By Cory Newman, PhD
Beck Institute Faculty
Part of establishing a constructive therapeutic relationship with an individual diagnosed with bipolar disorder is providing psychoeducation about the illness and its treatment in a way that invites their input. As such, the therapist’s words sound like they are coming from a place of partnership rather than from authority, and in a spirit of mutual education, rather than the mere unilateral delivery of information (Colom & Murru, 2011). This approach helps establish trust and teamwork.
To express accurate empathy, therapists need to offer validation for the individual’s sense of despondence and demoralization when they are in their down phases, and yet still offer sincere reasons to have hope and to keep trying. They should balance this with being truly happy for the individual when they are in their “up” phase, yet still offering caring, corrective feedback about hypomanic or manic behaviors and thoughts. That said, therapists should not assume that an individual who is experiencing hypomania necessarily has unrealistically ambitious ideas and goals. Therapists can be generally supportive of individuals’ endeavors while still guiding them through the steps of problem-solving, weighing risks and benefits, and seeking consultation from others (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2001). Additionally, when individuals express weary distress about the toll taken by the cyclical ups and downs of their functioning, and/or ongoing worries about future symptom episodes, therapists need to validate their sense that bipolar disorder is a significant life burden, while expressing hope that they will achieve healthy functioning through serious commitment to treatment.
It is sometimes difficult for individuals to accept a diagnosis of bipolar disorder. Even those who are willing to acknowledge the validity of their diagnosis may not want to pursue the goal of averting hypomania, reasoning that this phase of the illness helps them in a number of ways and provides a desired counterbalance to the misery of the depressive phases. To be maximally effective, therapists must try to avoid power struggles with individuals who express such sentiments. Instead, therapists can adopt the methods of motivational interviewing (Miller & Rollnick, 2002), a therapeutic stance that is congruent with good CBT in that it emphasizes collaboration, guided discovery, empathy, and striving toward graded improvements in function rather than taking an “all or none” position about adherence to treatment.
For example, the therapist can state that it is understandable that the individual may not want to seek a stabilized mood as much as they want to maximize their functioning. However, the therapist can use guided discovery questions to help the individual self-reflect on the matter. This may include, “I remember that you said you worked on multiple projects when you were in a manic phase, but that you couldn’t sustain the work, and therefore your projects remained unfinished, which greatly disappointed you. How might a more stable mood serve a useful purpose for you? What would be a more promising approach when you are striving for goals?”
Therapists foster a sense of collaboration when they show an interest in and respect for the individual’s goals and personal strengths. When patients want to show their therapists examples of their creative output, including journal entries, poetry, articles they have written, artwork and photography, or on-line links to their performances (e.g., singing in a band, doing stand-up comedy), it is important for therapists to engage and encourage them. The good will that is engendered will assist therapists in promoting the learning of coping skills that require self-regulation and routinizing the individual’s activities.
Therapists who are trying to nurture and preserve the therapeutic relationship also realize that they cannot assume that individuals will automatically buy into a “safe” treatment plan of taking appropriate medications, reducing excessive goal-directed behavior, and being receptive to cautionary feedback. Instead, therapists humbly negotiate a treatment plan, while advocating for those aspects of the plan that are high priority. For example, the therapist may acknowledge the individual’s intent to pursue challenging academic and/or professional goals but may also emphasize the importance of routinely getting enough sleep to reduce the likelihood of potentiating a manic episode (Gruber et al., 2011). As such, the therapist avoids coming across as trying to over-control the individual while still advocating for safeguards.
An exchange of feedback is a key component of a well-run CBT session, as a means by which to clarify communication, to summarize key learning points, and as a sign of respect (Beck, 2011). In CBT, practitioners make sure to ask individuals their opinions about the session, and about how they think they are being treated. They also give feedback to them, positively reinforcing their constructive efforts to engage with the treatment plan, and tactfully offering comments of concern if they appear to be off track. Toward this end, the following is a sample comment that therapists can make early in treatment:
THERAPIST: We will work best as a team if we can speak freely with each other. I am very receptive to your feedback about what seems helpful and what does not. I hope you will return the favor and allow me to give you feedback about how you’re doing in therapy. Does that sound okay?
THERAPIST: You can expect me to ask about your moods and thoughts every session. If I see anything that concerns me, I won’t jump to conclusions about your state of mind until I ask you for your opinion. I hope that seems fair. I’m optimistic that we can give each other constructive, respectful feedback, and make the most of this treatment. What do you think?
It is in a spirit of teamwork that the specific interventions and related Action Plans (therapy homework) will have their best impact.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford Press.
Colom, F., & Murru, A. (2011). The pivotal role of psychoeducation in the long-term treatmentof bipolar disorder. In H.S. Akiskal & M. Tohen (Eds.), Bipolar psychopharmacotherapy: Caring for the patient (2nd ed.) (pp. 447-463). Hoboken, NJ: Wiley-Blackwell.
Gruber, J., Miklowitz, D. J., Harvey, A. G., Frank, E., Kupfer, D., Thase, M. E., Ketter, T. A. (2011). Sleep matters: Sleep functioning and course of illness in bipolar disorder. Journal of Affective Disorders, 134, 416-420.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.
Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., & Gyulai, L. (2001). Bipolar disorder: A cognitive therapy approach. Washington, D.C.: American Psychological Association.
If you're interested in learning more about treating patients given the diagnosis of bipolar disorder, Dr. Newman will be teaching CBT for Bipolar Disorder from October 29-30. This interactive virtual workshop will emphasize the therapeutic relationship, case formulation, and interventions that build clients’ knowledge base and self-help skills.
CBT for Bipolar Disorder
Recovery-Oriented Cognitive Therapy (CT-R) is another evidence-based treatment approach that has shown positive results with serious mental health conditions, including bipolar disorder. Co-Directors of Beck Institute's Center for Recovery-Oriented Cognitive Therapy Dr. Paul Grant and Dr. Ellen Inverso will be teaching CT-R for Schizophrenia and Serious Mental Health Conditions on October 21, October 28, and November 4.