Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., & Gyulai, L. (2002). Bipolar disorder: A cognitive therapy approach. Washington, DC: American Psychological Association.
Overall, I liked this book and believe it to be a worthwhile read. There a few things that I did not like about the book, and I mention those here ahead of explaining what I liked about the book. This book is a composite work among several authors, and it is apparent in the multiplicity writing styles. I find it somewhat annoying when the writing style changes in mid-chapter. Another annoyance is the way the authors switch between using the terms "bipolar disorder" and "manic-depressive illness" only stating they are using "manic-depressive illness" (or "manic-depression") to honor Kay Redfield Jameson, and giving no other reason for this interchange of terminology. Finally, I missed having a glossary. A glossary would have been especially useful for those of us readers who are not familiar with all of the terminology; words such as, trait, state, and mode. These words do not appear in the index either, making it difficult to find them when one wants to review specific parts of the text that one has read at an earlier time.
The first two chapters serve as an introduction and supply background information for the rest of the book. Chapter one surveys the various presentations of bipolar disorder including diagnosis, comorbidity in diagnosis, etiology, epidemiology, and prognoses for different presentations of bipolar disorder. The second chapter surveys the cognitive therapy model as it could be applied to clients who have been diagnosed with bipolar disorder. The remaining chapters can be used as a treatment manual for the practicing therapist who has clients who have diagnoses of one of the presentations of bipolar disorder. There is emphasis on the cognitive model, especially the collaborative nature of cognitive therapy. The authors are careful to point out the desirability of commencing therapy prior to clients' reaching either a fully depressed state or a fully manic state.
Among several significant statements in the first two chapters, I found two overarching elements: an emphasis on the diatheses-stress model of mental disorders and the extrapolation of research on unipolar depression to bipolar disorder. I was somewhat surprised at the extrapolation from simple depression to the complexities of bipolar diagnoses, but it seems to be consistent with other research literature that I have read recently.
Two of the most useful chapters for me are the chapters titled, "Moderating mania and hypomania" and "Clinical management of depression, hopelessness, and suicidality in patients with bipolar disorder." Another chapter that is personally very meaningful to me is the one titled, "Bipolar disorder and the family." This latter chapter is meaningful to me because of the work that I have done with families who have members diagnosed with bipolar disorder.
The most effective cognitive therapy for mania or hypomania occurs with treatment when there are no symptoms or with prompt treatment during the prodromal stage. Treatment at this time allows clients to recognize their own signs of impending mania or hypomania. While clients are still experiencing hypomania, they can use cognitive restructuring "to test the adaptiveness of their hyperpositive thoughts, assumptions, and plans" and otherwise moderate their thoughts and behaviors. Therapists work with clients in having the clients apply cognitive therapy self-help methods to attenuate their mania or hypomania. Even though cognitive therapeutic interventions are extremely difficult to apply when a client is in a "full-blown manic episode," then the therapist is engaging in "all or nothing thinking" if she/he decides that talk therapy has no benefit at this stage of the client's disorder. Changes in medication and/or supervision might be needed at any time when the client is in a manic state.
The authors suggest that it is appropriate to use psycho-education, including bibliotherapy, with bipolar clients. Part of the psycho-education process is to help clients learn to recognize when there is an impending manic/hypomanic episode and to attenuate the consequences of a fully manic episode. Most clients have personal relapse signatures (prodromes) that they can learn to recognize even though there is substantial inter-client variability. It is important to examine the symptomatic uniqueness of each client, and each client's beliefs and schemas. Therapists can help their clients to change some of their basic thoughts about their bipolar disorder. There are certain indicators of impending mania that are common to many bipolar patients. Some of these are: (1) sleep disturbances, (2) and extreme reduction in anxiety, (3) excessive optimism, (4) social gregariousness with poor listening skills, (5) reduced ability to concentrate, (6) increased libido that causes unusual behaviors; e.g., hypersexuality, and (7) an increase in goal driven behaviors. The authors suggest the use of the Young Mania Rating Scale to rate the intensity of the symptoms. Therapists must be careful not to make clients feel overly monitored and/or controlled. Collaboration to the extent that the clients feel ownership of the interventions is required. Therapists want to teach clients reality testing of the thoughts they have when they are doing hyperpositive thinking. Specific types of thoughts that are common with manic and hypomanic clients are: (1) overestimation of capabilities, (2) reliance on luck, (3) underestimation of risk, (4) minimization of normal life problems, and (5) overvalueing of immediate gratification. Flashcards with statements to counter these thoughts can be used as covert reminders of the thinking errors clients make. Another technique is the use of the daily thought record to make the client aware of his/her automatic thoughts of this type.
Behavioral experiments can be used with clients in the manic/hypomanic phase of their disorder; however. Any behavioral experiment must be used with caution so that testing a client's theory does not lead to undesirable behaviors. Another worthwhile technique with bipolar clients is rational role-playing where the therapist plays the part of the client and the client tries to talk the therapist out of a high-risk behavior. This last technique is called the devil's advocate role play.
Some techniques that can be taught to a potentially manic client include the following when considering expansive thoughts, behaviors, or plans: (1) seek input at least two trusted other people about these plans or behaviors; (2) use two columns on a sheet of paper to make lists of the productive potential for an idea or behavior and the destructive risk for that same idea or behavior; (3) vary that technique to develop lists of benefits to others vs. costs to one's self; (4) establish a personal rule to wait 48 hours before acting on any idea, and (5) create a daily activity schedule doing only those activities that are on the schedule.
Hopelessness commonly accompanies bipolar depression. Consequently, many bipolar clients experience suicidal ideation with completion of suicide at 15% of the population with bipolar disorder. It is incumbent on the therapist continually to assess for risk of suicide in clients with bipolar disorder. Therapists can assess for suicide using direct oral questioning, self-reports of clients, and reports from other professionals or family members. The authors suggest use of the Beck Scale for Suicidal Ideation (BSSI). They also suggest use of the Beck Depression Inventory (BDI) and the Beck Hopelessness Scale (BHS). It is useful to negotiate an antisuicide agreement with clients who have expressed suicidal thoughts or feelings. They should be created collaboratively with the clients and include items such as, self-help steps the client can take when they feel suicidal, emergency contacts for the client, a list of people in the client's support system; e.g., family members who can be contacted when the client feels suicidal, and a statement of client's intent to live and to live within the spirit of the contract. Therapists must remain vigilant even after clients agree to an antisuicide contract. Therapists must help the suicidal client to replace dangerous beliefs with "alternative, life-affirming" beliefs. These clients still can do problem solving work with their therapist to try to reduce their emotional pain and to look at their life difficulties rationally.
Therapists can help depressed clients by encouraging them to take part in enjoyable and productive activities even the clients might "not feel like it." The therapist must talk to the clients about following the principle, "It is vital to do the things you would normally do if your in a good mood even if you are in a bad mood." Therapists also must teach problem solving skills to their clients, so the clients to not see problems as being hopeless with no solution. There are other techniques that can be used with clients who are depressed, but they are in other literature and not covered in this text. (I note that I was somewhat disappointed that this text did not cover the problem with suicidality in clients who are having a mixed episode. In my personal experience, the client in the most danger for attempting suicide is the client who exhibits both depressive and manic characteristics: suicidal ideation, but with enough energy to act on it.)
Finally, therapists should try to have clients and their families connect with psycho-social support groups such as the National Bipolar and Depressive Support Alliance (BPDSA, formerly NDMDA) and the National Alliance on Mental Illness (NAMI, formerly the National Alliance for the Mentally Ill).
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