Integrating the components

IPSRT is organized into three discrete treatment phases (the initial, intermediate, and maintenance phases). Within each phase, the components of IPSRT are administered variably, in order to accommodate the specific needs of each patient. The relative emphasis of psy-choeducation, social rhythm therapy, and IPT strategies will vary according to the phase of treatment and the acuity of the patient's symptoms.

INITIAL PHASE

The initial phase of IPSRT consists of gathering a psychiatric history, providing psycho-education about bipolar disorder, carrying out the interpersonal inventory, and introducing the patient to the SRM. During this phase, all patients are evaluated by a psychiatrist (if the therapist is not a physician) to optimize pharmacotherapy. Patients may enter IPSRT when they are euthymic, subsyndromal, or fully symptomatic. Thus, the duration of the initial phase varies considerably, ranging from 2 weeks to 2 months. During this time, the patient is seen weekly by the therapist and as often as needed by the psychiatrist in order to stabilize medications.

The first step of the initial phase involves gathering a thorough medical and psychiatric history. In the course of conducting the history, the therapist listens carefully for descriptions of disrupted daily routines or interpersonal relationships that may have preceded current or previous mood episodes. By carefully reviewing these events, the therapist develops an understanding of specific episode triggers and begins to conceptualize possible vulnerabilities in the patient's interpersonal life. The therapist uses this information to introduce the IPSRT paradigm to the patient, illustrating the connections among interpersonal events, social rhythms, and episode onset with examples from the patient's own life.

In the initial phase, the therapist also initiates the SRM. As discussed previously, most of the items on the SRM are prespecified on the instrument itself (that is, wake times, sleep times, meal times, and time of morning beverage). However, two items must be individually tailored to each patient. Therefore, in the initial phase, the therapist helps the patient identify two daily activities, such as exercise, watching a specific television program, walking the dog, etc., that will be used throughout treatment as anchors for the patient's daily routines. SRMs are collected weekly to define trends in the patient's daily rhythms; however, no effort is made to modify these rhythms unless there are clinically pressing concerns such as wildly erratic sleep times. For patients with limited interest in this area (many patients are actually very interested in making changes in this arena once they see the connection between routines and their moods and episodes), or more limited literacy or intelligence, or whom the therapist suspects will have difficulty complying with this aspect of the treatment for other reasons, there is the option of using a five-item version that captures most of the essential features of the monitoring process (Monk et al., 2002).

The final component of the initial phase is the interpersonal case formulation. The case formulation links the current mood episode to one of the four IPT problem areas and sets the interpersonal agenda for the next phase of treatment (Markowitz & Swartz, 1997). If the patient is manic or hypomanic during the initial phase, it may be difficult to complete the interpersonal inventory and establish a case formulation until medications have been initiated and some degree of symptom control has been established. In some instances, therefore, the initial phase of treatment may focus on psychoeducation and containment until the patient is able to engage fully in the therapy enterprise.

INTERMEDIATE PHASE

The intermediate phase follows from the interpersonal case formulation and SRM goals. Therapy focuses on resolving the chosen interpersonal problem, identifying and meeting intermediate and long-term SRM goals, and optimizing pharmacotherapy (in consultation with a psychiatrist). In addition, therapist and patient continue to monitor symptoms and side effects closely, using standardized rating scales such as the 25-item, modified version of the Hamilton Rating Scale for Depression (HRSD) (Thase et al., 1991) and the Bech-Rafaelsen Mania Scale (Bech et al., 1979) to track shifts in mood states. The intermediate phase typically lasts for several months, and sessions are conducted weekly.

During the intermediate phase, SRMs are reviewed weekly, searching for evidence of rhythm dysregularity. The therapist and patient jointly attempt to understand sources of rhythm instability, which may include emergent bipolar symptoms (for example, later sleep times driven by an evolving hypomania), interpersonal events (for example, very irregular meal and sleep times stemming from the chaos of caring for three children under the age of 6), or their combination. The therapist helps patients find ways to regulate their rhythms by setting clear, graduated SRM goals, and then using the SRMs to track progress over time.

An important issue that typically arises during the middle phase of treatment is the balance between stability and spontaneity. Many patients suffering from bipolar disorder are accustomed to hectic variations in mood and energy states. The prodigious efforts of the therapist to curb the variability in their mood and activities are not always welcomed by the patient. In fact, many patients believe they will find regularity boring and unappealing. If sensitive to this issue, the therapist can help the patient determine how much stability is required to lessen the risk of recurrence while encouraging patients to seek some degree of "safe" spontaneity in other areas of their life. For instance, if a patient's work schedule has variable demands (for example, big projects followed by lulls in activity), the therapist may encourage the patient to avoid rhythm-disrupting projects during the spring and summer when the patient is historically at risk of manic episodes, instead shifting them to the autumn and winter months when the patient is more likely to tolerate less structured social rhythms. Alternately, by using IPT strategies, such as grieving for the lost healthy self or managing the role transition from variable mood states to euthymia, the therapist can help the patient understand and mourn the lost highs while learning to value greater stability in mood and, ultimately, functioning.

During the intermediate phase of therapy, as in life, patients invariably experience changes in life circumstances that lead to changes in routine. For instance, patients may begin new jobs, start new relationships, move to a new apartment, or resume classes. The therapist helps the patient work through these changes in a manner that minimizes disruptions of daily rhythms. For instance, the therapist may encourage patients in a new relationship to speak with their new partner about the importance of routines, helping patients establish new patterns that do not deviate substantially from old ones. Patients starting new jobs are encouraged to shift their schedules gradually in order to minimize abrupt changes in daily habits and degree of activity. IPSRT uses social rhythm therapy techniques to protect rhythm integrity, and IPT techniques to explore and manage the interpersonal consequences of these events.

During the intermediate phase of IPSRT, the therapist uses the IPT strategies discussed in Chapter 9 to resolve the interpersonal problem identified in the case formulation. In addition to helping the patient see connections between the problem area and mood, the therapist explores the impact of the interpersonal problem area on social rhythm stability and medication adherence. For instance, if the selected problem area is a role dispute with a spouse, the therapist will ask the patient about the marital conflict over the past week. If the patient reveals that his wife now insists that he drop the children off at school early in the morning (this had previously been the wife's responsibility), the therapist will explore both the impact of the new schedule on the patient's daily rhythms (Will he have to get up earlier? Should he go to bed earlier? Will this interfere with his morning dose of lithium?), as well as the interpersonal meaning of the event (How does the patient feel about the new arrangements? How did the couple make this decision?). The relative emphasis and sequencing of the techniques are determined by the clinical judgement of the therapist.

MAINTENANCE PHASE

The maintenance phase is designed to consolidate treatment gains, optimize interpersonal functioning in the absence of syndromal illness, and prevent recurrence. Treatment frequency is tapered to biweekly for 2 months and then monthly. This phase of treatment lasts 2 years in our research protocol, although, in clinical practice, some patients may stay in maintenance psychotherapy indefinitely. Crisis intervention is provided on an as-needed basis in this phase of treatment.

Because bipolar disorder is a chronic illness, some might argue that combination treatment (that is, medication plus psychotherapy) is indicated indefinitely. In other cases, a patient may demonstrate appreciable improvement in multiple domains and may feel comfortable in changing to maintenance medication without psychotherapy. In the absence of data to guide this choice, the decision to end maintenance treatment is necessarily an individual decision. When maintenance treatment ends, we recommend a very gradual process of termination, over four to six monthly sessions.

The termination stage should be a period of reflection and encouragement. The therapist reviews the patient's progress and identifies areas in which additional improvement is needed. The therapist underscores the fact that the patient has acquired both new interpersonal skills and a new understanding of the importance of maintaining regular social rhythms, reinforcing the importance of practicing these skills in order to perpetuate therapeutic gains. In this final phase, it is also important to identify additional resources for the patient in the event that symptoms worsen. Virtually all patients with bipolar I disorder will continue maintenance medication indefinitely and should be referred to a psychiatrist for follow-up.

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