Although bipolar disorder is more well known than BFRBs, many do not fully understand the bipolar spectrum. It was previously called manic-depression. Many people picture the major mood swings of extreme depression and manias that include breaks with reality, and need for hospitalization. While these are considered some of the symptoms, they are not present in every presentation of bipolar disorder and do not encompass all of the symptoms that are often present. For example, I suffer from Bipolar II disorder, which means I am depressed about 75% of the time and although I do get hypomanias, I have never had a full blown mania.
Bipolar disorder is a life long mental illness that can be managed to allow for a happy, healthy, well balanced life. Suffers must be aware of and strive to minimize triggers (including self medication). A strong support network and willingness to seek help are crucial. Medication, including mood stabilizers, are a necessary part of treatment. They should not be stopped even if the condition seems completely under control, as relapse would be inevitable. Instead, medication can be slowly lowered to reach a minimum level. If a relapse occurs, the medication would need to be increased again.
However, under care of a mental health professional, these many be stopped for a brief time. For example, I did not take any medication while pregnant or breastfeeding. That was a personal choice that I wouldn’t change. It required an acute awareness of my triggers and slight changes in my mood, energy level, anxiety, and mental clarity. I managed to stay relatively balanced. After 4 children and 3 years without medication, my symptoms are strong. I have recently started a mood stabilizer that will help to level me out.
The following is part 1 of a 3 part series written by Ed Welsh. It provides a great overview of bipolar disorder.
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 erratically—staying up late and getting up early. The family didn’t 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 Diane’s 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, Diane’s mind was racing. Never before had she been so distractible or hyperactive. Her interpretations were increasingly bizarre. She simply “wasn’t 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 mania’s exuberant, “up.” Once clued in to these fluctuating, extreme emotions, her husband could easily cite several other periods of similar activity in Diane’s 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 article’s 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.
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 proof-texts. 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
- racing and impractical thoughts
- reckless behavior
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 doesn’t 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.
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 don’t 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 nonmoral—the 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 Diane’s 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 Diane’s behavior doesn’t 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 self-control. A chaotic mind seems random and quasi-delusional. Lack of self-control is always about violation of God’s 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 aren’t 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) won’t 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 problem—an illness—and 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 doesn’t 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 bipolar’s 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 data 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 person’s 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, Miklowitz’s 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.
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 author’s 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 medication”—exactly 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.
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.Endnotes1 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), 98-10.
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
Read Part 2 | Read Part 3