New Approaches to the Treatment of Bipolar Disorder: Effective Psychotherapy

© 2004, All Rights Reserved
Robert Reiser, Ph.D. and Larry Thompson, Ph.D.
Pacific Graduate School of Psychology, Palo Alto, California

What is Cognitive Behavioral Therapy for Bipolar Disorder?

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that teaches people specific cognitive and behavioral skills to help them control and even prevent serious mood swings. Typically, CBT involves a very structured systematic approach in which clients are taught specific techniques to address overly positive or negative moods that may escalate into new episodes of depression or mania. The therapist also helps individuals recognize and address environmental stressors (major life changes, relationship problems, over-stimulating conflictual situations, etc) that may exacerbate their mood swings. Such changes may require a great deal of practice, individualized attention and encouragement. However, once individuals learn that they can manage mood swings more effectively, their sense of self-efficacy and self-esteem typically improves, and they are much more likely to apply their newly learned skills in the future.
Most of us use many of these skills on a daily basis in our attempts to cope with the stresses and strains of daily living, but we apply them so naturally and easily that we simply have little awareness that we have done so. In our experience, these mood management skills or techniques can be taught effectively even to clients who have had very serious histories of hospitalization and long-term illness.

The Good News About Effective Treatment

A number of new approaches to the treatment of bipolar disorder have been developed in the past few years that are designed to supplement standard pharmacotherapy or medication management. The good news is that several of these approaches appear to be quite promising in terms of their ability to reduce the risk of future relapses (new episodes of illness) as well as offering an exciting potential for prevention and early intervention. The National Institute of Mental Health (NIMH) has recently published a strategic plan for mood disorders research which emphasizes the promise of new psychosocial and behavioral therapies.

"For people suffering from a mood disorder, the outlook has never been better. Effective therapies, both pharmacological and behavioral, can help them recover from potentially devastating episodes of depression or mania and prevent possible relapses." (NIMH Strategic Plan Report, Page 75)

This is consistent with our own experience in providing a specialized cognitive behavioral therapy program to clients with bipolar disorder at the Pacific Graduate School of Psychology Clinic in Palo Alto. Even clients with a past history of multiple hospitalizations and over 10 years of illness appear to find the treatment effective in helping them avoid relapses and spot warning signs of illness in time to avoid hospitalization. In an initial client satisfaction survey, 88 % of clients responded that the therapy program was extremely effective in helping them with their problems.

A recent study showed that not only was CBT effective, but it was also cost effective. The additional cost of psychotherapy was significantly offset by reductions in other costs (medical, inpatient, etcetera).

Why Consider Adding Psychotherapy to Medication Management?

Not every individual with bipolar disorder will require psychotherapy (otherwise known as behavioral or psychosocial treatment). Adding psychotherapy to your medication regimen should be considered if you are having difficulty remaining stable and experience significant breakthroughs of hypomania or depression even while on medication. In an excellent self-help book, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know by Dr. David Miklowitz has summarized the potential goals for psychotherapy as follows:

• Improves medication compliance and treatment adherence (or "treatment concordance")
• Assists clients in identifying stress-related triggers
• Develops self-management skills and coping strategies
• Helps clients maintain stable "social rhythms" and lifestyle
• Addresses the long-term impact of the illness on family members, spouses and friends
• To help you make sense of your current or past episodes of illness
• To discuss long-term planning, given your vulnerability to future episodes
• To help you accept and adapt to a long-term medication regimen

Here are some strategies that we have found helpful in reducing the likelihood of serious mood swings.

1. Learn how to detect subtle changes in your mood, and pay attention to them on a daily basis.
   Mood changes almost always occur as a result of specific events in your life situation, or a train of thoughts that you are having. Being able to identify the connection between these is the first step in knowing what to do. Being effective in controlling your mood is somewhat like using a road map to get to your destination. Unless you know your location on the road map, it will not help you reach your destination. Similarly, unless you carefully monitor and identify changes in your mood, you will have difficulty in seeing the connections and learning effective techniques to rectify them.
2. Learn how to monitor your thoughts carefully.
   Individuals who have intense mood swings may habitually tend to have automatic negative or positive thoughts that do not reflect an accurate or realistic appraisal of a specific situation. For example: John goes to a social gathering of a club he has just joined. No one talks to him, and he begins to feel anxious and a little sad, but soon he is feeling depressed, hopeless and wants to flee the situation. He thinks, "I am being ignored. It's because I don't know how to talk to people. This is why I never have friends. I'm totally ineffective. No one here likes me. I'm a wallflower."
   John started out with a negative thought construction that probably was incorrect. This increased his negative mood, which in turn gave momentum to his negative thinking. This leads to even more negative thought constructions, such as labeling himself a "wallflower". These types of thoughts are habitual or automatic and are accepted with little or no questioning on John's part. Had he been more aware of this process, he might have challenged some of these negative thoughts. He might have asked himself, "Wait a minute! What's the evidence for this line of thinking? Maybe they're not ignoring me. They just don't know me yet. People who know me don't ignore me. I do have friends." Such thinking would tend to interrupt negative thinking, and set the stage for a more positive approach to coping with the situation.
3. Learn to identify early warning signs.
   The best time to interrupt an episodic mood change is before it gains momentum. Usually individuals don't pay attention to the early changes that could alert them to the upcoming episode. They begin to notice that there is a problem only after their functioning becomes impaired, then it is more difficult to get control over their thoughts, feelings and behaviors.
4. Have family members or significant trusted others learn to identify your early warning signs.
   They may be able to detect them before you do, which will enable them to give you feedback that a possible episode is about to occur. This also helps family members to remember that the individual's behavioral difficulties are due to a disorder and not to be taken personally.
5. Develop and write down a personal coping plan.
   Begin to keep track of things that improve or stabilize your mood and develop a written plan to address early changes in mood. For example, loss of sleep is often an early symptom of a more serious manic episode, so one part of your plan might be to make an agreement with your doctor to authorize an adjustment in your medications or have a small prescription for sleep medication available in advance.
6. Try to keep a consistent regular schedule.
   Go to bed, get up and eat meals at regular times. This increases stability and promotes organization in one's life situation, which helps individuals reduce excessive stimulation. Frequently, over stimulation is associated with increased disorganization and the beginning of a manic episode. Keeping a weekly or monthly plan handy to review every day can facilitate this process immensely.
7. Plan a few pleasurable activities into each day.
   The experience of pleasant events each day can have an amazingly positive buffering effect during times of stress. The old saying, "When the going gets tough, the tough go shopping." speaks to this issue. The events do not have to be monumental. They can be as simple as having coffee with a friend, or taking time out to experience nature around you for a few minutes. The important thing is that you intentionally plan them into your day and then carry them out. This enables the individual to develop a perspective of being in control of themselves and their life, which has both ameliorative and preventive effects with respect to stress in their life situation

Self-Help Resources

Several excellent self-help publications are now available that illustrate how and when to use techniques to manage mood swings. We think that "The Bipolar Disorder Survival Guide- What You and Your Family need to Know" by David J. Miklowitz is particularly useful and well grounded in science and research.