What kind of work is best for son who's struggling?

Q: My son is 26 years old and does not seem to be able to hold a job. He was diagnosed with bipolar approx. 3 years ago and does take his lithium. He is very creative and a good worker but is late for work and ends up losing his jobs. What would be the best type of employment for a bipolar patient? As a mother how should I handle this? He does not live with us so finacially we are not supporting him, he lives with his girl friend. Thanks for your help. Sharon P.S. I should not nag him for not working, right?

Dear Sharon --
I agree with the P.S., in principle.  But perhaps that's the place to start.  Here are two ideas to consider:

#1.  Don't arrive at any conclusions, nor let anyone else, including your son himself, about his ability to work until his bipolar disorder is well-treated.  For most people that means:  no more cycling, including any remaining evidence of manic symptoms; depression minimal or none; sleep consistent around 7-8 hours; and generally his "usual self" most or almost all of the time.  For most people this can be achieved with few or no side effects if we work at using all the mood stabilizer tools, often in low-dose combinations; and if the "patient" him or herself does their share -- try to maintain a consistent schedule; limit alcohol to 1 drink per week, probably at most, and maybe less for some people; get regular exercise (probably harder than abstaining from alcohol in our society); and be consistent with medications too. 

Only then should we begin to wonder what kind of work he can do.  Most states have a "Department of Vocational Rehabilitation" that can then help decide and sometimes even help with finding appropriate work.  And most people seem to do better in life if they have some sort of "gig", even if it doesn't pay anything; so it's worth it to keep trying.

#2.  This has to do with the nagging.  We humans are animals too, of course, and that means we respond pretty much like the rest of the animal kingdom:  behaviors that are followed by "reinforcement" (meaning something good happens, or sometimes, something bad that has been happening stops!) are more likely to re-occur; and behaviors that are followed by nothing at all, are less likely to re-occur than those that are reinforced.  You often don't have to pull out the stick if there are well-applied carrots out there, if you know that phrase. 

So, you as a mother want to make sure that you are reinforcing any behaviors that go in the right direction; and make sure you are not reinforcing any that go in the wrong direction.  Sometimes this gets pretty tough for parents, who don't want their kids to suffer.  For example, if he doesn't get out of bed, in the "real world", there is no reinforcement for that (generally).  Make sure you don't do anything that makes not getting out of bed easier than it would be if you were'nt around (like calling his job, for example). 

And conversely, you want to make sure any behaviors you do want to see -- like getting out of bed by 0700, for example, are met with strong reinforcement -- like his favorite breakfast, if you're still doing that kind of thing for him.  Then you make sure breakfasts like that only occur when he's up by 7, never otherwise.  I hope that helps illustrate the general approach.  The trick to this is to look for anything that could be reinforcing his behavior, any little thing; and then work to make sure those reinforcements are pointing in the right direction.  There are therapists out there who specialize in helping people set up their lives like this, whom he might hire; which takes you off the hook for trying to arrange this kind of thing (including cooking breakfast -- which is going to offend someone unless I point out that I mean this metaphorically more than literally). 

Dr. Phelps

Published January, 2001