Family-Based Treatment for Bipolar Disorder
What Can I Expect in Treatment?
My Training in Cognitive Behavioral Therapy
What is Bipolar Disorder?
Bipolar Disorder (previously known as Manic Depressive Reaction and Manic Depressive Illness) is a mood disorder characterized by a long-term episodic cyclical course of extreme fluctuations in mood resulting in significant impairment in social, interpersonal and occupational functioning. The results of repeated extreme fluctuations in mood can be devastating. Bipolar Disorder is a serious illness that requires psychiatric and psychological treatment. Untreated individuals with bipolar disorder have a significantly higher lifetime rate of attempted and completed suicide.
The most severe form of the disorder, Bipolar I Disorder, is characterized by one or more Manic or Mixed (Manic and Depressed) episodes of sufficient severity to cause marked impairment in social and occupational functioning often resulting in a psychiatric hospitalization.
Typically, individuals with Bipolar I disorder experience extreme fluctuations in mood ranging from severe Depression to Mania. During Manic Episodes people experience elevated or irritable moods in which they may become highly energized, have an inflated sense of self-esteem, experience a reduced need for sleep, become very talkative, have racing thoughts, may take on multiple projects at once and become easily distracted.
People in a more severe state of mania may lose their normal sense of judgment and may undertake risky behaviors with the potential for painful negative consequences. In the most severe stages of Mania individuals will become disorganized in their behavior and thought processes. These behaviors and thought processes may appear bizarre to others and they may experience strange or unusual ideas.
People with Bipolar Disorder also experience significant periods of depression in which they may experience depressed mood and loss of interest or pleasure as well as the following symptoms: significant weight loss or decrease or increase in appetite, sleeping too much or too little, being agitated or slowed down or feeling fatigued. During depressed periods individuals often report feelings of worthlessness, excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, or suicidal thoughts or plans.
Careful assessment before prescribing medication is important because people with Bipolar Disorder experience significant periods of depression as well as distinct periods of elevated mood. About 60% of people who present initially with mainly depressive symptoms may go on to experience a manic or hypomanic episode. People who receive an anti-depressant medication may experience a medication induced manic or hypomanic Episode.
Bipolar II Disorder is characterized by one or more major depressive episodes with at least one Hypomanic Episode in which the patient’s functioning is not compromised severely enough to cause marked impairment in social or occupational functioning. Bipolar II Disorder, while by definition not involving an episode of severe mania, has a high risk of suicide and is often associated with a severe depressive course just as devastating as that experienced in Bipolar I disorder.
New Approaches to the Treatment of Bipolar Disorder: Effective Psychotherapy
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 bipolar illness) as well as offering potential for prevention and early intervention. According to the National Institute of Mental Health (NIMH):
“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.”
(Breaking Ground, Breaking Through, The Strategic Plan for Mood Disorders Research of the National Institute of Mental Health (NIMH, 2003), Page 75.
Why Consider Adding Psychotherapy to Medication Management?
Not every person with bipolar disorder will require psychotherapy (otherwise known as cognitive, cognitive-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, Dr. David Miklowitz has summarized the potential goals for psychotherapy as follows:
- Improves medication compliance
- Assists in identifying stress-related triggers
- Develops self-management skills and coping strategies
- Helps maintain stable “social rhythms” and lifestyle
- Addresses the long-term impact of the illness on family members, spouses and friends
- Helps “make sense” of the illness
- Discusses planning and strategies to keep stable, given vulnerability to future episodes
- Helps acceptance of a long-term medication regimen
(Adapted in part from Miklowitz (2002) table on page 122)
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. CBT involves a structured systematic approach in which clients are taught specific skills and strategies to address overly positive or negative moods that may escalate into episodes of depression or mania. For example, clients in a hypomanic or manic state typically underestimate the risks and negative consequences of their actions. The therapist works collaboratively to help the client challenge overly positive thoughts (“Everything will turn out fine” “I feel lucky”; “I can’t go wrong”) and evaluate possible negative outcomes and to reduce impulsive behaviors with a high risk of harmful consequences. The therapist also helps clients recognize and address environmental stressors (major life changes, relationship problems, over-stimulating conflictual situations, etc) that may exacerbate their mood swings. CBT strategies may require a great deal of practice, individualized attention and encouragement. However, once clients learn that they can manage mood swings more effectively, their sense of self-esteem and confidence typically improves, and they are more likely to apply their newly learned skills in the future.
Many people use these cognitive skills on a daily basis to cope with the stresses and strains of daily living, but they are often applied so naturally and easily that we simply have little awareness that we have done so. These mood management skills or techniques can be taught effectively even to clients who have had very serious histories of hospitalization and long-term bipolar illness.
Here are some CBT strategies that have been found to be 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, or thoughts that you are having. Being able to identify the connection between moods, events and thoughts is the first step in getting better. Being effective in controlling your mood is somewhat like using a road map to get to your destination. Unless you know your current location on the road map, it will not help you reach your destination. By carefully monitoring and identifying changes in your mood, you will know where you are on your emotional map and this can be the beginning of getting to your destination- mood stability. Use of a daily mood graph can be very helpful in this process.
2. Learn how to monitor your thoughts carefully.
People who have severe mood swings may tend to have automatic negative or positive thoughts that do not reflect an accurate, adaptive or realistic appraisal, of specific situations. 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, and soon he is feeling depressed, hopeless and wants to leave 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’s negative thoughts may have been distorted. These negative thoughts contributed to his negative mood, which in turn gave momentum to his negative thinking. This leads to even more negative thoughts, such as labeling himself a “wallflower”. These types of negative thoughts may be habitual or automatic and are accepted as true and accurate with little or no questioning on John’s part. Had he been more aware of this thought process, he might have questioned some of these negative thoughts. He might have asked himself, “Wait a minute! Where’s the evidence for these thoughts? 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.” Thinking about situations in a different way tends to interrupt negative thinking, sets the stage for a more positive approach to coping with the situation and leads to an improvement in mood. See: Sample Unhelpful Thought Record
3. Learn to identify early warning signs.
The best time to address negative or overly positive changes in mood is before your mood shift gains momentum. Often people don’t pay attention to the early changes that could alert them to the upcoming episode. They may begin to notice that there is a problem only after their functioning becomes impaired, and at that point 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.
Other people may be able to detect your mood changes even 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 activities 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. One part of your plan might be to make an agreement with your doctor to authorize an adjustment in your medications to help you sleep better. Another part of the plan might be to have additional sessions at this point in order to prevent a more severe manic episode.
6. Try to keep a consistent regular schedule.
Go to bed, get up and eat meals at regular times. This increases both physical and emotional stability. 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 also facilitate stability and consistency.
7. Plan a few pleasurable activities into each day.
The experience of pleasant events each day can have a positive effect during times of stress. Pleasant 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 pleasurable activities into your day and then carry them out. This may also enable you to develop the perspective of being in control of yourself and your life.
Seeking Professional Help
Some people are able to remain relatively stable on a long term medication regimen. However, if you are continuing to have episodes or significant periods of depression or hypomania, despite being on medication you should consider cognitive behavioral psychotherapeutic help, especially if you are having suicidal thoughts, severe hopelessness and depression or hypomanic episodes that have caused significant problems for you. It appears that only certain specific structured and directive psychotherapies, including cognitive behavioral therapy, are particularly helpful in terms of being effective in reducing the severity of mood swings and future episodes.
Self-Help and Other Resources
Several excellent self-help publications are now available that illustrate how and when to use techniques to manage mood swings:
“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. (available at www.amazon.com)
“Overcoming Mood Swings: A self-help Guide to using Cognitive Behavioral Techniques” by Jan Scott (New York University Press, 2001)
"The Bipolar Workbook- Tools for Controlling Your Mood Swings" by Monica Basco (The Guilford Press, 2006)
I have recently published a book on Bipolar Disorder. Click here www.hhpub.com for information about: “Bipolar Disorder: Advances in Psychotherapy- Evidence-based Practice”.