Playing theManic GameInterpersonal Maneuvers of theAcutely Manic PatientDavid S. Janowsky, MD; Melitta Leff, MSS;and Richard S. Epstein, MD, Bethesda, Md

The acutely manic patient, with his abil-ity to create interpersonal havoc with fami-ly and therapist alike, can be one of themost challenging, taxing, and difficult ofpatients. It is our purpose to describe thecharacter structure of the acutely manicpatient, to define his patterns of interactionand communication, and to emphasize theimpact these qualities have upon thosearound him.

While previous studies have described theintrapsychic dynamics, pathogenesis, andcharacter structure of patients sufferingfrom manic-depressive psychoses,1-5 thefashion with which the acutely manic pa-tient deals with others, and the impact thishas on them, has received sparse attention.

Dooley1 described patients with frequentmanic attacks as being headstrong, self-sufficient, know-it-all types of people whowill get the upper hand of the analyst.Gibson2 noted that while manic-depressiveindividuals appear remarkably insensitiveto interpersonal subtleties on a consciouslevel, they can be extraordinarily perceptiveon a subconscious or unconscious one. Hefelt that these patients are proficient inevoking and utilizing the feelings of others,especially guilt feelings, and that they are

extraordinarily adroit at handling and ma¬

nipulating other people. Four characteris¬tics Gibson stressed regarding the manic-de-

pressive character structure included: (1)difficulty in dealing with feelings of envyand competition; (2) strong dependencydrives; (3) the frequent use of denial as a

defense; and (4) a value system based onsocial conventionality.

Fromm-Reichmann3 described manic-de¬pressive patients as being more clever andsuccessful in finding vulnerable spots thanare the people who are targets of theirhostility. She stressed their ability to be¬come immediately acquainted with anyonethey meet, establishing quick, superficial,contacts which are not accompanied by a

genuine interest.Cohen et al4 reviewed the psychoanalytic

literature concerning manic-depressive pa¬tients. They summarized Abraham's ideason the characterological features of manic-depressive patients as including impatience,envy, increased egocentricity, and intenseambivalence. Cohen et al further describedhypomanic patients as being conventional-minded, independent, and possessing a cer¬

tain social facility. They felt that a hypo-manic's appearance of closeness is providedby his liveliness, talkativeness, wittiness,and social aggressiveness. They emphasizedthat, on close observation, the hypomaniccan be seen to be carrying out a relativelystereotyped social performance, taking littleaccount of the other person's traits andcharacteristics. They also noted that maniesand depressives tend to have only one or a

very few close, dependent relationships.Cohen and her collaborators found that theconcept of reciprocity is missing in manicsand that they utilize others as they wouldpossessions or pieces of property. The ma¬nic seemingly does not perceive others asfull-sized humans, but rather as entitieswho are now good, now bad. Manics aredescribed as good salesmen, who utilize hy-permorality and conventionality as tools forbargaining. Cohen et al noted that aggres¬siveness in manics is motivated by need,dependency, and emptiness, rather than byhostility.

MethodologyThis paper is derived from our collective

clinical experience in treating a total of 15acutely manic patients in a hospital setting.Patients included were judged to be moderately

Submitted for publication Aug 4, 1969.From the section on Psychiatry, Laboratory of

Clinical Science, National Institute of MentalHealth, Bethesda, Md. Dr. Janowsky is currentlywith Harbor General Hospital, Torrance, Calif.

Reprint requests to Harbor General Hospital,1000 W Carson, Torrance, Calif 90509 (Dr. Janow-sky).

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or highly manic during part of their hospitali¬zation, as evaluated by the Bunney-Hamburgscale.6 Each patient was diagnosed as having a

manic-depressive psychosis, manic phase, bytwo or more psychiatrists. All patients were

hospitalized on a research unit designed for thestudy and treatment of affective disorders. Thepatients showed symptomatology includingflight of ideas, insomnia, hyperactivity, grandi¬osity, strong denial of illness, high energy level,intense irritability, liability of affect, manipula-tiveness, logorrhea, and assaultive behavior.Many required use of a seclusion room formanagement of uncontrollable activity.

The interactional styles to be described, aswell as their impact on psychiatric personneland family members, were evaluated in variousways. We listened to tape recordings of individ¬ual and group therapy sessions, reviewed physi¬cians' and social-work treatment notes, andanalyzed nurses' behavioral descriptions andratings. These notes, ratings, and recordingswere collected according to predeterminedstandards, not connected with this study. Inaddition, patients were directly observed andencountered in individual, group, and milieutherapy situations and in family-therapy ses¬sions. The observations noted were thus dis¬tilled from personal experiences, rather thanderived from a theoretical framework.

Observations

Possibly, no other psychiatric syndromeis characterized by as many disquieting andirritating qualities as that of the manicphase of a manic-depressive psychosis.These characteristics seem specific to theacute attack, and are less prominent duringnormothymic, hypomanic, or depressedphases of the psychosis.

The acutely manic patient is often able toalienate himself from family, friends, andtherapists alike. This knack is based on thefacile use of maneuvers which place individ¬uals relating to the manic in positions ofembarrassment, decreased self-esteem, andanxious self-doubt. Those dealing with themanic patient frequently find themselves onthe defensive, attempting to justify theiractions and motivations. Commonly, theyfeel "outsmarted" and "outmaneuvered."They may "know" that their judgment andactions are appropriate, yet be out-arguedand manipulated into positions which theyconsider unacceptable. Ultimately, those

close to a manie may find themselves with¬drawing in anger and rage.

The ease with which the manic patientinduces discomfort in those around him isin part based on the following five types ofactivity which were noted in the patientsobserved.

Type 1.—Manipulation of the self-esteemof others: sensitivity to issues of self-esteemin others, with the increasing or lowering ofanothers' self-esteem as a way of exertinginterpersonal leverage.

Type 2.—Perceptiveness to vulnerabilityand conflict: the ability to sense, reveal, andexploit areas of covert sensitivity in others.

Type 3.—Projection of responsibility: theability to shift responsibility in such a waythat others become responsible for the ma-

nic's actions.Type 4.—Progressive limit testing: the

phenomenon whereby the manic extends thelimits imposed on him, "uping the ante."

Type 5.—Alienating family members: theprocess by which the manic distances him¬self from his family.

These are not the only behavioral modesused by the manic patient; and patients inother diagnostic categories also employsome of these maneuvers. Yet, the overallpresence of these characteristics in the pa¬tients studied seems to be the hallmark oftheir interpersonal activity.

Manipulation of the Self-esteem of Others

The manic individual, with extroverteddrive, is able to establish rapid, superficialliaisons with those around him. Initially, beseems friendly, bright, cheerful, resourceful,and entertaining. He is talented in sensingwhat form of attention or flattery appeals toothers. Such flattery is usually presented inways which seem quite sincere, probablybecause the patient, at least temporarily,believes that what he is saying is true.

Those interacting with the manic are usu¬

ally intrigued by his manner and may de¬velop fantasies of benefiting through him, as

well as of protecting or rescuing him. Situa¬tions wherein the manic patient increasesthe self-esteem of others by appealing totheir sense of self-importance are illustratedby the following examples.

One manic ended an hour with his new

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therapist with the statement, "I have never hadsuch a wonderful physician. I think you reallycan help me."

Another manic patient told the social workerthat he had always related better to women

than to men. He emphasized that this was

particularly true in the current hospital setting,since the doctors were young and the socialworker was obviously a therapist of great expe¬rience.

A manic's proposals are often sufficientlyreality-based as to invite involvement byothers. Because their ideas seem super¬ficially logical, manics may stimulate rescuefantasies and appeal to one's narcissism.Others, be they therapist, family, or friends,get reenforcement from the patient in feel¬ing that they represent someone who "cantalk sense" or get the patient to listen.

Once an individual is invested in main¬taining this new-found source of self-esteem(and this is difficult to avoid), he becomes a

party to the manic's interactions, since henow has a narcissistic investment in main¬taining his source of gratification. Thus, themanic's appeal is a seductive one, carryingthe message that another is unique, useful,powerful, and needed. What is temporarilyoverlooked is the fact that the manic pa¬tient may reverse his stance, taking away as

well as giving, and making another feeldemeaned and degraded. The relationship ismade open for exploitation by the patient,who titrates esteem offered against demandsmet. This "giving" and "taking" is illustrat¬ed in the following example.

In psychotherapy, a manic patient initiallyseemed inordinately insightful and introspec¬tive, eagerly complying with cues offered by hisnew therapist. Later, as he became disillusionedwith his physician, he utilized progressivelymore denial in the psychotherapeutic sessions.The therapist felt increasingly impotent, and,with frustration, described the patient as "shal¬low, willful, and uncooperative," rather thanpsychologically incapable of introspection.

Smith7 has discussed the manner inwhich manic-depressive patients use con¬

ventionality in their communications. Ininteractions with others, the manic individ¬ual touches on needs to conform to socialrules and to a pedestrian form of common-sense logic. Manics make statements whichare often judgmental, critical, and moralis¬tic. Their impact is to awaken, in others,uncertainties and conflicts about being

morally "good" people. Thus, by appealingto the childish, rigid conscience of another,conflicts concerning being good, bad, right,or wrong may be awakened. An individual,encountering a manic, often finds himselfexperiencing feelings centering around ear¬

lier relationships with stern or critical au¬

thority figures. Thus, the manic patienteffectively appeals to one's need to main¬tain a positive conventional self-image.

Perceptiveness to Vulnerabilityand Conflict

Intimately related to the manic's abilityto appeal to the self-esteem systems ofothers is his extraordinary perceptiveness.In interpersonal encounters, the manic pos¬sesses a highly refined talent for sensing anindividual's vulnerability or a group's areaof conflict, and exploiting this in a manipu¬lative fashion. This sensitivity may be uti¬lized in dealing directly with a given indi¬vidual or in focusing on areas of conflictbetween others. In either case, the manicpatient is able to make covert conflictsovert, causing the person or group withwhom he is dealing to feel discomfort.

When placing an individual with whomhe is dealing on the defensive, the manicutilizes directly transmitted informationand unconscious cues to rapidly formulate acaricaturized version of the person in ques¬tion. Although this version may not be ac¬

curate in presenting a balanced picture, thecharacteristics stressed are usually presentin disguised, muted, or defended form.Herein lies the manic's ability to upsetthose with whom he deals. What he sayscannot be dismissed as untrue or unreal, forthe areas attacked truly do exist and, in¬deed, are areas of vulnerability. In relatingto an individual, the manic may make co¬

vert or unconscious vulnerabilities overt, or,alternatively, may bring into direct consid¬eration, issues which are well known buthave been suppressed. Problems related tosexuality, idiosyncratic behavior, preju¬dices, self-image, feelings of inferiority, ag¬gressiveness, ethnicity, and self-esteem are

commonly exposed.The following sequence is typical. The

manic may tell an individual or his asso¬

ciates about characteristics he finds undesir¬able. Usually, there is an initial feeling that

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one has been maligned and insulted andthere is an immediate attempt to deny themanic's observations. Seldom is the issue ofhow the manic came to his conclusions or

the reality of the allegations considered.Those under attack often feel "found out,"revealed, exposed, and demeaned.

We feel that such offensive action by themanic throws those with whom he relatesoff guard. They quickly assume the "onedown" role, becoming defensive and angry.Their therapeutic effectiveness diminishesmarkedly, since they are likely to be non-

objective and predominantly concernedabout their own self-esteem.

The following examples illustrate manicattacks on vulnerability.

The following examples illustrate manic at¬tacks on vulnerability.

A manic patient stated that a Negro atten¬dant was a prejudiced Black-Power advocatewho hated Jews. She proclaimed that the at¬tendant hated white people and that he was

brutalizing patients because of race and reli¬gion. She referred to him as a "black bastard"and concentrated on demeaning him and ques¬tioning his ability to be helpful to her, based on

his low educational level, lack of articulateness,and his presumed prejudice. The nursing at¬tendant, who had presented few overt problemsbefore, became increasingly angry with the pa¬tient. He began to avoid talking with her. Attimes he began to refer to her as a "rich bitch."He became defensive about his lack of educa¬tion and began to wonder why so few Negropatients were admitted to the ward and wheth¬er Negroes were being treated fairly at thehospital.

A manic patient told the ward staff that shecould not talk to her therapist because he was a

phony. She justified this by citing that thetherapist combed his hair forward to cover abald area. In truth, the physician was self-con¬scious about his hairline and felt defensiveabout the criticism and angry at the patient formaking a "ward issue" of the conflict. He beganto reflect this in his feelings toward the patient.

A manic patient wanted a pass. She statedthat her therapist was a rigid, overbearing,authoritarian individual, who was more inter¬ested in rules than in her well-being. Hertherapist prided himself on his liberalism and,indeed, felt threatened by individuals who as¬sumed the authoritarian role. Her attackcaused the therapist to question his own roleand motives, and to wonder if the patient werenot correct in her assumptions.

The manic patient may utilize his inter¬personal sensitivity to exploit covert or sup¬pressed conflicts between individuals andwithin a group. Here, the manic deals withissues which truly exist, but which may notbe recognized, or which have become taboofor consideration. The manic often will di¬vide therapeutic staff members by pointingout objectionable qualities of one faction or

individual to others, who usually are awareof the qualities exposed. Thus, the manicmay divide staff into those who are "good"and those who are "bad." He may be over-

solicitous to those who are designated"good," offering anecdotes and opinionswhich appeal to their prejudices and covertanimosities. Staff members may find them¬selves agreeing with the manic's judgmentsof other staff members, leading to a groupor individual feeling attacked by peers. Thisphenomenon is similar to one which occurswhen a child precipitates division betweenhis parents by exploiting covert conflicts.

The manic causes staff divisiveness inanother way. Because of his keen ability tosense areas of vulnerability, people findthemselves becoming anxious and tense.Unproductive modes of relating, often wellcontrolled in less stressful situations, fre¬quently become manifest. For example, in¬dividuals may resort to obsessive or pas¬sive-aggressive defenses under the pressureof the manic attack. These modes of relat¬ing affect others, inducing hostility and an¬

ger. Thus, the manic patient is able to bringout the worst characteristics of the individ¬uals in a group, leading to a fragmentationof working relationships. For example:

A patient complained to her physician-thera¬pist that she could not communicate with thenursing staff. She also informed the nursingstaff that they were poorly educated and notadequately trained to treat her. The therapisthad some doubts about the abilities of thenursing staff to relate to manic patients, andthey in turn felt that he was aloof and snob¬bish. The patient continuously repeated herdistrust of the nursing staff and her admirationfor the therapist. She insisted that her thera¬pist had agreed with her assessment. The phy¬sician and the nursing staff became increasinglyuncommunicative and hostile toward eachother. The nurses stated that "he can take careof her, since he likes her so much and won'ttell us anything." The therapist felt that the

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nurses were hostile and of limited use in man¬

aging the patient.A therapist and another physician entered a

room where a manic had become disruptive.The patient ignored her therapist and began toappeal to the other physician to settle theproblem. In the midst of her agitated behavior,she responded immediately and appropriatelyto suggestions made by the other physician.The therapist felt angry with his colleague for"interfering." The subtle and probably usualcompetition between two physicians on thesame staff was brought sharply into focus.

In the above examples, covert or dis¬guised conflicts are made overt in ways thatcause staff members to feel defensive andangry with each other. Often, therapeuticobjectivity is lost, as areas of conflict are

exploited and made overt. Anger is gener¬ated either among steff members or betweenstaff members and the patient.

This series of maneuvers appears to servea defensive purpose for the manic patient.Obviously, when anger is generated there isoften a breakdown of coordinated thera¬peutic attempts. Thus, the above maneuversserve as a diversionary tactic. Confusion isgenerated as individuals fight each otherand themselves.

Projection of Responsibility

After initially becoming engaged with themanic, individuals may find themselves tak¬ing responsibility for his actions. This takesthe form of accepting blame for plans goneawry and providing appropriate affect forthe manic's foibles. Thus, if a manic loseshis job, he reassures everyone that new

employment is imminent. Nevertheless, thetherapist and the family continue to worry.If a manic misbehaves in public, others are

concerned while the manic denies that any¬thing happened. If a pass from the wardends in disaster, the therapist is blamed or

blames himself for not having foreseen theunpleasant result. If a job is lost, the manicrelates that the employer is prejudiced orunfair and the manic's associates easilyshare the indignation.

This deflection of responsibility seems re¬lated to several factors. First, there existthe narcissistic needs of those who deal withthe manic. Once an individual's feelings ofself-worth are based upon how well the

manic does, there is a tendency for increas¬ingly frequent efforts to effect favorable out¬comes. A "significant other" may becomeprogressively more invested in making surethat "things don't go wrong." Progressively,the patient and those around him accept thepremise that he is incapable of assumingresponsibility for his fate. At this point, a

person relating to the manic feels responsi¬ble for unfavorable outcomes.

Basic to the manic's ability to projectresponsibility is his superficial "reason¬ableness." The manic patient is an exception¬ally good salesman and is quick with a

sound excuse when things go poorly. Like a

child, he is able to present obviously illogi¬cal arguments or premises in a logical way.He usually seems very sure of himself, as

though totally without ambivalence. Theimpact of these qualities, when found in an

adult, is to cause others to question theirown assumptions and to doubt their own

reasonableness. Unlike the schizophrenic,who is often dismissed as "crazy," the ma¬

nic patient's logic is more easily accepted. Itmay be possible that the much touted use ofdenial is central to this phenomena. Byutilizing denial and thus lacking consciousambivalence, the manic is so sure of himselfthat he convinces others. The following ex¬

ample is illustrative.A manic patient returned three hours late

from her pass. She said she was late becauseher friend's car had broken down. The patient'soriginal plans, previously worked out in a staffmeeting, were that she was to travel to an ap¬pointment by public transportation. While wait¬ing for a bus to return her to the hospital, shemet a stranger who offered to drive her and sheaccepted. Since traveling by private car was

less time consuming, she reasoned that theyhad time to stop at a bar for a drink. Whenthey finally did start back to the hospital, theacquaintance's car broke down. The patientargued that she surely could not be blamed, forwho could anticipate a car failure? The argu¬ment was presented in such a logical mannerthat it was only with difficulty that staff mem¬bers focused on the previously negotiated passrules—namely, that the patient had agreed toreturn by public transportation. However, evenwhen staff members could define the originalbreach of agreement, they had the feeling thatthey were "nit-picking," that they were in¬flating a minor issue, and that the patientmight really be blameless.

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Characteristically, the manic alwaysviews himself as blameless. When he speaksabout issues which involve self-disciplineand responsibility, there is detachment fromthe situation. When unfortunate situationsarise, they are reported as if the patientwere not an active participant. For exam¬ple, one patient, speaking about her promis¬cuity, stated that she never knew she wasgoing to bed with a man until she got thereand then "it just happened." Thus, themanic often gives a self-portrayal of aninnocent victim, passivelv buffeted by fate,not responsible for his life events.

Furthermore, and perhaps most signif¬icant, is the realistic fact that the man;cpatient often places those close to him innositions whereby they have no choice butto take responsibility. The manic may enterinto grandiose schemes, spend too muchmoney, incur bad debts, or make commit¬ments which, although he may feel able tohandle them, are obviously not nersonallyresolvable. In this situation, it often falls onthe family members and those in thera¬peutic roles to "bail out" the patient. Asneighbors, creditors, and representatives ofthe law converge with a barrage of com¬plaints and demands, those affiliated withthe manic may find it difficult not to acceptresponsibility.

Progressive Limit Testing

A phenomenon observed in all the manicsstudied was the progressive testing andchallenging of set limits. The manic's abil¬ity to seem reasonable, to exploit another'sfeelings of ambivalence or guilt, and toengage people appears central to this char¬acteristic. The first of a series of requests mayseem quite reasonable. However, once a nr'norconcession is made and it is establishedthat a limit may be challenged, the manicpatient very gradually increases the "ante."Each step appears to be a minor additionand in itself seems quite reasonable. Eachincremental request is stated in such a wayas to make the other person feel that if hedoes not meet the patient's demands, he isrigid, unfair, petty, and unreasonable. Fur¬thermore, implied in the setting of limits isthe possibility of antagonizing the manicand thus converting superficial charm and

ingratiation into a frontal attack on one'sself-esteem system. The following examplesare illustrative.

A patient asked a nurse if she could browsein a gift shop. The nurse consented. The pa¬tient then asked if she could buy some gumwith her own money. Again, the nurse agreed.Next, the patient decided that she wanted tobuy a newspaper and candy for all of thepatients and staff members on the ward. Sinceshe did not have enough money, she asked thenurse to lend her some. When refused, thepatient accused the nurse of trying to destroyher relationship with the other patients. Thenurse, who did not want to deal with a scene inpublic, was placed on the defensive and feltquite uncomfortable. She wondered if sheshould not have capitulated to the patient'sdemands, since they did not seem too unreason¬able.

A patient, placed in the seclusion room, wasscheduled for a five-min interview with hertherapist. She understood the terms of themeeting. After 4% minutes of banal chatter,she began to discuss her sex life and herrelationship with her husband. When five min¬utes had passed, the therapist said he was

leaving. The patient said, "but doctor, I was

just beginning to get into the heart of myproblems; don't you want to hear them?" Asthe doctor walked out of the door, she said,"alright, if you don't want to learn about myaffairs, that's your concern."

A manic patient, darting around the ward,was told either to sit in a chair or go to herroom. The patient walked to the chair andstood by its side. Staff members felt ambivalentabout how to handle the situation because theydid not want to be overly rigid, yet had stated a

mandate. After the patient was ignored andallowed to stand by her chair, she began towalk across the room, progressively resumingher hyperactivity.

Alienating Family MembersThe manic patient executes a series of

characteristic maneuvers which distancehim from his family. The previously men¬tioned behavioral patterns, considered inthe context of the therapeutic relationship,are present in the manic's family relation¬ships as well, and serve as a source ofmarital alienation. Characteristic interac¬tional patterns of the manic individual andhis spouse appear repeatedly. These will beconsidered from the vantage point of theimpact of manic behavior on spouse andfamily.

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The attitudes of spouses toward the ma¬

nic-depressive patient is significantly dif¬ferent from that of spouses of depressedpatients who do not have a manic compo¬nent to their illness. In contrast to thespouse's feelings concerning the unipolardepressed patient, which include anger to¬ward clinging dependency, sympathy for thesuffering of the patient, and occasional guiltconcerning personal contribution to the pa¬tient's depression, the spouse of the manicpatient is often motivated to dissolve themarital relationship. In the case of unipolardepressive illness, there seems little ques¬tion that the partners will remain together,whether or not the marriage has been grati¬fying. In contrast, all of the observed cases

of married manic patients had spouses whospoke of separation and who, in severalcases, carried out this threat. These spousesshowed increased anger and thoughts ofmarital dissolution which were most promi¬nent during manic phases of the illness, butalso occurred to a lesser extent when thepatient was depressed. Of the 11 marriedpatients in our sample of 15, the only ex¬

ception to this pattern was noted in a fe¬male spouse, age 62, whose manic husbandhad his first episode of mania following 25years of what was described as an idealmarriage. This spouse stated that the mem¬

ory of those 25 years prevented her fromentertaining ideas of separation. She dealtwith her husband's mania by sending himout of town on vacations during his manicphases.

The discussion of separation in the mar¬

riages of manic patients occurred so fre¬quently as to be a diagnostic differentiatorbetween patients with manic-depressive psy¬chosis and those with unipolar depressiveillness. Significantly, none of the spouseshad known the manic patients during a

manic episode prior to marriage.Diametrically opposed styles of marital

relating, occurring during depressed or ma¬

nic phases respectively, seem intolerable tothe spouse. The depressive phase is usuallyviewed by the spouse as an illness overwhich the patient has little control. Here,spouses offer significant physical care andemotional support. The patient, during thedepressive phase, often expresses much guiltand self-blame and sometimes speaks of the

spouse in laudatory and absolving terms.The "well" partner, along with angry,guilty, and negative feelings, also feels aug¬mented self-esteem, feeling important andrelevant to the patient. For example, a pa¬tient said, "my husband is a wonderful man

who has to put up with a lot from me. Iknow he loves me and only wants the bestfor me, but I am so depressed right now, Ican't even care about that, I just feel emp¬ty." Often, a spouse will feel that the pa¬tient is correct and is describing the rela¬tionship accurately. There is a tendency toattribute the patient's guilt, sadness, andinactivity to illness, rather than to feel thatany willful component exists.

In contrast, the attitude of the spouseundergoes a marked change when the pa¬tient is manic. The manic phase is perceivedas a willful, spiteful act. Lip service only isgiven to seeing the mania as an illness.There is always an underlying feeling thatthe manic can control his actions, and doesnot do so out of maliciousness, selfishness,and lack of consideration. This impressionis fostered by the fact that the manic oftenhas periods of seeming reasonableness.Calm, logical discussions take place, prom¬ises are made, and programs for workingout problems are developed. The spousemay optimistically feel he has scored a tem¬porary victory. Often, the spouse may agreeto concessions during these discussions andtry earnestly to live up to the bargainsmade. When, shortly thereafter, the manichas distorted or ignored all plans, thespouse feels duped. At this point the manicout-talks the spouse, turns defense intooffense, and angrily shifts the blame andresponsibility for his actions. One soouse

complained that he never was quite able todefine when reasonableness changed to un¬

reasonableness, when a rational or realisticplan became unrealistic, and he ended upfeeling exploited, his trust betrayed. It isthis feeling of having been lulled into tem¬porary security, only to confront blatantinsecurity, that is intolerable.

In contrast to the depressive phase, wherethe spouse feels venerated, he often becomesthe villain or the "bad parent" during themanic phase, seen as a hostile, unperceptiveopponent. He is the primary recipient of thepatient's anger. He is blamed for all trou-

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bles, considered the one who hinders andbelittles all achievements; and thought of asone who exaggerates trivial problems.

Additionally, the spouse rapidly becomesa buffer between the patient and the com¬munity. The environment demands that hecontrol the patient and he feels frustratedby his inability to do so. For example, oneman related extreme discomfort at havingneighbors call to complain about his wife,who had walked into their house and takensome of their belongings. The neighborsturned to the spouse, asking him to "keephis crazy wife off their premises." Otherspouses described situations where theywere hounded by creditors for large sums orfor uncovered checks, written by the pa¬tient. They felt helplessness and embarrass¬ment in trying to extricate themselves fromthese situations. They became concernedabout salvaging their own good names, aswell as trying to forestall what they per¬ceived as ruin for the entire family.

Related to issue of the spouse feelingbetrayed and experiencing diminished self-esteem is the problem of marital infidelity.Often, manic patients speak of divorce,make sexual advances to other people, be¬come engaged in affairs, and graphicallypoint out to their spouses that there areother fish in the sea—bigger ones. Thisoften is seen as a final affront by the spouse,who significantly, is not prone to engage inextramarital affairs. Thus, there is a greattemptation to go along with the sick part¬ner, readily agreeing to divorce plans, hop¬ing that someone else will eventually be inthe position of taking responsibility.

Spouses of manic patients often chosewithdrawal as a way of coping. One spouse,for example, related that she found it im¬possible to participate in any social activi¬ties with her husband during his manicepisodes, in spite of his frequent urging thatshe do so and his angry accusations ofrejection when she refused. She said thatshe could not tolerate the embarrassment ofgetting on a bus with him, having himargue with the driver, or going to a meetingand repeatedly hearing him interrupt thespeaker. While she could see these activitiesas relatively harmless, she simply could notstand the embarrassment of being identifiedwith him. Another spouse spoke of how he

avoided social situations with his wife dur¬ing her mania, since she would take delightin revealing intimate details of their mar¬

riage to others and berate and belittle himin front of significant associates.

In all these situations, the spouses felttrapped in what they perceived as an im¬possible situation. They felt caught in a

whirlwind of activity, personally threat¬ened, powerless to enforce limits, and oftenuncomfortable in situations that called formarital role reversal. Their moods and feel¬ings were intimately related to the diseasestate of the sick partner, rather than con¬

trolled by more personal considerations.They found themselves unpredictably switch¬ing from the benevolent caretaker role tothat of the adversary. They were first ex¬

tolled, then berated—unable to find a stablesystem of relating to their spouses, whomthey viewed as alternately "sick" or "bad."The spouse's most frequent reaction to thisconfusion and ambivalence was to try to dis¬tance themselves from the patient and to with¬draw.

Comment

In summary, the behavior of the manicpatient is based on a series of personalitycharacteristics which include the ability toseem reasonable, to make rapid, intense al¬though superficial object relationships, toappeal to the self-esteem of others, and tosense areas of conflict and vulnerability inothers. These characteristics allow the ma¬nic patient to successfully test imposed lim¬its and to project responsibility.

Why is all this disorder necessary andwhat purpose does it serve? It is impossibleto answer this question with certainty.However, we wish to propose some hy¬potheses which may be relevant to under¬standing the manic's interpersonal behavior.

We feel that a major issue concerning themanic-depressive patient is related to theneed to be taken care of. During thedepressed phase of the illness, this is oftenexpressed in terms of the patient's profess¬ing helplessness, uselessness, and ünworthi-ness. Others are placed in the position ofsupporting and caring for the patient in hisinadequacy. The severely depressed personmay refuse to eat, ostensibly because he

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feels unworthy, and may thereby uncon¬

sciously force others to interact with him ina caring way. Similarly, with the manicpatient a primary issue seems to be thefulfillment of dependency needs. However, a

manic often feels that it is threatening,unacceptable, and dangerous to rely on

others or to wish to be taken care of. As a

way of maintaining self-esteem, and feelingsof power and strength, the manic instigates a

situation in which he is able to control andmanipulate those people on whom he mustrely. Ostensibly, he is ultra-independent,needing no one. He may appear to be tak¬ing care of others as, for their benefit, heproposes grandiose schemes. He professes tobe totally autonomous and self-sufficient:vet his actions belie his words. By constant¬ly testing, racing, manipulating, dividing,overcommitting, and expanding the manicpatient increases his "independence" to a

point where he involves the resources andlife styles of those around him so that thevhave no choice but to control and take careof him. Thus, the manic assumes the de¬pendent role while chafing against all exter¬nal restraints and the ego-dystonic wish tobe cared for is gratified without his havingto consciously acknowledge his needs.

It may be that via lack of self-control andability to confer interpersonal havoc, themanic patient is seeking the perfect other:someone who will not be miffed by hisantics and who will supply the controls hedoes not possess. Through this association,he mav hope to attain the perfect dependen¬cy relationship in which he is restrainedand taken care of by a strong caring paren¬tal figure without having any requirementsfor reciprocity and without having to admitto himself that he is, indeed, dependent. Infact, in such a relationship he is able to giveup responsibility while maintaining the illu¬sion, belied by his actions, that it is he whogives to the other—that the other is depen¬dent upon him.

From another perspective, it is quite pos¬sible that the manic (as well as the depres¬sive) mode of interacting represents a com¬

promise in the issue of achieving intimacy.When the manic is interacting, there is no

question that a relationship exists. Thosewho deal with him contend and relate in a

profound way. However, such a relationship

lacks reciprocity and maturity. Lying be¬tween the poles of social isolation and lone¬liness characteristic of the schizophrenicand the intimate relationships of the matureindividual, the manic's interpersonal ma¬neuvers are simultaneously cementing anddistancing.

Therapeutic Implications

The difficulty of treating manic individ¬uals with psychotherapy has been empha¬sized by previous workers.14 While theefficacy of medications such as lithium car¬

bonate in controlling acute manic symp¬toms810 can be viewed as a major thera¬peutic advantage, this compound does notsupply complete answers to treatment prob¬lems. Although patients treated with lithiumcarbonate are increasingly able to make con¬

structive use of psychotherapy,11 the pa¬tient and his familv are often initially dis¬appointed that this drug does not solvepll problems. Indeed, sometimes it createsnew ones.12 Family friction, which has pre¬viously been ascribed to the illness, oftencontinues to exist, with mood swings no

longer the convenient scapegoat. Familyroles change and new adaptational patternsneed to be established. The patient himselfoften misses his mania and is skeptical aboutthe trade he has made—less grandiosity,hyperactivity, and narcissism, for more insightand the hope of ultimately closer and moremature relationships with those aroundhim.

Psychotherapeutic nihilism with thepoutelv manic individual, exclusive relianceon medication, and even a sincere desire on

the part of the therapist to see his patientshift to a depressive mood state, so he willbe ostensibly easier to work with, may hin¬der the optimal establishment of a workincrtherapeutic relationship. We feel that a

knowledge of the interactions characteristi¬cally used by manic patients is a crucialpart of psychotherapeutic work with them,regardless of subsequent mood shifts. Cer¬tain patients in therapy, through the course

of manic, depressive, and interim states,recall therapeutic work accomplished dur¬ing manic states. One woman remarked,"you accepted me when I was high, andthat enabled me to trust you."

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We have found that a logical system ofconceptualizing manic interpersonal activityhas been useful in serving as a frameworkfor interpreting and reacting to the manic'sstyle of relating. Expecting the manic pa¬tient to divide staff members, assault self-esteem, progressively test limits, projectresponsibility and distance himself fromfamily members, allows anticipation of theseactivities, with the possibility of formulat¬ing concrete responses and plans. It is mostimportant for those in therapeutic positionsto consider their own roles in interactingwith manics. How they may unwillinglyallow the manic to manipulate their self-es¬teem or how they may become defensivewhen the manic attacks their self-image isworthy of consideration.

We feel it is important to acknowledgeconflicts when dealing with the manic pa¬tient, thus deflating his tendency to manip¬ulate. Frequent staff meetings, centeringaround manic interactions, may undercutthe ability of the manic to divide; for it isin the context of faulty communication thathe is most effective. It may be useful toview the manic's ability to perceive covertconflict as a positive attribute, to be used as

a diagnostic tool to unearth and externalizeinterpersonal dissension.

It is worthwhile to focus on the feelings,realities, and affects which underly a ma¬nic's behavior, rather than to becomecaught up in a characteristic battle of se¬mantics. When a therapist agrees to engagewith the patient in semantic quibbling, hehas, a priori, abdicated bis objective useful¬ness to the patient by allowing a shift offocus to an arena in which the manic will besuccessful in avoiding therapeutic work.

Finally, we have found that the unambi-valent, firm, and rather arbitrary setting oflimits and controls is most useful in de¬creasing manic symptomatology. It seemsthat when the manic is unable to successful¬ly divide staff members, exploit areas ofconflict and vulnerability, and exceed setlimits, manipulative and uncontrolled be¬havior decreases. It may be that the psy¬chotic manic patient hears most easily thenonverbal communication implicit in thesetting of limits—the statement that indeed,the patient is controllable and that the thera¬pist cares enough and is powerful enough toprotect him from his self-destructive activi¬ties.

References

1. Dooley, L.: Psychoanalytic Study of ManicDepressive Psychosis, psychoanal Rev 8:37-72(April) 144-167 1921.

2. Gibson, R.: Psychotherapy of Manic Depres-sive States, Psychiat Res Rep 17:91-102 (Nov)1963.

3. Fromm-Reichmann, F.: Intensive Psychother-apy of Manic-Depressives, Confin Neurol 9:158-165(part 11) 1949.

4. Cohen, M.B., et al: An Intensive Study ofTwelve Cases of Manic-Depressive Psychosis, Psy-chiatry 17:103-137 (May) 1954.

5. Gibson, R.W.; Cohen, M.B.; and Cohen, R.A.:On the Dynamics of the Manic-Depressive per-sonality, Amer J Psychiat 115:1101-1107 (June)1959.

6. Bunney, W.E., and Hamburg, D.: Methods forReliable Longitudinal Observation of Behavior, ArchGen Psychiat 9:280-294 (Sept) 1963.

7. Smith, J.: The Metaphor of the Manic-Depres-sive, Psychiatry 23:375-383 (Nov) 1960.

8. Gershon, S., and Yuwiler, A.: Lithium Ion: ASpecific Psychopharmacological Approach to theTreatment of Mania, J Neuropsychiat 1:229-241(May) 1960.

9. Schou, M.: Lithium in Psychiatric Therapy-Stock Taking After Ten Years, Psychopharma-cologia 1:65-78 (Jan) 1959.

10. Maggs, R.: Treatment of Manic Illness WithLithium Carbonate, Brit J Psychiat 109:56-65 (Jan)1963.

11. White, R.; Schlagenhauf, G.; and Tupin, J.:The Treatment of Manic-Depressive States WithLithium Carbonate, Curr Psychiat Ther 6:230-242(Jan) 1966.

12. Aronoff, M., and Epstein, R.: Lithium Failurein Mania: A Clinical Study, read before the annualmeeting of the American Psychiatric Association,May 7, 1969.

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