Counseling Children With BPD: A Psychotherapist's Notes
by George Lynn, M.A., C.M.H.C.
George Lynn is a psychotherapist in Bellevue, Washington. His book, Survival Strategies for Parenting Your ADD Child, is useful in understanding the inner world of a child with a neurobiological disorder (including bipolar disorder) that affects emotions.
Children who are diagnosed with bipolar disorder come to counseling for a variety of reasons. Younger kids come in because of episodic rage, obsessions, and oppositionality. Teenagers tend to need help with self-esteem and motivation issues. They also may be involved in dangerous or destructive behavior. Some have school phobias or depression-related cognitive deficits. Therapy will have the best chance of being successful if the counselor is able to form a rapport to help these children integrate opposites within themselves.
A therapist who is in rapport with a child will pace his verbal and nonverbal behavior to that of the child and will listen with interest and respect. He will be present for the child, and will follow his client's lead in the conversation instead of trying to pull the child to participate in activities or a line of conversation that the child is resisting.
Amy, a bright twelve-year-old girl, came in with her mom. The mother told me that she could not handle Amy's rages and irritability any longer. My assessment of her home life led me to believe that she was getting great parenting. My task would be to help Amy develop more control over her mood swings.
Several sessions into our work, she brought in her pet boa constrictor, Mimi. "OK to let Mimi crawl up your arm?" she asked with a grin. This was my rite of passage in Amy's eyes. I suppressed a shiver as Mimi slithered up my arm. "Other kids treat me just like people treat Mimi." Amy said "They think she's creepy and disgusting. They don't see how cool she is! They don't see her personality. She's not mean at all."
"Yeah," I said, "She's awesome. But scary. She is so strange and different, and snakes like her attack people. It's hard for people to warm up to her. They just kind of automatically pull back."
Amy's expression got pensive as she petted the back of Mimi's head. "Yeah. People pull back that way from me too. Especially my dad. He doesn't do anything with me anymore."
I was pleased that Amy had opened up the subject because I knew that her relationship with her dad had deteriorated badly and I also knew that he had to get more, not less, involved in her life to help her. Rage and depression are made worse by stress. And she experienced more stress because she felt her dad was not on her side. Her comment to me opened the way for me to involve her dad in our process.
Gaining rapport with Amy meant that I listened respectfully without judging her. Kids do what they need to do to heal, and Amy's projection of her own issues onto her pet snake brought her troubles out in the open so that we could deal with them. Children who have bipolar disorder tend to be suspicious of therapists and other professional care-givers. But once they decide that it's safe to talk, they can become intensely and productively involved in the process.
Children diagnosed with bipolar disorder can exhibit a high need for control. Their world is highly unpredictable, even terrifying. It may take a lot of effort to get through the day. They can put out threatening verbal and/or nonverbal behavior if they get anxious.
One smart fifteen year-old boy I worked came in to counseling with a bipolar diagnosis from his psychiatrist. This boy had several "personas" that came into our conversation. One of these was the one I called "the hard guy," a tough talking, gansta-like-personality that the boy would slide into when he was angry, tired, or stressed. In these states, he would tell me "Shut up!" or "God, I can't believe my parents are paying you for this!"
Children like this boy can be intimidating. Effective psychotherapy requires that the therapist keep firm boundaries with the child and not give in to his demands because of fear of the child's wrath.
The child with bipolar challenges may also have exceptionally powerful verbal skills and the ability to talk in the most interesting way about intellectual topics. This skill can be used to throw the therapist off the task of helping the child wrestle with some predicament that he or she does not want to face. If the therapist starts feeling like a "best friend" relationship is coming into being, it is time to push for clarification of the agenda with a comment such as: "I'm really enjoying talking with you about this topic, but I am concerned that the issue of your mood swings may not get addressed if we don't spend some time on it. What do you think?"
The bipolar-diagnosed child may alternate between liking his therapist a lot or hating him depending on what the counselor said in the last session. The best way to limit damage to the therapeutic relationship is to consistently model assertiveness. This way the child knows what to expect and knows that it is a waste of time to try to manipulate and control the therapist.
If rapport is formed, and attempts at manipulation kept at bay, it is possible to go on to the process of integration of extreme emotionality within the child.
Psychotherapy with children with bipolar challenges should result in the integration of polarities in the child's personality in such a way that he gains more control over his emotional life. Dissolving rigid boundaries can be very psychotherapeutic. These polarities include:
- My brain against my heart--spoken by a child with rage whose "brain" ran his rage.
- The part of me that knows I'm OK and the part of me that can't stop thinking about horrible things--spoken by a child who couldn't control intrusive morbid thoughts.
- The part of me that's wide awake and the part of me that's still dreaming--spoken by a child with hallucinations.
- The part of me that wants to go kick my teacher and the part of me that says "No! Stop!'"
Techniques drawn from cognitive therapy can help the child integrate opposites within himself. One of these techniques is called the "Two Hand Integration Method." The child is asked to put one aspect of an issue on one hand and the other on the other hand and then to bring his hands together "only as fast as your hands feel like they want to come together." If the child can get into the spirit of the exercise, he will report a feeling of lightness or find new matter-of-fact solutions to some problem that may have been vexing him. Getting the opposites together often produces a solution that was not apparent before.
Integration of opposing aspects of the self does not result in the "curing" of bipolar disorder. The child may still rage, or obsess, or experience other kinds of distressing affect. But he will be more resourceful in dealing with these issues. The raging child will be able to pull back more quickly from losing it. The child with intrusive morbid thoughts will notice that these phenomena do not last as long and they do not distress him as much. The child with hallucinations will deal with them as one would a seizure; she will stop what she is doing, relax herself, and get in a non-demanding environment long enough to let these disturbing effects pass from consciousness.
Good therapy for a child diagnosed with bipolar disorder always points toward integration. The therapist must stay alert to opportunities to define polarities such as the "good voice" and "bad voice" in the child's psyche, and will seek ways to naturally merge conflicting aspects in more promising combinations. The child with this diagnosis needs a positive vision of healing and needs to know his life lives has meaning and purpose that is as great as the challenges that he or she faces.
George Lynn's next book (on parenting children with bipolar disorder and related neurobiological conditions) will be released in 2000. Contact George Lynn.