A good
mood.
When a client with bipolar disorder is happy, is it an early warning sign, or just happiness?
People with long-term mental health conditions often find that their ordinary feelings are read as symptoms. This case asks how different approaches might respond when a client with bipolar disorder arrives excited, and what it costs to get it wrong in either direction.
The short version
When a client with bipolar disorder arrives excited, a therapist may worry about the start of a high. Sometimes that worry is right. Often the person is simply happy, and being treated as a symptom is one of the most common and painful things people with long-term mental health conditions describe. The answer is a plan made together while well, with the client’s own early warning signs, so both people can check rather than guess.
The case
Leah is 36 and has bipolar disorder. She has been well for two years. She sees her therapist fortnightly, mainly to talk about her relationship with her mother.
Today she arrives talking fast. She has been offered a job she wanted for years, and she and her partner are planning to move. She laughs a lot and has a list of ideas for the new role.
Her therapist feels a flicker of alarm. Leah notices it. “Please don’t tell me this is just my bipolar.”
Leah is a fictional teaching example, not a real person.
What each approach would look for
Theory comparisonThese summaries describe what each approach characteristically attends to. They are simplified for comparison. The “what it can miss” notes are this site’s disability-informed reading.
Psychodynamic
May wonder about a manic defence: excitement keeping painful feelings, perhaps about her mother, at bay.
“I wonder what the excitement might be protecting you from.”
What it can miss: that good news can just be good news, and that interpreting joy as defence can teach someone to hide it.
CBT
Would look at mood monitoring, sleep and behaviour against an agreed relapse-prevention plan.
“How has your sleep been this week?”
What it can miss: very little, if the plan is Leah’s own and used to check, not to police.
Person-centred
Stays with Leah’s experience of the news and her hurt at being doubted.
“You sound thrilled, and hurt that I might not believe you.”
What it can miss: that warmth alone may not notice a real early sign, if one is there. Leah may want both.
Trauma-informed
Thinks about past experiences of being sectioned or disbelieved, and how a therapist’s worry may land.
“Has anyone treated your good moods as a problem before?”
What it can miss: little, as long as it doesn’t avoid the safety question altogether.
Systemic
Asks who in Leah’s life watches her moods, and how that feels.
“Who else gets worried when you’re happy?”
What it can miss: that Leah, not her family, decides who has a role in noticing.
Disability-informed pluralism
Goes back to the plan they agreed while she was well, and checks it together.
“Shall we look at the signs you asked me to watch for?”
What it can miss: little, provided the plan really was made together.
How Leah’s answer changes the picture
Two years ago, when she was well, Leah and her therapist wrote down her early signs of a high: sleeping less than five hours and not feeling tired, spending money she doesn’t have, and starting projects at night. Her therapist asks whether she’d like to check them.
Leah says yes. She is sleeping seven hours. She hasn’t bought anything. The ideas for the job are written in a notebook, in the daytime. “I’m just happy. I don’t get to be just happy very often without someone checking.”
Asking before deciding
“That’s brilliant news. I’m aware I had a flicker of worry, and I don’t want to act on it without checking with you. Would you like to look at the signs we agreed, or would you rather just tell me about the job?”
“Both. Quickly check, then the job.”
How you’d know it helped
They check the plan in two minutes and spend the rest of the session on the job and the move, including what the change might stir up with her mother. They agree to look at the signs again next session, briefly, because Leah asks to. Her joy isn’t treated as a symptom, and her plan isn’t ignored either.
When the therapist gets it wrong
If her therapist had said “this sounds like it could be the start of a high” without checking, Leah might have stopped sharing good news. A repair would name it: “I reacted to the diagnosis before I listened to you. I’m sorry.”
Words you can use
For clients, when well: “Here are my early signs. Please check them with me rather than deciding for me.” For therapists: “Can we make a plan together now, while things are steady, for how we’ll both know if something is changing?”
Questions worth carrying, as a therapist
- Do I let clients with a psychiatric diagnosis have ordinary feelings, including joy and anger?
- Is the plan for becoming unwell theirs, or mine?
- What would I do differently if this client had no diagnosis?
Related: Psychosocial Disability · Anger After Discrimination
Evidence & sources
The emphasis on choice, partnership and being treated as the expert on your own experience draws on Eleanor Longden’s account of what helped her, in a dialogue with Allen Frances (Psychiatric Times, 2013). Agreeing early warning signs while well is common practice in relapse prevention for bipolar disorder. The case and dialogue are this site’s own.