Dale Johnson: This week on the podcast we are going to address one of those very difficult issues that we see in life, where people experience very deep and dark struggles. This week on the podcast to address this very difficult issue we have Dr. John Street. John has been an ACBC member for many years. He has been on our Board of Trustees for many years as well. He now serves as the Chair of our Board of Trustees for ACBC. He is also well known as a Professor of Biblical Counseling at the Master’s University. He chairs their Graduate Department of Biblical Counseling and he’s married to Miss Janie, they have four children and he’s better known as a grandfather as Papa.
I’m so glad that he’s here with us today to discuss this issue of bipolar. John, thank you for being here and thank you for being willing to address this very difficult issue.
John Street: Thanks Dale, it’s a pleasure for me to be here.
Dale Johnson: As we think about this subject, people have all sorts of questions. Certainly in a short podcast we can’t answer all those questions, but one of the questions that we get regularly about this label of Bipolar Depression is: Can genuine Christians have bipolar symptoms?
John Street: The short answer to that is really quick. The answer is yes. That’s really very possible and you’ve got to understand that this is a very complicated issue. There are not simple answers in dealing with an issue like that. But we do know from a lot of studies that have been done, that a lot of people who suffer from this kind of problem have a background with certain drugs—sometimes they can be legal drugs or illegal drugs. Or they’ve had a background with alcohol abuse, or sometimes it’s due to a medical condition. For example Cushing’s Disease, multiple sclerosis, or even some kinds of strokes can produce bipolar symptoms. Now, Christians are very susceptible to those kind of things if it’s a physiological issue, and they can begin to manifest bipolar-type symptoms if they’ve had anything like that occur in their past.
Now, that doesn’t mean that everybody has those particular physiological problems have bipolar depression, but it does say that there are some bipolar manifestations that can come from those kind of physiological diseases. The etiology goes back to the disease itself. However, I think that in the church the vast majority of bipolar-type depression is not related to any of those diseases. It can be—especially in the general population, where they say that 2.8 percent of the general U.S. population and 2.4 percent of the world’s population suffers from bipolar disorder. The vast majority of that is either misuse of drugs or a misuse of some kind of alcohol. Among the Christian scene, I don’t think that is as much the case. It’s going to be quite a bit less in terms of manifestation because there’s going to be quite a bit less misuse of drugs and alcohol unless a person—before they were Christian—had that kind of behavior.
Once that person is a believer and is living a generally righteous life and they love the Lord and they understand the gospel, then at that particular point the questions is: Is it possible for a person like that to have bipolar-type symptoms? And the answer is yes. I’ve counseled those kind of people and it is a very difficult disorder, or really problem. As soon as we put it in the category of a disorder we kind of equivocate on whether or not it’s going to be a physiological problem or not. Frankly, even the best science that’s out there in the world talks about the fact that the science has still not come to a definitive conclusion as to what the physiological cause is.
That doesn’t mean that there aren’t physiological things that are operating behind the scenes. However, even if that is the case, we can still approach the spiritual side of this issue with people with the Word of God. I don’t think that we as Christians should be intimidated by what’s going on out there in the world when it comes to people claiming that this is primarily just a physiological problem. A lot of placebo studies have demonstrated that in working with bipolar people, placebos work just as well as antidepressants. That really is the case, it’s been proven time and time again, not only in the U.S., but in Canada in the medical system there and in the medical system in England. When they sought to treat bipolar with the use of SSRIs (selective serotonin reuptake inhibitors) or even herbal medications like St. John’s Wort, they found that placebos work just as well.
If it was a physiological problem, then we would have a much more difficult time dealing with this particular issue and placebos obviously wouldn’t work in typical studies. It’s really interesting that in toddlers and children—we’re talking about children from the age of 3 up to the age of 13—it is very rare to have bipolar type depression symptoms. That’s very rare. It becomes common, or very common, in teenagers beginning around the age of 14 all the way through adults aged 60, then it’s very common. Then it drops off quite a bit when it comes to the elderly. If it is a biological problem, then somehow children are somewhat immune from it, and so are many elderly people immune from that problem. We don’t find diseases tracking that kind of a pattern.
What do we conclude? Well, there’s a significant part of this that can be addressed spiritually and that’s what I usually do in counseling.
Dale Johnson: Yeah, that’s right. I think it’s helpful that we distinguish between having a label of some sort of “disorder” versus having symptoms. Even as Christians, we can express those types of symptoms where we see mood swings and that sort of thing. We have to be cautious, and I think it’s helpful even to know what science is saying about this today. That brings us to a point where we have to begin distinguish and discern in counseling. How do we know the difference between these things being caused or motivated by spiritual issues or physical issues?
John Street: If you’re going to counsel someone like this, you’ve got to gather good data and good background. Part of that is background use on drugs or alcohol. What drugs have they had? What alcohol? What kind of physical problems—have they’ve been diagnosed with Cushing’s Disease or multiple sclerosis or had a stroke? All of that is going to be critical in trying to identify if it’s more of a physiological problem or primarily a spiritual problem.
Of course, even if you are able to identify it as a physiological issue that really started their depression or manic swings, you can still address that from a spiritual level. In fact, the world recognizes that and there are many talk therapists who say that talk therapy oftentimes is just as effective as any kind chemical therapy.
That’s exactly what we’re doing as biblical counselors. We’re bringing the truth of the Word of God to bear upon the spiritual issues of their life. Their perception of what’s going on in their life is really critical. If you’re not used to the terminology of bipolar disorder, sometimes it has been referred to as manic-type depression. Bipolar disorder is where a person swings from a very manic mood or hypomanic, which is kind of less severe, where a person experiences a lot of euphoria and a lot of energy. I found out, at least in my counseling, that you can easily divide this down into people who have mild forms of this, people who have more moderate forms of it, and then those who have the more severe forms.
When we’re talking about the mild form, we’re talking about manic excitement with occasional or frequent downward mood swings towards depression, maybe within the same day. That would actually be a mild form. In fact, one of the illustrations I like to use in counseling is anytime you go to a soccer game or a football game, you can see bipolar behavior on a massive scale. When your team is winning, you are euphoric and you’re excited and you’re just on top of the world, and the moment your team falls behind, then all of a sudden everybody’s in despair. There’s bipolar behavior on a massive scale. That’s kind of a mild form of it, all within a short amount of time.
The moderate form of manic or even hypomanic phase one usually requires one or two days in length followed by restless sleep and depressive periods of equal length. This is stretched a little bit more. This can be more chronic where it reoccurs over and over again, but it’s still considered a more moderate form of that.
The more severe form of it has a manic or hypomanic phase that lasts from 7 to 10 days where a person is very euphoric, very active both day and night. Usually because of that they are deprived of sleep over those several days. That results in several days of severe depression after that’s over with. It’s associated also with a lot of suicidal thoughts. That’s the severe form of it.
How can you tell the difference between the two? Obviously unless you’re a medical doctor and you can run tests, you’re not going to really be able to fully identify as a biblical counselor whether or not there’s physiological causes behind it. It’s important that you have someone go to a qualified medical doctor to get a thorough examination. That’s really important. But let’s say setting that aside, and the person you’re counseling has already received a pretty thorough medical check-up and they’ve not been able to find anything that’s abnormal in their system or in their processing or there’s nothing that’s a part of their past that would lead to this, then let’s address this from a spiritual standpoint.
That’s what I usually say to people. Especially if a counselee says to me, “What if they’ve never discovered the physical cause of my problem?” Well, that’s true. Then that’s in God’s sovereignty too, so let’s address the spiritual side of this and then we’ll see how God can help you on that particular level. Usually, as time goes on, and their symptoms begin to improve by just addressing the spiritual perspective on this issue, then the issue of whether or not it’s a physical problem becomes less and less pressing for them.
Dale Johnson: You’ve delineated the difference between physical causality and even spiritual causality. We look at people who struggle with these symptoms and we’re still responsible for helping them. Even if we describe physical causes, it doesn’t mean that we as biblical counselors are obsolete and not necessary. That person still has to respond to whatever they’ve been diagnosed with from the doctor. They’re still responsible to respond to God appropriately. That brings in the question about medication, certainly. When we think about SSRIs, you mentioned selective serotonin reuptake inhibitors, and their value or their use to solve the problem. I think we can think about their use in a couple of different ways. Is someone who’s on SSRIs pursuing the most complete way to solve this problem of bipolar?
John Street: That is an excellent question. First, you’ve got to make sure as a good biblical counselor that you’re really dealing with a Christian. If you’re not, then we very commonly say that all counseling is pre-counseling until that person really comes to Christ because their heart is not going to be able to be responsive to the Word of God. But if this person is genuinely a Christian and there’s no physical disease symptomatology that’s behind it, then addressing that on a spiritual level is not just an option, it is necessary. It’s critical for them. They’ve got to be able to see that this is the way in which they are viewing life. Rather than viewing life from God’s perspective, they’re viewing life from their own perspective. As a result of that, they’re trying to deal with life in this way.
For example, a lot of the studies that have been done on bipolar disorder—one in particular from Harvard University—indicated that many people who begin to manifest these symptoms are people who have been under stress for a significant amount of time, and eventually that manifests itself in this kind of behavior. Stress is key here. That tells me as a counselor to ask, “How’s that person really dealing with stress?” For example Proverbs 14:32 talks about a tranquil heart is life to the body, but passion is rottenness to the bones. When you take a look at the terminology that Solomon uses there, a tranquil heart is a heart that’s really at peace. That doesn’t mean that our environment is at peace, but our heart’s at peace. Then it goes on and says, “but passion.” The Hebrew word for passion there is a word that has to do with agitation. When a soul or a heart is agitated over a period of time, will there be certain physiological effects to that person because of that agitation? The answer is yes. Can it manifest itself in manic episodes of euphoria and then later on depression and sometimes severe depression? The answer is absolutely yes.
Just to give you an illustration of this: I have in my backyard an orange tree. It has some of the sweetest oranges on it you’ve ever had in your life. If I were to pick one of those oranges and I began to peel that orange, you can smell that sweet orange, you can look at it and see how deep orange it is. Now just in describing that, I know that some of the listeners are already salivating. They don’t have an orange in their environment, there’s nothing that they’re smelling. Just the mental description of that has caused physiological effects in their body.
The same thing is true with the way in which we think about life. Are there going to be physiological effects in the way that we’re dealing with life over a long period of time especially dealing with stress? The answer is categorically yes. Scripture tells us that a tranquil heart is going to bring life to the body. There’s going to be a confidence and stability to life. That doesn’t mean that the stress and their environment is gone. It’s just that they’re dealing with that stress while really trusting the Lord in the midst of it.
Dale Johnson: That is the work of biblical counseling. I wish we could spend a lot more time talking about this issue, it’s certainly a broad and big issue and one that we could say so much more about. The point I think, as we boil this down, is that we address a person holistically. We can’t allow a secular field to narrow down one aspect of a person and think that that’s addressing a person toward true and legitimate health. We have to begin to address some of the specific spiritual issues that arise and to see that there’s biblical hope to be found even when dealing with very complex issues like bipolar.
John Street: That’s exactly right. When a person becomes a very severely depressed, they may think suicidal thoughts, and one of the places that I go to when a person starts doing that is the book of Jonah. If there ever was a man who was given over to suicide, it was him. Here’s a man who is running from the Lord. He catches a boat heading in the opposite direction from Nineveh, because he doesn’t want to go there. The Ninevites are sworn enemies of Israel. He doesn’t want to go and preach the gospel to them. He gets on the boat and he’s perfectly at peace running away from the Lord. He falls asleep in the middle of the storm. Even the secular sailors are scared for their lives. He’s sound asleep and they have to go wake him up and bring him up. Rather than repenting, Jonah is suicidal. He so angry, Jonah is the ultimate racist. He doesn’t want to see God show His mercy to the Ninevites.
Later on in Jonah 4, when Jonah is confronted by the Lord, he says in verse 2, “I knew that You are a gracious and compassionate God, slow to anger and abundant in lovingkindness, and one who relents concerning calamity. Therefore now, O Lord, please take my life from me, for death is better to me than life.”
I’ve had bipolar people say that kind of thing to me. Death is better to me than life—that was Jonah. But he was running from what the Lord really wanted. And then of course, you know the story on how God causes a gourd to grow up over top of him and shades him from the heat of the hot sun. After being in the belly of a big fish, and being bleached white because of the digestive juices there, his skin was especially sensitive to the sun and God has this gourd grow up over top of him. The Bible says, when God appointed the gourd to grow there, it says Jonah was “extremely happy about the plant.” That was his manic. The Hebrew terminology is very clear. He’s greatly greatly glad. There is his extreme euphoria going on. Then God causes the plant to die. After that, Jonah says in verse 8 “Death is better to me than life.” He goes back to suicide again.
How is he processing life? What is a person doing in relationship to the Lord in this way? This becomes really key.
Dale Johnson: John, thank you for a very helpful discussion as we talk about this issue of bipolar and the complex problems that people face. A beautiful thing we can trust in is that God in His Word has given us context and hope to deal with these very difficult and complex problems in life.