The Role of Psychotherapy in BiPolar Disorder
from Medscape Psychiatry & Mental Health
Posted 08/11/2003
Deborah Spitz, MD

Bipolar disorder is normally viewed as an episodic illness in which interepisode functioning returns to normal. As pharmacologic treatments for bipolar disorder have become more successful, many individuals with manic depressive illness lead lives that are not only creative and productive, but stable as well. Pharmacology is the bedrock of treatment. With our greatly expanded pharmacologic armamentarium, we know well what medication can do -- but we also know what it cannot do. There are patients who do not respond completely to even the most aggressive and complex psychopharmacologic management, whose disease is virulent, resistant, or atypical, or whose ability to manage a chronic illness like bipolar disorder is limited. For these patients, psychotherapy is a necessary and invaluable adjunctive treatment. Medication cannot, alone, foster acceptance of a chronic illness. It cannot nurture anticipation, teach preventive strategies, or foster coping when those strategies fail. And it cannot, alone, rebuild lives that have been thrown into chaos because of an illness that affects judgment, insight, and choice.

Who, then, needs psychotherapy for bipolar disorder, and what kind? Every patient needs education about bipolar illness, about medication and its side effects, and about managing time, sleep, and structure to protect against future episodes. This basic information is the first step in preparing the patient to cope with bipolar disorder. And communication must be a 2-way street: it is essential to know how the patient feels about the information, indeed whether the patient accepts it at all, to gauge how much of a collaborative and productive relationship there will be between psychiatrist and patient. A number of specific psychotherapeutic approaches have been developed to focus on psychoeducation. These include individual and group psychotherapy, couples therapy, and family therapies, some manualized and research-based. In all, information about bipolar disorder, its symptoms, and its management are central pillars of therapy. Patients and families need to know the general early warning signs of depression and mania, and to identify those particular early warning signs that may signal the onset of an episode for an individual patient. Groups can be especially effective in addressing these issues, as patients can compare notes and share information. In Britain, the national manic depressive association runs groups, led by people with bipolar disorder, to teach basic information and coping strategies to patients and family members. Beyond education, patients may need skills to deal with depressive cognitions that can worsen depression, or techniques to reduce stress that might contribute to vulnerability to another episode of illness. These skills can be taught in groups, individually, or within families.

Some patients can accept the diagnosis and its management with little difficulty. Many patients are grateful for a clear diagnosis that makes sense of the past chaos and irrationality in their lives, and hopeful that there are treatments and management techniques that may limit future episodes. For others, however, the diagnosis poses an intolerable threat to a sense of wholeness. The adolescent or young adult who is filled with a sense of invulnerability, fueled perhaps by hypomanic grandiosity, may meet the diagnosis of manic depressive illness with doubt, contempt, and denial. Any illness can be experienced as a narcissistic injury, but the stigma of psychiatric illness may feel even more threatening. Acceptance of the illness is the first and major hurdle in treatment, and it can take some patients years of repeated episodes and involuntary hospitalizations to surmount. During these years of denial, they may lose friends, leave education or vocational training, and lose crucial life skills. Repeated episodes may render them more vulnerable to future episodes of illness as well. For such patients, engagement in psychotherapy itself is difficult, and building an alliance is the major task. Only after that can psychotherapy focus on issues of loss and grieving as well as the reality of the illness, the need for medication, and compliance with treatment.

In spite of the episodic and remitting nature of bipolar disorder, there are increasing data that some bipolar patients experience a decline from premorbid occupational and social functioning. They may have episodes that are longer or refractory to medication, they may suffer with serious side effects from medications, or they may have chronic subclinical syndromes with associated mild cognitive and/or affective impairment. For these patients, the therapist can be a stable point during shifting affective states, attempting to support the patient in tolerating the losses associated with illness and treatment, to reframe the problems so as to rekindle hope, and to enable the patient to make realistic choices for the future.

What data do we have to support the use of psychotherapy? There is limited information and a lack of systematic data about the efficacy of psychotherapy in improving outcome in bipolar disorder. Nonetheless, there is an emerging clinical literature that supports the utility of individual cognitive behavioral therapy and both individual and family psychoeducational approaches to increase adherence to medication, improve coping with environmental stresses, and optimize social and occupational functioning. Recent review articles by Swartz and Frank[1] and by Patelis-Siotis[2] review the clinical literature on manualized family and marital treatments, interpersonal psychotherapy, social rhythm therapy, group therapy, and cognitive-behavioral therapy, and find benefit from a wide variety of focused treatments. Clearly, this is an area that needs more research.

Beyond acceptance, coping, and occupational and social functioning, some patients emerge from their experiences with bipolar disorder with deep questions about who they are and what has happened to their lives. Manic depressive illness can cut a swath across life's trajectory; later, in times of relative quiet, patients may need to re-evaluate goals and re-examine past decisions. What choices were "real," and which were influenced by mania or depression? When mood swings stabilize and life is more predictable from one day to the next, some patients struggle with issues of identity. If adolescence was marked by severe mood swings or periods of rapid cycling, it may have been impossible to forge a solid sense of self. What sense of self there was may have developed around depressive, grandiose, or otherwise unrealistic sets of core beliefs. Developmental threads that were dropped need to be picked up again, if possible, or relinquished and laid to rest. Adults whose mood swings are rapid and severe may experience a disrupted sense of identity as well. They may be left with the sense of not knowing what is illness and what is self, and how to tell them apart. They may have a tenuous sense of autonomy and feelings of great vulnerability, as well as a sense of uncertainty about what they can count on in themselves. These issues require both time and space for review and exploration, and this is the stuff of psychodynamic psychotherapy.