The Treatment of Bipolar Disorder in Pastoral Counseling

Community and Silence

David Welton, Harold G Koenig

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317786559
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Learn how religion can help in treating those suffering from bipolar disorder

The Treatment of Bipolar Disorder in Pastoral Counseling introduces a new treatment model based on Quaker ideas and practices that can be used in conjunction with medical and psychological practice for treating manic-depressive illness. This unique book examines the interplay between religion and psychoanalysis, using the latest research on the importance of silence, prayer, and meditation in psychotherapy, the role of community in healing, and the problem of God and suffering. The book includes clinical examples from the author's counseling practice, case studies of bipolar clients, and an extensive bibliography of materials on this crippling disorder that affects more than two million American adults.

With its multidisciplinary approach, pastoral counseling may be the most effective psychotherapy for use with medical and pharmacological treatments. Pastoral counselors can gain valuable insights from psychodynamic, cognitive-behavioral, learning, and family systems theories for a more complete understanding of their clients. The Treatment of Bipolar Disorder in Pastoral Counseling examines current understandings of the disorder, including the effects, advantages, and disadvantages of medications, genetic factors, and the search for a mood gene, and looks at current treatment approaches, including object relations, psychoeducational, and narrative psychology.

The Treatment of Bipolar Disorder in Pastoral Counseling examines:

• the writings of Quaker reformers, their methods of treatment, and the philosophies behind them
  
• key theological ideas of Quakerism that are helpful to pastoral counselors
  
• the ethical implications of pastoral counseling
  
• self-emptying as a way toward health
  
• the client's right to privacy and individuality
  
• the nature of suffering
  
• the public perception of mental illness
  
• theological reflections of mental illness
  
• and much more

The Treatment of Bipolar Disorder in Pastoral Counseling also includes case studies of bipolar clients and an extensive bibliography of books, journal articles, and Internet resources. This unique book is an invaluable resource for pastoral counselors and psychotherapists in private practice, as well as chaplains and parish pastors.

Chapter 1 Current Research into Bipolar Disorder

DOI: 10.4324/9781315808444-1

DEFINING BIPOLAR DISORDER

The term “bipolar disorder” is a relatively recent designation in the American Psychiatric Association (APA) guidelines. It refers to what was called “manic depression” and suggests the presence of two poles in the affective experience of the patient. Although each person has a unique pattern to his or her illness, most bipolar sufferers go through episodes of mania and major depression, either swinging rapidly between the two poles, or in discrete episodes that may be years apart. A recent article in the journal Mental Health Weekly summarizes current understandings of bipolar illness:

Bipolar disorder is characterized by manic and depressive phases, and the mood swings can be debilitating. It affects nearly one in 100 people, many of whom also have other psychiatric illnesses. An estimated one quarter of those affected attempt suicide. Bipolar disorder has no cure, the APA says, but treatment can increase patient functioning and decrease mortality. (Hirschfeld, 2002, p. 1)

The experience of mania is a difficult one to describe, yet those who treat clients with this disorder can recognize it immediately:

The patient becomes very hyperactive. He or she doesn't sleep, and doesn't need to sleep. Thoughts race, and they talk very, very fast. They may be hypersexual and spend huge amounts of money. They get in all kinds of trouble, fights, even car accidents. (Lewis, 1996, p. 27)

The depressive side of bipolar disorder is often overshadowed in the popular mind by the wild ride of mania that so many patients experience, yet the episodes of depression can be as equally debilitating and often lead to suicide. During depression, people withdraw from the world and relationships with friends and family. Sufferers may lose all hope that life will get better. They may feel that going on is fruitless. They may even lose the ability to express the inner experience, so that this isolation in suffering intensifies the sense of desperation. Suicide can seem like the only remaining option (Kimberly, 2002, p. 1).

It has been suggested that bipolar disorder first appears in a patient between the ages of eighteen and twenty-four (Griswold and Pessar, 2000, p. 1343). Yet many mental health providers see the signs of this illness even earlier. In their 2000 study of children and the likelihood of developing bipolar disorder, doctors at the University of Miami studied children who seemed to exhibit the mood swings so particular to the illness (Egeland et al., 2000). They describe a young girl, Emma, who presented with bipolar disorder at age sixteen. When consulting the parents and teachers, doctors recorded a list of behaviors that may have been early warning signs of bipolar illness.

Age 8: Bold, demanding, very outspoken.

Age 10: Obsessive-compulsive traits, mood changes, overly sensitive.

Age 11: Irritable, mood changes, depressed mood.

Age 12: Bold, intrusive, demanding, outspoken. Obsessive-compulsive disorder (OCD) and somatic traits.

Non-episodic symptoms: Energy loss, sleep unspecified, ruminations, fears, phobias, panic symptoms, worried/fearful/tense.

When she came for treatment, she had what was described as both euphoric and irritable moods, and she was often noncompliant with treatment, especially medications. When she began to accept help, she improved quickly and returned to school (Egeland et al., 2000, p. 1250).

Clearly, what patients experience with this disease hinders their ability to enjoy their lives and be productive people. What is becoming more clear is the early onset of the illness and the visible signs that family, friends, and teachers might recognize, in order to guide the person to help. The next section addresses the current ways that bipolar disorder is treated by the medical community.

TREATMENT BY PHYSICIANS

The family physician is often the first health professional to treat the bipolar patient. If he or she observes symptoms and behavior consistent with bipolar disorder, he or she must decide whether referral to a psychiatrist is best for the patient or if placement in an inpatient facility is necessary (in cases of acute mania or suicidal depression). In any event, the eventual treatment plan will include medication and psychotherapy, as well as counseling for the patient's family. As this book will attest, the involvement and support of the family will expedite the treatment and recovery of the bipolar sufferer (Griswold and Pessar, 2000, p. 1343).

In 1994 the First International Conference on Bipolar Disorder was held in Pittsburgh, Pennsylvania. The content of this meeting included issues of diagnosis, differentiation of types of bipolar illness, research into the genetic clues to the cause of this illness, and current drug therapies available to the physician. For more than forty years now the standard treatment for manic depression has been lithium, a naturally occurring salt that acts as a mood stabilizer. As the presenters pointed out, the rate of success with lithium has been good. However, the drug's side effects can be intolerable and many do not respond to it.

In the past twenty years new medications have been used with wide success and offer other options to patients. One class of drugs are the anticonvulsants, usually prescribed for seizure disorders. Two such drugs are carbamazepine (Tegretol) and divalproex (Depakote). Current studies (Friedrich, 1999; Bowden et al., 1994) indicate a similar rate of success in treating bipolar illness as with lithium, with fewer side effects. A second class are the medications that have been used are the antidepressants, most notably selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil). However, other varieties of antidepressants, namely, the tricyclics and monoamine oxidase inhibitors, have been observed to increase the rapid-cycling variety of bipolar disorder (Himmelhoch and Thase, 1994, p. 6). Another researcher at the Pittsburgh conference raised the issue of “polypharmacy” or the treatment of psychiatric disturbance with multiple medications. It has been observed that some patients respond better to a regimen of two or three drugs. What seems to be the operative factor here is the atypical nature of bipolar disorder in many patients who present with the illness. The multiple-drug therapy seems to meet the unusual needs of those who may experience psychotic episodes or rapid cycling. Nevertheless, what this doctor has found is the effectiveness of lithium and psychotherapy together being the most effective treatment for the majority (Mallinger, 1994, p. 7).

In May of 2001 the annual meeting of the American Psychiatric Association took place in New Orleans, Louisiana. A substantial portion of the conference dealt with the management of bipolar disorder in the United States and Europe. European researchers raised the possibility of regular use of the antipsychotic drugs, or neuroleptics, with bipolar patients. Neuroleptics were first used in the acute, mania phase of the illness, helping to reduce anxiety, manic behavior and thoughts, and psychotic symptoms accompanying the mania. These doctors have since discovered the long-term role of the neuroleptics in the maintenance treatment of the disease (Patten-Hitt, 2001). These medications include clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) (Harvard Mental Health Letter September 2002, p. 5).

The use of drugs in treating psychiatric illness has long been accepted as effective, yet the conference recognized the necessity of psychotherapy and other areas of study as well. Dr. C. Robert Cloninger of Washington University, St. Louis, discussed the “psycho-biology of human personality” and concluded that personality traits had much to do with a patient's response to antidepressant medication. He further recognized that certain symptoms of bipolar disorder required initial treatment with pharmacotherapy, and then follow-up with psychotherapy. He observed that patients with anxiety, impulsivity, suicidally, and paranoia would be best served by medication first, then therapy to follow (Patten-Hitt, 2001). Dr. Ellen Frank, from the University of Pittsburgh, spoke about managing depression in the bipolar patient, and raised the importance of the psychosocial environment to the recovery of the sufferer. She suggested that patients are “vulnerable to new episodes of the disease when they experience disruptions to their daily routines or social rhythms.” Psychotherapy can be the mode of treatment to help stabilize these patterns in the patient's life (Frank, 2001, p. 7).

The medical literature often addresses regarding the efficacy of the standard drug treatments, and much of the news is good. Recognizing the difficulty in treating the bipolar patient and gaining compliance with the treatment can be the hardest steps to recovery. Recent articles in both the British Medical Journal and the Journal of the American Medical Association report that lithium has reduced the risk of suicide and normalized rates of mortality. The function of lithium as a mood stabilizer has been effective, and so has its role in preventing future acute manic episodes (Friedrich, 1999, p. 2271). Although the long-term effects of the antipsychotics are not known, they seem to be most effective in controlling the acute phases of bipolar disorder and not effective in any prophylactic use (Young, 2000, p. I). What may be most useful to the patient over the long term is the application of combination therapy in the form of drugs and psychotherapy. Early diagnosis and prompt entry into treatment is also critical. Bipolar patients go undiagnosed for many years and can relapse even during treatment. The chances for recovery are better if the disorder can be screened for and treated quickly (Petersen, 2000, p. 45).

One other medical treatment that is available to patients has been and continues to be controversial. Electroconvulsive therapy (ECT) has been used for decades, and at one time was the only treatment available for depression. The journal American Healthline (“Electroconvulsive Therapy,” January 2001, p. 1) presented an objective look at the benefits and harmful side effects of ECT. The primary benefit seems to be the rate of remission in severely and psychotically depressed patients. The journal reported a study by the National Institute of Mental Health claiming a success rate of 95 percent, fargreater than any drug therapy. Those who have protested the use of ECT, including former patients, have suffered substantial memory loss and loss of cognitive functions such as short-term memory. They also say that this treatment is violent and authoritarian. The doctors who use this method say they can't be sure if the memory loss is a result of the patient's mental illness or of the treatment.

Is ECT useful for patients with bipolar disorder? Katherine Lerer tells her story in the May 2000 issue of Psychology Today. Her description of the severity of her bipolar illness is vivid and frightening; her account of the electroconvulsive therapy is discouraging:

My next memory is of wobbling back to the next room guided by a nurse. I felt confused and disoriented, like I was twirling in space. I was glad it was over…. The memory loss was so profound at times that I got lost just walking a few blocks in my neighborhood. The period of time before, during and after my treatment permanently vanished into the deep channels of my mind. Short vignettes are all that I have left of my four months of ECT. (p. 28)

Other physicians have written passionately about the effect of ECT on the brain and the cruelty to patients who cannot decide for themselves on their course of treatment (Johnson, 2001, pp. 3–13). It is the emphasis of this book that humane treatment of the mentally ill is our primary responsibility to our society. In some trials, ECT has proven successful in alleviating depression. To many this treatment seems inhumane. To others who have gotten relief from debilitating symptoms, it is a necessary method. What is humane may be up to patients to determine.

GENETIC FACTORS IN BIPOLAR DISORDER

In her article in the Journal of the American Academy of Child and Adolescent Psychiatry, Clarice Kestenbaum (2000) defines the two questions pertaining to genetic research and psychiatric illness: What are the factors that predispose one to manic depression, and are illnesses such as bipolar disorder genetically determined? She explains:

… the fundamental insight of the last decade in neuroscience and molecular biology is an understanding of the way genes and the environment interact in complex and inseparable ways. The work of Hyman and others revolutionizes the understanding of normal and pathological development and links molecular biology and behavior so as to render the mind-brain dichotomy moot. The salient point in the emerging understanding of the brain is plasticity; that the ability to learn and change is brain-based, so that at any given moment there is a complex mix of one's genome and environmental interventions. We know now that psychotherapy and medication both act on the brain to change behavior, brain neurophysiology and neurochemistry. (p. 7)

What Kestenbaum describes is a flowing relationship between the sciences that help us to see ourselves and our world as a system. In that system are people who suffer from psychiatric disorders, and those disorders arise in complex ways. The genetic makeup of a person might be one factor of many in determining the likelihood of someone developing bipolar disorder. Kestenbaum is even suggesting that the environment and psychosocial surroundings might influence the biological and chemical makeup of our bodies, indeed even our genetic makeup. So, the question might be better put: Is it accurate to assign a predisposition to a particular illness when so many factors affect the genetic code?

Nevertheless, genetic research goes on in the quest to find the source of behavioral traits. One such study is the Human Genome Research Institute of the National Institutes of Health, which launched a three-year project in behavioral genetics. Specifically the areas include impulsivity, intelligence, and bipolar disorder. One of the emphases of the study will be the effect on the general public of such research. The questions include, “In a society of classification and discrimination, what would be the impact of genetic information about behavior? Will genetic information reinforce racial stereotypes, for example, or create new ways of categorizing people?” (Strobel, 2000, p. 47). In the past, theories regarding genetic predisposition led to the horrors of eugenics in this country, and the Holocaust in Nazi Germany. A justified reaction of fear results when we consider the ways in which society might use this information.

In a related study, researchers at Baylor University are analyzing blood samples of patients with bipolar disorder to “identify the genes responsible for susceptibility to schizophrenia and bipolar disorder” (Goodman, 2001, p. 1). Baylor is home to the Human Genome Center and has a clinical focus to its research. Their aim is to find more effective treatments for the two diseases by better understanding the genes involved. Dr. Heather Goodman says, “Clearly these are complex illnesses, which likely involve many genes interacting with one another. We are hopeful that the advances made in genome research will lead to better diagnosis and treatment options.”

Neurobiologist Samuel Barondes is searching for what he calls the “mood genes” that would be the key to finding drugs to control bipolar disorder. In his book Mood Genes: Hunting for Origins of Mania and Depression (1998) he tells the story of how this scientific detective work is done. Journalist Jeff Minerd (1999) summarized Barondes’ search in The Futurist:

The mood-gene hunter first finds a family or isolated population that is prone to manic...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• About the Author
• Introduction
• Chapter 1. Current Research into Bipolar Disorder
• Chapter 2. Current Pastoral Counseling Theory
• Chapter 3. Quaker Treatment of the Mentally Ill
• Chapter 4. Silence and Psychotherapy with Bipolar Disorder
• Chapter 5. Community in Treatment
• Chapter 6. Theological Reflection on Bipolar Disorder
• Chapter 7. Conclusions
• References
• Index