Existential Despair and Bipolar Disorder: The Therapeutic Alliance as a Mood Stabilizer

The major clinical morbidity of bipolar disorder is chronic depression. Yet this depression, which is resistant to our best pharmacological treatments, may represent something else. We suggest it may involve existential despair, as a consequence of the losses incurred by this illness, as well as the result of our treatment approaches. Such chronic depressive symptoms may be seen as existential, rather than biological, consequences of the failed hopes of mania. Contrary to traditional psychoanalytic views, we suggest that psychotherapeutic work can be done with manic patients through existential and interpersonal methods to develop a strong therapeutic alliance with the manic patient. We draw on the existential work of Karl Jaspers and the counter projective methods of Harry Stack Sullivan to lay out these approaches. An existentially oriented therapeutic alliance can be seen as a mood-stabilizing treatment in patients with bipolar disorder, which augments the benefits of mood stabilizing medications.