Basics about Bipolar

by Edward T. Welch

Starting with a case study and a biblical framework, this article takes us through a review of four books on the topic of bipolar disorder. Ed summarizes and interacts with these secular materials, gleaning what we can learn from them, while he builds a distinctly biblical interpretation of the struggles and symptoms of those facing this problem.

Part 1 of 3

Diane, a thirty-five-year old wife and mother, was becoming increasingly irritable. Her flashes of anger at the slightest provocation put everyone on high alert. Adding to the family tension, she was sleeping erraticallystaying up late and getting up early. The family didnt really know what she was doing with her time. Half-finished projects littered the house, none in synch with family priorities. These tensions weighed on her husband and were compounded by Dianes apparent unwillingness to listen to the concerns he or others had about her behavior. Conflict was inevitable.

After an especially intense argument, Diane stormed out of the house. She ended up in a bar about ten miles away, met a man and went to bed with him. When she finally came home the next morning, disheveled and distraught but still testy, she told her husband what had happened. He, of course, was extremely distressed. He called his family physician who told him to take Diane to the emergency room. From there the doctor admitted her to the psychiatric ward.

It sounds like a case of pride coming before the fall, and it is. But there is more. Superimposed over whatever was going on in her heart, Dianes mind was racing. Never before had she been so distractible or hyperactive. Her interpretations were increasingly bizarre. She simply wasnt herself.

The diagnosis for Diane in the psychiatric hospital was bipolar disorder. Diane was artificially high manic. Her high was exaggerated, exhibitionistic, talkative, restless, wired, and self -destructive. This is one extreme of bipolar disorder (previously manic-depression). Depression is the other pole, the subdued or down mirror image of manias exuberant, up. Once clued in to these fluctuating, extreme emotions, her husband could easily cite several other periods of similar activity in Dianes life.

The diagnosis of bipolar is a welcome challenge to careful, practical theological development. Since Scripture speaks with breadth and depth to all of life, a biblical counselor should be eager to examine every

human experience. So far, however, there has been very little written about the bipolar experience from a biblically thoughtful perspective.1 This articles brief foray into bipolar considers how to think biblically about this topic when a concordance is of no help, and when no biblical characters exhibit bipolar symptoms. This article will also review several current books on the bipolar experience.

Psychiatric Words

One feature of biblical counseling has been its interest in the vocabulary used to describe and label problems. What should biblical counselors make of words such as mania and bipolar? At issue is not so much whether some words are right and others wrong, but some words come prepackaged with an entire worldview that can obscure or distract from the inevitable spiritual issues that run throughout the behavioral symptoms. Mania is one of those words. An even more basic reason for care in the use of vocabulary exists. Biblical counselors want to think biblically in order to proceed redemptively and helpfully. It is a challenge to think biblically when you cannot locate a specific problem in Scripture, when some of the phenomena simply do not appear. In this sense, mania is similar to such words as dating, stress, obsessions, and ADD. None of these words appear in Scripture. Some Christians respond in a biblicistic manner to these terms. They either deny the existence of the problem or they force the phenomena into implausible prooftexts. Other Christians respond in a syncretistic manner. They turn to psychological models and accept definitions and explanations at face value. Neither approach does the hard work of thinking biblically about a difficult topic related to human behavior.

In order to locate mania in the Bible, you must first reduce it to concrete and descriptive terms. What does it look like? What does it do? How does it think? What does it feel like? As we answer such questions, an experience not initially cued to Scripture can now be understood through a biblical lens. As you do this, you will find that the manic end of the bipolar disorder continuum combines varying degrees of the following thoughts, behaviors, and emotions: elated mood extreme unwarranted irritation or anger decreased need for sleep unrealistically high self-estimation talkativeness racing and impractical thoughts impulsivity reckless behavior

y y y y y y y y

These words and phrases describe mania concretely. Blend them together and it gives a context for personal and interpersonal chaos with a cascade of bad results (cf. James 3:16).

Mania shuns limits. It can even merge with depression and become a tangled, emotional mess in which someone oscillates between the highs and the lows, the manic and the depressed. It can soar beyond the boundaries of all that seems normal, becoming a whirling, unstoppable torrent that confuses both the affected person and their frightened families. A stranger invades the home. This stranger combines a volatile mix of overestimating personal ability to achieve, while at the same time underestimating the risk of these erratic behaviors. The crash is inevitable.

When a diagnosis of bipolar is given, it inadvertently releases the person from self-responsibility. But the behaviors on this list (carried to the extreme by the bipolar person) are ungodly behaviors. The mania experience doesnt erase personal moral responsibility, but it does alert you to look for other possiblecontributing influences. Consider this parallel example. If Billy hits another child, the behavior is wrong. But if Billy had previously been mocked, picked on, or beaten by John, you would certainly take that into account as you discipline and disciple Billy.

Relevant Theology

Even with concrete descriptions of bipolar, relevant Scripture might not come to mind immediately. There are hints from James and Proverbs about self-control and listening more than talking. But these verses dont provide enough superstructure to minister effectively. In order to gain a comprehensive biblical picture, we must look for both specific Scripture passages as well as large scale biblical doctrines that rise out of Scripture. Two broad questions can lead to relevant doctrine: Who are we as human beings? Of what do we consist?2 These questions will help to organize and interpret this motley array of bipolar behaviors.

There are various theological angles on these questions. Most applicable to this discussion is what has been called the ontological perspective which examines the basic building blocks of humanness. Of what substance do we consist? And how many substances? Are you just a body or is there something more? For the purpose of this discussion, I will assume that a human being consists of two substances, body and spirit, material and immaterial. Spiritual substance is apparent when the problem is clearly moral. If some thought, act, or emotion violates the commands of Scripture, the spirit or heart is the ultimate cause. Other strengths or weaknesses, abilities or disabilities, are nonmoralthe physical equipment to which the heart reacts.

At first glance, manic behavior appears to be clearly spiritual: inflated sense of self, impulsivity, reckless behavior, talking and not listening. These are moral matters. But a second pass raises questions. Take Dianes case. You have never before witnessed her mind so active and chaotic. It is as if the normal guardrails have been removed. There is no contour or structure to her thoughts. Does Scripture demand a slow or methodical mind? No. God calls for an anxious mind to be at rest in Christ, but Dianes behavior doesnt look like anxiety. Instead, she looks like a woman on amphetamines, and this is a physical experience. Elated mood, decreased need for sleep, inaccurate estimates of strengths and weaknesses, and nonstop thoughts can all be conjured by changes in brain activity.

Scripture does call us to self-control, and the bipolar experience seems to be in clear violation of this call. But as you listen to a bipolar person you can often discriminate between a chaotic mind and a lack of selfcontrol. A chaotic mind seems random and quasi-delusional. Lack of self-control is always about violation of Gods Word. These two intertwine, but they can be distinguished.

Armed with this basic theology, you have a means to interpret observations about bipolar made by secularists. Biblical counseling interprets other perspectives, including secular ones. It does not ignore them. Since most work on bipolar comes out of the secular community, and since most pastors and biblical counselors do not have case experience from which to draw, we have no choice but to interact with this secular material. Of special interest are books, articles, or internet sites that present case detail: biographies, or even better, autobiographies of men and women who have gone through this experience.

Review of Secular Literature

The four books reviewed in this article represent a spectrum of genres dealing with bipolar phenomena: self-help, cognitive therapy, bipolar in children, and an autobiography of a person given this label. I will review the observations and practical suggestions of these books, then put them in a biblical framework.

David J. Miklowitz The Bipolar Disorder Survival Guide (New York: Guilford, 2002), 322 pages.

One problem with self-help books is that few people actually do what the books prescribe. To put all this advice into practice would be a full-time job! Most readers settle for a few snacks rather than the entire meal. This tendency is exaggerated with those who exhibit symptoms of bipolar disorder because they arent persuaded that they even have a problem. They are not inclined to invest in the process of change when they do not see that change is needed. They think that the real problem is the other people who have

low tolerance for the more energetic and creative moments of their bipolar flights. And they certainly do not see the need for hospitalization.

Very few people will use all of The Bipolar Survival Guide. Those with bipolar who minimize the problem (the majority of them) wont be interested. But for counselors, this guide does offer sane advice. As with most good books not rooted in Scripture, there are provocative and importable pieces. That does not sound like much, but when you lack experience with bipolar, you welcome even a few fragments as a catalyst for hard thinking and wise practice.

The basic premise of the book is this: knowledge is power. The more you understand about the problem, the more you will be able to accept it and manage it. It reviews the symptoms, possible causes, traditional treatments, and self-management strategies.

The book begins with vignettes from the lives of people who have experienced the highs and lows of bipolar. For readers who have rarely, if ever, witnessed bipolar, such stories create an opportunity to accumulate vicarious experience. Secular books can be the greatest help when they give careful descriptions of unusual experiences.

From there, Miklowitz presents a few chapters on the traditional psychiatric perspective regarding bipolar disorder: this is a biological probleman illnessand only a combination of medication and counseling will help. If you deny this, or are lackadaisical in affirming it, the author believes that you hurt the bipolar person. Those who have been through mania are already predisposed to ignore the problem, and the author doesnt believe that they should be abetted in that denial.

Comments like these wave a red cape in front of biblical counselors. But before charging the cape, biblical counselors should recognize that bipolar people do have unique disabilities. They rarely believe that they have a problem, and that alone can make them insufferable to family and friends. The traditional view emphasizes medication, in part, because it seems to inject clarity and protection into an otherwise destructive course.

The actual evidence for a biological substrate is admittedly weak. But a brief overview of a bipolars family tree suggests that something is going on. To pin it all on either the common features of the human heart or on nurture is a stretch. Ask questions about the extended family, and you will usually find a suicide, a hospitalization, an eccentric aunt, or an unpredictably moody parent. In other words, although the evidence is weak at this moment, you suspect that further investigation might yield more definitive dat a for some biological influence.

But biological explanations are not what they once were. When they first emerged in the popular press, the worldview assumed that everything was ultimately biological. But biological explanations are now more nuanced. Miklowitz exhibits some of that nuance. For example, while he is persuaded that there is a biological difference inherent in bipolar, he believes that this tendency interacts with both the circumstances of life and a persons interpretation of those circumstances. That shows common sense. He calls those interpretations the way we think. Biblical counselors call them the outworkings of the human heart. Thinking always reveals how a person relates either to God or to falsehoods.

With this in mind, Miklowitzs explanation of bipolar is that a genetic predisposition can be latent until provoked by difficult life circumstances and/or by unhelpful interpretations the person makes. Therefore, the pillars of this treatment plan include (1) medication, (2) changing the environment, and (3) changing how one thinks.

His thoughts on medication are predictable: medication is essential, and a bipolar person will probably take it for life. He suggests that medication can extend the length of time between recurrences. If there are recurrences, medication limits the extremes of the highs and lows.

Regarding changes in environment and lifestyle, he includes suggestions that most biblical counselors would also mention: Avoid all drugs and alcohol. Deal quickly with conflicts. Stick to a wise schedule. Opt for as much sameness and predictability in life as possible. For example, go to bed and rise at the same times and avoid allnighters. There is some reason to think that significant and rapid changes to the routines of life can trigger those vulnerable to bipolar highs and lows. His psychotherapeutic component focuses on present problems more than past history and addresses these questions: How does bipolar affect your work and relationships? Have you identified early warning signs? Do you know how to grow in your relationships? How have you handled the possibility of future bipolar fluctuations in your life? The author gives practical suggestions for identifying early warning signs and assembling a team of persons who can help. He advises that whenever the bipolar person notices connections between early behavioral changes and later bipolar highs, he (or the counselor) should write these down, then date the paper and sign it. If, during more stable periods, the bipolar person acknowledges that certain steps would be wise to follow during the highs, he or the counselor should write these down as well. These steps could include taking away (or giving up) car keys and credit cards as a means to limit the damage done by impulsive decisions.

y y y

y y y y

What are biblical counselors to do with all this? Biblical counseling has historically had an uneasy relationship with such secular material. Some suggestions seem like common sense, some seem misguided, and all need renewal of the heart and the power of God in order to truly be successful. Some material is more helpful and some less. In general, a biblically-attuned audience will find more user-friendly advice when authors meet the following criteria: They bring a wealth of case experience with prominent description. They offer pragmatic and common sense suggestions rather than being devoted to a highly specific theory. Their theory is broad, inclusive, and flexible, rather than reductionistic. As far as psychiatric books go, this book satisfies these criteria. It is relatively easy to reinterpret and adapt. We can learn from its descriptive and practical aspects. The authors experience is evident. This makes his suggestions more useful. The book is pragmatic. It is oriented toward what helps and what works. It shows evidence of common sense in how he locates a bipolar-anger nexus around personal desires and demands. Though he does not interpret desires biblically, the reinterpretation is not difficult. The drumbeat of the book, however, is take your medicationexactly what would be expected from a traditional secular approach. The less a person knows about the heart, the more he or she focuses on medical technologies. Miklowitz does allow for contributions beyond the genetic. As a result, biblical readers will agree with some of his practical suggestions.

y y y

y y

Biblical counselors could translate the book this way: because people are embodied souls, we expect to notice distinct contributions from the heart, from the body, and from the social context. Mania might in part result from a physiological proneness toward a racing mind and energetic body. It might show a correlation to social stressors. This presents us with two spiritual tasks: to understand the unique struggles imposed by the extreme behavior fluctuations to help the person live in dependence on Christ in the midst of these behavior fluctuations (not necessarily to abolish these fluctuations, though we would like to assist with that, if possible) Obviously, the book does not offer advice with these distinctions in mind, but theologically alert readers can find material that can be reorganized around a biblical view of the person. The book also challenges biblical counselors to develop their views on psychiatric medications.

y y

Endnotes 1 Robert Smith, Lithium and the Biblical Counselor, Journal of Pastoral Practice 10:1 (1989), 8-18; Joseph VanderVeer, Pastoral Psychopharmacology, Part II, Journal of Pastoral Practice 3:3 (1979), 9810. 2 Cf. Michael Emlet, Let Me Draw a Picture: Understanding the Influences of the Human Heart, Journal

of Biblical Counseling, 20:2 (2002), 47-52; Edward T. Welch, Blame It on the Brain (Phillipsburg, NJ: P&R,1998).

Basics About Bipolar - Part Two

by Edward T. Welch

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.

Part 2 of 3. Read Part 1

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, cognitivebehavioral 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 socia l fallout of bipolar disorder.

Essential to meeting these stated goals are checklists of symptoms and self-monitoring charts. These selfawareness 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 approachesand it doesn't take longyou 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 co mpared to the problemsolving 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 en d 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 moves the bipolar diagnosis downward to include children. Like psychiatric words in general, they point out real problems, but they can blind you to the ordinary dimensions of those problems. The real problem is children who go ballistic over the word no. They become unglued over unpredictable change, such as their balloon breaking or their ice cream being served in the wrong bowl without their favorite spoon. Or a comment about France persuades them that they must go to France immediatelytheir very life depends on it! But these children are just like all other children: they are on a journey in which they are learning self-control and other features of wisdom. Some children pick it up quickly; others learn it gradually after years of creative and patient parenting. Being able to see the ordinary humanness in unusual

10

behaviors is a powerful way to understand and help. It will always be the chief emphasis within ministry. But biblical counselors must also pause and reflect on the unusual nature of some children's behavior. The degree of the problem certainly feels out of the ordinary to parents. Even the children sometimes ask, "Why am I different from other people?"

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

11

wonderful opportunity to bring godly instruction to the child. So later, during a calmer time, they must explain to the child that: 1. 2. 3. It is hard to be teachable and have self-controlthese 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 proc ess. 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

12

knowledge of God into the daily life of our children. And secular literature inevitably misunderstands the meaning of its partial insights and practical advice.

Basics about Bipolar - Part Three

by Edward T. Welch

In this last installment, Ed reflects on Kay Jamison's autobiographical account of living with bipolar, discusses the use of medication, and then revisits the case study of "Diane" whose story was introduced in part 1.

Part 3 of 3. Read Part 1 | Read Part 2

Kay Jamison An Unquiet Mind (New York: Vintage, 1995), 219 pages.

A good autobiography invites you into another person's world, then reveals both the beauty and the blemishes of the humanness of that world. Kay Jamison's book does this masterfully. Jamison is a psychologist, an expert writer about moods, and a world-class researcher on the faculty of UCLA and Johns Hopkins psychiatry departments. She writes about bipolar fluctuations because she has personally been affected by bouts with it. Along with her more technical writings, she has written popular books about mania and creativity. She has also written about suicide. An Unquiet Mind is a must-read for anyone dealing with bipolar tendencies.

When I am high I couldn't worry about money if I tried. So I don't. The money will come from somewhere; I am entitled; God will provide. Credit cards are disastrous, personal checks worse. I bought twelve snakebite kits, with a sense of urgency and importance. I bought precious stones, elegant and unnecessary furniture, three watches within an hour of one another (in the Rolex rather than Timex class: champagne tastes bubble to the surface in mania), and totally inappropriate siren-like clothes. During one spree in London, I spent several hundred pounds on books having titles or covers that somehow caught my fancy: books on the natural history of the mole, twenty sundry Penguin books because I thought that it could be nice if the penguins could form a colony. (p. 74)

Like all good stories, this one has complexity and unexpected paths. For example, Jamison was surprised when her personal story became a story about love. During her crises there was always at least one devoted, understanding, and loving friend who provided a safe harbor. Love was not always enough, in

13

itself, to pull her out of the depths or down from the heights, but it softened the blow of bipolar and changed her more than she had realized at the time of the events.

Jamison takes the traditional line on bipolar: medication and therapy are essential. Some might suggest that her story is an advertisement for Lithium. One of her aims is to get people to take their medication. But don't dismiss her writing too quickly. Such zeal makes sense when you watch her on or off medication. Medication clearly puts boundaries on her manic-depressive extremes. While it is always difficult to precisely identify the effects of medication, and someone could always find other variables that incite emotional ascents and descents, Jamison is persuaded that medication spares her and others much grief. Her personal distaste for Lithium and its accompanying emotional restraints makes her support for its effectiveness all the more persuasive.

A final note. Biblical counseling needs to grow in its use of case studies. Too of ten we create a caricatured, two-dimensional person at the service of a particular principle. Jamison's book is a paradigm for the next generation of case studies. In it you will find a three-dimensional, messy life that will engage you in a conversation with a real person.

Medication

This literature on bipolar raises many questions and observations for biblical counselors, as good secular literature should. The most obvious question has to do with psychiatric medication. The literature is resolute in its commitment to medication, but biblical counselors are, at best, uneasy with the use of medication. The tension between these two positions creates an opportunity for biblical counselors to listen to others, and then continue to refine our application of Scripture to this important discussion.

Is it wrong to take psychiatric medication? Within the biblical counseling movement, the answer has never been an easy yes or no. Here are three broad positions commonly seen.

First, among those who lean toward no medication ever, most acknowledge that Scripture contains nothing as bold as "thou shall not take psychiatric medications." They explain the wrongness of medication with the following explanations: 1. 2. 3. Medication can be taken with the wrong motives. An unbiblical worldview is often swallowed with the medication. This approach bypasses God-ordained means of sanctification. The problem is not so much with the medication per se, as it is with the person's heart.

14

Those who hold a more moderate view believe that though medication is wrong, it is not the worst wrong. It is like smoking cigarettes or drinking an occasional glass of wine. Some Christians believe that these activities are wrong, but they aren't in the same class as murder, thievery, or sexual misconduct. Whenever someone says psychiatric medication is "wrong," biblical counselors must carefully evaluate and define the nature and definition of that wrong. 3

A second position within biblical counseling says that we must focus on what is clear in Scripture. That includes the pride and unilateral decisions inherent in most mania, the reckless spending and sexual behavior that so often express it, and our calling to erect walls between the manic person and dangerous behaviors. When the mania burns out, there is much work to do with the family and other relationships. Since our attention is consumed with these matters, and we don't consider ourselves experts in this area, we put psychiatric medication in the wisdom class rather than the immoral class. We encourage the person to make decisions by seeking counsel from those who have experience with medication.

A third position could be biblically argued that those with bipolar symptoms should be urged to consult with someone about psychiatric medication. If he or she decides to take the medication, then it should be taken as recommended. The motivation could be love: to bless family and friends, all of whom have been hurt and alarmed by the manic symptoms. Also, medication could be viewed as a means of erecting walls that help with self-control. Medication can't change the heart and infuse godly self-control, but it can serve as a restraint during chaotic times.

Here is one possible trend among biblical counselors. As we accumulate more experience with bipolar, we notice that medication helps fewer people, and hurts more, than commonly known. But when medication does limit the highs and lowsand there are certainly people for whom it doeswe welcome its benefits. Biblical counselors never rely solely on medication. It certainly is not enough to support anyone's hopes. Instead, if a person takes psychiatric medication, move toward this person because he or she needs the body of Christ to meaningfully point them to the wisdom of God.

These possibilities with medication do not apply to children. Very few biblical counselors have spent enough time with children, before and after medication, to observe its long -term benefits and possible side effects. What is known about the physical effects of the medication in adults is more than enough to scare most parents into considering alternatives to medication. Without this critical experience, caution is the norm. It is hard to imagine a biblical counselor ever encouraging bipolar medication for children, even though it seems like a wonder drug for some. Scripture is dense with parenting guidance, and that will always be the priority.

15

This in no way means that bipolar-like experiences are absent in children. If anything, emotional fluctuations, in the extreme, are more apparent in children than in adults. Also, this doesn't mean that all children respond to godly parenting. They don't. There is no question that there are parents in most every church who are overwhelmed with an out-of-control child, and there are no easy answers or homework assignments for these parents.

Application

I will close by revisiting "Diane" whose story began this article.

By the time you become involved with Diane, she is already taking medication. Any evaluation of that decision is certainly not the most important issue at this moment. Much more critical is that she has just seriously betrayed her husband, and he is both broken and angry. Can this marriage be reconciled?

Begin with the person. Listen to Diane. Observe. What is her experience? What is she doing? Thinking? Feeling? Sometimes Scripture initiates, other times it responds. Either way it intends to shape the way you think about everything. Gather initial information from Diane or her family. Then let Scripture propose tentative ways to think about the problem. (I say "tentative" because of weaknesses in our understanding, rather than ambiguity in God's point of view.) A dialogue will ensue, in which we seek to refine our understanding of the particulars of Diane's life.

Diane's betrayal of her husband through adultery is obvious. Regardless of the provoking circumstances, this act cannot be pinned on anything other than her own heart. Neither the wild fluctuations of mania, Satan himself, nor her husband's contribution to the argument can coerce one into breaking marital commitments. Diane intuitively understands that. She feels guilty and quickly acknowledges her wrong. Scripture clearly addresses adultery. Before her hospitalization, Diane would get irritable, angry, even enraged, whenever someone did not support her wild ideas. Scriptures clearly addresses anger. James 4 explains this situation. Diane wants something. She craves getting her own way. Others hinder her from getting it. A discussion with Diane about holding more loosely to her "wants" is appropriate. Unchecked desires become idolatrous and provoke vengeful responses.

Mania and anger share a common bond. They both exhibit relentless pursuit of desired ends. But Diane shows no sign of willingness to release her desires. She either dismisses you as one without vision, or doesn't seem to hear you at all. Wait. This is the right track to pursue. It is right and relevant, but so far, with Diane, it is not effective. Pastoral care must be both right and effective.

16

Is Diane hardhearted? That would be a logical conclusion, and there might be truth to it. But let's say you are a novice in interpreting bizarre behavior. You know you are on terrain where there are many different opinions, so walk carefully and cautiously. If you pursue her hardheartedness, you must be certain. It leaves you no other place to go. Also you have good reason to believe that confrontation may well provoke her to greater anger and agitation. Furthermore, if that becomes the premier explanation for her behavior, and her family adopts that view, the results could be full -blown disaster.

Continue to explore. Diane's story illustrates a premise that will always hold up when you meet an extreme problem not clearly addressed in the pages of Scripture: behind the bizarre and unusual is the normal and commonplace.

Try to understand what happened with Diane. She is, no doubt, feeling guilty and confused. As her story unfolds, she reveals that she has never been sexually unfaithful to her husband before, and she has never entertained such thoughts. She remembers the argument with her husband, and she remembers her dramatic exit. After that, everything feels like chaotic pieces. But now she is committed to doing whatever she can to reconcile and protect her marriageHer husband is reeling, but he is willing to work on the relationship. Nothing can take the sting out of the betrayal, but he believes that his wife was not highly intentional in her adultery. He is not sure what to think about the diagnosis of bipolar, but he believes that it is, in some way, a mitigating factor.

Your approach to Diane is that nothing can make her sin, other than her own heart. She intuitively understands this and accepts responsibility for what she did. She confesses her sin to her husband, though she recognizes that her confession is just the beginning of the work that must be done.

Diane's confession certainly pushes the reconciliation process forward, but her husband is concerned that the mania could emerge again with the same results. This is a reasonable concern. Medication is no guarantee against future manic swings, so you allow Scripture to add important detail.

Whatever mania does, it can only act like a temptation, not the power that coerces you into foolishness. So the task is to become more alert to this particular temptation and more equipped to do battle with it. There are plenty of temptations with mania. For example, the highs invite Diane to be absolutely confident in what she thinks, wants, and demands. There are no uncertainties at those times, and no listening to the

17

wisdom of others. So, one of Diane's tasks is to grow in humility before the Lord, and as a result, before other people.

Diane must make the James 4 passage her own. During her emotional escalation, Diane wants something she craves getting her way and others hinder her from getting it. In other words, the diagnosis of bipolar alerts us to certain unique temptations. Diane, like the rest of us, wants what she wants (the normal and commonplace). During times when she is emotionally more stable, this comes out in occasional marital conflicts. But during her bipolar swing everything is exaggerated, including her anger. Her behavior becomes more bizarre.

This gets you started. Along the way you might go online or read one of these books as a way to get more understanding about an experience that is hard to describe. Mania is a unique temptation, and you want to be as prepared for it as possible.

What causes the manic swing? We don't know. But one of the beauties of Scripture is that it guides us in doing helpful ministry even when we don't know the precise causes and influences on a person's particular struggles.

Whenever biblical counselors encounter new problems, it is a natural time to develop better application of Scripture. Mania is one of those new problems. Since we are certain that Scripture is infallible and sufficient, there is absolutely no threat to our biblical foundations. But, since we are fallible, we must come to the process with humility that listens to one another and even listens to voices outside our tradition. What we anticipate is a course where Scripture accounts for reliable observations and speaks with greater depth than any biblically unaided approach.

Endnotes
3

If the word "wrong" didnt have ambiguities, biblical counselors who adopted this position would have to

tell all Christians who take psychiatric medication to simply stop taking it.

*****

18