention. While it is understandable that people link state to behavior, it is important to understand that the behaviors are the issue. Some people attempt suicide or exhibit extreme behavior when in extremes states. Other people do the same at lessor states. If we are going to understand how to use the concept of comfort zone, we need to change our beliefs to see behavior as the issue.
Suicide is obviously in need of major intervention. To get so far outside of our comfort zone as to think that the only way back is to kill oneself is incredibly dangerous. Some say that 40% of all people with bipolar or depression attempt suicide at some point. Yet, there are many other behaviors that are just as dangerous with the added risk that other people are also at risk. Out of control mania can include behaviors that put everyone at risk. While forcing someone into treatment can be seriously abused, there is no doubt that some behaviors need to be stopped at all cost.
If we can catch ourselves or others earlier, there is a chance that such extreme measures are not necessary. While it is true that many people rapidly go from “normal” behaviors to out of control, most escalate slowly enough that a lessor intervention may be all that is needed.
If we can learn to be more aware of our behaviors, we can use more subtle tools to bring ourselves back to “normal.” It may only take a couple of days off or a change in sleep to bring us back. Catching ourselves earlier is the key to getting bipolar in control.
A more productive way to consider our comfort zone is to look at the relationship between our state, the behaviors associated with it, and the intervention needed to return to “normal.” By doing so, we can more clearly see the assumptions that color our beliefs. Seeing how the state is separate from the behavior and how the intervention is based on behavior helps us to put mania, depression, hallucinations, and delusions in a context that can lead to growth.
Nonetheless, even with the inclusion of behavior, there is still a flaw in the way that the mainstream sees it. Any state outside of the comfort zone is seen as in need of intervention. As compared to the earlier chart about comfort zones for “normal” people, there is something critical missing: growth.
As stated earlier, the mainstream assumption is that elevated or low energy states are the precursor to high mania and depression. Allowing them at all is thought to risk rapid escalation to extreme states. It is considered dangerous to allow any states outside of the comfort zone no matter how narrowly defined that zone becomes.
Many, if not most, people have learned that they can function in the slightly elevated or low energy states once they develop the skills and use the tools that help them to keep the condition from escalating out of control. It takes hard work and tremendous insight to make sure that we are not deluding ourselves into thinking everything is fine when it is not, but with the help of others we can learn to recognize that we have gone just over the line to the part outside of our comfort zone where growth takes place.
As growth is a necessary requirement to be alive, it is advantageous to make the effort to occasionally take ourselves into the growth area outside of our comfort zone. The process, as will be described in detail later, is to take ourselves slightly into the growth area and back into the comfort zone. Repeated practice helps us to become comfortable and leads to much greater awareness of exactly where the line is that we cross. By making sure that we do not go too far over the line, we develop the skills and awareness to do it safely.
Rage and Bipolar Disorder:
I have long been a fan of The Hulk, but I had not noticed the incredible wisdom of Dr. David Banner until The Avengers movie made it clear.
In his wisdom about managing rage he grasps the secret to managing depression and mania too. In one brief statement he captured the greatest flaw in the current paradigm about treating bipolar.
Unfortunately, most people missed it because they thought it was just one of the many great jokes in the movie.
The early scenes in The Avengers included much concern that Dr. Banner would lose control and turn into The Hulk. Tony Stark even tried messing with him to see if he could trigger it. Like me, Tony Stark was fascinated with the potential of harnessing the power because he knew it was possible in spite of the protestations of those who feared it. It helped that Tony in his Ironman suit had the tools to protect himself from the danger just as I have developed tools to protect myself and others from the dangers of depression and mania.
If depression or mania get too intense I have tools to lower the intensity without needing to be hospitalized. (You can explore the metaphors of harnessing the cube that had unlimited power and the struggles every character had with control in the comments if you like.)
Later in the movie there was a scene where Dr. Banner was entering into the battle as himself and the others were worried that he needed to turn into The Hulk first. The insinuation was that he needed to get angry first to make the transformation. Dr. Banner smiled back at them and said that the secret to his control is that he is always angry. It was a pretty funny line, but the implications for treating bipolar are profound. It also illustrates what I have been saying for many years.
What Dr. Banner knew was that trying to suppress his anger would never give him the control he needed when anger was provoked. He learned to be angry without allowing it to control him. He was still afraid to let it go too far, but as he grew to understand it he even learned how to harness The Hulk and use the power under control.
Those who do not understand depression and mania think that the only way to control it is to make it go away. It works for a while, but, just like with anger for The Hulk, when mania or depression returns they find themselves back in crisis with no awareness or skills to do something about it. When mania, depression, rage, hallucination, delusion, or any other manifestation return, chaos ensues just as anger triggered The Hulk in previous movies.
You must make sure you are working with a level that you can control. That is what Dr. Banner learned and what I have been teaching people to do for many years. It is not necessary for Dr. Banner to be angry all of the time, but to have enough experience with it to understand both the limits of his control and the tools available to maintain it. We do not learn to control things by avoiding them or denying their existence. We learn by finding the limits of our range and keeping ourselves within it.
The focus of Bipolar IN Order training is recognizing the edge and learning tools to get back within it when we cross it. We teach people how to expand their range instead of contracting it. The focus of the old paradigm is to try to make mania and depression go away. That may not seem like a big change, but it is “the difference that makes the difference” as Gregory Bateson (a famous real person) so eloquently stated. Our approach needs to be different (from the old paradigm of making it go away), but not too different (as it would be by letting depression and mania go completely unchecked).
My daughter Kate is in her fourth year of medical school and is well on her way to becoming a very caring doctor. Her greatest gift is the ability to connect with people, which thankfully is being recognized in the hospital settings as an asset.
She creates strong bonds with her patients and their families by communicating how much she cares about them. Among so many other admirable traits it is the one that makes me the most proud of her. It has been her greatest gift for as long as I can remember.
The ability to form strong emotional bonds is not without tremendous risks though. It hurts her deeply when a patient that she is involved with dies. It is a testament to her awareness, understanding and strength that she can perform even on days when she sees the worst aspects of the medical profession; in spite of their best efforts, they cannot save everyone. Kate has grappled with that many times and come out the better for it.
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