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This is a very concise, very readable, and very comprehensive guide to bipolar disorder geared toward caregivers and loved ones. In its purpose, at least, it fills a significant need and I commend Last her clarity and accessible style. The author is herself a Survivor, with Type II bipolar disorder. Her experience managing her condition with the assistance of her husband will lend her credibility to many readers, and supplement her letters as a practicing psychologist. Her description of bipolar behaviours, triggers and contributing factors is quite sound (chapter 2); her advice on forming a “treatment team” and her exploration of caregiver stress are also well handled (both chapter 5); and many will doubtless be helped by her diplomatic solutions to the domestic standoffs inevitable in a “bipolar household”. As a day-to-day guide, then, this is likely to be of use to many, replete as it is with the worksheets and informative bullet-listed talking points we expect from self-help literature.
That said, the book suffers from some major flaws. In her therapeutic leanings Last is strictly conventional, presenting the run of boilerplate treatment modalities and endorsing medication optimistically and uncritically. But medication is not neutral. Its role in the treatment of mental conditions involves a host of extra-clinical considerations, many of which are related to simple expediency. Meds are the gold standard merely because nothing else works as well--but that doesn’t mean they work particularly well, or often at all. On this she has precious little to say (p.153). Moreover, in situations where side effects are severe, she comes down on the side of sticking with the meds at the expense of what some would call a significant diminishment of quality of life (p.157ff), and her assumption that we must at all costs flatten the highs of mania or hypomania in order to essentially fill in the trough of depression (p.161ff) smacks of moralizing: not all bipolar individuals are capable of remaining in a baseline state for any length of time, regardless of treatment method, and a glance at Survivor accounts by those who have learned to positively channel their prodigious energies suggests that mania is not de facto a bad thing. At any rate, without alarming the reader or attempting to incite distrust of the medical profession, there is an onus on the writer of a book such as this to prepare one for a truly long haul, including the very real prospect of not finding an adequate meds protocol, and encountering difficulties with corporate or government bureaucracy if the chronic nature of one’s condition defies “timely” solutions.
Next, the author unwittingly raises some disquieting questions concerning her construction of bipolar as an illness. While being careful to avoid the blatant untruth that bipolar is physiological, she pushes on us the tired analogy of chronic medical conditions such as diabetes (p.67); this may be helpful to the uninformed reader who needs some way of coming to grips with a complicated situation that involves medication, but it is not correct. Worse, a statement such as “unlike a number of other psychiatric disorders, bipolar disorder is an illness that gets ‘managed,’ not cured” (p.67) is wrong on both semantic and medical grounds. Cured? Assuming that all the DSM-IV conditions are in fact diseases, which of these is ever “cured?” Such pronouncements are not small potatoes. They undermine her legitimacy.
My biggest beefs, though, are with her countenancing the use of coercion and underhanded methods. It’s one thing to resort to subterfuge in moments of extreme crisis when the bipolar individual is irrational and potentially dangerous. But it’s a different matter when dishonesty is used as a tool to ensure compliance to caregiver wishes. Thus, in trying to convince one’s partner to take meds, the caregiver is called upon to claim that “people are taking these drugs in record number today so that the stigma once associated with this form of treatment no longer exists.” (p.67). Ignoring the implications of the first (true) half of this statement, the second part is patently absurd. Psychiatric conditions and meds are prominent and visible, but the stigma surrounding them is arguably as powerful as it has ever been. And what are we to make of the following: “Look at all those commercials on TV--the drug companies wouldn’t be spending all that money on them if there weren’t tons of people taking those drugs”? (p.68) It’s a self-supporting proposition, a logical non-sequitur apparently meant to establish some sort of implausible connection between the prevalence of meds and their effectiveness, but really stating nothing. Truly problematic, though, are Last’s unabashed (and admitted) uses of direct manipulation, such as her feeding into a client’s delusions in order to convince him to obtain counseling (p.74f), or the advice on how to sneakily get around signed consent for(p.130). Actions like this by medical personnel diminish faith in the system; such behaviour from loved ones is a major violation, the consequences of which in a loving relationship Last utterly avoids. When such actions are discovered--and surely they will be!--a person prone to manic paranoia can find their fears unwittingly confirmed by the people they trust the most.
Regrettably, this is not the book it could, or should, have been. Last has an engaging style, and her book is bursting with information, yet I await a more ambitious treatment: one with a more balanced presentation of psychiatry, which engages less simplistically with some issues (the consequences of hospitalization, for example), less summarily with others (suicide and self-harm get short shrift), and which presents us with strategies that focus more on empowerment and not at all on manipulation.
© 2011 Richard-Yves Sitoski
Richard-Yves Sitoski is a psychiatric Survivor and writer on mental health, social justice and food topics based in Owen Sound, Ontario, Canada. He maintains an advocacy blog at www.wundernutbar.wordpress.com.