When you’re living with bipolar disorder, the right combination of medication and therapy is crucial for managing symptoms.

Rebecca had her teenage son Daniel in the care of a psychiatrist who specializes in adolescents. (The names in this one case have been changed.) Before his psychiatrist correctly diagnosed Daniel as having Bipolar disorder, he was behaving so violently in school that he was facing expulsion. Moreover, he had been so rough with his younger sisters at home that his mother had despaired of keeping her family together.

“When Daniel got started with the right medications, they made a huge difference almost immediately. He’d often get so agitated at night, but then I’d give him his medicine and I could practically see a physical change,” Rebecca says. “Therapy is so important, too. As a person with Bipolar Disorder, Daniel has had to learn that the medicine isn’t everything, and that he has the power to stay in control. With the therapy, he learns this — to be empowered, to be in control. He couldn’t have learned that he’s responsible for his behavior without that support, but he couldn’t have maintained control in lots of stressful situations without his medicine either. Both are so important.”

The Benefits of a Combined Approach to Therapy

A growing body of research indicates that the majority of individuals with bipolar of any age benefit from a combined approach to therapy. “Ideally, therapy for bipolar disorder is used in combination with medication and not as substitution for medication,” says James Waxmonsky, MD, professor of psychiatry at Penn State College of Medicine and division chief of child adolescent psychiatry at Penn State Health Milton S. Hershey Medical Center in Pennsylvania. “Unlike classical or unipolar depression, it’s highly unlikely that therapy alone will be sufficient to achieve stabilization for patients,” he says. Both are needed.

Ellen Frank, PhD, is professor of psychiatry and psychology at University of Pittsburgh School of Medicine and director of the depression and manic depression prevention program at Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania. There are now about five or six large, well-controlled studies of medication, plus or minus psychotherapy, for people with bipolar, she says. “All but one of those studies did tend to show an overall advantage for the combination.” According to Dr. Frank, this means that if “on average, you take one hundred bipolar patients, fifty on medication alone and fifty receiving both medication and therapy, some patients who receive only medication do just fine. But, overall, the people in the combined therapy group have tended to fare better.”

Cognitive Behavioral Therapy for Bipolar Disorder

The research points to one form of psychotherapy, cognitive behavioral therapy (CBT), as holding special value for people with bipolar. Joseph Biederman, MD, professor of psychiatry at Harvard Medical School in Boston, describes CBT as “a specific kind of short-term treatment that focuses on certain key aspects and on very practical here-and-now techniques. [CBT imparts] coping skills, teaches compliance with treatment, and includes education about the disease itself,” he says. “And these kinds of techniques have been found to be most effective.”

Dr. Biederman adds that “CBT is a large group of treatments and they should be individualized to the needs of the individual.” Through CBT, people with bipolar learn to identify and consciously correct distorted thought patterns associated with their illness.

Seeking a ‘Quick Fix’ With Medication

Despite such evidence, many diagnosed with bipolar disorder and their relatives often expect drugs alone to provide a quick fix. Indeed, medications for bipolar disorder have continued to improve. The emergence of highly promising medications for the disorder has expanded choices and options. “There is a great need for medication management by a mental health specialist,” stresses Waxmonsky. “Bipolar is a complex illness.”

“Often, patients and families just want to go for the pill [meaning medication alone],” reports Delia Saldana, PhD, associate professor in the department of psychiatry at the University of Texas Health Science Center at San Antonio. Dr. Saldana explains that people are accustomed to seeing advertisements for much-promoted drugs such as antidepressants.

“People tend to be heavily influenced by all that advertising,” Saldana says. “Many doctors also focus heavily on the best and newest medications. The ‘pill’ is a good start but I think people are overemphasizing medications.”

Bipolar and the Challenges of Medication Management

The nature of bipolar disorder can create special difficulties for people when it comes to using their medicines reliably. “Many individuals with bipolar face a dilemma in that they’re willing to risk both extremes for the sake of the high [that comes during manic spells],” Saldana explains. “The manic times can feel so good. People are often in a state of grandiosity. Then the medications knock them down a bit and they don’t feel nearly as good. It can feel downright boring to have normal moods. But we can predict that as high as a person goes during manic times, they will also go that low during the depressions, and the periods of depression tend to be longer than the manic periods.”

What Therapy Can Do That Drugs Alone Cannot

Saldana says “psychotherapy has a role in fulfilling two main intents” of great importance for most people with bipolar. First, the therapist can provide empathy and support, forming an alliance with the individual and acting as an understanding helper, not a judge. The therapist can also become involved in a whole range of problems that the person faces (these can be legal or financial complications, indebtedness, or familial and job-related consequences).

Second, a psychotherapist can also assist both those with bipolar and their loved ones in educating themselves and developing important new coping skills. Time is spent outlining problems and constructive approaches to those problems. Family members of people with bipolar often react in certain ways that are understandable yet unproductive “when faced with someone who is acting in an extreme manner,” Saldana explains.

“The normal reaction is to correct that person’s behavior and get upset about his or her behavior, but those kinds of reactions can have an exacerbating effect on their symptoms. Families need to learn to react in a way that is counterintuitive. Relatives can first learn to understand the person’s experience, rather than focusing solely on the symptomatic behavior. And second, they can learn to problem-solve in a way that respects the perspectives of the different people involved.”

She offers this example: A person with bipolar might be somewhat suspicious and paranoid because of her illness. Say her father’s favorite aunt is coming to visit, yet she chooses to stay upstairs in her room, which upsets her family because they want more interaction between the guest and the entire family.

The father’s first instinct might be to berate his daughter for rudeness. His wife might find herself in the middle, between the angry father and the frightened daughter. Through training, this family might be able to learn to resolve this kind of situation, by establishing an equal respect for each family member’s experience. Then, if the father’s and the daughter’s experiences are equally valid, “the family can work toward an acceptable solution for all.” (Saldana points out that research supporting this kind of equalized approach to family problem-solving has focused on white, middle class families and that the approach may defy traditional hierarchies that exist in other cultural groups.)

The Common Elements of Successful Psychotherapy Techniques

Frank offers an explanation of the common elements that “successful psychotherapies generally share.” The common elements, she says, include the following:

• Education for the individual, to build a base of knowledge about the disorder, the medications being taken, and additional medications that might be available.
• Devoting attention to side effects the drugs may be causing and assisting with the management of those side effects.
• These efforts can contribute to adherence to the medication regimen.
• Putting an emphasis on regular sleep-wake cycles and the importance of adequate rest for optimum health.
• Therapist assistance as social support and help for the person to seek as much support as possible from his or her own social networks.
• Assisting the individual or his/her loved ones to develop a better awareness of how the early warning signs of an episode look and feel.
• Helping the person and his/her support people become more astute at realizing he/she is starting to become depressed or manic.
• Providing assistance to develop a plan for how to manage things, when those early warning signs do arise.

Forming a Partnership With Your Treatment Team

Dave and his wife Beverly live in Rock Hill, South Carolina. He held an executive position with a multinational chemical company until 1990 and he believes his then-undiagnosed bipolar disorder actually contributed to his success in the years he worked for that firm.

“I had tremendous enthusiasm [for work]”, Dave says. “I was a risk-taker and worked incredible hours. I thought that was just my personality, but it was my base personality with mania added. Colleagues called me ‘the human computer.’ I seemed able to handle any kind of pressure.” He explains that following those bursts of productivity, “I would swing to the depression side, although at the time I just thought I was exhausted.”

Dave had a complete breakdown in 1990 and entered psychiatric treatment. When he attempted a return to corporate America, it wasn’t feasible. “I didn’t have the emotional stamina,” he says. “I couldn’t handle the pressure anymore.” Dave, who was diagnosed first as having social anxiety and later bipolar disorder, says his psychiatrist acts as his “partner” in trying to resolve his problems and that the psychiatrist did refer him to a psychologist who practices CBT.

That psychologist helped Dave, in part, by teaching him a skill called “cognitive restructuring.” Dave explains this practice: “When you have an irrational thought or fear, you confront it with reality. For instance, one component of depression is anxiety. It might be my 100th depressive episode, but I’d start to think that I would never get better. Through cognitive restructuring, I learned to tell myself that my depression wouldn’t last forever.”

Dave’s therapist also taught him what he describes as “a form of meditation, a simplified yoga.” That practice allowed him to redirect his focus and his mental flow into open space. “It’s very relaxing and you stop obsessing about whatever it is that worries you.”

Having left the business world, Dave began volunteering to help people with mental illnesses through the National Alliance for the Mentally Ill (NAMI). Beverly also became deeply involved; they both worked closely with NAMI. “We’re trying to give hope to those with mental illness and to fight stigma with knowledge,” Dave says. “That is our total focus.” (Dave has written a book called No More Secrets: A Courageous Journey from Tragedy to Recovery.)

Learning Relaxation and Meditation Techniques

Angelique also reports having reaped huge benefits from a balanced approach to therapy. In 1998, a psychiatrist diagnosed her as having bipolar disorder and prescribed lithium. The normally slim Angelique rapidly gained a large amount of weight.

“Taking medication at all was really hard for me,” says Angelique, and the weight gain infuriated her. She and her psychiatrist worked together to find a healthier regimen. She did lose much of the initial weight she’d gained but, after several years of treatment, she began struggling with this issue again. Still, she says, “I’d rather have a stable mind and a little extra flab on my body than be my skinny old self with a very unstable mind.”

Angelique worked with a therapist, Howard K. Weissman, PsyD at Chicago’s Stress Relief Center. “I could totally be myself with him and get out whatever I needed to get out,” she says. He taught her several relaxation skills that were sorely needed and that she now uses with natural ease.

“At first I learned to practice relaxation using tapes he gave me, and then I started meditating. Doctors never tell you about this kind of stuff,” says Angelique. “At first I meditated sitting quietly at home. But now I can be walking and meditating, and I try to stay centered all day, all the time.” Angelique says, “I call my psychiatrist and my psychologist my extended family. I don’t feel like just another patient.”

Changing the Doctor-Patient Relationship

It’s not unusual for people with bipolar disorder to have trouble communicating with their psychiatrists or primary care physicians. Gloria Pope, director of external relations with the Depression and Bipolar Support Alliance (DBSA), says most people with bipolar do receive their medicines from primary care doctors. Many consumers feel shortchanged by infrequent appointments that prove to be only quick med checks.

What Can You Do to Fix It?

• Understand your own position and the extent of your options.
• If you’re assigned to a psychiatrist and have little choice about changing doctors, you can still speak to your doctor about improving doctor-patient communications.
• If opportunities do exist for you to change, clearly define in your own mind why you want to switch and be able to articulate the reasons.
• If you know specifically what qualities you’re looking for, you’re more likely to find them with your next doctor.

Getting the Most From Your ‘Talk Time’

• Be cautious about abrupt changes in your treatment team, advises Waxmonsky. He suggests reviewing any decisions with trusted family members/friends and trying to make these changes when your mood is stable.
• Waxmonsky also cautions that if your medications have been prescribed by your general medical doctor, “make sure that he or she is a valuable part of the medical team, but not the whole team.”
• Plan to be an active participant in your treatment. This means educating yourself about bipolar disorder. Visit bphope.com and the site’s resource links, or use reliable sites such as dbsalliance.org, nami.org, www.nmha.org, or nimh.nih.gov. Remember that primary care doctors are not specialists in psychiatric disorders.
• Ask your doctor specific questions about dosages and how to take your medications (with or without food, what to do about a missed dose, etc.).
• Ask about risks of the medications and decide together if the benefits outweigh those risks. Find out what you should do about possible side effects.
• Inform your doctor of any other illnesses you have (diabetes, asthma, etc.) and any over-the-counter drugs or nutritional supplements you use regularly.
• Ask your doctor about steps you can take to improve your response to treatment. Should you change your diet, sleep patterns, or exercise habits?
• Discuss options for psychotherapy with your doctor. Some patients who forego one-on-one psychotherapy still find it beneficial to join a support group, or even to speak with another individual with bipolar disorder. DBSA and NAMI can also be valuable resources in finding a group or peer.

UPDATED: Originally printed as “Striking the delicate balance: meds + therapy”, Winter 2005

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