Abstract
While our understanding of the biological aspects of the treatment of Bipolar Affective Disorder (BAD) has grown exponentially over the last few decades, our grasp of the psychological aspects of treatment have not evolved as dramatically. Psychosocial factors may contribute 25–30% to the outcome variance of bipolar disorder [1] and despite optimal pharmacotherapy, up to 50% of sufferers may encounter further episodes [2]. In recent years, psychotherapies that are focal and structured have enjoyed increasing support in the management of a variety of psychiatric disorders, including severe mood disorder.
CURRENT PSYCHOTHERAPEUTIC APPROACHES TO BIPOLAR DISORDER
According to Goodwin and Jamison ‘Clinical pragmatism, buttressed by biological assumptions about etiology long ago determined the dominance of organic therapies in the treatment of bipolar illness’ [3]. Despite the dominance of psychopharmacology in the management of BAD, several promising focal interventions in the psychological management of the illness have emerged in recent years.
Family Therapies
Several studies report the efficacy of intensive, brief family focussed interventions in both inpatient [4,5] and outpatient [6] settings, with evidence that these lead to the reduction of morbidity, although the benefits are seen more with female patients. There is an observed tendency for these benefits to decay over time [4].
Group Psychotherapies
Several studies suggest the benefits of group therapies, although no actual controlled studies exist. There is limited evidence of benefits in the areas of compliance with medication, problem solving and interpersonal function [1].
COGNITIVE BEHAVIOUR THERAPY
To date, Cognitive Behaviour therapy for BAD has focussed upon improving compliance [7] or in recognition of early symptoms of relapse [8], although there are limited observations of improvement in social functioning and employment stability which are encouraging.
Interpersonal and Social Rhythm Therapy
Frank and colleagues in Pittsburgh have evolved a view of mood disorders that integrates the postulate that interpersonal events impact on the course of mood disorder by virtue of disruptions to daily routines [9]. An intensive, individual weekly treatment programme based on the basic principles of Interpersonal Therapy (IPT) and Social Rhythm Theory has been studied by the Pittsburgh group over most of the last decade. So far, their final data are unpublished, although favourable results were reported recently [10].
Interpersonal Therapy for Bipolar Disorder
Interpersonal Therapy was originally developed as a research protocol in the treatment of depression [11], and has been summarised in this publication previously [12]. Since then adaptations have been made for a variety of conditions. In IPT the patient's social functioning problems are conceptualized as one or more of four areas: Interpersonal Disputes, Role Transitions, Grief and Interpersonal Deficits or Sensitivity (S. Stuart, pers. comm.). Identification of these problem areas and subsequent changes made by the patient, with the guidance and support of the therapist, are associated with symptom relief.
INTERPERSONAL DISPUTES IN BIPOLAR DISORDER
During and following an episode of affective disorder, numerous interpersonal conflicts may emerge between the affected individual and their families. Often incidents occurring whilst an individual was ill, such as physical aggression, financial or sexual impropriety, may have damaged relationships substantially. Moreover, when affective disturbance has been present for prolonged periods, such as protracted depressions in a type II bipolar disorder, there may be significant alteration to the dynamics of a relationship, e.g. prolonged periods of submissiveness leading to excess control by the unaffected partner. Another, more complex area derives from difficult responses of the partner to the patient deriving from the partner's frustration or anger at the disruptive effects of the illness. These responses may be well defended psychologically and may be manifesting in far more covert ways than overt hostility or arguments.
When a patient achieves a period of euthymia, many interpersonal disputes may come to awareness and may represent perverse disincentives to maintain wellness. The therapist must help the patient achieve a clear understanding of the situation. The goals are to:
help identify the stage of the dispute, e.g. re-negotiation, impasse or dissolution;
clarify issues further (in case of an impasse);
identify unrealistic or unreasonable expectations in both members of the dispute;
identify problematic communication styles; and
help the patient formulate and implement courses of action in response to the dispute.
In some cases, the relationship is so disturbed and damaged that termination is the likely outcome, in which case the therapist may need to help the patient focus upon a role transition out of the relationship.
CASE1
Yvonne was a 33-year-old married architect, who had been diagnosed as suffering Bipolar Disorder at age 22. She had suffered an initial hypomanic episode that had lasted intermittently for 18 months while at university. During her illness, she had suffered several episodes of mixed-affective states and depression. She had been stable for 18 months taking a combination of Sodium Valproate and an antidepressant.
She had met and married her husband, Andy, at university. She admitted that she was probably hypomanic at the time of the marriage. Andy was a post graduate student completing a doctorate in philosophical studies as well as an amateur musician. Yvonne reported that since her mood had stabilized their relationship had changed and significant conflicts had emerged. Interpersonal Therapy was offered and the problem area of Interpersonal Disputes was chosen.
During the stage of gathering the history of the dispute, it appeared it was at the ‘impasse stage’. The history of the relationship was explored and it became clear that she had entered it and then married Andy while hypomanic. Yvonne described that she had wanted to be with Andy because ‘he was a philosopher, musician and mentor’ while she was in a ‘heightened state of awareness and creativity’. Yvonne also described being able to work 14–18 hours a day as an architect as well as maintain a vibrant social life while hypomanic.
Subsequent to her mood stabilizing over the last 18 months, Yvonne had recognized the need for financial stability in her life. Her ability to work long hours had diminished and she was no longer able to ‘subsidise’ Andy's writing and music. When Yvonne had approached Andy to modify his studies and work part time to help stabilize the couple's finances, he became resentful and more distant from the relationship. Yvonne had also come to realize that, because of her mood state, she had endowed Andy, and the relationship, with qualities that had been ‘exaggerated’.
During the conduct of IPT, Yvonne had worked on clarifying her expectations of the marriage as well as improving communication with Andy, which, as evidenced by her report of conversations in the sessions, had become quite hostile and misleading. Yvonne tried to communicate that her mood state had changed as had her needs and expectations of Andy and their relationship. She also explored how her perception of Andy had changed since her mood had normalized. During the later sessions she revealed that Andy had feared she would no longer want to be with him, as she ‘had changed’ and that he had not seen this change as a function of her mood state normalizing. This was explored in IPT as a potentially hazardous dynamic, as it raised the possibility of her illness becoming a precondition of the relationship's survival. Yvonne and Andy explored how their relationship had changed and were able to modify their expectations of each other. (Andy had consistently refused to attend sessions with Yvonne as he had feared ‘scrutiny by her and (her) therapist’).
ROLE TRANSITIONS IN BIPOLAR DISORDER
The original description of role transitions by Klerman and Weissman defined these as situations in which individuals were confronted with changes in their lives that are distressing or stressful. The therapist aims to assist the patient to clarify the ‘old role’ and mourn aspects of it that are lost or modified as well as identify the ‘new role’ and in particular highlight the challenges of assuming this. In a patient where an illness is recently diagnosed or present long term, the use of ‘role transition’ as a category is suitable. In the case of a patient who has recently developed an affective disorder, the adjustment to a chronic illness process and its treatment may challenge their concept of themselves as well as necessitate modification of expectations. Moreover, in a patient whose illness, or its prodrome, has been present for a prolonged period, a role transition may be appropriate where the loss of the ‘beneficial’ effects of hypomania, e.g. energy or creativity, may occasion a role transition.
The loss of the sick role for some patients may necessitate a role transition, particularly when control of symptoms indicates that return to work or a higher level of social functioning should be considered. For many patients who have been chronically unwell, the sick role and the associated primary and secondary gain, may be a significant loss.
CASE 2
Brett, a 34-year-old dentist, had suffered a psychotic manic episode followed quickly by an episode of major depression. He had been unwell for six to nine months and had achieved a remission in his symptoms with a combination of sodium valproate and risperidone. Brett had likely suffered periods of hypomania throughout his 20s. He had made several major changes in his life in the previous five years including several relocations overseas and changes of private dental practice. He had worked as a locum over the six months prior to his last episode of mania. After some discussion, the problem area of ‘role transition’ was chosen.
Brett described having endured a pattern of consistent disruption to his life because of his likely recurrent mood disturbances. He had lost touch with many of his friends because of his continual changes and found himself away from his family and social supports during his most recent episode of psychotic mania. As the diagnosis had been only made during the episode, several sessions were devoted to identifying the relationship between his mood disturbances and the changes he had made in his life. Brett expressed considerable distress at being given the label ‘manic-depressive’ and felt ‘at a loss’ regarding his options.
During the course of IPT the impact of the diagnosis and the necessary changes to be made by Brett were continually reframed as a ‘role transition’. The early sessions were devoted to helping Brett acknowledge his anger, fear and sadness at developing a mental illness as well as allowing him to ‘grieve the loss of his health’. As is necessitated in IPT, the later sessions addressed the lifestyle, personal and professional changes that needed to be made by Brett. Brett decided to move closer to his family of origin and also endeavoured to re-contact his old friends. He contacted several university colleagues and arranged to work in a group practice, rather than ‘endure’ the demands of his own small business commitments.
INTERPERSONAL SENSITIVITY IN BIPOLAR DISORDER
This area is considered the most difficult and perhaps reflects, more than the others, the presence of personality pathology. The use of the phrase ‘Interpersonal Sensitivity’ perhaps less pejoratively depicts this problem area. Interpersonal Sensitivity is noted when individuals describe a paucity of relationships, or relationships in which there are gross issues of interpersonal difficulties, e.g. avoidance, dependency, exploitativeness. The therapist must help the patient identify problematic issues by exploring old relationships (this does deviate slightly from the ‘here-and-now focus’ advocated by IPT) and identifying attitudes and behaviours within the therapeutic relationship. In bipolar disorder, the therapist should help the patient explore the effects of illness on their interpersonal behaviour as well as expand the social networks and possibly help the patient improve social skills. A therapist must acknowledge the effects of the illness (often chronic) and its prodrome on the development of the personality of the patient and help them to see where their deficits may lie.
CASE 3
Eleanor was a 24-year-old assistant film producer. She had suffered four severe psychotic manic episodes since the age of 16. Her most recent episode of mania had necessitated admission to hospital under the Mental Health Act. She had been well for nine months, although her illness required combinations of lithium and Sodium Valproate at high serum levels to remain well. While she was functioning well in her work, Eleanor had endured significant impairment of her interpersonal life since the first episode of illness. After some discussion, the problem area of Interpersonal Sensitivity (or deficits) was chosen.
Eleanor had been hospitalized during her first manic episode. She was in Year 10 of high school and was absent for 6 months, requiring her to repeat the year. Lithium therapy at that time had caused considerable weight gain, sedation and worsening of adolescent acne leading to significant degrees of sensitivity in her interactions with her peers. She was able to complete her matriculation level studies and attended university. During her first year of university study she suffered another manic episode during which she became quite hostile. Her behaviour significantly alienated her immediate friends, leading to her changing campus following recovery. She remained well for the next two years and entered a relationship with an exchange student from the USA. As the relationship evolved, the increasing demands of intimacy lead to significant distress for Eleanor and she left the relationship. She subsequently suffered a further episode of mania.
As one of the tasks of ‘interpersonal sensitivity’ requires non-psychodynamic exploration of the therapeutic relationship, the initial sessions of IPT focussed upon rapport development. During the middle sessions a consistent pattern of Eleanor frantically attempting to avoid any self-disclosure emerged. She also communicated considerable anxiety dealing with the therapist. When her behaviour was examined in more detail, her self concept of being ‘damaged’ and ‘unattractive’ became apparent. When asked to elaborate, Eleanor communicated considerable fear that her illness would always disrupt her life and that her recurrent experiences of relationship failures was evidence that her life would be less disrupted if she avoided interpersonal interactions beyond immediate family and work colleagues.
The IPT therapist took time to create a therapeutic relationship with Eleanor, which she grew to consider as stable. During the sessions, she suffered several minor destabilizations of her mood, usually at the time of minor conflict within her family. Her anxiety in dealing with the therapist was addressed and she became better able to communicate, unhindered by interpersonal anxiety. She entered several new social relationships and discussed their progress to the IPT therapist. A decision was made to pursue maintenance IPT and she met with the therapist monthly for the next 9 months. During this period, she made attempts to contact friends from university and school, and entered a romantic relationship. The focus of the IPT sessions was how to communicate and limit her illness-related vulnerabilities in these relationships and how to deal with self-disclosure, conflict and demands for intimacy.
GRIEF IN BIPOLAR DISORDER
In strict IPT terms, grief is considered a problem area where there is loss through death. Many authors have tried to couch non-bereavement loss as grief in IPT and this is a controversial area. The grieving of a lost potential or lost period of life is best considered in the domain of role transitions rather than grief to avoid such confusion. Bereavement constitutes a severe life event that may be a precipitant or exacerbation of episodes of illness. The tasks of the therapist are to provide an environment in which the patient can reflect upon the loss in detail and explore the affect in a way in which the loss and its associated affect can be processed.
FUTURE RESEARCH
So far there is only little published data available on the outcome of IPT based interventions. Research conducted in optimal conditions with highly trained therapists and methodological rigour also offers evidence of efficacy in only a limited number of patients and treatment settings. Many authors view group-based interventions as having a potential advantage over individual-based therapies dealing with bipolar disorder. At present, field trials of a group based IPT programme for bipolar disorder are underway in Sydney. Studies that identify not only which interventions reduce relapse, enhance compliance and provide optimal psychosocial functional outcome but also some indicators of patient factors that are predictive of outcome, are needed.