Cognitive Strategies

Thought Elevators

Change Limiting Beliefs

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The cognitive therapy techniques used for bipolar disorders include strategies aimed at the processing of symptoms and cognitive distortions relating to hypomanic and manic episodes. Furthermore, they aim to address beliefs and attributional biases linked to the psychological effects of long-term impairment through chronic mood-related difficulties and/or residual symptoms.

Most patients suffering from bipolar disorders describe mood-related difficulties and their social and interpersonal consequences as dating back to early adolescence. The longstanding nature of many of the associated difficulties and variation in intensity and severity over time make it difficult for many patients to identify areas of normal functioning or the clear demarcations of the "healthy self". Some schema work can therefore prove to be extremely useful in re-examining the value and evidence of old belief systems and the generation of new sets of beliefs adaptive to the current actuality.

Cognitive therapy follows a constructionist view of reality as being created by the individual's idiosyncratic preconceptions, perceptions, and memories. Cognitive therapy strategies, in the face of significant emotional difficulties, take into account the systematic distortions and maladaptation that can significantly influence the individual patient's world-view. This approach aims at the correction or re-evaluation of these systematic mood-congruent biases by re-examination of actual experiences and current interpersonal interactions, including the therapeutic relationship (e.g., Newman et al., 2002). In the presence of signs of mania and hypomania, cognitive therapists would aim to help patients to reality-test and re-examine their extremely positive world-view and self-perception, taking into consideration their current interactions and environmental stressors. Similar microtechniques and strategies come into play, for example, in the observance of daily thought records. Systematic thinking errors are driven by hyperpositive automatic thought patterns and beliefs not unlike the ones observed in depression, but with the opposite valence, such as overgeneralisation, mind-reading, and personalisation. In the re-evaluation of these thought patterns, it is important for the therapist to support patients in the process of rationalising by emphasising the maladaptive nature of such styles and consideration of the likely consequences of hyperpositive thinking.

Especially for manic or hypomanic patients, these attempts might be perceived as extremely counter-intuitive and controlling in the light of their self-perception of enjoying life and their new-found energy. It is therefore important for cognitive therapists working with bipolar patients to aim at preserving their sense of autonomy, self-efficacy, and control over their own lives. Techniques that support the self-efficacy and the re-evaluation of maladaptive beliefs include behavioural experiments, the feedback of close others, and anticipatory problem solving.

Patients can be encouraged to test their assumptions by creating real-life experiments. In hypomanic patients, this technique could lead to some reckless behaviour when hyperpositive thoughts are put to the test. In hypomania, therefore, behavioural experiments can be constructed to test the assumed consequences of not following impulses, acting with caution, and time-delays. To make constructive use of their social support system, bipolar patients often have to meet previous agreements with significant others regarding their intervention and advice, as hypomanic individuals often do not appreciate the influence of others.

One of the main features of manic or hypomanic phases is excessive risk taking. This is accompanied by a set of cognitive biases that leads many bipolar patients to underestimate the potential harm or overestimate the potential benefits of their behaviours (Leahy, 1999). Newman and colleagues (2002) introduce a version of the cost-benefit sheets often employed in CBT problem-solving techniques to get bipolar patients to balance the risk and benefit of actions prospectively—the "productive potential versus destructive risk rating technique". In this technique, patients use a two-column table balancing the "productive potential" and the "destructive potential" with the support of the therapist, a procedure which should allow individuals in a hypomanic or manic phase to consider the potentially negative consequences of their actions for others.

Related to these techniques which attempt to help bipolar patients to re-evaluate their hyperpositive thoughts are the following CBT applications to moderate their impulsivity. One example of this is the "time-delay" rule, encompassing contracted agreements to delay the execution of "spontaneous" ideas that might include adventurous activities or large purchases. The CBT technique of scheduling daily activities is commonly used to help depressed patients to master day-to-day activities and to reactivate the enjoyment of favourite pastimes; for bipolar patients, this technique can be employed to slow down the vicious cycle of mania driven by excessive activities, poor decision making, and more poorly deliberated and ineffective activities. Anticipatory problem solving regarding early warning signs of imminent mood swings and in relation to life stressors that might exacerbate symptoms (Johnson & Miller, 1997) appears to be crucial in these two areas where the coping abilities of bipolar patients can be particularly challenged. Therapeutically, the process of anticipatory problem solving includes the retrospective evaluation of past crises to identify potential problem areas in major life domains, and using problem-solving techniques to deal with these problem areas and obstacles in advance. Another technique to moderate hypomanic and manic mood is stimulus control. This includes the ability to moderate drug and alcohol use, and not to engage in extreme sports and other risk-taking and "exciting"

activities. Medium to long-term choices in this connection include the regulation of working patterns that do not include extreme hours and frequent disruptions of sleep cycles. These strategies, especially when viewed medium to long term, might seem very challenging to individuals who are prone to act impulsively and like to engage in activities without much prior consideration and planning. To avoid conflict with the high autonomy of bipolar patients, the therapist needs to take as collaborative a position as possible.

Many bipolar patients argue that, in particular, their high moods, euphoria, and heightened irritability are autonomous from their volition. Therapeutically, it can be extremely challenging to moderate these mood states and to increase patients' willingness to participate in interventions that are incongruent with their current mood. Cognitive behavioural techniques that can be applied in that context are relaxation and breathing exercises, cognitive strategies to compare the lasting effects of pleasant affective states with their intensity, and the appraisal of positive beliefs that are linked to the high feelings themselves.

Individuals with bipolar disorder experience frequent and prolonged periods of depression which gradually foster feelings of hopelessness strongly associated with suicidal thinking and suicide. This is seen as being directly related to the problems created by frequent mood swings and associated behaviours. Bipolar patients frequently have to reassemble their lives after episodes of manic acting out and depressive withdrawal; they find it difficult to trust their euthymic mood and not to worry about the impending relapse. The diagnosis itself, its cyclical episodes, and their treatments are further associated with stigma and shame, making it harder for individuals to utilise and maintain their social support network, and prolonging their depressogenic beliefs and hence their vulnerability to relapse (Lundin, 1998). In sum, bipolar disorder contains painful and unstable affect, extremes of cognitions and behaviours, interpersonal deficits, and a lasting sense of Sisyphus' despairing exhaustion. As a result, the lifetime suicide rates have been found to be 15-25% (Goodwin & Jamieson, 1990; Simpson & Jamieson, 1999; see Chapter 18). An assessment of risk therefore needs to be an ongoing feature in the treatment of individuals suffering from bipolar disorder.

The CBT of depression is discussed in detail elsewhere in this volume (see Chapter 8) and generally applies well to the depressed mood states within bipolar disorder. Here I would only like to point to a few specific aspects that might be more specifically relevant to individuals suffering from bipolar disorder.

Many people suffering from bipolar disorders report a long history of several significant illness episodes, the traumatic impact of multiple hospital admissions, and partially successful treatment regimens involving several different psychotropic medications. Individuals in this disorder group often suffer from significant residual symptoms and have experienced short periods of remission followed by frequent relapses. This poses a particular challenge to the clinician, and patients and their significant others might express increased hopelessness regarding remission and scepticism regarding the model offered by the clinician. Key characteristics of chronic or partially remitted disorders, such as suicidal ideation, hopelessness, low self-esteem and self-efficacy, avoidant coping strategies, and poor problem solving are amenable to change through cognitive behavioural strategies.

In a high-risk population, such as patients with bipolar disorder, it is advisable to negotiate an antisuicide agreement, and although such contracts do not prevent suicides, they highlight and validate the importance of a safe environment for patients and therapists alike (Kleepsies & Dettmer, 2000; Stanford et al., 1994). In the face of intense suicidal ideation, the therapist aims to reveal the beliefs underlying suicidal thoughts and to engage the patient in the exploration of alternative and life-affirming beliefs. These interventions include the open investigation of the pros and cons of suicide, the gentle challenging of assumptions behind suicidal thoughts (for example, suicide as solution to all problems), and consideration of the social context and the consequences of such thoughts and actions. As utilised in the CBT of unipolar depression, the increase of mastery and pleasure in productive and enjoyable activities can instil hope and encourage self-efficacy. Cognitive factors associated with increased risk of suicidality are "cognitive rigidity", perfectionism, and poor autobiographical recall (Blatt, 1995; Ellis & Ratcliff, 1986; Evans et al., 1992; Scott et al., 2000). Cognitive rigidity refers to depressogenic, all-or-nothing thinking and has a strong link with the hopelessness and despair associated with suicidality. This particular thinking style is therefore at the core of cognitive interventions. Likewise, perfectionism describes a set of beliefs that makes individuals vulnerable to depression and hopelessness, and it compromises constructive problem solving. Zuroff and colleagues (2000) suggest that perfectionist beliefs are related to self-criticism, perceived stress, and increased interpersonal problems, and they can further impede the therapeutic alliance. Poor autobiographical recall has been linked to problem-solving deficits in unipolar and bipolar depressed individuals (Evans et al., 1992; Scott et al., 2000); it compromises their ability to learn from past experience, and it can thus confirm old dysfunctional beliefs.

Central to the effective treatment of chronic or acute depressive difficulties in bipolar patients is the optimal utilisation of their social support network. The consequences and interactional styles of both manic and depressed episodes can easily compromise the individuals' relationships. A careful assessment of the individuals' social network and the relationships that survived following many mania-induced conflicts and depression-induced estrangements will provide a fruitful starting point for the rebuilding of a stable and supportive social environment. Detailed analysis of specific interactions or situations as well as role-playing and other social skills-training techniques might provide crucial assets in the cognitive behavioural intervention.

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