Information on Treatment of Bipolar Disorder

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”, and “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 conflict 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.

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.


Family-based Treatment of Bipolar Disorder

The following material is adapted from:
Bipolar Disorder: A Family-focused Treatment Approach
by D.J. Miklowitz,  and M.J. Goldstein, M. J.

The Rationale for Family-Based Treatment for Bipolar Disorder

Families provide the most important and enduring resources for individuals with a serious illness. For young adults with significant family involvement, the family the constitutes a critical support system. The burden of longer-term illness often falls upon the family. Families are a neglected resource for mental health professionals. This approach is 'family friendly'.

The immediate post-hospitalization period can be the most stressful for families dealing with bipolar disorder. There are two major familial style predictors that dictate whether the client will recover or face another episode:expressed emotion and affective style.

High expressed emotion is characterized by excessive, overt hostility, criticism, and over – involvement. Negative affective style is characterized by negative, conflicting interactions.

Dr. Miklowitz has developed an evidence-based approach called Family Focused Therapy (FFT) to provide psycho-education, and help families with communication skills and problem-solving skill in order to more effectively deal with the stresses related to having an individual member with a serious illness. Studies of family based treatment (FFT) suggest that in comparison to standard treatment, FFT reduces the likelihood of future episodes of illness and re-hospitalization one year after treatment.


Six Major Goals of Family Focused Therapy (FFT)

  1. Help family to process and integrate experiences from episodes of bipolar.  Most families have difficulty recognizing the symptoms of bipolar, understanding the “inner experiences” of the patient, and accepting the seriousness of the illness.
  2. Help family to accept that bipolar is a lifelong disorder – with future vulnerabilities!  Most families want to believe that the episode was a 'fluke'. Recognizing that the affected individual may have a future vulnerability involves reorganizing the patient’s identity and the family’s as well.
  3. Help family to accept the need for ongoing medication for symptom control.  Most families agree that medications are needed immediately post-hospital, but believe that medications can be stopped once patient is “back to normal.”
  4. Help families to correctly identify symptoms of bipolar compared to the personality of the individual.  Some families become hyper vigilant and label every sign as an impending relapse. Such over-generalizations and negative labeling may create backfire and negative reactions and resentment. Family members may mistakenly believe that the patient is playing the “sick role.” Some patients stop medications in order to differentiate personality traits from bipolar disorder ("What's me and what's my illness?"). Some patients over-identify with the diagnosis and blame everything on their illness. It is often difficult for families to differentiate between 'bad behavior' and bipolar symptoms.
  5. Help families realize that stressful life events trigger recurrences and give them methods to recognize and cope with stressors.  It is useful to help families understand the vulnerability – stress model. Stress acan be controlled and managed, whereas the innate biological or genetic predisposition to mood episodes is a given.
  6. Help families reclaim pleasant and functional relationships after the episode.  Conflicts (between patient and family ) often involve angry feelings related to the episode, denial of the disorder, need to reestablish independence, and possible medication non-compliance. These conflicts can trigger a rapid deterioration of family engagement. Treatment works to restore family functioning and develop more positive interactions between family members.


Social Rhythm Stability Hypothesis

A number of treatment approaches to bipolar disorder consider the role of stability in routines and sleep-wake cycles as a protective factor that reduces the likelihood of further severe mood instability. It is important to regularize routines and sleep-wake cycles to minimize deregulation which may make individuals with bipolar disorder more vulnerable to an episode.

"Social zeitgebers" provide an external clock to regulate daily habits.

"Zeitstorers" (disruptive events: time changes, over-work, late night overtime, swing shifts, loss of sleep, etc.) tend to disrupt daily rhythms.

Family-Focused Treatment (FFT) Core Assumptions:

This approach is 'family friendly'. The family is an important and underutilized resource for treatment. Episodes are highly stressful for the whole family and can produce family disorganization. The ultimate goal of therapy is to reestablish a new equilibrium and help the family as a whole cope with the illness.


Other Resources

I have created a list of books, websites and insightful articles that can be of great importance to those struggling with Bipolar Disorder.  It can be found on the additional resources and  publications page.