Running head: BIPOLAR TREATMENT

Bipolar Treatment Approaches Kimberly Heutzenroeder University of the Rockies

ORG 7260 Alesia Richardson May 30, 2011

Running head: BIPOLAR TREATMENT Bipolar Treatment Approaches Bipolar disorder is caused by an imbalance in brain chemicals (Rivas-Vasquez, Johnson, Rey & Blais, 2002). The bipolar individual experiences extreme highs or lows which often may result in negative behaviors such as hyperactivity, recklessness, impulsivity, mood swings, and being antisocial (Rivas-Vasquez, Johnson, Rey & Blais, 2002, p. 220). Without treatment, they may have chronic interpersonal or experience occupational difficulties. Moreover, bipolar symptoms are apt to increase without treatment causing even more personal, social and workrelated issues (Miklowitz, 2006). Bipolar disorder effects every aspect of an individuals life his work, his relationships, his experiences, and even his view of the world. Quite a few studies have been conducted concerning what causes bipolar, the biological processes that trigger episodes of depression or mania, and the effectiveness of using psychopharmacology as a treatment method. These studies and their discoveries are very important, as they aide in the understanding of what is behind this often devastating disorder. However, limiting our view to physiological aspects and treating only the mechanics of bipolar has proven ineffective. What

increases treatment effectiveness is psychotherapy with accompanying medication. This begs the question of what type of therapy is most effective. In most cases, therapy approach depends on the unique situation and personality of the patient. Often times a combination of approaches are used, and during a session they may even be combined. For instance, Cognitive-behavioral therapywhich helps people learn to change patterns of thoughts or behaviors which are harmful, is often combined with psychoeducationwhich teaches people about bipolar disorder and signs that signal an impending episode. Another example is Interpersonal and Social Rhythm therapywhich helps people to relate to others and manage routines and schedules in daily life, which, although considered its own form of therapy, is actually a behavioral approach. A

Running head: BIPOLAR TREATMENT

demonstration of this is when a patient is helped to see a negative thought or behavior that is not working for them, and then replace it with a thought or behavior that has a more positive result. Thus, psychotherapy for bipolar often includes many different styles and approaches. Mainly treatment approaches differ in whether the individual only participates in therapy, or if the family is involved. This decision, like all decisions in psychotherapy, is made based on the individuals needs and what is most likely in this situation to increase successful outcomes. Individual Therapy Individual therapy in the treatment of bipolar typically consists of some type behavioral intervention. This is because the behaviors exhibited during episodes are what causes the individual to suffer consequences in relationships, life choices, and employment. One of the most common and successful methods in use is cognitive-behavioral therapy (Miklowitz, 2006). A problem that leads to a lack of therapy success is medication non-compliance. Patients with bipolar may discontinue medication treatment when they do not like the side effects, feel like they do not need treatment anymore since the medication is working and thus they lack symptoms, and if they miss the euphoric feelings associated with manic episodes which are controlled by the medications. Therefore, the main focus of treatment is medication compliance because the medications stabilize the chemical pathways, which in turn helps to control mood swings. Additionally, therapists educate and monitor progress, always being on alert for signs of episode triggers or symptoms in order to activate an intervention plan. By teaching the individual to pay attention to his mood, think about his behaviors and the consequences of them, and take care of himself, the patient becomes more in stable and has a sense of control (Miklowitz, 2006). Sometimes these patients are in denial of consequences, or conversely may feel remorse and guilt for past actions (Rivas-Vasquez, Johnson, Rey & Blais, 2002). Therapy helps the patient

Running head: BIPOLAR TREATMENT express and learn to cope with these feelings in a healthy manner (Rivas-Vasquez, et al., 2002).

Cognitive-Behavioral Therapy helps the patient to recognize what he is thinking/feeling and how this influences his behavior. Once the thoughts/feelings and behaviors have been recognized the patient is taught to employ new thoughts and response behaviors. In doing this, the patient avoids negative consequences and can proactively institute interventions for an upcoming episode. Aside from medication compliance, the main goals in therapy are to learn how to recognize manic symptoms early and change behavior prior to a mania, and to learn how to withstand depression through the use of behaviors and thoughts that help to cope with negative moods (Rivas-Vasquez, et al., 2002). According to Huxley, Parikh and Baldessarini, Cognitive-Behavioral Therapy challenges the patients beliefs or assumptions about his or her self, world, and future that contribute to the long-term vulnerability to mood disorder (pg.31, 2000). Patients learn to monitor their moods and take note of early episode warnings. Once noted, the patient employs a behavioral activation plan that he had developed in conjunction with the psychotherapist (Huxley, et al., 2000). In a study using Cognitive-Behavioral Therapy in this manner it was found that patients who received Cognitive-Behavioral Therapy, in conjunction with psychopharmacology, had higher survival rates, spent fewer days in bipolar episodes, and had higher social functioning during year 1 than in comparison patients (Huxley, et. al, 2000). However, the preventive relapse measures were not maintained when measured over the course of months 12 through 30 (Huxley, et al., 2000). In a similar study using Cognitive-Behavioral Therapy, it was discovered that patients with fewer than 13 episodes responded well and had fewer recurrences, but patients with 14 or more episodes responded better to other types of therapy (Huxley, et al., 2000).

Running head: BIPOLAR TREATMENT

Rivas-Vasquez, Johnson, Rey and Blais reviewed the current studies and came to similar conclusions (2002). They state, beyond the need to challenge cognitions that may activate episodes of mania or depression, Cognitive-Behavioral Therapy can also target cognitions related to pharmacological compliance (Rivas-Vasquez, et al, 2002, p. 220). For instance, one study they examined provided evidence that Cognitive-Behavioral Therapy was associated with a significant reduction of residual symptomatology (Rivas-Vasquez, et al., 2002, p. 220). In summary, these researchers established that although more studies are needed to determine a specific process, it is evident that individualized Cognitive-Behavioral Therapy addresses the needs of most bipolar patients, especially those with fewer numbers of episodes or those in need of quick intervention for safety reasons. Family Focused Therapy Family Focused Therapy is another approach often used with bipolar patients. The greatest benefit of it is the usefulness for both the bipolar individual as his family members (Huxley, et al., 2000). Various styles of this type of therapy are used depending on how the family relates to one another. Often times a cognitive-behavioral approach is taken because when family members exhibit certain behaviors it tends to aid the patient in being successful (Huxley, et al., 2000). This is a result of positive interactions, which are conducive to healthier and happier relationships. By teaching family members the skills to use in specific situations, the interactions can be more productive even during episodes. Family members are also taught skills that help them feel better (Huxley, et al., 2000). Accepting the patients condition, learning how to respond appropriately, learning to take care of self, and learning how to protect themselves during episodes gives the members a sense of control. Thus, family therapy focuses on both interaction and functioning within the family as well as each of the individual members.

Running head: BIPOLAR TREATMENT

According to Huxley, et al., Family Focused Therapy focuses on the etiology, treatment and self-management of bipolar disorder, including how the family can help the patient recover and a relapse drill in which patients and their family members identify early warning signs of recurrences and rehearse an early preventive intervention plan (2000, pg. 29). During therapy the family learns about the various types of resistance to treatment that are displayed by bipolar individuals (Huxley, et. al, 2000). In learning to recognize the resistance, and then using a planned intervention, the family interactions are preserved and the patient may be more compliant (Huxley, et. al, 2000). Family Focused Therapy educates families and the patient about bipolar disorder, and helps all members to accept the need for medication for life as part of the treatment because bipolar cannot be cured (Huxley, et. al, 2000). In a study comparing individualized therapy with family therapy, patients treated with Family Focused Therapy endured an average of 20 weeks longer and were 3 times more likely to survive the two-year follow-up without relapsing (Huxley, et al., 2000, pg. 30). Interestingly, the two groups were equal in success rates of re-hospitalization during the first year, but by year three 60% of the patients receiving individual therapy were re-hospitalized as compared to 12% of the Family Focused Therapy patients (Huxley, et al., 2000, pg. 31). Lastly, in a study examining Family Focused Therapy versus individual therapy for medication compliance rates, it was found that: 45% of Family Focused Therapy patients were fully compliant as compared with 21% of the individual patients; Partial adherence had similar rates in both groups and; non-compliance was an astonishing 16% in Family Focused Therapy, approximately 3 times less, than 44% in individual therapy. Obviously, having family members involved in treatment greatly decreases medication non-compliance. Studies examining the effects of Family Focused Therapy on interactions and family functioning demonstrate similar rates with individual therapy in response

Running head: BIPOLAR TREATMENT to crisis management. However, after 1 year, Family Focused Therapy had improved family interactions such that members were engaged in more productive problem-solving, acknowledgement of each others points of view, and positive non-verbal behavior (Huxley, et al., 2000, pg. 30). Moreover, patients improvement in mood disorder symptoms was highly correlated to improvement in communication with relatives (Huxley, et al., 2000, pg. 30).

Huxleys examination of various studies proved that Family Focused Therapy delays recurrences of episodes, stabilizes symptoms, enhances communication, and increases medication compliance, and is therefore an effective treatment choice. Rivas-Vasquez, Johnson, Rey & Blais examined current studies for evidence of the effectiveness of Family Focused Therapy in decreasing relapses triggered by the expressed emotions of family members. They found that not only did Family Focused Therapy yield longer periods without relapse, but that family members used more positive communicationwhich improved symptoms (Rivas-Vasquez, et al., 2002). Different studies cited by this group confirmed that Family Focused Therapy decreases expressed emotion among families which in turn positively impacts the decreased likelihood of relapse (Rivas-Vasquez, et al., 2002). Finally, therapy with spouses or partnersa branch of family therapy, correlates with improvement in patients social adjustment and global functioning (Rivas-Vasquez, et al., 2002). In conclusion, this set of authors also found Family Focused Therapy to be an effective treatment for bipolar disorder. Comparison Bipolar treatment focuses on reducing mood swings, coping with symptoms, communication skills, increasing medication compliance, and developing a plan to head off depressive and manic episodes. These foci are apparent in both individual and family therapy.

Running head: BIPOLAR TREATMENT The difference between the two is that by working with family members an understanding support system can be built. This system includes involving others in the recognition of warning

signs, ensuring medication compliance is monitored, and communication skills which are learned by all parties. These behaviors translate into more successful outcomes, which include; a decrease in symptoms, decrease in relapses, decrease in re-hospitalizations, increase in survival, and increase in quality of life for all family members (Rivas-Vasquez , et al., 2002). Psychopharmaceutical therapy helps to modulate brain chemicals, and therefore medication compliance is mandated in the treatment of bipolar disorder. Along with medication, patients often need help in acceptance of the disorder, acceptance of the need for medication, communication and relationship skills, recognizing symptoms of episodes, and instituting an intervention plan. Research studies confirm that behavioral approaches are successful in helping in each of these areas (Rivas-Vasquez, et al., 2002). Additionally, research demonstrates that involvement of family members in the therapy process significantly increases positive outcomes. In giving communication skills to all family members their interactions change and relationships are built. When all members, including the patient, are educated about the disorder and learn to recognize signs for impending episodes, an intervention plan can be put into place early and is therefore more likely successful. By involving family members in the intervention plan, they know how to respond appropriately and feel more in control during a crisis. Additionally, they learn to express emotion in a way that doesnt trigger an episode in the patient and yet still allows them to communicate their needs and emotions. The patient learns skills about how to interact in a positive manner, and the family members support these new skills so they become a normal habitual pattern of relating. Lastly, through Family Focused Therapy family members are given a place to vent and then learn how to live in a healthier manner ensuring they take care of

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themselves as well. Family focused therapy produces better outcomes and helps all of the people involved, for bipolar effects everyone in the family. For that reason, appropriate care should include Family Focused therapy whenever possible.

Running head: BIPOLAR TREATMENT References

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. Huxley, N., Parikh, S., & Baldessarini, R. (2000, September). Effectiveness of psychosocial treatments in bipolar disorder: State of the evidence. Harvard Review Psychiatry, 8(3), 126-140. Miklowitz, D. (2006). A review of evidence-based psychosocial interventions for bipolar disorder. Journal of Clinical Psychology, 67(11), 28-33. Rea, M., Miklowitz, D., Tompson, M., Goldstein, M., Hwang, S., & Mintz, J. (2003). Familyfocused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 71(3), 482-492. Rivas-Vasquez, R., Johnson, S., Rey, G., & Blais, M. (2002). Current treatments for bipolar disorder: A review and update for psychologists. Professional Psychology: Research and Practice, 33(2), 212-223.