What to Expect From Psychotherapy for Bipolar Disorder

If you struggle with symptoms of bipolar disorder, you've no doubt been advised to get psychiatric help and perhaps even become involved in psychotherapy. As I was recently thinking about this it occurred to me that despite the frequency with which this advice is given, a more definitive explanation of what it really means to be in psychotherapy is often absent.

Psychotherapy for the individual with bipolar disorder will take many different forms. The two most salient defining variables are: 1) how the therapist approaches the work and 2) the nature of the patient’s symptoms and where he/she is with the course of the disorder. To the last point, the individual first encountering a hypomanic or manic episode will have very different therapy needs than someone who has lived with their disorder for 15 years. Simply stated, people’s psychopathology and accompanying treatment needs change as they age.

The place where mental health assistance usually starts is clinical assessment. With bipolar disorder one has to get a very clear picture of symptom patterns over time. Relevant areas of inquiry are extensive and will include:

• age of onset
• progression of symptoms over time
• description of specific depressive symptoms
• description of experience in mid-range
• description of specific symptoms during elevated mood
• description of sleep patterns and physical energy in each of the different mood phases
• approximate duration for each of one’s mood phases
• how one’s judgment and impulse control are affected by different moods
• presence of any psychotic symptoms during different mood phases (delusions or hallucinations)
• presence of any mixed symptoms (concurrent elevated and depressed symptoms)
• presence of suicidal thought and accompanying risk factors
• extent to which mood changes are or are not linked to external precipitants
• current and historical substance use patterns and their effects on mood phases
• extent of functional impairment during mood phases
• impact of symptoms upon interpersonal relationships
• individual and family psychiatric treatment history

As is apparent, the process of gathering information essential to the establishment of a definitive bipolar diagnosis is a complex undertaking. A comprehensive assessment of someone who may be bipolar typically requires a minimum of 90 minutes, if not two hours. As such, the initial assessment phase of treatment may need to be conducted over the course of several sessions.

If the diagnosis does turn out to be bipolar disorder, the next step is conveying that information to the individual who has sought help. This is no small task. Most of the implications of being informed that one has a chronic psychiatric disorder that will probably impact mood, thought and behavior over the course of one's lifetime, are too much to take in. Furthermore, if the individual is to be successful in gaining some measure of control over his/her symptoms, there's usually a broad range of lifestyle modifications which become necessary. For those ages 17 to 25 (typical age of onset) the diagnosis and recommended lifestyle adjustments are like being hit psychologically with an 8.2 Richter scale earthquake. The after-shocks may continue for many months, if not years.

The initial post-diagnosis phase of therapy may be the most important of all the work done with bipolar disorder; this is the acceptance phase of treatment.

No one wants a psychiatric illness, especially one with strong mood and energy fluctuations, intense irritability, impulsivity with impaired judgment and potential transient psychotic symptoms. Post-diagnosis reactions commonly include anger, depression, rejection of treatment, increased substance use and medication non-compliance. What’s worse is these maladaptive responses to the diagnosis can actually worsen the impact of the disorder over the course of one’s adulthood. Given what’s at stake, I often recommend that during this adjustment phase, a patient meet with a therapist weekly for at least the first several months after receiving their diagnosis. The work during this time will be twofold: it will focus upon acceptance of the diagnosis while also being strongly oriented towards symptom reduction and stabilization.

It would be cleaner if these two aspects of treatment were better differentiated or perhaps even sequential, but the reality is that acceptance and symptom reduction must go hand-in hand. One can’t make lifestyle changes that will mitigate symptom intensity while rejecting the diagnosis. Similarly, it’s difficult to get oneself into an accepting frame of mind while being tossed about by bipolar symptoms.

Most with bipolar disorder find the use of some medication to be helpful and often necessary to reduce symptoms. Usually, the medications used with bipolar disorder are drawn from the classes of drugs referred to as mood stabilizers, atypical antipsychotics, anxiolytics (ant-anxiety) and/or sedative-hypnotics (sleep aides). Whether medications are utilized will have everything to do with symptom acuity as well as how responsive symptoms are to lifestyle modification. I do suggest that even if an individual is biased against psychiatric medicine, it can still be worthwhile to obtain a psychiatric consult from a bipolar expert to at least hear what medication options exist and to learn the potential risks and benefits of the different options. Good information is the key to good treatment. The more you know, the more you can be assured that your decisions are well-informed.

The second essential aspect of symptom reduction entails helping the patient to develop strategies for implementing accurate self-observation, adaptive intervention strategies and lifestyle changes that will facilitate maintenance of mood stability. This aspect of the therapy is often pragmatically oriented and directed towards tasks such as: 1) learning to adhere to a stable sleep cycle, 2) developing an effective self-monitoring perspective in order to identify early signs of emerging symptoms, 3) developing interpersonal and treatment-oriented support systems, 4) addressing the consequences of one’s mood instability upon one’s immediate family members and other close relationships, and 5) acquiring enduring positive alternatives to drug and alcohol-related recreation patterns.

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Even with the therapeutic tasks being divided into several identifiable areas, the issues addressed here are extensive. Individual differences will require a very broad range of therapeutic approaches and each therapist will approach them with his/her unique blend of methodologies. But it’s not uncommon that the focus upon self-awareness and lifestyle change can take a couple of years. A key determinant is how well one has managed to truly accept the diagnosis. Where there is a strong degree of continued resistance then the lifestyle modifications will take much longer to acquire. The prevalent theme entwined within all the lifestyle issues involves establishing patterns of living which facilitate balance while minimizing influences which can be destabilizing. It’s not rocket science but it’s not formulaic either. The challenge is figuring out how to achieve this balancing act.

If an individual has had loving and supportive parenting and stable family relationships, then it’s often the case that his/her personality style will likely engender positive relationships. Conversely when childhood and adolescent development is fraught with conflict, inconsistent patterns and family disruption, then we often see broad patterns of maladaptive behavior. Essentially someone may be living an adult life as if still in the midst of negative childhood influences. We all do this to some degree. But when maladaptive patterns are pervasive then the personality style of the bipolar individual will invariably become its own pathogenic enemy. Therefore, behavioral patterns resulting in recurrent negative outcomes must become modified. If not, the individual with bipolar disorder is faced with repeatedly trying to put out fires while concurrently adding kindling to the embers. It’s not a formula for success. However, altering that formula takes a significant commitment of intentionality and resources (money, insurance, time, etc.). Next to the challenge of accepting the reality of the bipolar diagnosis, altering maladaptive personality patterns stemming from earlier development can be amongst some of the most difficult aspects of psychotherapy for bipolar disorder. No one easily changes how they are in the world.

Supportive psychotherapy and brief therapy for relapses are two additional aspects of treatment that go hand in hand and are entwined through much bipolar oriented therapy. All too often, living with bipolar disorder is just hard. Imagine never quite knowing when your automobile is going to speed up or slow down independent of anything your foot is doing in relation to the brake or accelerator. Or instead, imagine you’re driving on a winding road and despite your sharp focused attention you still drift out of your lane or worse, over the guard rail and down an embankment. The experience can be terrifying.

Once you’ve dealt with the immediate crash you’ll need help getting back behind the wheel. This is where the initial work on symptom reduction comes back into play – kind of like a refresher course where you’re reminded of what you’ve already learned.

But there’s another part of the process that simply entails receiving emotional support. Your friends, your spouse or your partner may become worn out by your driving. The painful reality is that sometimes those who are closest to you can’t always be relied upon to provide the support you may need. This is where having a therapist who really knows and understands what you’re going through can be an invaluable resource. Being received in your depressive despair or receiving support while picking up the pieces from a recent manic episode can truly make a difference in your ability to manage. These are the relational aspects of supportive psychotherapy that have little to do with method or theoretical orientation. It’s more a matter of having someone who is present to your pain and your challenges without also being adversely affected by them.

There are two other aspects of therapy for bipolar disorder that diverge from the intense dyadic nature of individual psychotherapy. These are couples therapy and participation in a bipolar support group.

Couples therapy is applicable for those in committed relationships where the quality of the relationship is being adversely affected by the individual’s mood instability. The work here often entails learning to separate the symptoms of the disorder from the individual with the disorder. Once a couple is able to achieve that perspective then the therapeutic work is aimed towards helping the couple become allied in their efforts to collaboratively manage the bipolar symptoms and their impact on the relationship. Couples therapy or even family therapy can be an important aid to living well with bipolar disorder.

The last modality that’s integral to treatment entails involvement in a bipolar support group. Most with bipolar disorder often feel very alone, stigmatized and misunderstood by others who know little about the disorder. Conversely, when a group of people with bipolar disorder meet on a regular basis, they’re often able to receive rapid understanding, empathy and helpful advice from those who share similar struggles. It’s one thing to feel like your world is crashing down because you’ve just recently been diagnosed with bipolar disorder; but it’s an entirely different experience when you can hear others’ accounts of parallel experience while also recognizing that they’ve come through their early post-diagnosis years in one piece and perhaps even with positive outcomes. This kind of perspective can go a long way towards mitigating some of the catastrophic thinking that people often experience during the early course of the disorder. Beyond these shifts in perspective, the opportunity to openly share the experience of being hypomanic or depressed without guilt, shame or embarrassment can truly be transformative.

It’s important to recognize that a support group may not be an adequate substitute for the other aspects of therapy that have been outlined above, but it can be an invaluable augmentation for most who live somewhere on the bipolar spectrum.

If someone advises you to consider seeking help from a mental health professional, perhaps the prospect of doing so will now be somewhat clearer. And if you are struggling with bipolar spectrum symptoms, you owe it to yourself to determine if the diagnosis fits, and if so, what comes next.

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Russ Federman Ph.D., ABPP is a licensed psychologist in private practice in Charlottesville, Virginia. He is co-author of the book – Facing Bipolar: "The Young Adult's Guide to Dealing with Bipolar Disorder"(New Harbinger, 2010). A more in-depth look at his work can be found at: www.BipolarYoungAdult.com