By Kelsey Trainor
I. Definition
Secular Perspective
Those diagnosed with bipolar disorder are characterized by intense mood expressions that cycle from very up (manic) to very down (depressed). These moods typically last for weeks at a time. While there is great variation in secular approaches to treating and explaining bipolar disorder. There is overwhelming consensus that it is in fact a real physical disorder and not merely a habit pattern that the counselee falls into.
DSM-5: Bipolar is placed between Schizophrenia and depressive disorders, in DSM-5 because it is thought to relate to both and appears practically to be a cross between them. Since a bipolar diagnosis requires the counselee to experience both manic and depressive episodes, there must be criteria for qualifying these states, and that is what the DSM-5 tries to do.[1]
Manic episode:
“A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).”[2] With three or more of the following:
-Inflated self-esteem, grandiosity
-Decreased need for sleep
-More talkative then usual
-Flight of ideas
-Distractibility
-Increase in goal-directed activity
-Excessive involvement in activities that have a high risk of painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretion, or foolish business investments).
These episodes must be “severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.”[3]
These episodes must not be caused by a substance or other medical condition.
Hypomanic Episode:
This is essentially the same as a manic episode, but lasting at least 4 consecutive days instead of 1 week.
Major Depressive Episode:
“Five or more of the following have been present during the same 2-week period and represent a change form previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
-Depressed mood
-Diminished interest
-Significant weight loss
-Insomnia or hypersomnia
-Psycomoter agitation or retardation
-Fatigue
-Feelings of worthlessness
-Diminished ability to concentrate
-Recurrent thoughts of death
Severe enough to cause social or occupational impairment.
Not caused by substances or other medical conditions.[4]
With these criteria defined, bipolar can be broken up into the following categories and qualifiers.
Bipolar I:
“An illness in which people have experienced one or more episodes of mania. Most people diagnosed with bipolar I will have episodes of both mania and depression, though an episode of depression is not necessary for a diagnosis. To be diagnosed with bipolar I, a person’s manic episodes must last at least seven days or be so severe that hospitalization is required.”[5]
Bipolar II:
A subset of bipolar disorder in which people experience depressive episodes shifting back and forth with hypomanic episodes, but never a “full” manic episode.”[6]
Cyclothymic Disorder or Cyclothymia:
“is a chronically unstable mood state in which people experience hypomania and mild depression for at least two years. People with cyclothymia may have brief periods of normal mood, but these periods last less than eight weeks.”[7]
Substance induced bipolar:
Some drugs can contribute to the onset of bipolar disorder.[8]
Bipolar due to another medical condition:
There are some medical conditions such as hypo or hyperthyroidism
Bipolar Disorder, “other specified” and “unspecified”:
“When a person does not meet the criteria for bipolar I, II or cyclothymia but has still experienced periods of clinically significant abnormal mood elevation.”[9]
[The following chart may be a helpful, visual representation of the differences between the various types of bipolar disorder.[10]]
Biblical perspective
From a medical standpoint, it is difficult to determine whether it is a true disorder, merely a behavior, or something in between. From a spiritual standpoint, there are many temptations, sins and struggles that could be associated with it, and these will likely be very different from person to person. Drawing a distinction between the physical and the spiritual will be particularly challenging and it behooves the counselor to not assume that they understand what the problem is before they have done proper inventory with their particular counselee. That being said, one very likely issues that may be encountered is simply convincing the counselee that the problem is more than physical and that actions which the Bible clearly defines as sin are always sin, regardless of what physical weaknesses one may be suffering. Some of the most common, deeper issues behind the expression of bipolar behavior could be anger, foolishness, recklessness, despair, and fear.[11]
II. History
Bipolar disorder is difficult to trace through history because of the subjective nature of it’s definition. However, there are some traces of it throughout history. It used to be called manic-depressive disorder and even earlier was called circular insanity. In early days, it was thought to arise from an imbalance in the ‘Humors’ of the body. Bipolar was once termed manic-depression, but was changed in the DSM-III. Even before that it was called circular insanity by Jean Pierre Falret who may have been the one to first to label it.[12]
III. Evidence of the Problem
External evidence of bipolar disorder primarily centers around what is manifested in a manic state, since what distinguishes bipolar from other mood disorders like dispersion is the presence of manic states in addition to depressive states. The expressions of a manic state are:
-Inflated self-esteem, grandiosity
-Decreased need for sleep
-Being more talkative then usual
-Flight of ideas
-Distractibility
-Increase in goal-directed activity[13]
The characteristics of a depressed state are:
-Depressed mood
-Diminished interest
-Significant weight loss
-Insomnia or hypersomnia
-Psycomoter agitation or retardation
-Fatigue
-Feelings of worthlessness
-Diminished ability to concentrate
-Recurrent thoughts of death[14]
IV. Etiology
With bipolar, distinguishing where the physical stops and the spiritual begins, is particularly murky; however, there is no reason for the biblical counselor to be discouraged or to completely hand over a counselee with this prevention problem to a secular psychologist.
One reason why this issue is particularly difficult is that there is no conclusive scientific cause of bipolar. There are however several theories. These are primarily, gene sequences,[15] hormones,[16] neural pathways,[17] and “biostressors”[18]. All of these could very well be strong factors in the disorder; however, none of them are conclusive, and there is need for further scientific research on the topic. An alternative theory is that stress, and the sleeplessness that commonly accompanies it, effect the body in such a way that the endocrine system (the system responsible for the regulation of hormones) in particular could be damaged, at least temporarily. The hormone cortisol is particularly implicated.[19] This also occurs with other disorders like adrenal fatigue which may be related.[20]
V. Examining the Heart
With bipolar in particular, it can be rather difficult to discern what the central heart issues may be, since bipolar itself is not necessarily a sin, if we define it as having a propensity towards intense moods. The need for counseling comes in once the counselee fails to manage their moods well and has developed bad reactionary habits in stressful situations. This can manifest in multiple heart theses and idols. It may come down to the counselee trusting their own emotions over God, or they may be seeking escapism instead of right relationship with God, preferring to cycle through emotionally consuming experiences instead of facing the reality of their guilt before God, which becomes much clearer when one is in a more sober frame of mind. This may be rooted in a fear of facing their guilt before him.[21] The chart below is from Counseling the heard cases and it lists several posable heart themes.[22]
VI. Biblical Solutions
Perhaps the best place to start with a counselee who is seeking help with their bipolar disorder is to realize that bipolar is not what they need counseling for at all; their reaction is. Providing a comprehensive strategy for every potential issue which one could encounter in a counseling situation is outside the scope of this article, but since angry outbursts are seen in many with this diagnosis, the following will focus on that issue in particular.
The “8 Is:”
Involvement
It may be particularly challenging to counsel a person with bipolar because they may be up the first few weeks and down the next. It may be tempting in these times to be impatient with them and not to practice the principal of Romans 12:15 to weep with those who weep, so be on guard with that. It may help to thing of meeting them where they are at, but also not letting them stay there; which will be worked out in the rest of the counseling process.
One source pointed out that approaching a manic counselee may need to look a bit different then in other circumstances, “With Bible in hand, counselors would not get very far with persons whose auditory hallucinations make out impossible to concentrate. Bringing spiritual reality into a severely psychotic or manic person’s world is like standing at a fixed point and talking to someone who is riding a high-speed merry-go-round. The person may be able to comprehend a simple verse or biblical concept, but there is little ability to focus and the merry-go-round never slows.”[23] Perhaps one way to help combat this type of situation would be to take your counseling outside and walk as you talk. This may not always be a possibility, but it may also help them focus greatly. Garrett Higgbee found it helpful in his counseling to let his counselee take breaks to go for a walk.[24]
Inspiration
There are many good general passages for hope that are always applicable in counseling, Romans 8:29, 1 Corinthians 10:13, and 2 Peter 1:3 to name a few. But one that may be particularly helpful in the case of bipolar is Isaiah 26:3 “You keep him in perfect peace whose mind is stayed on you, because he trusts in you.”
Inventory
Asking good inventory questions is always key. In bipolar in particular it is important to understand the counselees history of the problem and what behavioral patterns and reactions they have established. Here are some questions that may be helpful.
What things usually happen before you slip into a depressed or manic state? Are there certain people, or events such as a loss or frustrating situation that you have noticed being a trigger?
When you are in a manic state, do you typically have a desire to get out of it? If so, how do you try to do that? What if anything has helped in the past?
When you are in a depressed state, how do you know that you are either slipping into it or in it already? What is the worst aspect of it for you? What usually helps you get out of it? What copping mechanisms have you used, if any?
Interpretation
Is this their way of avoiding something? Like feelings of guilt or fear. Is laziness involved? Could it be a way of manipulating those around them? Bipolar behavior could be a mask to cover these or other issues. The label itself can easily become an excuse to act badly and treat others un-lovingly.
They may be stuck in a cycle of bad reactionary habits that keep feeding into each other and causing this cycle of depression and mania. It may have begun with the loss of a loved one, which influenced them to feel sad, which they reacted to by putting off their work, which caused them to become more depressed, then, sick of being depressed, they may at some point, find something that they felt they could invest both their energy and their hope in and pursued that with fervor, but when that proved to be unsatisfying or when another hardship came there way, they sank into depression again, and the cycle continues. Discovering where this pattern started and the many other things that could contribute to it can be very difficult, so good inventory is necessary before even getting to this point.
Instruction
Since there will likely be other heart issues and habits related to bipolar, what you address first will very case by case, but in regards to the mood instability and the cycle mentioned above under interpretation, the best instruction may be to help them see this pattern objectively for themselves. You may be able to put together what this may look like based on your inventory, but to help the counselee do it, you could read to them a case study (either real or manufactured) of someone else who was stuck in this cycle and then call their attention to that cycle, make sure that the counselee can track what was going on in that case and then ask them to see if they can identify a smaller cycle in their own life. Be sure to help them out along the way, if they get stuck, but always be ready to reevaluate your interpretation and avoid leading questions.
Once the counselee has thought through their emotional cycle, the things that need to be put off and put on will likely bubble to the surface naturally. They could be, laziness to working heartily to the Lord, bitterness and anger to humble forgiveness, fear to trust in the Lord, or many other things. Regardless, they can learn to put off instability and put on hope in the Lord.
Inducement
It will likely be difficult for your counselee to change these well ingrained habits. They may not be convinced that it is possible for them to change, or they may not be completely convinced that they need to change, but not know how to start. This is where you will have to the get back to the hope of true change that you exposed them to in the beginning and to the principal that we are to honor the Lord in all that we do and that we cannot honor him properly when we let our moods dictate how we do our work and treat others.
Implementation
To help the counselee apply these changes you should start by helping them to recognize when they are tempted to swing towards one extreme or the other and to respond with prayer that the Lord would help them to be at peace and to honor him and to expose any sin that may be involved in their feelings, but also to not have any misplaced guilt and to not put to much trust in their emotions.
Integration
Once the counselee is able to see what is going on in their hearts when they are feeling like they are moving towards an extreme and can biblically evaluate their emotions and moods and respond in a way that honors the Lord, and can help another to do the same, they are ready to end counseling
Recommended Books
Scott, Stuart, Heath Lambert, and Master’s College. Faculty. Counseling the Hard Cases : True Stories Illustrating the Sufficiency of God’s Resources in Scripture. Nashville, Tenn.: B & H Academic, 2012.
Thomson, Rich. The Heart of Man and the Mental Disorders : How the Word of God Is Sufficient. Second Expanded ed. Alief, Texas: Biblical Counseling Ministries, 2012
Asher, Marshall, and Mary Asher. The Christian’s Guide to Psychological Terms. 2nd ed. Bemidji, Minn.: Focus Pub, 2014.
Moncrieff, Joanna. The Myth of the Chemical Cure : A Critique of Psychiatric Drug Treatment. Rev. ed. Basingstoke: Palgrave Macmillan, 2009.
Recommended Homework Resources
Anger: A study of James 4:1-10
Disciplined Thinking: A DWT on Philippians 4:8
Depression: “Depression: Help for Overcoming Depression” from A Christian Growth and Discipleship Manual Vol. 3[25]
Self-control: “Self Control and Discipline” from A Christian Growth and Discipleship Manual Vol. 3[26]
[These resources were suggested in Counseling the Hard Cases]
How to Handle Trouble
Chapter 4 of Instruments in the Redeemers Hands,
“Motives” a booklet by Ed Welch
The following assignments may also be helpful:
Understanding the Cycle of Bipolar Disorder
For the counselor:
[This is a pattern that you may see when your counselee completes this exercise.]
A manic state may come after a traumatic life event.
- Why might one want to move into a maniac state?
-Pleasure: To mask their feelings of disappointment, productivity, personal glory, attention from others, excitement/entertainment
- What might one be wanting when they are moving out of a manic state?
-Peace: freedom from seemingly uncontrollable racing thoughts, with the people around them, physical rest
A depressed state may after a traumatic life event, after a threshold of fatigue is reached due to a manic state, or after a manic state fails to achieve the desired result, thus producing disappointment.
- What might one be wanting when they are moving into a depressed state?
-Pleasure: To dwell on dis-gratitude (to mope, complain internally or externally), to put off responsibilities, to have an inflated view of ones own responsibilities/sovereignty,
- What might one be wanting when they are moving out of a depressed state?
-Peace: Freedom from guilt, worthlessness, anxiety
For the counselee:
[They can complete this as homework between the first and second session, or you would walk through it in session as part of your inventory. The latter option may be a better idea if they are in a particularly extreme mood and are having trouble thinking clearly about thinks.]
First, pray and ask the Lord’s help in thinking through your past experiences in a way that is accurate and thorough.
- Think back to as many manic episodes as you can and list them as best you can. What were the circumstances leading up to those periods? What were your activities, and what were you wanting in each of those activities?
- How did each of these episodes end? Where there any negative ramifications? What external factors may have influenced you to come out of that manic state? Did you stay in a comfortable state for a time, or did you slip straight into a depressed state?
- If you moved into a depressed state, either immediately or eventually after any of these manic states, list them as well. What were the circumstances surrounding these periods? What changes took place in your activities? What changes took place in your thoughts? What were you longing for in these times?
- How did each of these episodes end? What habits of yours changed? Was there anything in particular that you saw as prompting you to come out of depression? What were you wanting most in those times?
Proverbs 3: Gaining Wisdom
[Before assigning this homework, be sure your counselee understands that this chapter does not teach the prosperity gospel.]
- Pray and ask the Lord to help you understand, love, and obey his word.
- Read Proverbs 3 through carefully
- Read it again and highlight the verses that most apply to your current situation.
- Now go through it again and mark all of the commands.
- Now go through and mark all the promises.
- Which of these commands and principals do you need to put on? Wright them down on a separate piece of paper.
[Note for the counselor: Verses 5, 7, 13, and 21 will likely be the most relevant for your counselee, as they deal with gaining right wisdom and understanding form the Lord. But also be aware of some of the other verses which address other heart themes that your counselee may be dealing with: uncontrolled spending 9; trouble viewing discipline of the Lord as a good thing 11; if they are struggling to sleep, 24 may be comforting; and if there is a thread of anxiety 25-26 would be relevant. There are certainly other principals here, but these are the ones that may be most prominent in someone with bipolar as their presenting problem.]
Bibliography
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders : Dsm-5. 5th ed. Arlington, VA: American Psychiatric Association, 2013.
Asher, Marshall, and Mary Asher. The Christian’s Guide to Psychological Terms. 2nd ed. Bemidji, Minn.: Focus Pub, 2014.
Basco, Monica Ramirez, and A. John Rush. Cognitive-Behavioral Therapy for Bipolar Disorder. 2nd ed. New York: Guilford Press, 2005.
Bloem, Steve, and Robyn Bloem. Broken Minds : Hope for Healing When You Feel Like You’re “losing It”. Grand Rapids, MI: Kregel Publications, 2005.
Mack, Wayne A, and Wayne Erick Johnston. A Christian Growth and Discipleship Manual. Homework Manual for Biblical Living, 3. Bemidji, MN: Focus Publishing, 1995.
Moncrieff, Joanna. The Myth of the Chemical Cure : A Critique of Psychiatric Drug Treatment. Rev. ed. Basingstoke: Palgrave Macmillan, 2009.
Plunkett, Jeanette M. Bipolar Disorder : Causes, Diagnosis and Treatment. Nova Science Publishers, Inc, 2011.
Scott, Stuart, Heath Lambert, and Master’s College. Faculty. Counseling the Hard Cases : True Stories Illustrating the Sufficiency of God’s Resources in Scripture. Nashville, Tenn.: B & H Academic, 2012.
Simpson, Amy. Troubled Minds : Mental Illness and the Church’s Mission. Downers Grove, Illinois: InterVarsityPress, 2013.
Smith, Robert D. The Christian Counselor’s Medical Desk Reference. Stanley, N.C.: Timeless Texts, 2000.
Strakowski, Stephen M. Bipolar Disorder. Oxford American Psychiatry Library. Oxford: Oxford University Press, 2014. 2014. Accessed February 22, 2019. INSERT-MISSING-URL.
Thomson, Rich. The Heart of Man and the Mental Disorders : How the Word of God Is Sufficient. Second Expanded ed. Alief, Texas: Biblical Counseling Ministries, 2012
Watson, Tom, and Stan Schmidt. Holding God Hostage. 1st ed. Brentwood, Tenn.: Wolgemuth & Hyatt, 1991.
https://www.apa.org/pubs/books/4600100
https://www.apa.org/topics/bipolar/index.aspx
https://www.apa.org/monitor/feb08/consistent.aspx
https://www.mayoclinicproceedings.org/article/S0025-6196(11)60846-X/fulltext
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/216291184
https://commons.wikimedia.org/wiki/File:Bipolar_disorder.webm
https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
https://www.psychiatry.org/patients-families/ect
https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder
https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955
https://www.sciencedirect.com/science/article/pii/S000632230000929X
Works Cited
[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders : Dsm-5. 5th ed. Arlington, VA: American Psychiatric Association, 2013. (123)
[2] Idid (124)
[3] Ibid (124)
[4] Ibid (125)
[5] https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder
[6] Ibid
[7] Ibid
[8] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders : Dsm-5. 5th ed. Arlington, VA: American Psychiatric Association, 2013. (142)
[9] https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder
[10] https://commons.wikimedia.org/wiki/File:Bipolar_disorder.webm
[11] Thomson, Rich. The Heart of Man and the Mental Disorders : How the Word of God Is Sufficient. Second Expanded ed. Alief, Texas: Biblical Counseling Ministries, 2012 (1148)
Scott, Stuart, Heath Lambert, and Master’s College. Faculty. Counseling the Hard Cases : True Stories Illustrating the Sufficiency of God’s Resources in Scripture. Nashville, Tenn.: B & H Academic, 2012. (3472 Digital)
[12] https://www.verywellmind.com/why-did-manic-depression-become-bipolar-disorder-379822
[13] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders : Dsm-5. 5th ed. Arlington, VA: American Psychiatric Association, 2013. (124)
[14] Ibid (125)
[15] https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955
[16] https://www.sciencedirect.com/science/article/pii/S000632230000929X
[17] Ibid
[18] Basco, Monica Ramirez, and A. John Rush. Cognitive-Behavioral Therapy for Bipolar Disorder. 2nd ed. New York: Guilford Press, 2005. (60)
[19] https://www.bphope.com/bipolar-buzz/3-ways-cortisol-levels-affect-people-with-bipolar-disorder/
[20] https://www.mayoclinic.org/diseases-conditions/addisons-disease/expert-answers/adrenal-fatigue/faq-20057906
[21] Thomson, Rich. The Heart of Man and the Mental Disorders : How the Word of God Is Sufficient. Second Expanded ed. Alief, Texas: Biblical Counseling Ministries, 2012 (1145)
[22] Scott, Stuart, Heath Lambert, and Master’s College. Faculty. Counseling the Hard Cases : True Stories Illustrating the Sufficiency of God’s Resources in Scripture. Nashville, Tenn.: B & H Academic, 2012. (3472 Digital)
[23] Bloem, Steve, and Robyn Bloem. Broken Minds : Hope for Healing When You Feel Like You’re “losing It”. Grand Rapids, MI: Kregel Publications, 2005. (184)
[24] Scott, Stuart, Heath Lambert, and Master’s College. Faculty. Counseling the Hard Cases : True Stories Illustrating the Sufficiency of God’s Resources in Scripture. Nashville, Tenn.: B & H Academic, 2012.(Kindle Version 3290)
[25]Mack, Wayne A., and Wayne Erick. Johnston. A Christian Growth and Discipleship Manual. Focus Publishing, 1995. (87)
[26] Ibid (185)
The Encyclopedia of Biblical Counseling 