Existential despair and bipolar disorder: the therapeutic alliance as a mood stabilizer.

Talking with a manic patient is not easy, but it is also not hopeless. Manic patients are hopeful, ever hopeful, and indeed often too hopeful. But their hopes and dreams, however big, are usually brief and soon damaged by the realities of life. Ultimately, most patients with bipolar disorder become chronically depressed, denied of their hopes by others. Appropriate medication treatment is necessary, but not sufficient, for many such persons. The job of the clinician is twofold initially: first, to seek to existentially be with manic patients and then, to counterprojectively give perspective to those patients about their manic worldview, without completely denying it. This twofold approach then can lead to a healthy therapeutic alliance, which itself has a mood-stabilizing effect. Along with mood-stabilizing medications, this alliance can then lead patients toward full recovery. Put more simply, clinicians need to talk to manic patients about their hopes, to explore the limits of their grandiosity without judging it, to seek out their strengths and to validate them. They also need to go where the patients are, to encounter patients and find the person beneath the illness, to provide a strong relationship, an alliance that cannot be shaken, to conflict with the patient sometimes and not at other times. It is a tall order, and one not infrequently avoided. Yet the times seem to call for a return to actually talking with manic patients, and maybe curing them with such talk. Or perhaps that is grandiose.