Gestalt

Review, 14(1):71-88, 2010

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Gestalt Therapy and Bipolar Disorder

d A A n VA n B A A L E n , M . d .

ABSTRACT
About one in 200 people will suffer from a bipolar episode at some time in their lives. Bipolar disorder is a disorder mostly treated with medication. However, medication alone neither cures the disorder nor prevents relapses. Studies referred to in this article suggest that a combination of medication, psychotherapy, and psychoeducation would improve the course of the illness. Different psychotherapeutic modalities are discussed, as well as psychoeducational treatments. A case description shows how Gestalt therapy can be a relevant psychotherapeutic modality from which clients with a bipolar disorder can benefit. Specific Gestalt therapy interventions are demonstrated and discussed.

Background I began my career as a medical doctor in general practice where, from the start, I struggled with both the potential and the limitations of the medical model. In general practice, patients and doctors are more often than not confronted with multi-causal and complex sufferings. The medical model I had

Isabel Fredericson, Ph.D., served as Action Editor on this article. Daan van Baalen, M.D., has been involved in research as an assistant professor at the Erasmus Universiteit in Rotterdam (EUR), The Netherlands, specializing in the field of chronic diseases and Gestalt therapy. He is a founder of the Norwegian Gestalt Institute and has worked as a therapist, supervisor, and trainer since 1975. He is the principal of the Norwegian Gestalt College and a guest trainer in several European countries. He is a board member of the European Association for Psychotherapy and a former board member of the European Association for Gestalt Therapy.
2010 Gestalt Intl Study Center

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learned had not prepared me well enough for this confrontation. Although I was introduced to Gestalt therapy accidentally, I found it a model for dealing with the complexity I was experiencing in my practice. Since then I have been intrigued by the idea of a possible integration of Gestalt therapy and the medical model. A consequence of this interest was research that I did at Erasmus University in Rotterdam (EUR), the Netherlands, and later at Norsk Gestaltinstitutt (NGI) in oslo, Norway. This work resulted in a number of articles, one of which is entitled, Spontaneous Regression of Cancer: A Clinical and Psycho-Social Study (van Baalen and de Vries, 1987). The latter is a quantitative study among clinical proven mortally ill patients, who survived despite their diagnosis, and without medical treatment. The results of our study suggested that there might be significant differences between the psychological history of patients having a spontaneous regression of cancer and other cancer patients. In other papers, I put forward a Gestalt diagnostic system that could possibly support Gestalt therapists in their work and communication with medically oriented health workers (van Baalen, 1998, 2000). Bipolar disorder aroused my interest by accident as well. A client of mine, Anne, experienced a typical bipolar episode. She became psychotic, hyperactive, and sleepless when I was on holiday. She was hospitalized and medicated. After being in the hospital for a short time she was referred back to me. Consequently, I was confronted with a medical diagnosis while practicing as a Gestalt therapist. I recalled from my medical training that a medical diagnosis of bipolar disorder meant having a lifelong mental illness with manic-depressive episodes; the only treatment was lithium and/or anticonvulsive drugs. What was I to do? Continue with Gestalt therapy? And, if so, how? In an attempt to answer these questions, I turned to a review of recent literature on the subject, some of which follows below. Annes case will also be presented and discussed below, and some of my findings with regard to her case will be compared with the literature reviewed. Review of Literature A moving personal and poetic experience described by Kate Redfield Jamison (1995) demonstrates the drama of bipolar disorder:
Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and,

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not infrequently, suicide. . . . I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do. (p. 6)

What Is Bipolar Disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a persons mood, energy, and ability to function. In contrast to the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. Bipolar disorder causes dramatic mood swings from overly high and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression. Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one third have some residual symptoms. (National Institute of Mental Health, 2007, passim, emphasis mine)

The classic form of the illness, which involves recurrent episodes of mania and depression, is called Bipolar I Disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called Bipolar II Disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have Rapid-Cycling Bipolar Disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than men. People with bipolar disorder can lead healthy and productive lives when the illness is treated effectively. Without treatment, however, the natural course of bipolar disorder tends to worsen. over time, a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. But, in most cases, proper treatment can help reduce the frequency and severity of episodes and enable people with bipolar disorder to maintain a good quality of life (Miklowitz, D.J. 2008). Epidemiological studies emphasize the need to study this illness further:
two to four new cases occur per 100,000 people per year for

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bipolar affective disorders; the above means that about one in 200 people will suffer from a hypomanic episode at some time in their lives; peak age at first diagnosis of bipolar disorder is age 25-30, but many patients have affective episodes in adolescence or early adulthood; 15-20% of patients with the disorder commit suicide, acute depressive and mixed episodes being the periods of greatest danger. (Drug and Therapeutics Bulletin, 2005)

The study by Morgan et al. (2005) suggests that the quality-of-life of bipolar patients is compromised due to the disruptive impact of the illness. Their results also point to important gaps in health care that may be overcome by ameliorating the access to support services. What Correlations Can Be Found in the Disorder? Kiesepp et al. (2004) show in a nation wide twin study (USA) that bipolar disorder tends to run in families. There was high concordance of bipolar I disorder in a nationwide sample of twins. Wals et al. (2006) show that children of bipolar parents are at increased risk of developing mood disorders and Kessing (2006) shows that age is of some importance. High creativity and bipolar disorder seem to correlate in families, according to Simeonova et al. (2005). Prognoses According to Simon et al. (2006), a comprehensive treatment program pays off in bipolar mania; systematic care was associated with a significantly greater reduction in mean level of mania symptoms. Patients with clinically significant mood symptoms at baseline appeared to benefit the most. Treatment Medications known as mood stabilizers are usually prescribed to help control bipolar disorder. Examples are lithium and anticonvulsant drugs (National Institute of Mental Health, 2007, 2009). Garnham et al. (2007) state that psychoeducation or psychosocial interventions tend to enhance pharmacotherapy outcomes in bipolar disorder. Doctors are to apply a combination of pharmacological and psychoeducational treatment for the long-term benefit of these patients. Bernhard et al. (2006) describe the impact of cognitive-psychoeducational intervention on bipolar patients and their relatives. Reinares et al. (2006)

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come to a similar conclusion in a study about what really matters to bipolar patients caregivers. Fleck et al. (2005) describe treatment strategies that could target at minimizing the self-perceived stigma associated with taking psychiatric medication, and at alleviating the fears of becoming addicted. These can be effectuated in a number of ways: discussion of compliance with the patient; using rating scales for assessment; cognitive behavioral treatment and behavior modification techniques; teaching patients about the disease; and adaptation of medication. Fagiolini et al. (2004) justify long-term clinical support based on the high risk of suicide in bipolar disorder. According to Baethge et al. (2005), patients with bipolar disease also have a high risk of drug and alcohol abuse. Swann et al. (2004) advise intervention at an early stage in bipolar disease in order to limit the patients abuse of drugs or alcohol. Goldstein et al. (2006) recommend that bipolar patients abstain from drinking alcohol. Almost half of all bipolar patients suffer from alcoholism during their life. This is especially true of young people, according to Fleck et al. (2006) There is strong support for a combination of medical (i.e., drug) and psycho-social-educational treatment plans. Simon et al. (2006) conclude that such comprehensive treatment programs that include psychoeducational pay off in bipolar mania. Miklowitz et al. (2007) maintain that psychosocial interventions should be part of a treatment package that most patients with bipolar disorder receive. Even in the prestigious British Journal of Psychiatry, Scott et al. (2006) conclude that for stable, lower-risk populations early in their history of bipolar recurrences, cognitive behaviour should be considered as an adjunctive treatment. According to Miklowitz et al. (2003), examples of psychotherapies and/or psychoeducation in comprehensive programs are:
1. rodrome Detection (Perry et al., 1999): Teaching patients with P bipolar disorder to identify early symptoms of relapse and obtain treatment; 2. Psychoeducation (Colom et al., 2003): Group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission; 3. Cognitive Therapy (Lam et al., 2005): Relapse prevention; 4. Interpersonal/Social Rhythm (Frank et al., 1999); 5. Family-Focused Therapy (Miklowitz et al., 2003): Family-focused psychoeducation and pharmacotherapy.

Miklowitz et al. (2003) conclude in their study that intensive psychosocial

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treatment as an adjunct to pharmacotherapy is beneficial. Most studies cited not only emphasize looking and planning for signs of relapse but also include some means of looking at illness acceptance. Several place some emphasis on regular rhythms of sleep and activity. one emphasizes involving the family very directly. All five examples of psychotherapy and/or psychoeducation show solid evidence demonstrating their effectiveness. The Harvard program treatment contract (revised 2007; original 2003) is another example of psychoeducation not mentioned in the summary given by Miklowitz et al. out of two hundred persons one will suffer from this disorder, of which 15% will commit suicide. The disorder is seen as a potentially life-long disease, and medication alone does not prevent new episodes. Psychotherapy, i.e., cognitive therapy and psychoeducation for patient and caretaker, impact the long-term outcome of bipolar disease. Special stress, life events, alcohol consumption, and discussion of compliance are mentioned as complementary areas for psychotherapy besides medication. Gestalt therapy was not mentioned in the literature reviewed; nor did I find publications about bipolar disorder in the Gestalt literature. one of the biological findings of Thase et al. (2000) is significant. They have shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. This strikes me as significant, because bipolar disorder patients can easily be misunderstood and diagnosed as depressive (as I have experienced in my own clinical practice), leading to mistreatment with antidepressant medication. Striking to read was that less than one-third of patients treated with lithium achieved remission; the effectiveness of other treatments in this naturalistic sample was even lower (Garnham et al., 2007). When only onethird, or even fewer, achieve a remission with pharmacotherapy, and when psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder (Miklowitz et al., 2007), then psychotherapy is in fact indicated. My original questions what was I to do? continue with Gestalt therapy? and if so, how? become even more relevant after the above review of the literature. Based on all the references referring to the beneficial effects of psycho-social-educational treatment, including psychotherapy along with medication, I would like to reformulate my original questions into one: How can Gestalt therapy impact the treatment of bipolar disorder?

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Case Study At the start of therapy Anne was a divorced woman, living alone. She has a daughter born in a former relationship. She is educated as an artist and works as such in her own atelier and is rather successful. As a teenager (age 16) she had a sexual relationship with an art teacher, a relationship that confused her. She had been diagnosed with postnatal depression seven years before entering therapy. Her mother was probably suffering from mild depressions (my conclusion), and her brother was diagnosed with schizophrenia. She is a tall elegant, good-looking, charming woman. When she came into my office for the first time, I became aware of her charisma. Anne chose me as her therapist because of her interest in Buddhism. She knew that one of my former teachers in Gestalt therapy was known to be a practising Buddhist. She had been attending meditation courses for some years and had heard that Gestalt therapy has roots in Buddhism. Anne became my client five years ago, and at the start we saw each other once a week for an hour; later more or less frequently, depending on Annes life situation. Initially, she expressed two issues she wanted to work on: first, her interest in Buddhism and the Buddhist view on spiritual development; and secondly, a hope that the creative processes in her work as an artist could become less demanding. She described feelings at the onset of a new project as empty and dark: I will never make it; I am not good enough. She told me she would often sit for hours in despair in her atelier, without producing any result. (My conclusion: depressive episodes.) I experienced Anne as expecting a lot from me concerning Buddhism and art. Having had a general intellectual and philosophic education during my training in medicine and later as a psychotherapist, I had no particular skills in art or in Buddhism. I soon became aware of wanting to hide the fact that neither art nor Buddhism was my thing. I started to feel insufficient, unable to fulfill her expectations. Produce, be good were words coming up in me. From the beginning of our sessions, I remember her beautiful large, questioning eyes making me feel insufficient, not knowing what she wanted, not knowing what to do. Later in the session, her eyes would turn inward, become empty, making me feel lost, and then suddenly become dark and angry, as if accusing me of not being of any help. My experience of feeling inadequate, lost, and accused surprised me, since initially I was not aware of the parallelism between my experience and her description of her creative processes in the atelier. Whenever we made a new appointment, I particularly expected to not be good enough; I was pleasantly surprised when she even showed up. I carefully brought up this point in a session, whereupon she assured me that what we did was just fine which, of

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course, I was unable to believe. Gradually, however, our awareness increased and the figure of our work became: expectations, not being good enough, frustrations, and despair. Together, we slowly began to see parallels between the experience in the sessions and her creative process. Annes interest in Buddhism was another cause of her frustration. Values such as non-attachment, equanimity, and patience, which she practised during her meditation training, gave her periods of relaxation in the training hours. Nevertheless, upon coming home she experienced herself once more as very impatient and as losing her temper, especially with her daughter. She asked herself why her meditation did not help her to practise her values in her daily life. once more, produce and be good was the figure of our work. During her sessions with me she started physical training classes, where, after a year, she found her present partner. This was an important life event. But she was thrown into turmoil of both happiness and doubts. We practised classical work with the empty chair. Dialogues with her new lover projected into the empty chair diminished her turmoil. For example, she said: I am not worth being loved. In the empty chair she answered as him: I love you, you are intriguing. As herself, she then said: Intriguing? No I am difficult to live with! After six months in therapy with me, she had a manic episode directly after a Zen Buddhist retreat. She underwent vivid awareness and exquisite sense experiences, visually as well as audibly. She described lying on her back one evening, looking at the clear night sky, and feeling being part of the universe and knowing. on her way back from the retreat, she walked through a forest and saw and heard things she had never seen or heard before. She felt excited and happy. At the same time, she could not sleep and was frustrated at not being able to share her experience with others in words, especially not with her partner. This had happened in the summer, while I was on holiday. on the instigation of her partner, she went to see a colleague, a Gestalt therapist, who viewed her as psychotic, with hallucinations, delusions, gross behavioural disturbances, and exhausted. She was hospitalized and put on medication (an anticonvulsive drug). After ten days she became an outpatient, regularly seen by a psychiatrist, who regulated her medication. She then continued seeing me, along with the psychiatrist. The contract between her, the psychiatrist, and me was that I was not to interfere with the medication. I would just continue our sessions. Her diagnosis was Bipolar Disorder I, with a psychotic episode. Her post-natal depression could have been a misdiagnosed depressive episode of her bipolar disorder (my conclusion). Because of the medication, her weight increased after her manic episode, and her moods were less expressive than I was used to. The doom of her diag-

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nosis loomed over our relationship, as well as the idea of life-long medication, the risk of another episode and, on the advice of the psychiatrist, the banning of meditation retreats. As a medical doctor trained in psychiatry, I forgot to think as a Gestalt therapist and was caught in the medical model; I saw no cure, only life long medication for a chronic disease and no good reason for continuing Gestalt therapy. Her partner, informed by the psychiatrist, understandably insisted on her continuing the medication. Anne thought that his fear of another manic episode was the cause of their emotional discussions; she could not see his care for her in his insistence. Her work as an artist became difficult too; she felt depressed and lonely in her atelier and could not stand being there. What had been a relatively good place for her now brought agony. The doom, as I called it, which loomed over our sessions and over her private and professional life, made me feel that we had come to a deadlock. once more, I felt inadequate, this time not because of the challenge the client had been, but because of the limitations of the medical model, where I did not see possibilities for recovery. Again, I did not see the possible parallelism between our relationship and her diagnosis. I did not see that we were depressed after a manic episode and emotionally flattened by medication. Awareness of this situation came gradually: first how my body felt bent down, hanging in my chair, then how my breathing became superficial, and finally how an hour felt long. As I became aware, I noticed that Annes eyes were looking down. Her breathing was flat, and her body posture was collapsed. I did not dare mention this, nor ask her to experiment with her body posture and breathing, for I was afraid that she would only hear criticism. However, my awareness of emotional flatness kept growing and became figural. During a session I experimented with myself, trying flat breathing even more, consciously and carefully exaggerating my body position. Parallel with this experiment, and to my pleasant surprise, Anne said: I feel calmer today in this session. The next session, as I saw Anne walking into my office, I noticed something different in her body and facial expression; as her awareness went up, my mood went up as well. I stated: Anne, I am aware that your shoulders are up, your eyebrows are up, and you breath is high in your chest, and I feel loosening up and enthusiastic. After some time, she answered: Yes, I feel sort of up, and I am afraid I will become manic again. I dared to ask her to experiment and said: Can you experiment with your upness, by searching for up-and-downness in your breath, your shoulders, and your eyebrows? After experimenting on her own for a while Anne answered: I am not sure. Not being satisfied with her answer, I invited her to find an exercise with me where she could experiment with sinking down; she called it yielding into the floor. She lay down, letting herself sink into the floor. She said: It feels

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as if Im lying on a beach, curling in the sand. Then she said: Yes, I can do this, and I am aware that I can regulate myself more to go down; I can go down when Im up. We experimented further with what could bring her down. Anne was interested in these exercises and went on experimenting at home. The next session she reported that she could keep herself down to a certain degree when she felt too high up. She lost a little of her initial fear of another manic episode. A few weeks later though Anne said: Now I am down, and afraid of becoming depressed. I took some time for my awareness to build up and saw that Anne was dressed only in black: black skirt, black sweater, black shoes and stockings. Even her facial expression was dark, as she was hiding her face behind her long, dark hair. Remembering that Anne in fact often wore black, I asked her if we could experiment with colours. I gave her a colourful shawl and waited to see what happened. Anne draped the shawl around her shoulders and walked around a little feeling the shawl, then started to move slowly and elegantly through the office. After a while she reported: Interesting, I move a little from down to up. She experimented more, doing some dance movements, and said: I can regulate my mood with this as well. She continued: often in the morning when I am down, I dont have the energy for clothes and just put on what is there. I answered: Yes, Im aware that you often wear black, however sometimes with a colourful streak. Could you also experiment with what makes you go up, when you are down? The next session she reported: Yes I can, though I really have to pull myself together to do so, but once I do, my mood indeed goes up. Colourful dressing helps, so does physical exercise such as walking. When I want to, I can regulate my down mood to go up. The following period Anne and I experimented, reported, and discussed our findings with up and down. Anne carefully started to use make-up, which she had never used before. We then experimented with going even further down when she felt down, the way I had done earlier with myself. She reported: Strange, going down on purpose makes me less afraid of going down; it gives me a feeling of mastering my moods. Inspired by this effect, we then also experimented with going even more up when she felt up. Anne enthusiastically reported the same effect. She was at the same time still medicated and under her psychiatrists supervision. Together they decided to reduce gradually and eventually stop the medication. only during a period when she once more became sleepless did she use the same anticonvulsive drug for a week to restore her sleep rhythm (as suggested by the psychiatrist). Anne and I continued working together, and other issues came up. one remarkable episode worth mentioning was when Anne invited me to see some of her artwork in a park close to my office. Remarkable, since Anne

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had only once shown me a little piece of her work, probably as a test to see how I would react. Remarkable also, because I had never asked her to show me anything, certainly for fear of being caught with her in the figure produce and be good, and afraid of not being able to comment on her work without her feeling critiqued. We went for a walk together to visit her work in the park; she appeared to enjoy both our walk (which I enjoyed as well) and my pleasant surprise when I saw her work. We both seemed able to endure the tension of intimacy created by the exposure of her artwork and the walk, without excessively going up or down or being caught in produce and be good. Anne also started to experiment with co-artwork, inviting individuals to her atelier to create an artpiece together. She received a grant and a commission for a co-product with a colleague. Anne and her colleague worked in a prestigious atelier offered by the local community, and there she did not suffer in the way she had in her own atelier: she did not feel alone or empty or dark. Maybe we will make it; We are good enough. She experienced their meetings as meaningful. The relationship between Anne and her partner became strained because of different opinions about Annes medication. Anne wanted to stop; her partner wanted her to continue. He obviously felt insecure after Annes last manic episode. Whenever the couple had a conflict, he used her illness to explain their disagreement and ensuing strong emotions; he saw it as a reason for continuing the medication. Whether he was right or wrong, his perspective certainly upset Anne. We dealt with the issue by using a classical projection exercise, the empty chair. By being him in the empty chair, she found that her partner was afraid of new episodes and wanted to protect her. This insight calmed her down, and their relationship slightly improved. Anne and I discussed the option of couple therapy, done by a colleague. We gave up the discussion when her partner refused, saying: I am not ill. I did meet her partner, however, at an exhibition of her work. Recently, Anne and I made an appointment to visit her own atelier. She still had problems working there. Her atelier was cold, and I was overwhelmed by the disorder everywhere she could work. I had come with a feeling of expectation, which immediately disappeared after seeing boxes and cupboards full of stuff, tables with large heaps of materials. I told her: I am not surprised that you cant work here. She was surprised and relieved that I as a visitor immediately understood that she could not work there in its present state. She told me that she had tried several times to clear away the mess and create a sort of order, never succeeding. I suggested that she have a dialogue with the room, where she could also answer as the room. Room: I am cold and do not want to be filled up with more than I already have here; leave me alone.

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Anne cried and answered: Im so sorry to have put so much into you; I have tried to clean you up. The room answered: You have tried so often, you wont make it alone, you need movers to do the job. After this dialogue, Anne decided to ask friends to help her move stuff out of her atelier. Three months later, we decided to see each other less frequently. Anne felt that she could have more control over her moods, and her artistic work did not upset her as before. She said, I am not as much a victim of my moods anymore. I know when I am up or down in different situations, and I can deal with these situations better than before. We see each other now and then, based more on my interest in bipolar disorder than on her need for therapy. Discussion How Can Gestalt Therapy Impact the Treatment of Bipolar Disorder? First, I want to discuss the work in the beginning, when my experience became so similar to what Anne was experiencing: I will never make it, I am not good enough. I started to feel insufficient, unable to fulfill her expectations; my feelings were similar to those Anne had expressed. This an example of what I think Wollants (2007) meant about having deep immersion in the clients experience: comprehending the clients behaviour client by perceiving it as she does (p. 80, emphasis in original). I experimented with these feelings, consciously trying out my flat breathing even more and carefully exaggerating my body position. By so doing, I influenced the Anne-Daan situation. Anne noticed, saying: I feel calmer today in this session. Wollants continues, stating: Awareness can be defined as the on-going process by which the body [i.e., my body] implicitly senses the present situation as a whole, as yet undifferentiated from its separate parts (pp. 86-87). I experienced an immediate and implicit bodily sense of the Anne-Daan situation. I influenced its progression by exaggerating my feelings and body position, immersing myself in the ongoing experience, and being aware of and becoming a part of it while at the same time keeping my distance from it. Both heightening awareness and feeling part of the situation are typical of Gestalt therapy and open up possibilities beyond diagnosis in the medical sense. Secondly, I want to address experimenting as typical of Gestalt therapy. Perls et al. (1951) define experiment as: a trial or special observation made to confirm or disprove something doubtful, especial under conditions determined by the experimenter; an act or operation undertaken in order to discover one unknown principle or effect, or to test, establish or illustrate some suggested unknown truth, practical test, proof (p. xii). Zinker (1977) elaborated upon these points and came up with the structured Gestalt experiment, which has at least seven distinguishable steps (pp. 123-155).

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Examples of experiments in my work with Anne were two-chair work, experimenting with being up and down, and visiting her atelier. Simultaneously, the development of the Anne-Daan relationship was an experiment in itself. In the beginning of the therapy when I experienced being inadequate, lost, and accused, I experimented with my own experience. Moods and affects are not something a person has; they come out of a multi-person system, as Wheeler (1991, 1996, 1998) indicates. My moods were not only mine but also Annes. Exaggerating my mood had an effect on her; I feel calmer today in this session, she said. Experimenting with up or down and obtaining control over too much of either pole helped Anne lose somewhat her fear of a new manic-depressive episode. She also managed to regulate better her emotional state and felt more capable in the event of new episodes. Typical of Gestalt therapy is staying with what is, as Yontef (2005) explains: The goal of a phenomenological exploration is awareness, the exploration works to reduce the effects of bias through repeated observation and inquiry. We not only experimented with what is but also exaggerated it, as discussed by Korb et al. (1989, p. 103), experimenting with going further down and further up when she felt either up or down. Anne could also feel the effects of her experiments with awareness. Earlier, I had been the one with awareness of our situation. Later, she experienced it as well. Her tendency to become the victim of her moods diminished while being with someone else. Exploration works systematically to reduce the effects of bias through repeated observations and inquiry (Yontef, 2005 ). The bias was her fear of ups and downs. According to Melnick et al., (2005), An experiment can also be conceived as a teaching method that creates an experience in which a client may learn something as part of their growth. The above-mentioned experimenting with up and down is also typical of Gestalt therapy, as E. Polster and M. Polster (1973) point out: Whenever an individual recognizes one aspect of himself, the presence of its antithesis, or polar quality, is implicit (p.61). In this case, down can be seen as thesis, up as antithesis, and synthesis as managing to regulate her emotional state and make her more capable in case of new episodes. Relational Work Bipolar disorder patients have been seen as manipulative, according to Zwanikken et al. (1990, p. 204). Manic-depressive behaviour functions in a relational system. By pleasing and denigrating, the manic-depressive patient manipulates the experience of others; they test boundaries and try to change them. Clearly, Anne and I influenced each other, which is essential for therapy to occur. But I would not call that manipulation or testing boundaries, as does Zwanikken. However, Annes partners refusal to go to couples therapy with

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her can be seen as an attempt at manipulation. Dialogues with him projected onto an empty chair diminished her turmoil around happiness and her doubts about the relationship. Staemmler (1995), however, describes a grading process of the dialogue, in which he would have Anne first imagine her partner and then use the empty chair. our Walk to Visit Her Work in the Park According to oNeill (2008), the insight that the whole determines the parts (Perls, Hefferline, & Goodman, 1951.p. xi). . . encourages us as therapists to move beyond the individual, reductionist nature of current psychology [and medicine] that sees only the separate nature of the therapist and client contact. To move beyond this point is to develop an awareness of the self of the therapist/client dyad [situation] (p. 21). The whole of Anne-Daan in the park and the art structure determined the parts, Anne, Daan, and the art structure. The whole determined my experience of pleasant surprise which I became aware of, replacing the pat phrase, produce and be good. We, or at least I, moved beyond the individual psychology of Anne as artist and her insecurity about being not good enough, and mine of not being good enough. We let ourselves consciously be determined by the whole and expressed what we experienced. The figure formations produced awareness of emotional flatness and ups and downs. Knowing that I was part of the situation made it possible to raise awareness of the situation; it was a working example of Beissers (1970) paradoxical theory of change. To exaggerate the situation and to be fully where we were, instead of trying make things change, eventually created change. It is possible that, as result of our relational work, Anne started to experiment with co-artwork. She enjoyed her craftsmanship in relation to her colleague without being self-critical, as she easily had become when working alone on a commission. Clearly, (re) establishing relationships with important relatives and colleagues, and not solely with her close family, seemed to have a stabilizing effect. Being an Artist The case of Anne seems to illustrate the findings of Simeonova et al. (2005), which suggest that there may be a correlation between high creativity and bipolar disorder. Drugs, Alcohol and nutrition I do not know whether drug abuse is involved in this case. Nevertheless, the findings of Goldstein et al. (2006), who point out that almost half of all bipolar patients suffer from alcoholism, are a reminder for me to consider

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that possibility. For three years (at the time of writing this paper), Anne has had regular therapy sessions but no disorder episodes, and she has not taken medication for two years. She remains a passionate woman; her passion, if much appreciated by me, is not easy to live with neither for her, nor for her intimates, nor for me. Conclusion Gestalt therapy seems to be a modality of psychotherapy from which some clients with a bipolar disorder can benefit. In this case, we practised being in middle mode polarity work and phenomenological exploration, and we experimented with the empty chair (projection work). All the time, our approach was relational. We also worked on the clients relation to her lover, her colleagues and her atelier. Is Anne cured in the medical sense? If her diagnosis of Bipolar I was correct, then the medical theory of this disorder must be reviewed, and Gestalt therapy could be the first choice of treatment for some patients. However, we would need more qualitative research focusing on bipolar disorder and Gestalt therapy in order to be able to answer this question. An important aspect here is the cost-effectiveness of Gestalt therapy interventions. Intensive treatment such as Gestalt therapy seems to be effective in hastening recovery from episodes, maintaining stability, and delaying recurrences, but it is costly. Treatment-associated costs must be carefully balanced against the potential gains for patients when it comes to functioning and quality of life, and to possible reductions in rates of hospitalization or polypharmacy.
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