Cognitive-Behavioral Therapy for Bipolar Disorder

In 1949, Frieda Fromm-Reichman wrote a brief paper attempting to explain why her colleagues were reluctant to do therapeutic work with individuals who had manic-depressive illness and why there had been so little research on dynamic psychotherapy with this disorder (1). Her experiences did not paint a pretty picture. Patients with manic depression, she wrote, were insecure, manipulative, and superficial. They suffered from a lack of close interpersonal relatedness and attempted to compensate by clinging dependently on the therapist. They experienced intense feelings of hatred and were more interested in and clever about finding vulnerable spots in the therapist than were other psychotic patients. She thought psychotherapy with patients with schizophrenia was an easier and more rewarding activity and recommended that patients with manic depression not be seen more than two or three times a weekin treatment. It is interesting to speculate what she would think of Cognitive-Behavioral Therapy for Bipolar Disorder.

Fromm-Reichman’s pessimistic formulation appears to have had a lasting effect, because this work by Basco and Rush is the first modern attempt to produce a psychotherapeutic treatment manual focused on patients with bipolar illness. The overall structure of the proposed therapy is similar to that promulgated for the treatment of unipolar disorder, with a somewhat greater emphasis on the role of medication, treatment adherence, and the importance of symptom monitoring. The authors caution that because their overall program has not been formally evaluated in randomized controlled clinical trials, questions remain as to whether it is effective and, if so, for whom. Nevertheless, the reader will be impressed with the face validity of many of the recommendations and with the practical and immediate benefits of increasing patients’ knowledge of their illness as well as the benefits of family education and involvement.

The book’s target audience appears to be nonmedical mental health workers with limited clinical experience. It identifies many common psychotherapeutic issues in depressive and manic episodes and in times of remission and articulates specific interventions for the therapist, to the point of suggesting the actual language to be used and the questions to be asked. Consistent with the overall cognitive framework, interpersonal problems are defined principally as errors in communication based on incorrect assumptions and misattributions. To help patients improve their communication, therapists are encouraged to play “the communication game,” which is defined as assuming the role of coach and teaching “the players the basic rules,” having them demonstrate the behavior and practice between sessions, watching them play, and providing feedback on ways in which they could improve their skills. Such strategies are undoubtedly helpful for certain types of psychosocial stresses, as illustrated by the clinical vignettes provided, reflecting common experiences in the course of treatment.

What the limitations are of such interventions and what to do when they seem to fail is a relative weakness of the book and, perhaps, of the overall approach. Denial, someone once said, is not simply a river in Egypt. In these pages the discussion of denial occupies approximately three paragraphs; denial is seen as a conscious process emerging from the holding of false negative beliefs about the disorder or its treatments. Unconscious impediments to the benefits of rational intervention or correct information are not addressed, and neither countertransference nor unconscious processes are listed in the index. From an ideological point of view, this is not surprising, but it raises the question as to why a treatment manual that so successfully incorporates the benefits of pharmacotherapy into its schema of optimal clinical utility could not have similarly absorbed key psychodynamic contributions to clinical care as well. This may be an unfair expectation, given the absence of such integration in practice patterns in the field at large.

This manual deserves high praise for its simple existence, as a sensible and practical treatment guide specifically addressing the needs of patients with bipolar disorder. Dr. Fromm-Reichman might disagree with some of its content, but she could not disagree with the need.