The third phase of the treatment is targeted on the interpersonal difficulties that precipitate or resulted from the disorder. This is where cognitive strategies address core beliefs and schemata. The goals for this phase of the treatment include the experience of increased self-efficacy and the rebuilding of a more solid and autonomous sense of self. This takes account of the impact of the illness, which often occurs in a developmentally critical time when self-esteem and identity are formed. It further appears that the impact of mania and depression at an early age are significant, as they dramatically affect important developmental milestones such as educational achievements, early work experience, and important interpersonal relationships. Essential cognitive structures such as dysfunctional core beliefs will probably become self-perpetuating. Examples of these beliefs include a distorted sense of autonomy or personal capability, vulnerability to harm or illness, and a sense of defectiveness and unlovableness. Maladaptive core beliefs that may have been established by the early onset of the disorder or traumatic events are important to address, as it will help those individuals to understand and cope with the specific psychosocial impairments experienced later in the life course.
These interpersonal vulnerabilities and risk factors can play a major part in the recovery and prevention of relapse of the individual. Therapeutically, some of this process will consist of the facilitation of successful transitions following major episodes, significant psychosocial changes, and the adjustment to necessary lifestyle changes. As in the above mentioned model of the importance of corrective experiences and behaviour change in individuals with bipolar disorder, these changes in the cognitive emotional schemata of the bipolar patient are achieved through consistent behavioural adaptations to the vulnerabilities intrinsic to the disorder. In their reformulation of the interpersonal psychotherapy (IPT) framework for bipolar disorder (IP/SRT), Frank and colleagues (1997) combine the key interpersonal difficulties associated with bipolar disorder with an introduction to the strict monitoring of social routines and circadian rhythms (see Chapter 15). By addressing interpersonal problems and the regularity of daily routines, this method deals with both concurrent symptoms and the impact of interpersonally based stressors on patients' life, and increases their resistance to potential vulnerabilities.
The application of these techniques within a CBT framework allows the patient to develop an understanding of how adverse interpersonal experiences create maladaptive schemata about the self, foster dysfunctional attachment beliefs, and impair the acquisition of effective interpersonal problem-solving strategies. Patients also advance their understanding of how these might alter the threshold of stress needed to trigger a depressive or manic reaction, and how the generation of these events might be maintained by dysfunctional ways of solving emerging interpersonal difficulties and by conflicts arising from maladaptive expectations about others (Lovejoy & Steuerwald, 1997). The direct therapeutic targeting of these interpersonal vulnerabilities can lead to schema change and the development of stable supportive interactions in the presence of negative life events that aid the prevention of relapse.
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