Treatment for Bipolar Disorder
A recent review of 39 randomized clinical trials (Miklowitz, 2020) has found that combining medication with psycho-educational therapy is more effective at preventing a recurrence of illness in people with bipolar disorder than medication alone.
Psychological treatment for bipolar disorder can help you begin to look at how the illness is affecting your life and what kind of adjustments are necessary so you can respond in an emotionally healthy way. As many of my patients have found, medication is important, but as a stand alone treatment is not enough and future relapses are more than likely if we expect medication to do all the work.
Therapy will help you to foster a willingness and commitment to:
- Accept that one has the illness.
- Monitor mood easily every day using mobile app technology.
- Take medication as a preventative safety net.
- Identify and be vigilant of one’s own early warning signs.
- Learn about the nature of Bipolar disorder, especially high risk activities.
- Manage your particular stressors and potential triggers at work and play.
- Keep regular patterns of eating, exercise, sleep and relaxation.
- Formulate a wellbeing plan and work through issues which may be fuelling stress and triggering relapse.
- Work on relationship issues to ensure/improve cooperation with family or friends in detecting early warning signs.
- Allow trusted others to mention warning signs, and to learn to respond effectively.
- Alternatively, if family/friends are themselves problematic stressors, find ways to avoid/nullify those stressors.
- Take a preventative self-management approach overall to become adept at avoiding episodes.
- Cultivate mindfulness so that self-monitoring happens naturally in response to potential triggers.
During our sessions I will be using a variety of evidence based techniques and strategies in order to help you come to terms with your disorder and find new ways of being. Sometimes this also goes much further than just symptom management and talk about Bipolar Disorder. As a psychologist with over 15 years clinical experience I also am skilled at treating a myriad of other life issues that usually come along with Bipolar Disorder.
The following is some information and ideas that I would like you to foster during our time together:
- Please feel free to take notes both during our sessions and outside of them. Therapy is not just about our one hour session together it is also about what you do with your thoughts, feelings, and behaviour outside of our sessions! Therefore…
- Be mindful of what has been spoken of and agreed to in therapy and carry it through into your life. Take notes as experiences, feelings or thoughts happen. Bring them back to therapy. Successful therapy is a two way process whereby we both bring material to the table and work together.
- Be willing to take risks. During therapy I will be asking you to try out new behaviours and experiences. What this does is allow you to gather new evidence and start to think and behaviour in different ways.
- Keep an open mind. Creating change means being open to and willing to accept thinking, feeling and behaving in different ways. Please be open to new experiences and techniques that we might adopt along our journey.
- Provide feedback and ask questions. I will be asking you throughout our sessions for feedback on what is working for you and what is not in our time together. Please use this opportunity to be honest and reflect back to me if you do not understand or feel something isn’t working about our sessions. I encourage and appreciate feedback so that you get a better result.
- Commit to change. Change is a process that requires time and patience. You have been conditioned to think, feel and behave in a certain way for as long as you are old. It will take time to reverse these old patterns and patience and commitment to doing so. Be realistic in your expectations to change and commit to the process.
- Educate yourself. If we are working on a certain topic, psycho-education and self-directed learning are incredibly important tools to arm yourself with. I encourage all of my patients to do recommended reading in their time outside of therapy. Within my office is an extensive library that I often refer to and you can purchase or lend from so please do.
What kind of therapy will be used?
During our sessions I will adopt an integrative approach that may encompass some or all of the following evidence based methods of therapy for Bipolar Disorder and emotional dysregulation:
There is an increasing amount of evidence to show the benefits of lifestyle and environment choices upon mood regulation. Each week we will focus on small incremental changes to help you make better informed mood stabilising choices around: nutrition, sleep, exercise, life stress, light/sunlight exposure, pleasurable engaging and soothing activities, technology use, alcohol consumption, nicotine use, and illicit drugs.
CBT is a widely used form of evidence based therapy that looks at the way thoughts and beliefs influence our behaviour. It adheres to the notion that if you want to change your behaviour you must first change the way you think. A lot of time in therapy will be spent looking at the content of your self talk and how this affects your behaviour in negative ways. I will be helping you to start thinking in less negative and more realistic ways. It will feel silly and uncomfortable at first but with time you will learn a more realistic view of yourself. The relationship between situations, thoughts, feelings and behaviour is called the ABC model and underlies the basis of CBT.
Interpersonal Social Rhythms Therapy (IPSRT)
IPSRT emphasises the link between regular routines (establishing circadian rhythms) and moods and uses a social rhythm metric to monitor routines. When you have a mood disorder your body clock (circadian rhythm) is much more sensitive to shifts in schedules, time zones, and changes in external clocks. This means it is harder for your body clock to stay regular than most people. Not having a regular routine makes your moods worse. IPSRT is designed to help people improve their moods by understanding and working with their biological and social rhythms. IPSRT has been found to lower the risk of new mood episodes in Bipolar Disorder I by a staggering 66% over a 2 year period (frank et al., 200%). It has also been found to treat Bipolar II depression as well as Quetiapine (Seroquel) (Swartz et al., 2019). It is an essential and extremely effective non- medication approach to mood regulation.
‘Mindfulness’ is a hot topic in Western psychology: increasingly recognised as an effective way to reduce stress, increase self-awareness, enhance emotional intelligence, and effectively handle painful thoughts and feelings. Although mindfulness has only recently been embraced by Western psychology, it is an ancient practice found in a wide range of Eastern philosophies, including Buddhism, Taoism and Yoga. Mindfulness involves consciously bringing awareness to your here-and-now experience with openness, interest, and receptiveness. Jon Kabat-Zinn, a world authority on the use of mindfulness training in the management of clinical problems, defines it as: “Paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”
- to be fully present, here and now
- experience unpleasant thoughts and feelings safely
- become aware of what you’re avoiding
- become more connected to yourself, to others and to the world around you
- increase self-awareness around your illness
- become less disturbed by and less reactive to mood swings
- learn the distinction and how to defuse between you and your thoughts/moods
Dialectical behaviour therapy (DBT) treatment is a skills based approach that emphasises tools for emotional regulation – or how to cope with sudden intense urges of negative emotion. Whilst CBT focuses on behavioural change through thought challenging, DBT focuses on teaching skills to help people regulate and cope with intense emotions. Both approaches are helpful due to the thought-feeling-behaviour connection (thoughts influence feelings, which influence behaviours).
DBT is designed to help emotional regulation difficulties such as the following:
- Painful emotions that are experienced as intolerable
- Quickly shifting between different emotions and moods
- Feeling controlled by your emotions
- Intense self-hatred and shame
- Prone to irritability and anger
DBT also addresses other difficulties::
- Relationship difficulties
- Interpersonal communication skills
- Intense fears of abandonment and sensitivity to criticism
- A profound sense of emptiness or emotional numbness
- Self-defeating behaviours that are impulsive or destructive (self-harm)
- The symptoms that accompany Bipolar Disorder or Borderline Personality Disorder
A randomised, controlled study published in a 2013 found that a 12-week course of DBT reduced depressive symptoms and led to fewer mental health-related hospital admissions in people with bipolar disorder. Additional research has confirmed positive outcomes: The authors of a 2017 study of DBT and emotional regulation in bipolar wrote that their findings “support a burgeoning literature that DBT is a feasible adjunct intervention for patients with bipolar disorder.”
DBT helps people learn and implement these four skills to create what they determine to be a life worth living: mindfulness, the ability to tolerate distress, the ability to regulate emotions, and healthy communication skills.
Acceptance & Commitment Therapy (ACT)
ACT encourages a type of psychological flexibility that, through mindfulness, allows people to accept their internal experiences and develop a more compassionate relationship with unwanted thoughts or feelings.
With ACT, there’s a tendency to help clients be more accepting of emotions as a passing phenomenon, because they can be so intense and all-encompassing.
The commitment piece comes from clarifying values and making behavioural changes that support those values.
Schema Therapy (Core Beliefs)
Schema Therapy is a type of cognitive therapy created by Jeffrey Young. A schema is an internalised and enduring belief system that drives thought, behaviour and emotions. In schema therapy, schemas specifically refer to early maladaptive schemas, defined as “self-defeating life patterns of perception, emotion, and physical sensation”. Often they take the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive (have an “emotional button” or “trigger”) about his/her perceived value to others, which in turn could make him/her feel sad and panicky in his/her interpersonal relationships.
- David J. Miklowitz, Orestis Efthimiou, Toshi A. Furukawa, Jan Scott, Ross McLaren, John R. Geddes, Andrea Cipriani. Adjunctive Psychotherapy for Bipolar Disorder. JAMA Psychiatry, 2020; DOI: 10.1001/jamapsychiatry.2020.2993
- Swartz, H. A., Rucci, P., Thase, M. E., Wallace, M., Carretta, E., Celedonia, K. L., & Frank, E. (2018). Psychotherapy alone combined with medication as treatments for bipolar II depression: A randomised control trial. Journal of Clinical Psychiatry, 79 (2), 16m11027.
- Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A. Fagiolini, A. M., Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with Bipolar I disorder. Archives of General Psychiatry, 62 (9), 996-1104.