The Therapeutic Alliance

It has become clear that the efficacy of cognitive-behavioral therapy (CBT) rests on the strength of the therapeutic alliance. For the clini-cian’s part, respect for patients’ preferences and needs, even when counter to clinical judgment, is a cornerstone of a strong collaborative relationship. For patients, trust in therapists, even when the feedback is not what the patient wants to hear, is critical to the task. Patients must feel comfortable telling therapists when symptoms are beginning to reemerge, and therapists must be able to give honest feedback to their patients when the warning signs are overlooked or when their actions place them at risk for relapse. Because of its pivotal role in the delivery of CBT, we begin this chapter with suggestions for building and maintaining a therapeutic alliance.

Commitment to Treatment

Unlike acute treatments for unipolar depression or anxiety disorders using CBT, the effective treatment of those who suffer from bipolar disorder requires a longer-term commitment. With its waxing and waning course, symptoms of bipolar disorder will remit spontaneously or with the aid of treatment and will recur with either precipitating events or on their own. The clinician’s task is to not only help a person overcome the symptoms of the illness and recover from its psychosocial consequences but also to prepare for its inevitable return. This means that the course of therapy may follow an untraditional pattern. Visits usually occur weekly during the first phase of treatment when skills are taught and symptoms are reduced. As progress is made and patient distress decreases, the interval between visits is lengthened to biweekly and then again to monthly depending on the need of the patient. Once the patient is stable, therapy may take a pause for several months or perhaps years until the services of the therapist are once again needed. Cues to resuming therapy include a return of symptoms, stressful events, or life transitions. If therapy is discontinued for 6 months or more, it is helpful for continuity of care if the patient makes contact with the therapist to provide a progress update, either in writing or with a brief phone call. This helps the therapist to track the progress of the patient and stay aware of major life transitions. When and if therapy resumes, the therapist can help the patient pick up where he or she left off in the story. Rather than following the “no news is good news” rule, therapists should encourage their patients to call in when things are going well or when they have good news. This positive feedback provides positive reinforcement to the therapist for previous therapeutic efforts and communicates to the patient that he or she is of interest as a person not just as a disorder or problem. While in large practices this may seem impossible, a short note or brief phone mail message that takes only a small amount of clinician time will be returned with a better therapeutic bond that can be important when the patient is having difficulties with adherence to treatment or control of symptoms.

Stability and Structure

Psychotherapy is often a stabilizing force in the lives of patients. Therapy visits can provide a structure for marking the passage of time, for monitoring progress, and for achieving goals. Feedback from therapists on changes seen since the last visit or since beginning treatment can help patients gauge their progress and feel good about their accomplishments. Regularly scheduled visits where patients report on their progress between sessions provide opportunities for patients to be accountable, thereby increasing the chance that they will implement the plans made in therapy. Regardless of the time interval, anticipation of therapy visits cues patients to be self-observant and to identify difficulties they hope to address with the therapist. Most people who are not involved in psychotherapy do not regularly take the time to monitor their feelings and actions, nor do they make time to identify personal problems and set goals for improvement. Psychotherapy that focuses on symptom monitoring, goal setting, and relapse prevention provides a structure for self-improvement.

Symptoms and Therapy

There is interplay between a patient’s symptoms and his or her experience in the therapy session. Cognitive and affective symptoms have the greatest impact on the therapy process. When concentration is poor or the person is easily distracted, it is hard to accomplish much in session. Sometimes it is necessary to shorten sessions, limit the agenda, or give the patient a mental break between topics of discussion. If the individual’s outlook is colored by depression, efforts at reviving hope must be intertwined with other agenda items. Hypomania can begin with subtle cognitive changes. Increased optimism or desire to accomplish more may appear to be within normal limits, especially if it comes on the heels of a depressive episode. This enthusiasm can be very seductive for the therapist who wants the patient to feel better and achieve his or her goals. You might find yourself agreeing with the patient’s numerous plans before realizing that the improvements in energy and optimism may be symptomatic.

If the patient has racing thoughts, it is possible that he or she will forget any plans made before the next session occurs. Note taking can help to cue the patient’s memory between visits and can help the therapist to keep track of the number of plans made or homework assignments given within a session.

When a patient with bipolar disorder is hypomanic, therapy sessions can be quite enjoyable. There is often an injection of humor that may have been missing when the patient was depressed. The rate of speech is usually faster, perhaps an improvement over psychomotor retardation that may have made prior sessions seem to drag on. The quicker thinking of the patient and fluidity of new ideas can give the impression that time is being used more efficiently. These sessions often leave the therapist feeling more optimistic and perhaps energized.

In contrast, when patients are depressed and demonstrate some psychomotor retardation, therapy sessions can be slow and difficult for both parties. The therapist may feel compelled to help the patient more, fill in the blanks when word-finding difficulties occur, or show more enthusiasm in hopes that it might brighten the mood of the patient. A clinic day with several patients in a depressed state can leave the therapist feeling drained, discouraged, and useless. It takes some self-monitoring on the therapist’s part not to communicate the impotence they may feel in the face of the patient’s severe depression. Students of CBT who are instructed to set an agenda and accomplish tasks within session often feel particularly compelled to push their depressed patients to accept interventions, may resort to giving advice when the collaboration is slow, or may feel the urge to give up on CBT altogether.

CBT methods work just as well for therapists as they do for their patients. Therefore, when feeling internal distress during therapy sessions, therapists should be mindful of their automatic thoughts, search for thinking errors, and correct their distortions in logic before they have a negative effect on the therapeutic process. A recent doctoral student was treating a middle-age woman with chronic depression. The student’s internal monologue was something like, “This woman is so sick. I can’t begin to help her. She probably needs to be in the hospital. I have no idea what I’m doing here. She is bringing me down with her negativity. How much longer do we have until I can get out of here?” While the therapist was able to maintain composure and not show the distress, this train of negative thinking kept the student from selecting a CBT strategy that might have been useful. Instead, there was an overreliance on reflective listening.

Seeing the Person Separate from the Illness

The phenomenon of bipolar disorder can be so overwhelming to the patient and to care providers that it dominates the focus of therapy. It is easy to depersonalize the conceptualization of the problem or to organize treatment around remediation of individual symptoms and lose sight, to some extent, of the impact on the person. People who suffer from bipolar disorder have difficulty knowing where their symptoms end and their personality begins. As one patient put it, “Am I an impatient person and judgmental toward others or do I have an illness that makes me act that way?” Another asked, “I think I am a natural pessimist given all the tough times I went through as a kid. But on the other hand, could it be that I have been depressed for so long, that I’m just accustomed to thinking negatively?”

People try to understand themselves and their experiences. They want to know what is stable and permanent in their lives and what is likely to be transient or a product of their mental illness. They also want others to see them as people, not as patients, or a case of bipolar disorder, or an oddity. Attention to non-illness-related topics during therapy sessions is one way of communicating to patients that we are interested in them as people. During the first few minutes of most therapy sessions there is time for chitchat or storytelling—disclosures unrelated to illness that give clues to the happenings of patients’ lives. Some patients are too verbose and allowing too much time for storytelling can detract from the work of therapy. However, eliminating such discourse altogether in the interest of time may send a message of disinterest in the nonpathological elements of the patient’s life.

To keep the focus on the individual and not just the illness, inquire about patients’ lives before the illness began, what they are like between episodes, and what stays the same in them regardless of how they feel. Characteristics such as intelligence, sense of humor, social comfort, interests, sources of pleasure, and preferences for activity are elements of the person that are independent of the illness. Other clues about the person behind the illness can be gleaned from knowing about the family of origin, how other members of the patient’s family function, and what would have been expected from life had the illness not intervened. When a therapist takes the time to inquire about these things, he or she is showing interest in the person and communicates a value for the patient’s personal life.

Preexisting Coping Skills

CBT is a skills-oriented form of psychotherapy. Therapists are equipped with a number of tools for helping patients to manage their moods, restructure their thinking, and cope with their problems. It is easy to assume that the patient is a blank slate and that the skills to be introduced are not part of the individual’s behavioral repertoire. As clinicians, we sometimes forget that the people we treat have managed to get along in life long before therapy came along. They may not have managed in an optimal manner, but chances are they possess some skills and have learned from their experiences along the way. When we assume that people have preexisting coping skills and we communicate that either verbally or through our actions, they get the message that we think they are competent, able to solve problems, and smart enough to know when to ask for help. Validation of this type enhances the collaborative nature of the therapeutic bond—an essential in CBT.

People who are distressed probably coped better with life at times when they were not distressed. Skills do not disappear when the symptoms of bipolar disorder emerge. However, the emotional upheavals, confusion, and loss of motivation and energy can make it difficult for people to access their skills. Many, in fact, forget they even possess coping skills. Their distress coupled with an eagerness to help can lead the therapist to introduce CBT methods before assessing the patient’s existing coping skills. Some suggested questions for tapping into patients’ skills include the following:

• “If you were not so distressed, how might you handle this problem?”

• “Have you run into this problem/symptom before? What has been helpful to you in coping with it in the past?”

• “What do you think would be a good way to deal with this?”

• “How do you imagine other people cope with things like this? Would that work for you?”

• “What advice would you normally give to a friend if they had a similar problem?”

As will be discussed in Chapter 7, one of the first steps in CBT for bipolar disorder is to get patients to avoid doing things that will make them feel worse. Interestingly, most patients quickly respond with a list of actions, thoughts, and situations that would likely made them more depressed or more manic. They have figured these things out from their experiences with the illness. Likewise, if the clinician inquires about things that might make their situation better, they will very likely come up with at least a few ideas. If reasonable, the clinician should go with their ideas first (e.g., visit with a friend instead of being alone), and then work on adding to their existing coping skills. If their coping ideas sound unreasonable (e.g., take sleeping pills in the early evening and sleep rather than face the loneliness of the evening), get patients to elaborate on their reasons for choosing such an intervention and then ask them to consider the disadvantages. Often there are short-term advantages for coping choices, such as allowing avoidance of stressful situations, but longer-term disadvantages (i.e., the problem never really gets solved).

If time in psychotherapy is limited, never sacrifice attention to the therapeutic alliance in order to teach another CBT skill. In the long run, if the patient does not feel respected or doubts the compassion of the therapist, he or she will not use the skills outside the therapy session.

A Reformulation of CBT for Bipolar Disorder

The first edition of Cognitive-Behavioral Therapy for Bipolar Disorder provided a 20-session protocol including session procedures and homework assignments. That structure was omitted in this second edition to make the intervention applicable to a broader range of individuals with bipolar disorder. Instead, we present and discuss cognitive and behavioral skills for management of the symptoms and problems associated with bipolar as well as some guidelines for selecting the interventions that best meet the patient’s needs. When we originally developed the CBT protocol for bipolar disorder we wanted to define the procedures of the protocol in such a way that they could be tested empirically. In the world of clinical research, procedures must be specified with enough detail to be easily replicated across clinicians with varying levels of training and skill. Therefore, it seemed necessary to provide session-by-session instructions. The first edition accomplished this goal. These session-by-session instructions are provided in the Appendix for anyone interested in using the standardized treatment protocol. With that goal accomplished, we now turn our sights toward providing an intervention that is flexible enough and complete enough to be useful with a broader range of patients, including those who have been recently diagnosed, those who have mastered the management of the illness, and those who struggle day to day to achieve symptom remission.

Patients’ therapeutic needs will vary depending on their level of acceptance of the illness, experience with symptom management, and degree of symptom control. For example, basic education will be necessary for the patient who is unfamiliar with the illness but may be unnecessary for those who have dealt with it for many years. CBT techniques may be helpful to someone who realizes that his or her thoughts and feelings vary with the course of the illness but may be too complex for a person who is still questioning the accuracy of the diagnosis. In the sections that follow, suggestions for treatment are provided for three patient groups, those who are newly diagnosed, those who are experienced with the illness but have not yet reached stability, and those who are in sustained remission. Table 1.1 provides an overview of suggested interventions for these three groups of patients.

The Newly Diagnosed Patient

It is not unusual for a patient to have suffered through several episodes of depression or mania before the illness is diagnosed (Suppes 2001). Unless they are severe enough to include psychosis, a dramatic decline in functioning, or behaviors that draw the attention of law enforcement or health care providers, the first few episodes of depression and mania often go undetected or are misdiagnosed as stress reactions or medical conditions, such as the flu. This underestimate of the severity of the situation may be reinforced by the presence of stressful life events, which is often associated with the first few episodes of depression or mania (Brown & Harris, 1978). In children, the symptoms of mania can be easily mistaken for conduct or attention problems, while depressive symptoms may be attributed to the child’s temperament.