Max Littman, LCSW
September 12, 2023
If you are interested in learning more about integrating Internal Family Systems (IFS) in therapy with people affected by bipolar and psychotic disorders, please read on. I recommend having a baseline understanding of IFS before proceeding.
My intent here is to share what I’ve learned experientially in working with client internal systems affected by organic bipolar and psychotic disorders using the IFS model. I rely on my past experiences working with these populations as a psychiatric social worker in an outpatient crisis clinic and my current experiences as an IFS-informed private practice psychotherapist. Of note, I never sought to become experienced in using IFS in cases involving bipolar and schizophrenia spectrum disorders. It was a happenstance that I had clients with these conditions and wound up adapting what was in my clinical toolbox to help in the best way I could.
*Psychosis, psychotic disorder, and schizophrenia spectrum disorder are used interchangeably in this article.
What do I mean by “organic”?
By organic, I mean that these disorders are not originally caused by something outside of the mind. My belief is that many disorders laid out by the DSM are not biologically innate. They are caused and exacerbated by experiences and energies in the external world permeating into the inner world.
A few examples of disorders originating in interactions with the external world are generalized anxiety disorder, major depressive disorder, trauma related disorders, eating disorders, OCD, and borderline personality disorder. Though there may be a genetic or biological predisposition to such disorders, I believe they can be best understood as parts doing their jobs to protect against exile burdens being felt by the system. For example, I see the symptom of recurrent suicidal ideation in major depressive disorder as a suicidal firefighter, and the symptom of worthlessness as the burden of an exile. I also believe that in such cases access to Self energy, secure relationships between Self and parts, and the unburdening of exiles will lead to symptom reduction and the “curing” of the disorder.
Bipolar and various disorders on the schizophrenia spectrum, to the best of my knowledge at the point of this writing, do not necessarily indicate a burdened exile and cannot be fully alleviated only by the unburdening of exiles. They are descriptions of well known clusters of symptoms that have no known external cause. Symptoms of bipolar and schizophrenia spectrum disorders point to significant disturbances in perception, mood, energy, inhibitions, and attention that appear to have no functional intent. IFS founder Richard Schwartz has come to the same conclusion that such disorders are similar to that of asthma and migraine headaches where the illness is biological. Importantly, he has recognized that like biological vulnerabilities and illnesses, the conditions of bipolar and psychotic disorders can be exacerbated by certain internal and external environments.
My Own Parts
Identifying, working with, speaking for, and asking for space from our own parts remains vital when using the IFS approach in helping clients with bipolar and psychotic disorders access the Self energy within themselves needed for healing.
I am grateful to my many managers that learned over the years how to diagnose, spot symptoms, interact with multidisciplinary providers, advocate for clients, empower clients to advocate for themselves, work within imperfect systems of care, detect parts, and follow the flow of the IFS model. I’ve been aided by working with my own IFS therapist and by doing extensive parts mapping of my own system over the years, much of it drawn from Michelle Glass’s Daily Parts Meditation Practice.
The parts of me that I am aware show up in working with clients affected by bipolar and psychotic disorders include the following: a part that holds the knowledge and ethics of my schooling and professional experiences as a social worker, a part that is good at noticing and synthesizing information into a cohesive story, a part that takes notes during sessions with clients to track information learned from the client’s system, a part that likes to feel helpful to my clients, a part that is proud of the skills my system has developed in regards to mental health diagnosis and treatment, a part that insists I be perfect and effective at all times as a therapist, and empathic parts that can get overwhelmed when they sense my clients have parts that are they themselves feeling hopeless.
Knowing these parts show up in these sessions helps me to bring attuned Self energy into the room and to make it available to the client’s system, should their system feel it safe to welcome it in. I name these parts and speak for them from time to time in session, which helps to make clear to the client’s parts that these parts of me may have agendas as to what may resolve the issues their parts are bringing to the therapy, while I (my Self) do not. My Self holds the intention of being attuned to and in relationship with the client and their parts, trusting that that will facilitate whatever needs to happen for healing to occur.
Differential Diagnosis
It can be quite the task to determine if the symptoms presented are parts-led or biochemically led. A word to the wise, always remain curious about the symptoms a client is bringing to the therapy room, whether that be by demonstration or report. Even though in cases where it becomes clear parts are not causing the commonplace perceptual, mood, energetic, and attentional symptoms of bipolar and psychotic disorders, I remain open and curious to there being other possibilities, especially when the flow of energy feels “off” in the field of Self energy. Relatedly, in my experience, bipolar is an overly diagnosed disorder that oftentimes can be better described as some form of a traumatic or stress disorder that is typical of parts protecting and/or holding a burden. Currently, the DSM is not equipped with a diagnosis to get this right. Additionally, if needed and with consent, bring in a trusted and competent diagnostician (e.g. a psychiatrist) to help get the diagnosis right.
Without going into great detail about the diagnostic criteria for bipolar and schizophrenia spectrum disorders, I’d like to lay out a general guide for identifying and differentiating parts led from biochemically led symptomatology, specifically in cases of bipolar and schizophrenia spectrum disorders.
Bipolar involves marked fluctuations in energy, goal related activities, self esteem, disinhibition, mood, and, for some, perception of reality.
Whereas schizophrenia spectrum disorders involve the individual or combined presentation of the following: distorted perceptions of reality (e.g. delusions, hallucinations), disorganized and incoherent thoughts, speech, and/or behaviors, and a flattened range of emotive expression and motivation.
I always begin with the assumption that all presented symptoms are a part until the following occurs which may take some time:
- Parts contacted don’t know what to make of the symptoms
- The symptoms are affecting parts’ relationship with Self or access to Self energy
- The symptoms are exacerbating the burden of an exile without a clear good intention from a part
Of note, if the client does not come to the therapist already having a diagnosis and understanding their diagnosis, it takes time and the client’s system’s earned secure relationship with the therapist to get it right.
Important rule outs include:
- substances
- medical conditions
- similar symptoms of other mental conditions
- parts related symptoms
- unattached burdens
A Hypothesis on Psychosis
In his recent book on unattached burdens, Robert Falconer expounds upon the porous theory of the mind. In his view, of which I currently agree, the mind is porous, meaning that it takes in energies, content, etc. that come in from the outside world. Some elements are soaked in and kept, while others are expelled, are forgotten, or some other mysterious vanishing occurs.
Although I have little evidence to back up this claim, I believe that in some cases of psychosis, what is happening in the affected person’s system is a flood of unattached burdens (or what Falconer terms as “others within”). I believe that this occurs because some internal systems are highly sensitive to taking in the energies of the outside world and the inside worlds of others. I believe that in these cases, the mind is so porous and, for whatever reason, without enough protective energy from parts that the system becomes flooded with energies from other sources and cannot be organized into a coherent whole. There becomes a world inside that is highly disorganized, chaotic, confusing, and oftentimes frightening. Conversely, I believe internal systems not plagued by this condition are like a maze that is constituted of protective parts’ energies and ancestral energies. The protective energies can be understood as developed defenses of the psyche and ancestral energies can be understood as genetics, epigenetics, and inherited legacy protectors. The walls of the maze are still porous, but there can be an organization to and some control of the flow of the energies from the outside world going in and out.
With some psychosis affected systems, I imagine the maze walls to be lowered, lower, or non-existent. I believe this can happen with non-organic psychosis as well (e.g. substance induced psychosis). In such cases, I imagine the walls of the maze created by parts to protect the system from unsafe external energies to be lowered chemically, thus making the internal system more vulnerable to flooding of external energies into the system. I believe that shows up outwardly as symptoms such as disorganized behaviors, speech, and/or thought processes, delusions, and hallucinations. I suspect manager parts in charge of making sense of things and manager parts in charge of controlling the flow of information in the system are overworked in such situations and have little to no way of winning that battle for coherence or information flow control.
All of this is to say, ruling out “others within” is an important step to consider when working with systems affected by psychosis.
Therapist Parts
As anyone who has dived into the depths of the IFS model would know, working with our own parts is essential in facilitating the connection between a client’s Self and their parts. That is no different when working with client systems affected by organic bipolar and schizophrenia spectrum disorders.
I recommend attending to the usual therapist parts that can commonly arise in therapy with any client which may include figuring it out parts, doing it right parts, wanting to be liked parts, wanting to be helpful parts, annoyed parts, tired parts, bored parts, etc. However, parts I’ve found to be especially activated in my own system and parts that occur to me to likely be activated in other therapists’ systems in cases involving bipolar and psychosis include:
- parts holding first or second hand experiences with bipolar or psychosis
- parts that have agendas as to the client’s compliance with treatment recommendations
- parts that want to educate the client about the disorder
- parts that are enthralled with, critical of, or anxious about the diagnosing process
- parts that are afraid the condition is out of your scope
- parts that empathize with the client (especially with the client’s exiles)
- parts with strong opinions for or against medications
- parts that see the client has helpless and hopeless
- parts that get activated in collaborating with other mental health professionals
If any of these parts should take the lead, there may be backlash within the client’s system and, understandably, less trust in you.
I recommend checking in with your own system and seeing what your own parts need in order to let your Self take the lead. This may involve speaking for your parts in the therapy with the client more than you may be used to doing. I’ve found this strategy to be quite useful, keeping in mind I ask first for consent from the client and their parts to speak for one or more of my parts. I let the client and their parts know my parts have some valuable information that may be helpful to their parts, but it will only be shared with their consent.
Therapist Self
Of course all the qualities and energies of Self will be useful in such cases as bipolar and psychosis. However, the following qualities of Self energy I’ve found to be especially useful:
- Consent
- Though not included in the 8 Cs of Self, I’ve come to understand Self as consensual, consistently checking through multiple channels of visible and invisible communication (e.g. words, tone of voice, body language, collective energetic fields) that the interactions are welcomed by the client’s system.
- Confidence
- Literally translating to “with faith,” confidence emanates the quality of trust in the field of Self energy to guide the conversation and the relationship between the client’s parts, your Self, and their Self, to where the light of Self energy needs to flow.
- Patience
- To truly understand a client’s system requires time and patience. Some parts may not be ready at first contact, or even many subsequent contacts, to reveal what it is they protect. For this reason, patience is required in being reasonably confident that a set of symptoms appearing to be an organic bipolar or psychotic disorder are not in fact a cluster of parts.
- Perspective
- With consent, sharing the perspective with the client and their system that they have an identifiable, treatable, and organic condition, yet with unknown origins, can help the system orient itself toward Self energy and away from any burdens that are being carried.
Protector Perspectives
Client systems affected by bipolar and psychotic disorders have differing positions on the existence of these diagnoses within them. I suspect this will come as no surprise to practitioners who subscribe to the theory that the mind is multiple.
Upon having the suspicion of or certainty that your client’s system exists within the conditions of an organic bipolar or psychotic disorder, I recommend first asking for consent to share your hypothesis about what is going on and to educate the client and their parts with what you know about the diagnosis.
Welcome all parts that would like to share their responses and inquire about their responses. Do parts agree? Do they disagree? Are they overwhelmed? Are they sad? Are they angry? Do they have questions? Do they feel better? Are they thinking it over? Are they afraid? With this added context, do parts have more to share that would confirm or contradict the diagnosis? Did it feel like any parts felt less (or more!) ashamed upon hearing the hypothetical diagnosis? These are some questions for you, the client’s Self, and the client’s parts to get curious about together. Depending upon the client’s access to Self energy, which can be significantly lessened by the impact of bipolar and psychotic symptoms, it may make sense to do explicit direct access in gathering protector and exile perspectives on the matter of diagnosis. Parts’ perspectives on psychiatric treatment (e.g. psychiatry, medications, hospitalization) will be covered in greater depth later in this article.
Through such Self led approaches, I’ve found more willingness in client systems to accept diagnosis, collaborate about treatment, open new pathways to Self energy, reserve more space for Self to take the lead, and share what burdens reside in the system and where to find them.
Common Protectors
Below are the common protectors I’ve seen in working with clients with bipolar and/or psychotic disorders:
- Paranoid Parts
- These parts create mild to wild stories that range from unlikely to impossible about what may be happening in the external world and the internal world of others. Their goal can be to make sense of confusing stimuli that are exacerbating a burden and/or to prevent future exacerbation of a burden.
- Progress Parts
- These parts focus on making progress, usually professionally or in mental well being. They can be especially prevalent when a client needs to take time off work or even leave their job due to having either disorder.
- Substance Using Parts
- These parts are more common with bipolar than with psychotic disorders. They are usually firefighters unleashed during manic episodes when energy increases and inhibition decreases.
- Sexual Parts
- Again, these parts are more common with bipolar, and they are usually firefighters unleashed during manic episodes when energy increases and inhibition decreases.
- Withholding and Isolating Parts
- These parts take charge when a client has an exile that feels shame about their symptoms.
- Workaholic Parts
- These parts keep busy by working on projects, oftentimes in professional settings. They may ignore the needs of the body and other parts especially in the midst of manic or hypomanic episodes.
- Suicidal and Self Harming Parts
- When things feel especially hopeless, these parts take over and break the glass of the emergency system. These parts are more prevalent in the depressive episodes of bipolar disorder.
- Angry Parts
- I don’t have as much experience with these parts, but extreme anger is known to be one symptom of bipolar disorder.
Power Afforded to Firefighters
It is my belief that enormous power is afforded to firefighters in cases of bipolar disorder, especially in the depths of manic and depressive episodes. These parts can be quite powerful and resourceful in systems not affected by bipolar, but I believe that due to whatever biochemical situation is happening, firefighters have greater access to power in the mind and body of people with organic bipolar. This is to say that parts looking for fun and relief have an easier time taking the lead in the client’s system. These parts may use sex, substances, and thrill seeking to reach the goals of fun and relief. Meanwhile, managers may be locked behind a biochemical barrier and are helpless to prevent potential and/or actual physical, social, and psychological consequences to firefighters’ actions.
In regard to schizophrenia, my professional experience as a therapist is limited to delusional disorder (which is similar to paranoid schizophrenia). However, as a psychiatric social worker (which was prior to my exposure to IFS), I was exposed to a variety of manifestations of psychosis. Combining these experiences and my knowledge of IFS, I’ve come to believe that power is given to preventative parts (e.g. paranoid parts) and rescuing parts (e.g. isolating parts) in most cases of schizophrenia spectrum disorders.
Common Burdens
Burdens are rooted in shame, powerlessness, worthlessness, and aloneness. Below are burdens I’ve commonly encountered in cases involving bipolar and psychotic disorders:
- I’m too much
- This can occur in cases of manic or hypomanic episodes.
- I’m a failure
- This is especially true when the symptoms affect the person’s ability to function professionally, socially, and/or personally.
- Worthlessness
- See “I’m a failure”
- There’s something wrong with me
- I’ve found this burden to originate in or be exacerbated by client encounters with previous treatment providers, especially during involuntary hospitalizations.
- I’m crazy
- This burden can enter the system directly or it can be soaked in as a cultural legacy burden.
- Confusion, unpredictability, overwhelm, and powerlessness related to when and how the symptoms will arise and what will be the aftermath.
- Without knowledge about the symptoms of bipolar or schizophrenia spectrum disorders, many of a client’s parts will be confused, at a loss for predicting when and how symptoms will occur, overwhelmed by the symptoms, and feel powerless to understand or stop them.
- Burdens subsequent to sexual and other forms of abuse
- There is heightened risk for abuses of many forms for systems affected by bipolar and psychotic disorders. I think mostly about manic episodes where substance using and sex using firefighters, whether they are aware of it or not, put the physical body and psychological parts at risk for perpetration or actions taken upon the body or parts from others without the consent of or even the consideration of the client’s system.
- Cultural, familial, and societal legacy burdens (more on this in the next section)
Power, Privilege, & Legacy Burdens
Those affected directly by bipolar or psychotic symptoms are also impacted by the systems in which they are embedded. That is to say, how they are treated by family, peers, communities, societies, and institutions (especially systems of care) will differ based on an array of identities. The degree to which these identities have access to power and privilege can and do influence the accumulation and exacerbation of direct and legacy burdens. The Wheel of Power and Privilege illustrated by Sylvia Duckworth, adapted from the work of James R. Vanderwoerd, can be used as a resource in assessing vulnerability to such burdens (see below).
Though I do not cite evidence here, I think it is reasonable to believe that people with identities further from the center rung of the wheel (e.g. with lesser access to power and privilege) have been, will be, and will continue to be vulnerable to overt and covert prejudices and shaming about their bipolar and/or psychotic symptoms. Furthermore, I believe the further from the center one’s identity lies, the less likely adequate and non-shaming care will be available to address the bipolar or psychotic symptoms.
Caring for family members with such symptoms can be highly stressful and confusing. I imagine that if a caring family member were to be struggling with other stresses inherent to being in a marginalized body, they would be exacerbated by living in a culture marinated in white supremacy (e.g. racism, sexism, homophobia, classism, ageism, ableism), and this would increase the likelihood of their afflicted family member growing up in or living in an energetic field filled with parts energy and restricted Self energy. Also of note, some cultures and communities hold stigma toward mental health conditions and may have legacy protectors of their own that create a directly or indirectly invalidating environment for members of their own community affected by organic bipolar or psychotic disorders.
I would like to add here that my experiences, parts, and views as a human, a mental health professional, a writer, and an IFS therapist are informed by my positioning in mostly the central rung of the wheel. That is to say I am 37 years old, cis gender male, white, English speaking, a U.S. resident and citizen, neurotypical, with a post secondary education, financially secure, of mostly robust mental health, an owner of property, slim, and able-bodied. The only identity I hold outside the central rung is being a gay man. Although my intention is to be as inclusive, sensitive, and compassionate as possible in all that I do, including this writing, I am aware that my experiences in the central rung of the wheel and the degree of power and privilege I am afforded will impair my sight to many of the burdensome experiences of those outside of it. I hope that taking this moment and designating this space to name such things will be one small step in bringing the light of Self energy into spaces exiled from power and privilege. Of course, there is always more work to be done.
Volumes upon volumes can and probably should be recorded about such intersectionalities between culture, identity, power, privilege, internal systems, bipolar, and psychotic disorders. As a place to begin a deeper dive on this topic, I recommend All Together Us by Jenna Riemersma which includes many different IFS authors covering a wide range of identities within the Wheel of Power and Privilege. Though I admittedly do not dig deep into this topic, it merits further thought, discussion, and examination. I encourage readers to self reflect on what parts show up for themselves in this area and to research further.
External Care Team, Medications, Hospitalization, & Stabilization
Time, the therapeutic relationship, negotiating with your parts to soften back, and addressing protective parts concerns are key when it comes to connecting a client with an external care team, medications, and hospitalization. Furthermore, and perhaps more importantly, the goal in the use of an external care team, medications, and hospitalization is to increase a client’s access to Self energy and to a secure connection between a client’s Self and their parts.
In doing such, I recommend using a method adapted from Janina Fisher’s trauma-informed stabilization treatment protocol. With consent, have the client set up a safe meeting place for all parts who are interested in sharing their perspectives on medications, hospitalization, psychiatrists, etc[a]. I’ve found suggesting a conference room, dining room, rooms with comfortable cushions, or places in nature tend to work best. Have the client check to make sure all the parts who need to be in the meeting place are there. Once they are all there, have the client check how they are feeling toward the group. If it seems like there is a critical mass of Self energy in the room, proceed to have the client’s Self ask the parts what they would like the client’s Self to know about the external care being considered. If there is a part of the client taking the lead, see if that part would be willing to soften back and let Self listen to what parts need to be known. If that part is unwilling to soften, you can check on the concern this part has if it were to soften back. You can also shift into explicit direct access with consent from the client’s system. A note of consideration, check your own Self energy, perhaps checking for any internal agendas, to be sure you’re not leading explicit direct access from the energy of one of your parts.
Something also worth checking on is what the client’s parts know about medications, treatment, hospitalization, diagnoses, and other forms of external care. When I am given permission from the client’s system, I explicitly speak for my parts that are well informed about medications, diagnoses, symptoms, prognoses, treatments, psychiatry, hospitalization, etc. I make clear to any part of a client to which I am speaking that I do not have an agenda as to what they do with the information. I trust that the client’s Self and parts will come to an agreement most workable for their internal system. I cannot recall a time that saying, and meaning, such statements did not result in a softening in a client’s system and a trusting of their parts in my and the client’s Self energies.
Should the client’s system elect to take medications, I recommend you continue this protocol after meds are on board. Various side effects may occur which may be unwelcome by some protective parts and may exacerbate some burdens. Parts can and do have a client stop taking medications. They may or may not be aware of the risks in taking such actions without the guidance of a prescriber. It is important to work to understand the good intent of such parts. In cases of bipolar disorder, it is not uncommon for parts to miss the energy, self esteem, expansive mood, and creativity afforded by manic and hypomanic episodes.
Parts can also serve as allies in assessing the efficacy of medications being taken. Additionally, some parts may be hesitant to, afraid of, or not even aware they can advocate for themselves and partner with prescribers. My social work part appreciates it when I speak for her on such issues with a client and their parts.
If you get as far as connecting the client and their system to a psychiatrist, I recommend checking with the client’s parts what they do and do not want you to share with their psychiatrist. Though my experience is limited, in all the cases I’ve had involving bipolar or psychosis, all of the client’s parts were open to me discussing with the psychiatrist anything that I felt necessary to ensure effective treatment. Worthy of note, in these cases, I had been working with these clients for over a year.
The support of family and friends is known to be a significant mediating factor in cases of bipolar and psychotic disorders. I found using the same protocols mentioned above work well in solidifying a good support system. I’ve found client parts are more cautious in what they consent to me sharing with a client’s family and friends than with their psychiatrists.
Once the client has stabilized, the attention and flow of sessions gradually moves back the typical flow of the IFS model, focusing on protective parts, exiles, unburdening, and facilitating a secure and attuned connection between the client’s Self and their parts.
Conclusion
I imagine there will be perspectives, possibilities, evidence, and expertise that I have overlooked or to which I’ve yet to be exposed on this topic. A part of me even points out to me that there may be persons reading this piece with first hand experiences living with bipolar disorder or a schizophrenia spectrum disorder who are at present working with their own parts affected by these organic conditions. I welcome perspectives on this topic from all readers and their parts (though a part of me asks for responses to be as kind, respectful, and Self energetic as possible). Thank you for your time and attention.
I can be contacted at max@maxlittman.com.
I also provide consultations. Learn more here.
