PsychEducation.org (home)

The best book on this topic is by Julie Fast: Loving Someone With Bipolar Disorder.  You can read my thoughts on this topic below, but her book is the definitive reference.

If you have arrived from a link other than Chapter 14 in my book, please read this paragraph:  This web-page is a chapter which could not fit in my book on the bipolar spectrum.  Unlike the rest of the book, which is for people with depression symptoms plus some suggestion of bipolarity, this chapter is for their significant others. It thus talks about the person with symptoms, instead of to the person with symptoms, as does the rest of the book. I fear this chapter alone might seem a little offensive -- to find yourself talked about this way. The chapter is intended as an add-on to the rest of the book, which contains an even more important message for families and significant others: understand bipolarity and the complexity of treatment options.  That's what the book is about.  So, the most important thing for families and friends is to learn about this illness.  After that, the sections below may also be of value, and for anyone in the thick of it, get Julie Fast's book. 

How Family and Close Friends Can Help
(Written 11/2005)

• Introduction

• First, Do No Harm

• Don't Just Do Something, Sit There

• Ask, Don't Tell: On Collaborating

• Burn-out Prevention Strategies

• The Problem of Insight

• Dealing with the Doctor

Introduction

You may be reading  this chapter as a "significant other" (S.O.) of some sort, or someone with symptoms looking for hints on how to get your loved ones to assist you.  Here are some guidelines on how S.O.'s can help with someone whom they think has "bipolarity". Remember, this site is primarily about Bipolar II and other "soft" bipolar variations.  Bipolar I, with the potential for full manic episodes and a complete lack of insight on the part of the patient, presents some very different challenges.  Here we'll focus on the difficulties you might face when a person has repeated episodes of depression, and additional symptoms such as irritability, agitation, impulsive decision-making, and other features of hypomania, in addition to depression. 

As you have seen, my book emphasizes the many variations of mood disorders possible. Likewise, there is a broad range of challenges you may encounter in your relationship with someone who has Mood Spectrum symptoms.  Listen closely now:  maintaining a relationship with some people with such symptoms will require none of the following concepts or strategies. None. For many people with "soft" bipolarity, simply understanding the content of my book might be all you need.  If they were to read this chapter, I'd expect them to be offended: "hey, wait a minute, I'm not that bad! I'm not horrible to live with!" So, please take this whole chapter cautiously, and look for concepts which might apply in your relationship. Perhaps your situation is not very extreme -- yet you might be able to recognize something here that does describe your experience, or least sound familiar.  Okay, got it? This chapter is not for everyone. Take what you can use. 

First, for the perspective of people who've "been there", see the website for BiPolar Significant Others,  www.bpso.org . The organizers have done a superb job of presenting resources and connecting people.  Their website offers you an "expertise" I cannot even try to match.  (If your version or that of your loved one is a "soft" bipolar disorder, far from Bipolar I, then some of the resources online may not feel quite right to you, as they often emphasize Bipolar I. Remember, until the last few years, Bipolar I was the only version of bipolar disorder widely recognized.)  Secondly, there is nothing better than to learn a lot about what you're facing.  That's what my book, and this website, are supposed to help you with.  I hope you've found them useful.  

From there, let's take a look at the approach of a therapist and medication prescriber like me, because in some respects, your role and your challenges may be similar to mine; and because most of these ideas are unusual, if not downright paradoxical, so that you would probably not think this up on your own. Experience might teach you -- but maybe I can save you a few steps. 

Think about it: you have a desire to help; and you must maintain a relationship in the process. Most likely, in the long run you'd really like to see the mood disorder get better and fade into the background. You probably understand by now that it is not something you should be expecting to go away, but rather something that will require management over time, yet may be so well managed that symptoms are no longer interfering with your S.O's ability to function -- including in your relationship! Similarly, a therapist or psychiatrist or other health professionals who gets involved in her treatment also wants to help; and we know we'll be doing so over a period of time, striving to make the symptoms so mild that we can have a different relationship (in my case, becoming unnecessary! In your case, hopefully you can go back at that point to the joys and challenges found in all intimate relationships).  The point: there is a complex balance between these two goals: helping, and having a relationship.  Sometimes they complement one another but sometimes they require some decisions as to which is more important at the time, and in the long run. 

Thus our challenges may be similar, and therefore, some of the techniques and perspectives that we therapists use may be useful for you. Let's see. 

[This "chapter" has not been edited by the team at McGraw Hill, who made my book much better that the original version I sent them. Any style problems herein should not be held against them!]

First, Do No Harm

Medical schools all teach this concept.  Often you will be able to help a lot, they told us students; sometimes you may not be able to help much.  But at least, while you're trying, don't make things worse.  How might you S.O.'s be at risk for making things worse?  Here is one very common way:  judging.  This is a normal, natural thing for humans to do; our brain is built for it.  We see things and think "that shouldn't be so" (like seeing someone with a mental illness who is homeless in a big city), or see people and think "that's a strange way to act", and indeed, we watch ourselves, don't we, and think "I shouldn't have done that".  You can recognize these thoughts from the words in which they appear: should/shouldn't, must/must not, best/worst, bad/good, and so forth. 

Our brains add these judgements to events which simply are what they are.  The judgment is supposed to motivate us to act in a particular way in accordance with our value system.  And yet we make mistakes with these judgements all the time: we fail to notice some detail that changes everything, for example, like the fact that there was no detergent left, when John did not run the dishwasher as he said he would.  If we don't know about the detergent (neither did John, at first!), then we might think "John is so irresponsible" or "lazy" or "unreliable". 

So, here is my caution to you: watch out for judging thoughts about your loved one.  Ah, wait a minute.  If I'm right, you might just then have had a thought, or an irritated feeling: "who is this guy, telling me to avoid judging?  He has no idea of what's been going on around here. If he could just see what I have to put up with, why he wouldn't be giving me this advice, that's for sure"--or something like that. You might have felt like I really didn't understand what you're dealing with, or worse, that I was accusing you of judging, and hey, I don't even know you! 

I'm guessing this because it's what the theory says will happen (as well as having seen this come true many times in my office): when someone offers a thought that can be perceived as judging, the reaction is anger and resentment and resistance.  Therefore I'm doing now  what I do in my office when I know I've made a mistake, or when I can see someone has been stung by something I just did or said:   Quick, name the experience they are having, and demonstrate thereby that I understand it and am not judging it, that indeed I am finding it quite understandable. And then, go one step further: take responsibility for having possibly caused that feeling, and indicate this was not my intent. 

Aw, come on, you might think:  I can't be doing that in real life.  Phelps might be able to do that with a client, but I can't be doing that when Christopher has not done his homework yet again and now he's upset because I told him he had to do it!  Quite right.  This is not a plan for every situation. But you might be able to do this much: you might, if you thought about this paragraph while staring at Christopher, be able to say something like "Chris, there may be some very good reasons I don't know about as to why your homework is not done. When we have time, perhaps we can look into them.  For right now, it's clear there's one thing to do: homework" and see what happens. 

Everything I'm telling you here is just a hypothesis to be tested. Will this help?  Try it, or something close, and see what happens. And do not judge yourself for "not doing it right", either, okay? However, you are likely to encounter least two problems with this avoid-judging idea: first, how does one know when the time has come to use it (or do you have to live like this all the time?) And secondly, how do you find "neutral", when you're upset, so that you even have a chance to try this idea?  Let's take these problems one at a time. 

When to Listen For Judgement
No, you don't have to live like this all the time, listening for judgement -- although that's an interesting idea to consider, as indeed this process is an important part of some eastern philosophies.  But for us Westerners, here is one time when we should definitely consider applying this principle:  when we're angry.  The hardest part of this maneuver is not in applying the principle; it's in recognizing that we're angry!  Neck muscles tense, thoughts focused on the problem (and not on the beautiful day outside, or the rose in the vase, or the comfortable feel of the clothes on your skin, or the nice things Christopher did for you this morning): sound familiar? 

With some practice you can see it coming, especially if you learn, from experience, that you have a new technique which can help you navigate angry moments. But isn't anger a good thing sometimes?  Perhaps.  Just try the "go to neutral" approach a few times and see what you think.  Then, if you still think anger is useful, read a wonderful book by a Tibetan Buddhist (different from other kinds of Buddhism), called Working With Anger.  As my buddy Dr. Teresa pointed out to me, the book starts and ends with a chapter that is more about Buddhism; but the middle of the book is just one technique after another for dealing with anger (check out the list of all these tools, an appendix at the back: it's great to know that there is such a large number of them). 

Finding Neutral
How do you find neutral, when you're upset?  I'll offer you a psychiatrist's technique in the next section.  For now, try this: listen to yourself before you speak.  This is not easy, thus that well known advice, "Count to Ten".  Do your thoughts sound like judging? Listen for those judging words: good/bad, best/worst, should/shouldn't, etc.  If so, hold off on opening your mouth (like yelling at John about the dishes) until you are certain you have all the information you'd need to fairly arrive at that judgement.  The older I get, the longer it takes for me to become certain (perhaps because I can see more and more mistakes I've made thinking I knew what was going on!). And as a therapist, I've discovered I actually get much better results from very deliberately avoiding judgement.  People feel much more comfortable, they tell me more about what is going on inside them, and lo, we discover all sorts of things that make them look less judge-able. 

You might be one of those people whose mind is just wired to arrive at judgements.  Your mind is really good at coming up with them. Some people are like that. But your S.O. might be one of those people with bipolar disorder who can do some very unwise things, which even she recognizes as such--later. And thus trying to take it easy on judging can be very difficult, and challenging, and a repetitive sport. Yet when I try to maintain that non-judgmental stance with my patients even after they've done something very regrettable, I still get better outcomes, so I still think it is worth using this technique even in the most extreme circumstances.  The technique is about preserving the relationship with this person, exactly as you would wish to do, while still "getting traction" on the problem--using the technique described next, perhaps.  (A short book full of tools for balancing the need for change with the need for preservation of the relationship is a simple book on negotiating skills: Getting to Yes, one of my all-time favorites.)

As with all the suggestions in this chapter, you may find them easier to follow if you find yourself a therapist and ask for some help.

Don’t Just Do Something, Sit There

How do you get more information, about whether a judgment is called for, for example; or about what is really going on for your loved one?  This is another technique I learned in Psychiatry training: sit there. (Subject of all sorts of jokes, I know, but hear me out, it's not just sitting there…) You know the phrase "Don't sit there, do something!"  Doing is usually happens when your loved one is feeling badly, and you want to make that stop: you try to calm him, try to tell him everything will be all right, try to point out the good side of things, try to help him shift his attention elsewhere.  But as a therapist I was taught to let those feelings stay right there so that they could be examined and considered in detail; and even more importantly, so that my client would feel that having these feelings is acceptable, understandable, not as scary as they seem, and that while holding them right there, as bad as they are, they can become more manageable, more okay to just have. 

One of my teachers put it this way:  pain + struggle = suffering.  The struggle not to have what you have (in one way or another, e.g. alcohol, gambling, fast driving, or perhaps even writing websites and books?) makes pain turn into suffering.  Sometimes the pain is just going to be there--the pain of knowing you're stuck with a complex mood disorder, for example, or living with someone who's got one.  But the struggle with this pain, trying to make it go away when it cannot really go away, is what makes for suffering. Thus in treatment we often shift our attention to the struggle, rather than working on making the pain go away. Then both the therapist and the patient are applying the maxim: "Don't Just Do Something, Sit There." 

You desire to help your loved one will tempt you to action.  Sometimes that is very appropriate, and you will get good outcomes with your helping behaviors.  But if you are not getting such outcomes, you may need to consider a different approach, like this one. The hard part is to sit there with your feelings: when you watch your S.O. in pain, you want to make it stop, in part so that you won't feel so badly.  Tricky, isn't it, having to admit that? Remember, suffering = pain + struggle.  You too might be trying not to have something that you just have to have.  This trying often makes things worse, both for you and your loved one.  When you try to make her pain stop, you send several messages you don't want to send:

1. Don't have those feelings. Stop having them now. 

2. You shouldn't be having those feelings.  Have some different ones.

3. (Here's the clincher) I can't handle it when you have those feelings.

Message #1: You may be teaching your S.O. to struggle with her pain: "try not to have what you have". This can lead to more suffering than the pain alone. 

Message #2: "You shouldn't be having those feelings."  See the judgement word.  This can lead to anger and resentment and resistance, as discussed above. But the third message is in some ways the worst, especially if your loved one loves you in return.  When you send the message "I can't handle it when I see you hurt", he may respond, out of love for you, by trying to keep you from seeing it.  He may shove those feelings down where they won't bother you.  For some people, this may not be terribly harmful; but for others, this "stuffing" of feelings can keep them from being able to accept what they have.  Instead, they may pursue other coping strategies: exercise, that would be fine, but in excess perhaps injurious; or work, likewise okay in moderation but potentially a problem if it is being used to cope with pain; alcohol, definitely a problem; and so forth. 

So, the idea is, "just sit there".  But this is not a passive position, as the words might imply.  We therapists, if we are doing our job well, "sit" very actively (now there's a funny concept).  We do "active listening", a term now so commonplace it's a bit tarnished, I fear, and I hesitate to drag you through an explanation.  Suffice to say that this is a very active process of conveying "I'm understanding you" in several different ways, as you listen.  There are whole books written about this, but you'll do pretty well if you just:

1. Listen, hey, pretty basic: the key is to really want to understand what the person is saying. If you don't, you'll be faking it, and they'll know. So, don't worry about technique if you don't really care to hear what they have to say.

2. Make it clear that you're listening.  Most people can do this without saying a word, through facial expression. But if you aren't that facially expressive (some aren't), then you'll need to practice grunting.  Grunting?  Okay, we could call it "minimal verbal encouragers" if that would make you feel better.  You know what I'm talking about:  this is the well-timed "mmmhmmm" we psychiatrists are famous for. There are lots of variations: "mmm", is one of my favorites, and "mmm-mmm".  And I really like "uhmhmm".  And you're not taking me seriously now, I trust. Just make some noise when you get what they're saying, okay? 

3. Paraphrase now and then. If you aren't a natural at this, try jumping in periodically with "So what you're saying is...." and then summarize what you just heard briefly.  This will work a lot better if you were really listening, obviously. The most important thing to get in your summary is any emotion she or he is feeling, that you can recognize: "looks like you're feeling pretty hurt about Sara's cancelling your plans"; or "that phone call from Jack really made you angry?" . I never use the one people think we psychiatrists use all the time: "How did you feel about that?"  Duh.  If you have to ask, then you're not really getting what your loved one is saying, are you?  You should be apologizing for not getting it, rather than asking this dumb question-- that is, if you really care about what they're saying

This technique may be easier to learn if you've hired a therapist to work on one of the other techniques here, as she/he ought to be doing it with you (hard to beat that for a learning opportunity).     

Ask, Don’t Tell: Collaborating

You want a certain behavior to increase or decrease, but every time you push, you just get push back.  There is a different way, which emphasizes collaboration, and begins with learning what your loved one is trying to achieve with these behaviors; then comparing what you are hoping for.  If some common ground can be found, it will be much easier to work together. 

This "find common ground" approach is summarized in a superb little book on negotiating agreements, written by a team from Harvard that gathered the experience of a group of world-class negotiators (including those who created the SALT agreements on nuclear weapons between the U.S. and the Soviet Union).  The book is called Getting to Yes.  If you've read it, you'll know why I like it so much.  Of the 4 principles emphasized there, most central one, in my experience, is this: Focus on Interests.  Rather than announcing your position on an issue -- "Patricia, I want you to keep your room clean" -- stick with what you're trying to achieve.  What is it that you're after, with this position?  Perhaps you want to be able to invite guests into your house without being embarrassed by Patricia's room's appearance.  Okay, keep the focus there.  Avoid staking out a position, as this tends to force others to stake out theirs, leaving both of you resisting one another.

Inquire about what your loved one is trying to achieve with a particular behavior you regard as a problem, or a particular position, such as "I refuse to take this medication".  What lies behind his position?  What is worrying him about this medication, for example?  The general trick I use to remind myself about this approach is this: ask questions.  I'm trying to create an atmosphere of collaboration. One of the best ways to do this is to ask questions, and learn more about what lies behind the resistance I might be encountering.  This usually works far better than pushing harder on the resistance!  I might learn that Bob is concerned about possible weight gain from the medication; or that he doesn't like the taste; or that he doesn't think she needs it anymore; or that he has even more vague fears about what the medication might be doing to him.  When I know more about the nature of his resistance, I'll be in a better position to deal with it. 

If you like the sound of this approach, I cannot recommend Getting to Yes too highly. The authors use examples ranging from nuclear weapons agreements to negotiating a rental agreement with your landlord.  The book is easy to read, only about 100 pages, and could become a great tool for you.  For a summary -- although I urge you to get the book itself -- here is a brief overview. 

Setting Boundaries

This section could also be called "strategies for avoiding burn-out and managing safety".  You'll see that these goals both involve deliberate attention to your limits, the boundaries of what is sustainable for you in dealing with a person who at times has symptoms that make the long-term sustainability of the relationship challenging. Remember, this may not apply to your relationship, or might only apply to a very small extent. See what you think.  

How a long-term illness can make a person "dependent" on others
Some people have such bad things happening to them, which are not their fault, that they may be almost helpless for a while, such as after a major surgery.  But you probably know of people who seem to get through these kinds of stresses and challenges without much help; they send the message "I'm okay, I'll be all right" and can even fend away help.  While that too might reflect some kind of emotional issue, we can see that different people respond to events differently: some put up a sign, so to speak, saying "I don't need help, thank you (Go Away)" ; whereas others' signs say "Help me!"  

When the "Help" sign goes up, the response they get may be part of the reason why some people end up in the "victim" role.  Suppose a person with long-term illness (in medical jargon, this is often called a "chronic" illness) says "Help!", and their S.O's do indeed help, making pain or anxiety diminish or disappear.  In many cases, as a result of this experience, the person with the illness is likely to say "Help" again when facing similar circumstances.  This is what any animal does. Behaviors that are followed by some positive experience are more likely to occur again.  This is the basis of the behavioral principle of "reinforcement":  wait for a behavior you want, then provide some sort of reward, and the behavior will occur again more frequently than without the reward. For example, you are teaching your dog to come when you call.  If you say "Here, Spot!", and she comes to you, you know that if you provide her a nice little doggy treat, she is more likely to come to you the next time you say that, right?  We usually think of these rewards as something positive, like a dog-bone for your pet, but there is another kind of "reinforcer": simply removing something negative -- such as anxiety before an upcoming exam. When your friend says "Oh, I'll help you study for that", and you feel greatly relieved, because she knows the subject well, this experience can have a reinforcing effect as large as if she'd waited for you to give it a good try and then brought you a cup of tea. Helpers, by taking away anxiety, or diminishing pain, or otherwise decreasing their S.O's struggles, can reinforce the behavior of asking for help. And of course, people can ask for help in many ways, not just with words. Simply looking helpless works.  This is quite reliable!  When I'm looking for a doctor's office in a clinic I've never seen before, if I just look lost and baffled, some staff member is very likely to pipe up with "can I help you?"  

But imagine if your loved one is repeatedly reinforced when he asks for help (directly or indirectly). Unless some other factor prevents him (such as an awareness that asking for help too often is not healthy in the long run), he may respond to this reinforcement by asking for help again, perhaps now even when his needs are not so great.  He has been "shaped" (as the behavioral scientists would say) into a role of repeatedly asking for help. Worst of all, he may come to think of himself as someone who needs help. Now don't worry: this doesn't happen every time you help someone, as we'll consider in a moment.  But imagine what it would be like to find yourself needing help, and then be offered help which did indeed make things better for a while.  You might start seeing yourself as a person who needs help, as though this was a description of you, not of your circumstances.  If every time you thought "This is hard; I wonder if I could get some help with this", somehow that message came across to the people around you; and if they responded to the message by helping, yet again, then the very thought you were having -- "I wonder if I could get some help with this" has been reinforced, you see? 

Now please be careful here. I am definitely not saying you shouldn't help people who seem to be looking for help.  I am trying to help you understand what can happen over time when someone has a very serious illness that puts them in the position of needing help simply to function:  if a pattern of behavior is established in which they repeatedly ask for help and repeatedly receive it, then over a long period of time (not days or weeks; in most cases at least months, and usually years) they can be "shaped" into a role of being and feeling dependent on others. So what you have to watch for is this kind of a pattern. Because what happens to you, the helper, is also part of the problem.  Here's how -- if you haven't figured this out already.  

Making helpers resentful
If I showed up in that doctor's clinic looking lost and baffled, once a week, or worse yet once a day, then the staff would quickly tire of offering me help. If I was blind, and really could not make my way on my own at all, then their frustration would probably take longer to develop (there would be an obvious explanation for why I needed the help. Isn't it interesting that this changes peoples' attitudes. Notice that a mood disorder is usually not obvious, like blindness; and worse yet, with the mood disorder it's generally not so clear, as with blindness, that the person with the symptoms is "not responsible", in some way, for her symptoms, and for dealing with them). If I was very nice, and very appreciative of their assistance, I might be able to rely on their help for a long time. But if I took their help for granted, or worse yet if I was rude and irritable, yet still looked very helpless, then they might continue to help me but resent doing so.  They would probably  wish that I'd stop showing up. I'll let you draw the parallels from this example to your S.O., whose mood disorder symptoms might lead him to need help, at times; and who at times might be pretty rude and irritable while still needing your help. You can see how this pattern can very directly harm a relationship. 

"Persecution"
If this pattern of helplessness and resentful helping goes on for very long, frustration levels for everyone involved can spiral upward. Unless healthier outlets for this frustration are available (such as talking with a therapist), a new behavior is likely to emerge: "persecution".  The helper gets so tired of his role, repeatedly having to drop his own agenda to meet the needs of his S.O., he finally acts out his frustration in a hurtful way: he yells, or throws things; or he makes unreasonable demands he knows his S.O. can't meet; or threatens to leave; and so forth.  But the "helpee", tired of being in the dependent role, feeling so powerless, can also act out her frustration as well:  she may withdraw emotionally, even when she knows that her S.O. will be hurt by this; she may threaten to leave, or simply fire away verbally and wonder why, later, she was so mean.  She may not see the connection between her dependent position and her anger.  

The well-known therapy model for this is a triangle relationship is shown in the Figure below:   

The only stable position in stressful relationships is the middle of the triangle, the gray center.  If one person in the relationship allows herself to be pulled out toward a corner, she begins to force others to corners as well.  For example, if Sarah responds to her S.O.'s needs as a Rescuer, she may reinforce Paul's needy behaviors and push him toward the Victim role.  Ultimately one of them will tire what's happening and take on the role of Persecutor.  Ironically, the first one to Persecutor may not be Sarah.  The Victim role is an uncomfortable one. Paul might not recognize his resentment of Sarah's continual helping, until he lashes out at her.  He might unleash his anger at having bipolar disorder, and his frustrations with the unpredictability of his life which can accompany this illness, toward Sarah.  This is such an unfortunate irony, Sarah punished for trying to help. You can imagine how negatively this could affect their relationship.   

Another example: suppose that Jennifer has a bipolar-like mood problem.  Periodically, especially in the winter, her depressions return, for no apparent reason. When they do, she becomes intensely preoccupied with thoughts of suicide. Ask her during a good summer if she wants that ever to happen again.  No way! She does not wish, even in the slightest, that these symptoms show up. They just keep coming back, all on their own. When they do, she knows from experience that she can become quite dangerous to herself:  she has been hospitalized twice for taking an overdose of pills, both times in January; and she has seen herself get very close to other strategies during several other winters.  This year it's December when the depression becomes so severe, once again.  She doesn't want to go in the hospital, but she knows her thinking is getting dangerous again.  She calls her husband from the parking lot of a grocery where she had gone to buy Tylenol for an overdose. But he's in the middle of a meeting, and he's been through this before.  This time when he calls 911 and tells the police what's going on, he goes back to his meeting instead of going to the hospital emergency room, even though he knows she would very much like him to be there. His behavior is partly motivated by his anger, so this is a form of persecution, in the triangle-model. Although this year his actions are relatively mild, if something like this happens again next winter, he might not even visit her in the hospital; or he might begin thinking about divorce. All from a clear-cut seasonal worsening in her mood disorder that she wishes would not happen.  How then can these unfortunate and destructive patterns be avoided?  Although no solutions will fit all relationships, here are two, from my training in therapy. 

The patchwork quilt model 
First, you can see from all this that just having a long-lasting illness like the mood problems described in this book can put a person in a dependent position. They may not "live there"; they might just visit when their symptoms are severe. But if the symptoms return frequently, all involved will have to watch out for the three points of the triangle.  Is your S.O. being reinforced for "victim" behaviors? That may be all right in the short run, but if you're dealing with symptoms all the time, you probably need a strategy to avoid the "rescuer" position.  One of the best such strategies is this: don't be the only helper. Some people with these illnesses are going to need a lot of help. That's just the nature of the illness, unfortunately.  So, better spread the helping around as much as possible. Get more people involved.  One of my teachers used the analogy of a patchwork quilt:  to stay warm in winter, you need a good blanket.  If you have only one blanket, though, and that blanket went away, you'd freeze.  So, better to have a patchwork quilt:  if part of your insulation ever goes away, plenty of other patches are still there to keep you warm.  So, my teacher would recommend that people with long-term severe symptoms get all sorts of patches in their quilt, such as: 

• an activity class or club, such as yoga or basketball or dance or volleyball ; 

• a volunteer position, however small, such as an hour or two a week; 

• getting involved in a church community; 

• a pen-pal; 

• attending the library's book group; 

• a mood disorder support group (such as the many available on the Internet now, but probably even better in person if a good one is available; for anyone with the right history, Alcoholics Anonymous groups are found in many communities and are generally quite open to new members, for example); 

• perhaps a dog or other pet, if that is financially and physically possible; 

• maintaining several friendships; 

• working with a personal therapist, if that is affordable and available; 

• working with a psychiatrist separately, if that's how the local system operates; and 

• very carefully, perhaps, maintaining a more intimate relationship, if that works out.  

This last relationship would be protected, as much as possible, from victim-rescuer patterns, by pushing dependency needs toward the other sources of support and warmth.  In this model one of the tasks of the S.O. is to avoid becoming the only square in the quilt, so to speak.  You could support your loved one's efforts to develop other squares.  Work toward an open agreement that this strategy would be good for your relationship, in the long run.  That might include sometimes saying things like "I could help you with that, but we've agreed to watch out for patterns that might hurt our relationship in the long run. Maybe I'd better let someone else step in this time."  Obviously this has to be done gently, with great caution.  Better yet would be that your partner/family member himself would take responsibility for limiting requests for help, in the spirit of this plan, looking elsewhere most of the time, and keeping his relationship with you free of illness-related issues as much as possible. That's why I generally try to avoid having an S.O. become her or his partner's pill-manager, for example.  "Did you take your medicine?" is a dangerous question, for both parties in a relationship. (However, sometimes a spouse or mother or brother is in the best position to keep track of medication refills and such details.  Remember, these ideas and solutions do not apply for everyone.)  

Boundaries: my version and yours, if necessary
If your goal is to remain only one small square in the quilt, for issues regarding the illness and its treatment, then often this will require careful attention to what kind of helping you will do, and what you will try to leave to others.  You can think of this as managing the boundary of your role.  This too is something we therapists do all the time.  Take my role as the extreme, to illustrate this principle:  if I work at managing my own anxiety, I ought to be able to sit with someone for 50 minutes  no matter what kinds of symptoms they are having or displaying.  I may have to manage my own inclination to jump in and try to "help" (using the technique above: "Don't just do something, sit there"). I may have to manage my wish to make their situation better.  If I work at all these things, I can probably manage to be a stable presence, a person who can sit with even the worst symptoms without running away.  I can be someone who is not telling the patient, in one way or another, "Stop being like this!"  Notice that this takes a fair amount of work, but I ought to be able to manage that for 20 or 50 minutes, in the name of being around in this role for years to come if needed.  This extreme form of boundary management is only necessary for a few of my patients; but using this approach, I've learned that I can handle almost anything, no matter how severely the patient's symptoms might test an average person's patience.  Again, this allows me to get involved and stay involved, so that if there really is something -- like a medication -- that can help this person, I'll be able to stay in a position to keep trying things, looking for something that might be of benefit.  

Why am I telling you this? You couldn't even begin to make such restrictions on your role, your involvement!  Indeed, you may be able to place only minimal limits, Remember, your relationship may not require any  limit-setting at all.  I'm offering you the extreme version of boundary setting because it might help you see the general idea: watching out for interactions which call for more from you than can be sustained. Here are some examples of how this strategy might look in your situation:  you might limit how much you get involved in your S.O.'s medications, saying something like "I'll try to stay out of your treatment plan.  If I see a problem, I'll let you know so that you can discuss it with your doctor."  Or you might limit your phone availability during the day so that you are not torn between doing your job and being available to your spouse. You might decline the request to be your S.O.'s walking partner, as when she didn't go walking, you might feel resentful that she was not taking the necessary basic steps for her health. You might try to limit the extent to which you listen to your S.O.'s complaints and frustration about his symptoms, again noting that the whole point of setting limits is to enable you to stick around for the long-term. These are all forms of boundaries designed to keep the relationship healthy for the long term. 

Safety Nets: Don't Worry Alone
For S.O's whose partner can become suicidal, or whose symptoms have the potential to be dangerous in some way (spending limited family resources, for example), another another role-limiting structure can be important: maintaining safety-nets.  Imagine the long-term impact on a relationship of having to face the possibility that one's S.O. might just be gone one day, with no warning or chance to intervene; or that you might come home to find he has spent another $1000 you don't really have.  Because commitment is the cement of relationships, a constant fear of suicide or imprudence could significantly weaken the connection between two people.  Yet some people with severe mood symptoms know that if they are completely honest with themselves, they cannot really assure their S.O. (or their psychiatrist, as I know from experience) that they "would never do it."  (Some people can make this statement, however, and in many cases I believe it, based mostly on the way that it is said). Once a person makes a suicide attempt, his loved ones are very likely to worry, for years, at some level, about another attempt, this one perhaps resulting in death. Similarly, once he has racked up thousands of dollars in credit card dept, his spouse might need years to stop checking the monthly statements with a fearful eye.  Words of reassurance are not likely to make these kinds of fears diminish very much.  

If such fear can erode the relationship, or at least weaken it, by making full commitment difficult to muster, then another step should be taken:  "offload" some of the sense of worry upon someone else, if you can find a willing partner.  Build in to your plans a series of safety nets that can catch your S.O. before her suicidal thinking or dangerous spending or other concerning behaviors become a real problem. For example, in the case of a fear about credit card spending: limit access to large amounts of money that can be spent without your knowledge. In the case of a return to alcohol use, ask that for the sake of your relationship, so that you can worry less about this kind of relapse, your S.O. participate in regular Alcoholics Anonymous meetings (the more likely the relapse, the more often the meetings, perhaps). When someone else with experience in detecting alcohol use is there to help watch for the problem, you can then go to work on letting go of your fear. In the case of suicidal thinking, hiring a therapist for your partner or family member and making clear that part of the purpose of therapy is to watch for suicide risk, might allow you to let go of some of your fears about this. This could be money well spent.  Safety nets can include trusted family friends, pastors, other family members, AA sponsors, therapists, psychiatrists (and perhaps occasionally a trusted co-worker, but this must be handled with great caution; think of the workplace as another "long term relationship" that must be protected from constant worry about risk behaviors or recurrence of symptoms).  

All of the participants in such safety nets should know what their role is in this system: what are they supposed to watch for, how will  they know when they are seeing it, and especially, what are they supposed to do when they detect a problem.  Who will they call, and what will that person do?  Ultimately the concern should be forwarded in some fashion to the therapist and/or doctor involved.  But the specific safety-preserving actions will probably need to happen before this "inform-the-doctor" step: for example, stop payment on checks; take your loved one to the emergency room; or call 911.  These actions may fall to you, the S.O.  But if you know that there are other people helping you determine when such action is necessary, so that you don't have to play both roles, this is generally helpful.  In the words of another of my teachers, "Never Worry Alone". 

The Problem of Insight

This book is fine for people who know there's something wrong with their moods. What about those who don't?  How are you supposed to cope with repeated episodes of irritability and destructive behavior which your SO does not recognize as such; or with someone who simply refuses to get help?  Beyond the book on this issue for severe mental illness -- I'm Not Sick, I Don't Need Help, by Xavier Amador --  what else is there?  Here are two concepts from my training that may be of use to you; I use them all the time:  the "Stages of Change" model, and a technique called "Motivational Interviewing."  

Stages of Change
This model was developed by researchers studying cigarette smoking.  They found that people go through several stages in the process of deciding to quite smoking.  Before people actually begin to lower their cigarette use, they have to "contemplate' the idea of stopping.  In other words, before they actually decide to stop, and before their behavior begins to change, they go through a stage in which they consider the idea of stopping.  Before that, there is no such willingess to even consider smoking cessation.  The researchers called this very first stage "Pre-Contemplation".  Here is a version of these stages: 

The point of separating these stages is to enable helpers like you or me to tailor our strategies to the degree of willingness present.  Little benefit will come from promoting specific change behavior options if a person has not reached the Preparation stage. Pre-Contemplation and Contemplation are the harder stages to deal with, the ones which require more subtle strategies. That's where "Motivational Interviewing", discussed next, is most suitable. 

If you have taken the links and learned more, you'll understand the 3rd column in the next table, which I've included here because it is such an excellent summary of how strategies change at each stage.  

This table comes from a version used at UCLA's Nutrition program.  Now, we move on to a technique that was developed primarily for working with people in Pre-Contemplation and Contemplation stages: "Motivational Interviewing".  This technique was developed especially for counselors in alcohol and substance use clinics, where the counselors begin their work by interviewing clients about their problems, thus the name.  

Motivational Interviewing
Here are the general principles of this technique as I've carried them in my head for the last 15 years (the original version of this approach is more complex; you'll find a link to original sources below):

1. Assume Ambivalence.  Presume that the person you're dealing with has some small awareness of the problem and interest in changing her behavior.  This may be a very small part of her, perhaps just 1%, while the other 99% is the part you see all the time, looking oblivious to her problem, showing no willingness to change, and very actively resisting any suggestions from you.  Why assume this?  Because for one thing, it's nearly always true; and for another, it gives you the beginning of a foothold where otherwise you might find none. 

2. People learn what they believe by listening to themselves talk.  This is a well-known principle in Psychology.  Our attitudes are far more flexible than we humans would like to believe.  Just talking about a point of view makes us adopt that point of view, at least a little bit.  You may have had this experience if you've ever had to present an opinion that was not your own, in a debate for example. 

3. To promote change, "create suction". If you suggest changes to a person in Pre-Contemplation, you're likely to meet with resistance.  The trick then is to avoid that resistance.  Think about creating a "pull" rather than providing a push. 

To put these principles together, consider these "see-saw" examples:

As you may have experienced, if you come along and jump on one end of the see-saw, saying for example, "You have a mood problem", what happens?  You tend to get the other end of the see-saw back in your face, right?  "I'm fine! There's nothing wrong with me".  So, the trick in Motivational Interviewing is to avoid jumping on the see-saw; and instead, to create a suction that draws out the side of the see-saw you're after. That is, you try to get the person talking in such a way that she starts describing aspects of her problem (the problem the other part of her doesn't think she has!).

For example, imagine me sitting down with a patient who does not think he has an alcohol problem.  If I start talking about how he seems to have lost his last job because of  his drinking, I'm liable to get something like "nah, I lost my job because my boss was a jerk, that's why".  If I emphasize the risk of making his mood problem worse by drinking alcohol, I might hear "plenty of people drink more than I do out there, doc', you wouldn't believe it; I'm really not drinking all that much."  I'm creating resistance, in a way. 

By contrast, see what happens when I go about it this way.  "Don, in your view, you don't drink all that much, right? Not more than a lot of people you know? (He nods).  Are you having more trouble in your life than they seem to be having?" 

He clearly is, that's why he's in my office.  If he says no, I might use the old "dumbo Columbo" approach (from the old TV show with Peter Falk; sorry, this might be way before your time...).  Scratching my head, screwing up my face, I say something like "yeah, that's the thing, you know, I guess I am maybe a bit slow here. Uh, now are they having trouble with their jobs too?  [This is said very gently, almost apologetically, like I really don't get it; which, of course, is true]... Are they having trouble with their families like you too?  Are they having to keep finding new jobs twice a year like you've been having to do lately?  I guess I don't quite get it here.  Help me out here? I mean, you're here in my office and they're not, right?" 

When and if I can get Don to acknowledge that he is indeed having trouble in his life, I can ask him to tell me more about that.  Now I'm in the paydirt: he is talking about his problem.  That, in the motivational interviewing system, is all I can ask at this point. I'll just try to keep him focused on the problem, and keep him talking. Remember Principle 2: people learn what they believe by listening to themselves talk. Just help him keep going in this vein.  "What else makes you think the drinking might be causing problems?"   I might even use the Devil's Advocate approach: "now Don, are you sure you lost that job because of your drinking?  I mean, your boss does sound like a jerk all right"  -- as long as I'm quite certain that Don will respond by affirming the role of his drinking.  Now I have him in the position of trying to convince me he has a problem with alcohol!  (If I blew it, and he agrees with this Devil's position, I've got to regroup: "and yet, somehow those other guys are still working there, and here you are; I wonder how we're going to account for that?", say I, gently, screwing up my brow as though I really am kind of dim and need some help with this.) 

As you can see, I'm trying to "create a vacuum", create a sort of force that just pulls out of Don the side of the see-saw I want him to talk about.  Anything to get him to talk in a way which acknowledges that he really does have a problem.  If you took that link to the Stages of Change article, you've already seen some of the tools one can use to generate this kind of momentum (e.g. the Readiness to Change Ruler at the bottom).  If you'd like to dig into this technique -- if you've moved from Contemplation to Preparation, or even Action -- here's an entire website devoted to Motivational Interviewing. 

Okay S.O.'s, that's all I have for you in this "chapter". I hope you can see that there's much more which could be said; please consider these as "introductory remarks".  I'll leave you now to continue your learning, perhaps via some of the links here.  Good luck to you with your challenges.

JP