Nature versus nurture. Teasing apart these two contributions to behavior and mental illness has preoccupied philosophers and practitioners since antiquity. The confluence of these factors came home to me when I saw a woman who suffered from Bipolar disorder and PTSD.
My patient had recently separated from an abusive, alcohol-dependent husband. Not surprisingly, her father had had the same behaviors. Her father also suffered from Bipolar disorder. When manic, he drank. When drunk, he abused his daughter—physically and sexually. Her own Bipolar disorder was complicated by PTSD from her childhood, exacerbated by the stresses of her marriage repeating elements of her childhood.
So, presumably her dad had passed on to her the genetic vulnerability to develop Bipolar disorder, and via his comorbid alcoholism (well over half of patients with Bipolar disorder succumb to substance abuse) and resulting behavior, he abused her.
Treating a patient like this requires all of the art and science of our field. A therapeutic relationship is crucial. Therapy is essential—to help her with the symptoms of PTSD, as well as Bipolar disorder, and to help prevent her from repeating the pattern of destructive relationships. And all patients who have an unequivocal diagnosis of Bipolar disorder require maintenance medication. Needless to say, the medicine will only work if it is taken, again underscoring the importance of the therapeutic dyad.