Treatment for Bipolar Disorder Part II: Psychotherapy
There are many roles for the uses of psychotherapy in the treatment of bipolar disorder. Some of the roles for psychotherapy would be to psychoeducational, to teach skills for symptom management, to enhance functioning in social and occupational areas, and to keep patients adherent to their medication routines. Other important goals would be to help these patients learn to cope with stress triggers recognizing that certain types of life events and family tensions are potential risk factors that contribute to the expression of the disorder.
One of the most distressing issues regarding bipolar disorder is that patients have traditionally expressed their resentment regarding how little information they are given about the disorder that plagues them or the medications that they are prescribed (Goodwin, 2007). Psychoeducational sessions should consist of actual lectures about the disorder, the medications involved, the need for adherence, what to expect side-effect wise, etc. Early studies that used manual based education programs that teach patients about the signs and symptoms of the disorder and medication management display significantly lower rates of relapses than those that only receive medication management instruction, although the relapse rates in some studies were still high attributing to the chronic nature of the disorder (e.g., Colom et al., 2005). Psychoeducation may also have an effect on the severity of manic symptoms as well. For example, Simon et al. (2005) examined psychoeducation in the context of a multi-component managed care program. The program consisted of patients treated with a case management program (pharmacotherapy, telephone based monitoring, care planning with a team, and group psychoeducation) compared to patients receiving pharmacotherapy alone. Over a two year follow-up period had lower mania scores on standard measures and spent less time in manic or hypomanic episodes than the pharmacotherapy group, but there was no effect on depressive symptoms. Thus, it appears that psychoeducation should be an important part of any treatment program for bipolar disorder.
Cognitive Behavioral Therapy
There has been quite a bit of research investigating the use of cognitive behavioral therapy (CBT) used in conjunction with medications for treating bipolar patients. CBT addresses a client's belief system and behaviors and seeks to directly challenge and change these when they are dysfunctional. In a review of therapy studies Goodwin (2007) reports that between the years 1960 and 1998 there were more than 30 published studies that investigated the use of combined psychological and pharmacological treatments for bipolar disorder. However, the majority of the studies were not large and had a collective mean sample size of about 25 participants. The bulk of the studies addressed group or family therapies for bipolar disorder with a small number (four) reporting on the results of individual psychotherapy for bipolar disorder. In addition, nearly 20 of these studies were open cohort designs without a control group. In spite of the methodological limitations of many of the studies reviewed the participants in a majority of the studies that received adjunctive psychotherapeutic treatments demonstrated better clinical and social outcomes than the participants undergoing standard treatments comprised of medications (most often mood stabilizers) with some outpatient support. There was also evidence of observer-rated differences between the combined and traditional treatment groups that approached statistical significance. Overall these results motivated later randomized controlled trials using more targeted interventions.
There have been a large number of studies in several different countries looking at psychotherapy for bipolar disorder. Many of the trials focus on psychoeducational models and the best researched manualized psychotherapeutic approaches (following a manual to keep the treatment the same between different therapists): interpersonal social rhythms therapy, CBT, and family focused therapy (FFT). Some studies have concentrated on techniques drawn from these manualized therapies. Therapies are primarily used to improve awareness, adherence to medications, to instruct the patient in the recognition of prodromal symptoms (symptoms occurring before the onset of the disroder), and techniques aimed at relapse prevention.
For instance, Lam et al. (2005) compared a CBT/pharmacotherapy group (14 sessions and two booster sessions) with a control (pharmacotherapy) group of bipolar patients who had been in remission for six months but were believed to be at high risk for relapse. At a year follow-up the relapse rated in the CBT group was significantly lower than the control group (44% compared to 75%). The CBT group also demonstrated higher social functioning. However, at the 18 month follow up period the two groups did not differ significantly in regards to relapse rates. As one would expect, the effects of CBT were more salient on depression than on mania. It appears the addition of psychoeducation programs oriented towards symptom management have stronger effects on mania than depression (Butler, Chapman, Forman, & Beck, 2006). Lam et al. (2005) recommended that CBT techniques need to be formulated specifically for bipolar disorder as opposed to using techniques aimed at depression. Therapeutic techniques should address the specific cognitive distortions and cognitive styles associated with mania and hypomania including grandiosity, a pressured sense of time, etc.
A large scale study by Scott et al. (2006) looked a CBT (22 sessions) plus medications versus a medication only group in the UK recruited across five different sites. There were no differences to relapse; however, a there was a treatment by prior episodes interaction with CBT associated with longer time to relapse for those with 12 or less prior relapses. Thus, CBT may be more effective the earlier in the course of the disorder it is applied.
Miklowitz (2008b) discussed the results of studies of adjunctive therapies for bipolar disorder. Eighteen studies performed between 1984 and 2008 were included in the analysis. The effects of the treatment of different types of modalities varied depending on the clinical condition of patients at the beginning of treatment and the type of symptoms occurring at follow-up. Interpersonal therapy, family therapy, and systematic were most effective in preventing relapses when there were started following an acute episode. CBT and group psychoeducation were most effective when started during recovery of an episode. Individual psychoeducation and systematic care demonstrated greater effectiveness for manic as opposed to depressive symptoms and family therapy and CBT demonstrated the opposite pattern (greater effectiveness for depressive symptoms). Overall Miklowitz found the results to indicate that treatments placing their emphasis on early recognition of symptoms and/or adherence to medications were more effective for mania, whereas those stressing cognitive and interpersonal coping skills have better results on the depressive symptoms.
Meta-analysis combines the effects of several different studies.The results of meta-analytic studies investigating CBT on bipolar disorder have been mixed with some indicating no overall effects (e.g., Lynch, Laws, & McKenna, 2010) and others indicating effects similar to the aforementioned studies (e.g., Butler et al., 2006). However, based on the above discussion several mediating variables would need to be considered. Given these findings we can propose how CBT can be most effective in applying to patients with bipolar disorder.
Early in treatment it is important to provide patients with a model of bipolar disorder and a sound justification for the upcoming treatment procedures. Next the therapist should discuss or instruct the patient in the cognitive-behavioral representation of the interplay between thinking, feeling, and behavior. Patients can then be asked to supplement this information by observing their experiences, testing the CBT model, and identifying the role of their thoughts in influencing their mood. Sessions can be presented in a problem-solving design that begins with a review of the previous learning, developing an agenda for the current session, completion of that list of items focusing on the practice of concepts, and finally ending with homework to enhance skills. This particular format maintains focus on the sequential, goal-oriented, skill development approach advocated in the original CBT literature (e.g., Beck, 1995). To assist making the treatment more palatable the use of metaphors and stories can be used as well.
A good deal of research in clinical and social psychology suggests that compliance with requests is improved when the person’s agreement to comply is perceived as their own choice or in line with their opinion (e.g., see Cialdini, 1993). When we take this vast body of research into account we can understand that psychiatrists and therapists might be of more assistance to patients if instead of telling them why medications and other forms of interventions for their disorders are necessary they could get the patient to explain why such ongoing treatment may be of assistance to them. CBT therapists should become adept at this skill. Some utilize a life-history or disorder history graph as a strategy for getting the patient to visualize the impact of their bipolar episodes on their personal lives, goals, and relationships. A life-history timetable or graph requires the patient to construct a timeline of their disorder demonstrating their manic, depressive, and/or hypomanic, episodes and the contexts in their lives surrounding these occurrences. Once this timeline is constructed the information can be used as evidence to help the patient to decide whether the current treatment or an alternative treatment is the soundest strategy to follow. Moreover, the therapist can use the timeline as a clinical tool to help the patient identify triggers, stressors, and other incidents that are associated with the manifestation of their symptoms.
Goals to Make Treatment More Effective
The earlier treatment is attempted in the course of the disorder, the more effective we would expect CBT to be for bipolar disorder. Next, CBT should include aspects of psychoeducation symptom recognition, medication adherence, examining the patient’s views concerning their symptoms, and offering counter strategies to assist them deal with their disorder. We can outline five major goals for CBT in the treatment of bipolar disorder based on the aforementioned studies:
- Treatment adherence. The main goal of CBT for bipolar disorder would be to ensure that the patient remains in their specified treatment plan which most often would include adherence with their pharmacotherapy regime and would also include any other additional forms of treatment. Given the overall high rates of relapse the focus on compliance with the set treatment program presumes that even given the best possible circumstances most patients will find it extremely difficult or will not be able to comply with treatment in light of the fact that treatment is a lifelong commitment. CBT treatment should approach this goal by collaborating with the patient to identify factors that can interfere with compliance to the treatment regime and develop strategies to deal with them. If the patient is not ready to accept their illness, follow through with the treatment, and adhere to their restrictions then CBT cannot help them.
- Early detection of symptoms that trigger a relapse and a plan for intervention. One of the goals of the CBT treatment would be to alter the long term course of bipolar disorder in the patient. Every time a patient has a period of depression or mania it can be viewed as an opportunity to learn more about and understand the precipitating factors that signal a recurrence for a the patient. This also allows one develop a plan to deal with future situations. This would entail initial treatment and booster sessions as needed. During such booster sessions following a potential or actual relapse the therapist should determine if the situation was resolved and how much time will be required for discussion of the issue.
- Lifestyle management. One of the problems with medical treatments for psychiatric disorders is that medication use often leads people with these problems to become passive recipients of medical care opposed to being active participants in their care. By outlining a program of lifestyle management with the patient that includes stress management techniques (and giving the patient freedom to contribute) CBT can assist bipolar patients to become active in the management of their disorder. Some patients with long-standing bipolar disorder will need assistance to develop such skills. Moreover, such a program would allow for the inclusion of family members. Involvement of family in the therapy can be very constructive. It allows the family members a chance to meet with the therapist, learn about the treatment, demystifies the whole process for them, and it encourages family to facilitate in their care.
- Treating comorbid psychiatric conditions. A comorbid condition is defined as another psychiatric disorder that occurs as the same time as a primary psychiatric disorder. Thirty to fifty percent of bipolar patients will also meet the diagnostic criteria for substance abuse or dependence, a personality disorder, or other psychiatric condition (APA, 2000). Having a comorbid psychiatric condition is a predictor of poorer responsiveness to medication in bipolar disorder. Many of these comorbid conditions may precede the bipolar diagnosis (Judd et al., 2002). It becomes very important to make assessment an ongoing process in the maintenance of a chronic condition such as bipolar disorder to identify co-occurring complications (especially substance abuse, impulse control issues, and personality disorders). If any such conditions are suspected or uncovered (or are already present) these need to be dealt with in the context of the ongoing treatment. Comorbid conditions will most likely complicate the treatment of bipolar disorder on many levels. It is extremely important for the therapist to adhere to empirically supported methods of intervention in all cases, but in the situation where a patient has bipolar disorder and a comorbid or several comorbid psychiatric diagnoses it becomes crucial to adhere to interventions and strategies with a sound empirical basis.
- Treatment of depression. In addition to assisting the patient in managing signs and triggers leading to mania CBT can directly confront depressive symptoms via the use of standardized CBT techniques for the treatment of depression. CBT is an empirically validated treatment for depression and studies of CBT use with bipolar patients indicate that it is effective in treating the depressive symptoms associated with bipolar disorder.
By using these guidelines the application of CBT techniques can prove to be a valuable adjunctive treatment to standard pharmacological interventions and other treatments for bipolar disorder.
Family Focused Therapy
Emotion-Focused Therapy (EFT) is an empirically supported psychotherapy that has its roots in humanistic psychology, the study of emotions, and attachment theory (Palmer-Olsen, Gold, & Woolley, 2011). EFT views human emotions as crucial to one’s experience of self in adaptive and maladaptive situations. Emotional functioning is also seen as the vehicle for therapeutic change via awareness, emotional regulation, and reflection in the context of an empathetically regulated therapeutic relationship.
Family focused therapy is a type of EFT that attempts to affect change by focusing on the relationships within families. Family conflicts may be related to increased cycling in bipolar disorder (Miklowitz & Goldstein, 1997). One way to measure family stress is to measure the level of expressed emotion (EE). EE has been dived into three components (Vaughn & Leff, 1976): critical comments, hostility or personalized criticism, and emotional over involvement or the tendency to be over concerned or overprotective. EE has been demonstrated to be predictive of relapses in schizophrenia (Vaughn & Leff, 1976). It appears that high EE relatives of bipolar patients are more likely to attribute the symptoms of the disorder as under the patient’s control, are more negative in problem-solving situations, and engage in arguments behaviors than low EE relatives (Miklowitz & Goldstein, 1997). Arguments are often instigated by the patient, but high EE relatives are more likely to argue back as opposed to avoiding a volatile situation. Miklowitz and Goldstein (1997) developed FFT to deal with these family conflicts. FFT uses family assessments, psychoeducation, mood charts, problem solving skills, and communication enhancement training.
FFT as applied to bipolar disorder has six three principal assumptions (Miklowitz & Goldstein, 1997):
- A bipolar episode represents a family life cycle crises that is not normative.
- These bipolar episodes (manic or depressive episodes) bring significant disorganization within the family system.
- Reintegration of the family can occur only with use of new coping strategies that change old ways of interacting.
Objectives of Treatment
The six objectives sound much like the objectives in CBT and consist of:
- 1. Experience integration. Here the goal is to integrate the experiences that are associated with the mood episodes in bipolar disorder.
- 2. Disease acceptance. It is very important for the patient and the family to accept the probability and vulnerability of the patient to re-experiencing future episodes of bipolar disorder. This does not mean that the patient or family must assume a defeatist attitude, but the goal is to accept the chronic nature of the disorder.
- 3. Medication compliance. It is very important for the family and the patient to fully accept the fact that they will need to continue taking medication for the stabilization of their mood. The notion that one day they will not need the medication is a potential pitfall that could lead to a serious relapse.
- 4. Symptom recognition. As mentioned above it is surprising how many people with long-term bipolar disorder are unaware of their symptoms, especially those symptoms that precipitate a relapse. It is extremely important for the family and the patient to be able to distinguish between the individual’s normal personality and the symptoms of their bipolar disorder.
- 5. Stress reduction. Related to number four on this list, stress appears to be a significant contributing factor to relapse in bipolar disorder. Patients and their family need to be able to learn to recognize stressful life events that can help trigger a relapse of their bipolar symptoms as well as learning how to cope with stressful events that can make them vulnerable to relapse.
- Relationship restoration. Functional personal relationships are extremely important for one to have a stable and fulfilling life. One of the major effects of having bipolar disorder is its effects on the patient’s relationships. It is extremely important for the patient and the patient’s family to develop a plan to restore their relationships following a mood episode. No one should be blamed.
The six objectives defined in terms of two target situations, family environmental issues and stressful life events. Treatment in FFT is done with the patient and at least one family member which could be a spouse or partner, a parent, a sibling, or other significant family member (treatment is often done with the patient and more than one family member). The treatment is standardized and is partitioned into three modules that are delivered over 21 sessions. There are twelve weekly sessions, six biweekly sessions, and three monthly sessions that are scheduled over a nine month period. Empirical research investigating the use of FFT as an adjunctive therapy for bipolar disorder has been encouraging.
Bipolar disorder is a severe psychhiatric disorder that responds best to a multi-disciplinary treatment approach. It is clear that the first-line of treatment for bipolar disorder consists of pharmacotherapy; however, adjunctive psychotherapies appear to be able to add some noteworthy advantages to recovery. The addition of psychotherapy whether it is individual therapy, family therapy, or group therapy results in more positive for the disorder than can be achieved by the use of pharmacotherapy alone. The literature also targets different outcome domains that are affected by the addition of psychotherapy. In some studies the positive outcomes deal with relapse rates or the severity of the symptoms. In other studies the outcomes have dealt with medication or treatment compliance or overall levels of functioning. There have been a few studies that examine occupational or social functioning. However, it should be noted that psychotherapies for bipolar disorder are not considered by most as effective first-line treatments, but instead enhance the effects of medications by using education, symptom awareness, relapse prevention, and stress reduction as their contributions.
Continued research can better help define how psychotherapies can contribute to the recovery of those with bipolar disorder and design strategies to assist with the manic phases of the disorder. One area of focus for future research could investigate the impact of various types of psychotherapy delivered in community mental health settings by the clinicians who work in these types of settings. These therapists typically treat a more severely dysfunctional population of patients with comorbid conditions and work under more severe time constraints. Such a population would be more difficult to address, especially at the family level.
Another real world issue for the addition of psychotherapy is that of managed care. Insurance companies typically only compensate for a limited number of psychotherapy sessions and often to not pay for family therapy. For practical purposes, studies concentrating on deconstruction of the typical therapies used in bipolar disorder may help identify the most effective components of these interventions. Then these could be applied in suitable contexts. Nonetheless, psychotherapy for bipolar disorder appears to offer real benefits and should be included in the treatment regimes of these patients when practical.
References for Part I and Part II
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Miklowitz, D. J. (2008a). Bipolar disorder: A family-focused treatment approach (2nd ed.). New York: Guilford Press.
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Miklowitz, D. J. & Goldstein, M.J. (1997). Bipolar disorder: A family-focused treatment approach. New York: Guilford Press.
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Palmer-Olsen, L., Gold, L.L., & Woolley, S.R. (2011). Supervising emotionally focused therapists: A systematic research-based model. Journal of Marital and Family Therapy 37 (4), 411-426.
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Scott, J., Paykel, E., Morriss, R., Bentall, R., Kinderman, P., Johnson, T., Abbott, R., & Hayhurst, H. (2006). Cognitive behavioural therapy for severe and recurrent bipolar disorders : Randomised controlled trial. British Journal of Psychiatry 188, 313–320.
Simon, S.R., Majumdar, S. R., Prosser, L.A., Salem-Schatz, S., Warner, C., & Kleinman, K. (2005). Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: A cluster-randomized controlled trial. The American Journal of Medicine, 118(5), 521-528.
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