In this section of the article, Ed reviews and interacts with two books on bipolar disorder. The first book is written from a cognitive-behavioral point of view and the second addresses bipolar in children.
Monica R. Basco and A. John Rush
Cognitive-Behavioral Therapy for Bipolar Disorder, 2nd edition (New York: Guilford, 2005), 315 pages.
Cultural shifts accompanied changes in what is popular among secular therapies. Presently, cognitive-behavioral therapy (CBT) is especially stylish. It suits the insurance industry’s demand for shorter therapies with verifiable goals. It squares nicely with American sensibilities that focus on problem solving and results. As its name suggests, CBT focuses on education by identifying problems in thinking and behavior and suggesting practical solutions.
Cognitive-Behavioral Therapy for Bipolar Disorder is a more technical and thorough presentation of the cognitive approach that also steers The Bipolar Survival Guide. It aims to (1) identify the problem, (2) learn the early warning signs, (3) learn how to manage the symptoms, (4) develop strategies to aid compliance with medication, and (5) deal with the emotional, vocational, and social fallout of bipolar disorder.
Essential to meeting these stated goals are checklists of symptoms and self-monitoring charts. These self-awareness tools, also present in cognitive-behavioral strategies, include charts with scores of adjectives for depression and mania, mood graphs, automatic thought records, pro and con charts, activity schedules, priority lists, and diagnostic checklists. The purpose of these tools is to capture the “signature” of a bipolar person’s profile. Catalytic events, such as marital problems, might also be revealed. These tools help the bipolar person become more aware of a problem that typically defies self-awareness.
There is no universal pattern to bipolar fluctuations. Duration, intensity, preference for depression or mania, and speed of escalation or descent all vary. They arrive in unique patterns in each bipolar person. Is there a benefit to understanding a bipolar person’s particular profile? Absolutely. Cognitive-behavioral strategies and their obsession with detail can assist us in working with a person who usually feels harassed and controlled by those who want to help. Now the person can become a partner in the process of change. Here are two examples. First, if the bipolar person has previously listed some personal early warning signs, friends can use this list to help redirect the bipolar-prone person when those signs appear. Second, the charts and lists suggest safeguards that can be put into place. Predetermined decisions can be especially helpful when it relates to money. Limit the manic person’s access to money and you are guaranteed to be met with hostility. When the rationale for your intervention has been developed earlier, and the bipolar person has previously agreed to this intervention, then this strategy can be effective.
Cognitive-behavioral strategies, and this book in particular, remind you that it is worthwhile to develop a profile of the person’s mood changes. Most likely, biblical counselors get to a similar place on their own when they have opportunity to walk closely with those who go through bipolar episodes. It is part of wisdom to look back, understand what happened, observe the consequences, and take steps to avoid that path in the future. But the detailed, problem-solving, engineering-oriented approach of cognitive-behavior strategies will challenge you to be more precise, and there are times when such precision can be helpful. For example, gifted biblical counselors don’t need help in identifying their own moods. They already have the ability to reflect on what they are feeling, and they can put that into words. That is not, however, the experience of every counselor. And it is certainly not the experience of many of those who personally experience the confusing world of mania. Words quickly fail when these persons try to describe their own experiences. They would find useful descriptive aids among the multitude of lists and charts.
As you understand cognitive-behavioral approaches—and it doesn’t take long—you will be encouraged by two things. First, this approach assumes there is more a person can do for their bipolar tendencies than simply take medication. The approach does take medication as its basic building block for symptom management, but it includes suggestions that reach in the direction of what biblical counselors call wisdom. As a result, biblical counselors can be encouraged that even the secular community recognizes that human life, and therefore our means of help, can’t be reduced to mere physical phenomena. Second, the popularity of cognitive-behavioral approaches should permanently remove the stereotype of “superficial” from biblical counseling. In the old Freudian days, when gnostic examination of psychic secrets was the standard, biblical counseling was critiqued as shallow. But when compared to the problem-solving agenda of cognitive approaches, even the most simplistic of biblical approaches seems profound.
Judith Lederman and Candida Fink
The Ups and Downs of Raising a Bipolar Child: A Survival Guide for Parents (New York: Simon & Schuster, 2003), 294 pages.
This third book takes a look at mood swings in children. Here are several case descriptions:
I knew her violent behavior was beyond her control. Trying to deal with her was tearing our family apart . . . I was finally at the end of my rope . . . I felt like a failure having to admit I couldn’t successfully parent my own child. (p.13)
Jason is laughing on the floor one minute and crying the next, saying he wants to die. (p.71)
For many parents, these comments make the book priceless. “So, other parents experience this too!” After years of seeing that other people have good, obedient children in Sunday school and church, they have finally found someone who understands their problem.
The introduction tells the story of a five-year-old child who, after being told he couldn’t explore a particular exhibit, stomped to the end of a pier, teetered over the crashing waves and rocks below, and threatened to throw himself over the side. Pride? Yes. Ordinary rebellion against authority that can be found in every heart? Yes. But there is something about the extreme nature of the response and a five-year-old talking about suicide, that should lead you to ask what is unique with this child, and what is ordinary and universal.
Notice this point. What was once a label for a narrow band of the adult population is now applied to children. This is the inevitable drift within psychiatry. It begins by observing the behavior extremes in adults, gradually broadens to include adults with less severe symptoms, then broadens even more to include children.
This book adopts the view that bipolar-like behaviors in children are a biochemical problem, and medication is the cornerstone for treatment. But this book also offers practical alternatives that can be used by biblical counselors and Christian parents. For example, in a parent-child power struggle, it helps if parents prioritize the behaviors that must be addressed immediately and overlook those behaviors which, though irksome, can be ignored for the present. For parents who feel as though each bothersome and sinful behavior deserves the same level of attention, such prioritization can help bring sanity to a household controlled by unpredictable and frequent meltdowns.
Christian parents can, of course, arrive at these strategies without the catalyst of secular books. But when parents feel alone and incompetent, a book such as this reminds them that other strategies are available. No doubt, some parents and counselors need the reminder.
Be careful at this point. Secular books sometimes offer helpful advice that demands unique psychological or psychiatric insight. For Christian parents who are unsure how Scripture can guide them through the shoals of secular thought, a sudden bifurcation emerges. One path is the spiritual, which can be interpreted to mean that children only need to be converted and read their Bibles. The other is psychological or psychiatric, where real life problems and real solutions supposedly exist.
As a way to maintain the interpretive depth and breadth of Scripture and avoid this dangerous bifurcation, consider how the practical suggestions in a book like this are not the highly technical advice of a secular expert, but are available to any thoughtful biblical counselor. This is not to demean the helpful comments throughout the book. Rather, it is to remember that Scripture presents a coherent worldview that encompasses everything. Combined with hands-on experience, a biblically-oriented parent or counselor arrives at many of the useful suggestions of modern psychology, but it places those suggestions within a deeper, godward framework.
Here is how ministry can proceed without the stimulus of a book such as this one. Let’s start with the child who overreacts to changes and other unpredictable events by throwing a tantrum. At the first sign of this reaction, some parents might bring swift discipline in the form of a time-out or spanking. So far so good, but the child seems untouched by the discipline. While considering what might be more effective in the future, parents also must realize that they have just observed a foolish heart in action. A tantrum is a wonderful opportunity to bring godly instruction to the child. So later, during a calmer time, they must explain to the child that:
- It is hard to be teachable and have self-control—these are gifts from God.
- Responses to parents reveal a child’s heart toward God, so now is the time to grow to know God better.
- This is an opportunity to pray with the child and observe together how God sanctifies His people.
No doubt, parents will also be sanctified in the process. Their desire is that their children will see how God works.
At the child’s next explosion of blind rage, the parents are wiser. Yelling makes things worse and previous discipline didn’t help, so they choose to do nothing at that moment. They deliberately choose to handle the situation when calm prevails. The child is not in danger, but he is not open to wisdom at that moment, so the parents go about their business until the child calms down. Later, in concert with the child, they try to analyze what was happening before and during the tantrum. Sometimes the child has no words for his rising frustration. Parents can help by giving the child a vocabulary to describe his experience. This helps identify the issues. “You were feeling angry because you didn’t know that company was coming to visit, and that surprised you. You wanted to keep playing with your toys all by yourself.”
Parents know that wisdom does not come immediately, so they are patient with the process of change. Some behaviors can be overlooked, at least temporarily: rambunctious play, questionable manners, and even some forms of frustration and anger. Some matters, however, are intolerable. If the child makes threats to others or jeopardizes anyone’s safety, there must be immediate action. Isolating the child from others and removing privileges are just some of the possible reactions.
Along the way parents must try to preempt as many tantrum-provoking problems as possible. Structure is the rule. Overstimulation from TV, too many friends, or long hours with video games make things more difficult. But the child should not feel like everything is being taken away. Parents do not want to give that message. Vigorous and healthy activities must fill the gap for those children who engage in tantrums. The family must provide constructive tasks. And whenever possible, the parents must hold out the beauty of godly wisdom and allow the child to partner with them in their decisions. God’s creation must be explored and appreciated.
Wise use of secular literature does not force parents to choose between Scripture or psychiatry. Instead, it appreciates the catalytic effect of secular experience as we would appreciate the advice of an unbelieving neighbor who had similar child-rearing experiences. It will also discern the limitations of such advice. Secular literature does not provide direction on how to meaningfully inculcate the gospel and the knowledge of God into the daily life of our children. And secular literature inevitably misunderstands the meaning of its partial insights and practical advice.
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This article was originally published in The Journal of Biblical Counseling, Summer 2007 (Volume 25:3).