Challenging dysfunctional attitudes

The presence of extreme goal-striving attitudes represents another point with potential for intervention. The task of challenging these beliefs may be approached by illustrating to the individual how these assumptions have served them ill in the past. This may be achieved through examining carefully the period immediately preceding a previous manic episode: by definition, mania involves significant functional impairment, admission to hospital or the experience of psychotic symptoms (American Psychiatric Association, 1994); therefore, it often results in unpleasant consequences for the individual. Investigating the link between these consequences and the antecedent behaviour—and more importantly, perhaps, the assumptions guiding this behaviour—is one method of opening a discussion of the value of extreme goal-striving beliefs.

The high value placed upon autonomy is another aspect of this model that could be explored in therapy. The therapeutic approaches described previously encourage clients to identify prodromal signs of mania and depression, in order that action may be taken to prevent deterioration. In clinical practice, many clients report difficulty in recognising their warning signs once in the prodromal stages of an episode, particularly in the early phase of hypomania. Feedback from trusted others may aid early recognition of warning signs, but this feedback may well be ignored if the individual believes that the opinions of others are of little importance. High levels of social support have been found to predict a more favourable course in bipolar depression (Johnson et al., 1999). Thus, encouraging clients to put into place—and make use of—social support networks may provide some protection against the development of depression. The desire to operate autonomously may thwart attempts to encourage social interdependency. Again, these incidents may be used as examples of the way in which these beliefs might be unhelpful and impede recovery from hypomania and depression.

These beliefs also have implications within the treatment sphere. Reluctance to become dependent upon medication and the health services may result in lowered compliance with medication. Discussion within a treatment setting of the pros and cons of taking medication has been shown to improve outcome in this group (Cochran, 1984), and this component is present in the treatment packages described earlier. Issues of dependency and autonomy may also be raised within the process of therapy itself, and, if this is the case, an emphasis upon collaboration between therapist and client is particularly important.

In more general terms, a collaborative and empathic approach is of importance, given the focus upon regulation and moderation that the techniques outlined require. The experience of hypomania and the early stages of mania may be a positive one in many respects: some bipolar individuals report enjoying increased speed of thought, confidence and energy, as well as feeling more productive and creative (Lam et al., 1999). The appeal of this state should not be underestimated: recent findings suggest that euthymic bipolar individuals who view themselves as possessing these hypomanic-like traits and believe this to be positive are less likely to respond well to cognitive behavioural therapy (Lam et al., submitted), which requires clients to be willing to engage in monitoring and regulating mood and behaviour.

In addition, whereas some of the unhelpful cognitions that might be tackled in the treatment of depression could be considered undesirable by Western society—for example, over-dependency upon others, and ideas of passivity and helplessness—it could be argued that the notion of autonomous goal-striving is idealised by contemporary Western culture (e.g., Resnick, 1999). Therefore, in terms of challenging these beliefs in therapy, recourse to standards of desirable behaviour may be problematic. Acknowledging the attractions of hypomania, and of goal-driven behaviour, may be important if a balanced discussion of the advantages and disadvantages of mood and activity regulation is to be undertaken.

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