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Bipolar Disorder Treatment - Cognitive Behavioral Therapy (CBT) Continued

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Dysfunctional beliefs are thinking habits that people learn. They are irrational and not based on reality. They are not objective, unbiased observation. Because such beliefs are not linked to reality very well, they tend to appear rather distorted when compared with reality. Dysfunctional beliefs are all people typically have to help them make sense out of the events that happen to them. Snap judgments are made (called Cognitive Appraisals) based on the assumptions present within dysfunctional beliefs. These judgments end up being biased and irrational. People look to their appraisals of stressful situations to know how to react. When they do, they see that situations look simply awful and worse than it really would appear if some reality testing were to happen. They react to that false or exaggerated sense of awfulness, and then experience depressive symptoms.

Cognitive behavioral therapists teach their patients to identify, debate and then correct their irrational ideas. The disputing process involves teaching patients to systematically ask and answer a set of questions designed to draw out whether particular ideas have any basis. Examples of disputing questions include:

  • Is there any evidence for this belief?
  • What is the evidence against this belief?
  • What is the worst that can happen if you give up this belief?
  • What is the best that can happen?

After multiple sessions of CBT training, patients learn to monitor their own thoughts and do the disputing process on their own outside of therapy sessions.

The behavioral aspect of CBT involves replacing behaviors that are contributing to depression with healthier ones. The therapist will determine whether the patient's behaviors are the problem or if they seem to have trouble with coping or other skills. The therapist will then recommend different behaviors as more appropriate. The therapist will also teach the patient coping skills that may be missing. For example, the therapist may recommend that the patient get exercise, take up a hobby or join a social group. They may also suggest regular use of breathing, relaxation or visual imagery techniques. They may encourage hanging out with others or exercise for patients who have become withdrawn or isolated. CBT therapists may also use other techniques including role-playing (practicing new behaviors in session), having the person practice new behaviors outside the therapy session, assertiveness and communication training, and other strategies to help patients to improve.

CBT patients are given homework throughout the course of their therapy. Homework assignments usually involve instructions to keep a log of thoughts, behaviors, and moods. The log will also include written records of their efforts towards practicing new skills or coping strategies. Clients write down changes that happen as they try out new thinking or behavior skills, or fall back into old thinking habits. As negative patterns become clearer, patients can experiment by trying out new skills and seeing (by looking at their logs and homework assignments) how these changes positively impact their mood.

Along with reducing the number of negative thoughts and behaviors, CBT therapists also help people learn how to break complex tasks into smaller, more manageable components. Doing this increases their likelihood for achieving success with tasks that just feel too big to handle when they are depressed. For example, if cooking an entire meal seems overwhelming to a person with depression, then he might be encouraged to do whatever part of that larger task he can manage. He can feel good about making one course of the meal on a particular day. Teaching people with depression to take control of their negative anticipations and fears surrounding tasks, by disputing them or breaking them down into small manageable parts, can help decrease patients' avoidance and anxiety. This will result in more rewarding successes which increase mood and fuel desire and self-confidence for attempting new tasks. Cognitive behavioral therapy is offered in both individual and group formats, and in both outpatient and inpatient settings. Research-based therapy protocols typically last between 12 and 16 weeks in duration with weekly therapy appointments. However, the therapy can be adjusted by increasing or decreasing the frequency and number of sessions to fit patients' needs.

Cognitive behavioral therapy is a good fit for people who are willing to talk and set goals and that also want short-term, symptom-focused strategies. Because of this, CBT is generally best for those that have a certain level of insight into their bipolar disorder and the effects that it is having on their own life and the lives of family and friends. CBT requires that people commit to monitoring and practicing skills outside the therapy session. CBT is less of a good fit for people who have trouble with thinking about their own thinking process. It is also not usually a good fit for people that dislike logical debate and argument used to examine the appropriateness or truth of their thoughts. It is also not a good fit for those that are interested in a less directive therapist, or who are unwilling to monitor their thinking, behavior, and feelings outside of therapy sessions. Finally, it is not a good fit for a patient with bipolar disorder who is in the middle of an extreme manic episode.