You could try to work with him in order to find an objective to work on in his life. First a smaller objective, then a bigger one, so he can build his life mission. I don't know about his profession, but maybe you could try some vocational counseling/training? Then you could work on confidence building as he has a direction/mission/objective to use this confidence.

I also suggest a cognitive approach in his extra-depression period, trying to find with him his cognitive distortions regrading life meaning, but also regarding his social utility. Homework on these directions (cognitive or CBT model) could be also used in order to break his circularity through practice.

In addition you could suggest him to try some physical activity (fitness, maybe a game like football) on a regular basis, knowing that the physical activity helps to the balance of neurotransmitters and hormones in the body.

Good luck!

Many thanks Christian. I am solution-focused and CBT methods are compatible with SF. I had thought of your idea - small incremental objectives, one at a time - but have not implemented it systematically enough. The main challenge seems to be to work through (or break through) his 'delusion' that he can't start anything if he is not sure in advance that this activity will lead him to his mission in life (probably a rationalization for lack of self-confidence). I suggested that he start something extremely simple and put the life mission on hold, telling him that it would eventually become apparent. I suspect that his lack of confidence that he could undertake any adult vocational task without quickly exhausting his limited energy reserves (depleted by cycling) plays a major role in preventing him from starting. It's a question of making him more self-confident. Exercise is a good idea and he is a nature lover, which provides an opportunity for healing and getting rid of depressive ideas.

I have heard that chronic cients require more creatrivity of a therapist than acute ones since they have failed so many times that they despair of ever succeeding and tend to look passively to the therapist for new ideas rather than generate them themselves. Is that your experience?

Further ideas are always welcome.

Although I am not a specialist of the field, I am most curious to know your opinion upon a certain approach, that one might as well define as philosophical. It was also formulated this way by a comedian: 'the purpose of life is the life, the end of the life is the end'. To make it simple, the most purposeful way of living would be being able to enjoy yourself and what is around you at any moment. Education to wellbeing, regardless of the environment whose subject of conditioning one has happened to be. Getting used to this attitude, at a certain point one becomes capable of simply doing freely and gladly whatever chooses to, being in the same time dedicated and passionate to it and detached and playful. Do you think this zen-like approach is appropriated? Could and should it be taught somehow? I personaly wish someone taught it to me earlier. Please do criticize :)

Yes, Jeff, you're right: the chronic clients require more creativity. That's why I try to imagine different solutions depending on the client's personality, including his life experience.

Another idea: what about suggesting to the client to take care of something, maybe a pet? I tried this few times and it worked in depression and even in bipolar disorder. The client's attention will be directed outside, to the pet and he won't focus too much to his internal state, his thoughts and associated feelings. Moreover he will have an objective. It will give you a break to enter with some restructuring techniques while his resistance will be weaker because of the distracted attention.

Probably you did that, but what about his family and/or friends (if it is the case)? They support him? Maybe you could work with them too in order to have a "support-team" around the client...

Jane, yes, your idea could work on a healthy person. Unfortunately probably this is not the case. If the client suffer from bipolar disorder with suicidal tendencies, it is very difficult to help him to become aware of the life as a purpose itself. Especially in the case of rumination and sterile circularity.

Yet I think your proposal has a good point mainly for a preventive strategy.

Try to work together on a daily routine in short (15 minute) chunks: 15 min of reading; 15 minutes of house cleaning; 15 minutes of eating; 15 min of exercise; 15 min of phoning a friend; 15 min of piano playing; 15 min of TV and so on - the routine can be changed but, until it's changed, he has to stick to it. A rhythm to the day is important.

Cristian & Mary (a fellow Candian - SJ, NB),

I can not thank you enough. I have flirted with the idea of a structured routine but you have provided the devil's detail Mary, which I shall forthwith suggest to him. Responsibility is a good idea too and there must be something (new) for which he can take responsiblity. My working hypothesis is still that if I can break the circularity ('I know I have to find an occupation but I can't start that because I don't know what my life mission is') through building his self-confidence by having him execute small tasks successfully (DESPITE HIS DEPLETYED ENERGY), if I can do that, he will go on to greater things (greater for him).

Do you think if, for example, if he paced 3 km up and down his hall (or in nature or on the street) when depressive feelings started to announce themselves, he could avoid plummeting? Also, I have had him change small things, like his key chain, and pronounce the ritual formula, 'This is changed and I have changed it' - a kind of self-hypnotic suggestion, which might lead to bigger changes. What about EMDR?

Psychopharmacological therapies like Lithium might help as it is known to reduce suicidal thoughts/attempts independent of the mood improvement. In addition, mindfulness and alternative medicine approaches can help as well. With patients like these, finding a job where he or she could volunteer might help.

Hope my opinion can help. I have bipolar and treat it as my travel companion (I think you could see my story here). To encourage a peer, the most effective and constructive means are focusing on his/her strengths. I think a "meaningful" life means we live fruitful and happy. We can build our confidence and find our value by utilizing our strengths. I can't describe how depressed and helpless when I faced my mother's sickness together with the financial crisis. However, after getting through all these life challenges (I think all would have), we could learn the lesson and grow up. I witness there're many positive transformation stories by my peers here while assisting a peer support work project. Hope my experience helps.

Dr. Charles Reynolds in Pittsburgh is a wonderful psychiatrist who has experience and personal interest in this matter. you may want to check his work and reach out to him and his colleagues.

With patients with mood disorders, it is important to recognize sleep issues as a risk factor for suicidal attempts. There is increasing literature suggesting insomnia as a risk factor for emergence of a mood episode and for suicide.

I would strongly recommend "Treating Bipolar Disorder: A clinician's guide to interpersonal and social rhythm therapy" by Ellen Frank. Will help provide some of the structure to create a 'meaningful life'.

Sometimes dialectical behavior therapy can work wonders in patients with chronic suicidal issues. It is helpful in regulating emotions.

What is "optimally medicated" ? Has he been put on lithium ?

You mentioned responsibility, maybe a dog would help him get a routine. Joining an organization that require effort.historical or environmental group may be helpful. In Pittsburgh we have Venture outdoor group that one could become engrossed in while doing something either hiking, biking, canoeing, birding whatever his passion. There are different people to socialize.

I suffer from this disease and find that forcing myself to do things that I normally enjoy (exercise in my case, studying things of interest---I am trained as a scientist. Listening to or playing and creating music or art. Occupying my time with purpose) and even doing things that I have momentum trouble with like cleaning.  The key is repetitiveness to generate serotonin and to feel the satisfaction of accomplishment.  As others have stated having a routine is important (repetitive tasks in order).  An idle mind drifts to negative thoughts and spirals down to darkness.

Hi Margaret,

You have done well to remind me of the importance and curative power of action, even if intially it is without enthousiasm. I think that applies to depressive people too. It takes the kind of foresight you have developed to implement it.

Thank-you Jeff.  I have struggled with this all of my life that I can remember, so at least the last fifty years of it, and I have a great support system from whom I have learned much about ritual and its value to self .

Good Luck!

Yes, and as you also said, savoring the satisfaction of one's accomplishments is important. Reiminds me of progress-focused brief therapy (Coert Visser, the Netheralnds). Every heard of it?

Greetings Dr. Jeff. Bipolar depression is a very serious issue considering suicide. The patient's age and if he has attempted suicide previously  are two of the most important  factors considering assessing acute suicide risk, and they're critical at the moment of decide whether admit or discharge to outpatient services. In my experience I always include  the family's patient co-participation in the treatment process, since social support is one of the most powerful suicide protector factor. Furthermore, family's commitment and co-participation in the therapeutical process could be quite beneficial to the patient, of course when it is possible. Thank you

Jeff,

No, but as I stated, I am a scientist.  I am seeing a counselor and I kind of do the description above "progress-focused, brief therapy" as in moving forward with goals in mind while confronting past trauma, and since I have done intensive therapy at times over the last 30 years, at least, I now go only as needed or as when convenient for myself and my therapist.  My husband is very understanding when I have a bad day.  He understands me.  We try to minimize stress.