Rochelle I. Frank, PhD
Point Of View
Most clinicians who treat people with bipolar conditions embrace a theoretical model that includes biological, psychological, and social variables. Though often necessary, medication alone usually is not enough. Successful treatments typically target negative symptom reduction and include interventions that will maximize as well as sustain individuals' progress over time. Psychotherapy plays a critical role in educating patients about their condition and the many factors influencing its course. It also teaches skills that can help people overcome disruptions in functioning and improve their overall quality of living.
Integration With Team
The psychotherapist often is the first point of contact for the patient, who initially may have sought help for depression or anxiety. Once a diagnosis of bipolar disorder is made, the psychologist or other therapist (e.g., social worker, marriage and family therapist) plays a crucial role in developing, organizing, and implementing a comprehensive and effective care plan. A collaborative team approach - including psychotherapy, psychiatric care, recreation and exercise, nutrition, and many other aspects of health and wellness - is the key to successful treatment. The patient is the most important member of the team, and collaboration includes family, friends, and other significant individuals who are able to provide support and participate in the plan.
Many therapists in private practice work independently and do not have pre-established relationships with psychiatrists and other key professionals (e.g., personal trainers, professional coaches, nutritionists). Whereas this might not be an issue for most patients, individuals with bipolar conditions benefit greatly from such services, and typically need them to get their lives back in order. Thus, it is important to ask if your therapist has access to these services, and to discuss how to incorporate them into your treatment.
Due to confidentiality laws, it is necessary to provide consent allowing your therapist and others to exchange information about your treatment and progress. Similarly, your therapist might want to meet with individuals to gather important information, including how you were doing prior to episodes of illness. Such contact also requires consent. It is important to talk with your therapist early on about how to best get in touch with her/him; to establish how and when team members will be communicating with each other; the content of such communication; and what, if any, costs will be incurred.
Though patients and professionals ideally come together for periodic "team meetings," this may not be feasible. Fortunately, technology has made collaboration much more possible, though the confidentiality of email and cell phone transmissions cannot be guaranteed. Also, some professionals may not be comfortable utilizing these methods. Regardless of how therapists and other team members choose to communicate, frequent and open exchange of information is central to coordinated and collaborative treatment.
Assessment Process
Standard practice among psychologists begins with a comprehensive assessment of the patient's needs and strengths. Depending on the type of therapy practiced (e.g., cognitive-behavioral, dialectical behavioral, interpersonal social rhythm, psychodynamic), assessment may focus on underlying thoughts and behaviors, coping strategies, former and current relationships, daily schedules, and so forth. Identification of key problem areas (e.g., loss of income, social isolation, insomnia), and specific emotional (e.g., low or expansive mood) and behavioral (e.g., suicidal thoughts) difficulties, leads to clarification of treatment goals and decisions about interventions. Regardless of whether a DSM-IV1 diagnosis or a narrative description is established, it is important to get a clear and agreed-upon understanding of the issues that will be targeted for treatment.
Assessment often starts during the first telephone conversation, with a brief discussion of the reasons for seeking treatment, impact on current functioning, and identification of resources, supports, and existing services. This conversation provides both therapist and patient with a sense of "goodness of fit" based on personality characteristics, theoretical orientation and professional skills, and offers an opportunity to decide whether or not to schedule an office-based consultation.
Many clinicians, especially those implementing evidence-based treatment (i.e., treatment protocols developed through empirical research, producing consistent positive outcomes), utilize a variety of assessment tools. These range from questionnaires describing personal, family, academic, work, and psychiatric histories, to depression and other symptom inventories. Though important, these instruments do not replace a good face-to-face "clinical interview." The interview includes: discussing information provided on the forms; assessing mental status (e.g., mood, nature and quality of one's thinking and judgment) and current level of functioning (e.g., self-care, school/work performance); and discussing the individual's view of the problems and assessing his/her ability and willingness to participate in treatment. It also is important to identify personal strengths and other resources that bolster treatment outcomes, such as family/social supports, stable income, structured routines, etc. Since many people with bipolar conditions may not have accurate perceptions of their own lives, input from others who know them in various capacities and roles is helpful in providing a context for past and present functioning. Lastly, a discussion of previous treatment efforts and problem solving strategies facilitates informed decisions about current and new interventions.
Goal Setting
Meaningful outcomes derive from specific needs, though the task of developing treatment goals may be confusing and overwhelming. Breaking this task down into short- and long-term targets, developing a "wish list" for change, and thinking about how one's life would be different if problems miraculously disappeared, can be stepping stones toward goal setting.
Common goals might include a reduction in depressive, (hypo)manic, and other symptoms, as well as qualitative improvements in daily functioning. For example, the plan might focus on helping someone resume academics or work, increasing contact with others, and establishing healthy relationships. Health and wellness goals might reflect gaining/losing weight, improving nutrition, and developing an exercise plan. Increasing self-esteem and diminishing the shame that often accompanies mental health problems also are important, though determining one's progress on these dimensions can be difficult. All goals should include identification of clear and measurable outcomes in order to assess progress.
Treatment
In selecting a therapist that is the "best fit" it is important to consider rapport, ability to collaborate, experience, and expertise in treating bipolar conditions. The most positive outcomes seem to be achieved by clinicians who are trained in empirically supported treatments (ESTs).
A longstanding EST is cognitive-behavioral therapy (CBT), which helps people change underlying beliefs and maladaptive behaviors to facilitate reduction of negative depressive and manic symptoms. CBT also is effective with anxiety and obsessive-compulsive symptoms, which often accompany bipolar conditions. Interpersonal social rhythm therapy (IPSRT) facilitates functional and mood stability by examining and restructuring individuals' current activities, sleep-wake cycles, relationships, and situational stressors. Dialectical behavior therapy (DBT) was developed to treat borderline personality disorder, but recent applications also have proven effective in treating bipolar conditions in adults and adolescents. Family-focused treatment was developed for pediatric bipolar disorder, though adult interventions often incorporate family supports to help individuals recognize early warning signs and prevent relapse. Many therapists integrate components of different ESTs to address specific patient needs. Regardless of which therapist or type of treatment you choose, it is important to ask how your progress will be regularly assessed and monitored, since ongoing monitoring has been shown to facilitate the best outcomes.
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