Which Therapist Is Right for My Bipolar Child?

You may have decided by now that therapy is a good idea for your youngster. But perhaps the mention of the word therapy conjures up the image of a patient on a couch and a bearded male therapist who listens intently for the hidden secrets or long-forgotten traumas that control a person's behavior. In reality, this is the television and film industry's inaccurate portrayal of a specific type of psychotherapy: psychoanalysis. Psychoanalysis focuses on bringing out a person's unconscious struggles to help him or her relieve emotional pain. Psychotherapy, by contrast, has a much broader definition. It refers to the treatment of mental and emotional problems with the goal of relieving disturbing symptoms (such as anxiety) and helping to improve a person's daily functioning.

Just as finding the right psychiatrist for your child may take some hard work and trial and error, so will locating the best therapist for your son or daughter. But certain issues that all bipolar kids share need to be addressed in therapy, and it's important that everyone involved in the therapeutic relationship be aware of the following guidelines.

Therapy Is a No-Blame Zone

All members of the family are affected by the child's unpredictable mood and behavior. By the time they see a therapist, the typical family already has some significant dysfunctional patterns. It's important for the family and the therapist to recognize that these patterns likely did not play a role in causing the child's out-of-control behavior. Instead, they represent the ways in which the family is coping in order to survive life in a chaotic, ever-changing household. The concept of blame is not helpful to parents, the bipolar child, or anyone else in the home.

Biology May Not Be Destiny, but It Is Extremely Important

When the child has a major rage outburst and is out of control, parents and even therapists can lose sight of the fact that the child's biology is out of kilter. This doesn't mean that environment does not play an important role in who we are or who we will become or that kids don't need limits or behavioral supports. But biology and temperament are major forces as well. Though it's not necessary for therapists to be experts in Bipolar Disorder, they should have a basic understanding of the illness. In addition, they need to be open to learning more about it.

Flexibility Is Critical

When treating a bipolar child, the parents and the clinician need to be flexible and able to adapt to the child's changing needs. I often tell my families that stability is a temporary condition—be it for two hours, two days, two months, two years, or two decades. Medication may work for a while and then stop doing its job. A child's biology may change for unknown reasons or because of an environmental stressor. For example, the death of a loved one may trigger a child's depression. Puberty may also throw a wrench into the works. I tell parents and therapists that the majority of the bipolar kids I've seen sooner or later experience a change in their symptoms and level of functioning.

I recommend what I call an I.V. approach to therapy for children and families—I.V. referring to intensity and variability. The idea is that the symptoms of Bipolar Disorder will become more intense from time to time and will vary periodically. The therapist must understand that a treatment that worked for a reasonably stable bipolar child may have to be set aside when the child becomes depressed or manic. For example, a child who was doing well with Cognitive Behavior Therapy (CBT), in which a therapist worked with her to challenge her negative thoughts, before she developed a manic episode may do better with a supportive approach until after she stabilizes. Therapists including psychologists, social workers, family therapists, and psychiatrists must also be prepared to exercise some creativity. Whether that means following a child wherever that may lead when he tells you he's feeling suicidal or talking to a youngster in the office-building parking lot because he refuses to leave the car, a good therapist must approach treatment with the idea that tailoring the method of therapy to a child's current emotional state is part of the job description.

Once you've lined up a flexible, competent therapist, how do you know which approach your child will respond to best? Of the many different therapeutic methods for the treatment of bipolar and other psychiatric disorders, only a few have been subject to scrutiny by scientific studies designed to compare their effectiveness. In my clinical opinion (based on twenty-five years of practice and not a placebo-controlled, rigorous, scientific study, mind you), there's no one "best" therapy for a bipolar child.

A variety of factors must be considered when choosing a therapist. These include your child's age, cognitive ability, symptoms, temperament, and motivation.

Some kids need a therapist who is soft and gentle; others respond to one who is tough and more direct. A shy, frightened child will do better with a low-key and nonthreatening therapist (this in no way means ineffective). An angry adolescent may need a therapist with a strong, no-nonsense approach to treatment, whereas some irritable, tense teenagers may be calmer and feel less challenged by a soft-spoken therapist.

Another factor to take into account when choosing someone to work with you and your child is the therapist's gender. As youngsters approach adolescence and begin to explore issues of sexuality and identity, they may feel more comfortable with a same-sex therapist. Probably the single most important element of successful treatment, however, is trust. If a family does not feel comfortable with and have faith in a therapist, it is difficult for a child to make progress. The youngster senses the parents' doubts, and this colors her approach to treatment.

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