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462 The APA Publishing Textbook of Mood Disorders, Second Edition
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EE relatives than in patients with low-EE relatives (e.g., Miklowitz et al. 2009). One
limitation to family therapy is the fact that engaging entire families can be a challenge,
particularly when the patient has been struggling with the disorder for many years.
Clinicians may find it challenging to get family members to understand the importance of their role in the success of treatment.
Case Example
Stefan was a 15-year-old boy diagnosed with bipolar I disorder, ADHD, and an expressive language disorder. He began FFT with his mother, Judy, following a bipolar, mixed
episode that had led to his dismissal from a private school. At the beginning of family
sessions, he was not attending school; he was taking one online course and met once
weekly with a speech coach. Judy had quit her full-time job, and the two were home
together most of every day. They both complained about excessive conflict in their re
lationship.
In initial psychoeducation sessions, Judy wondered aloud whether Stefan really had
bipolar disorder. She expressed her doubts about whether his medications (aripip
razole and valproate), administered by a local psychiatrist, were helping or were even
appropriate. Stefan, who had trouble attending to the content of sessions, was able to
describe the initial phases of his manic escalation in the most basic of terms (e.g., “I got
mad, I couldn’t sleep”). His mother referred to his recent mixed symptoms as “behavior
problems.” Much of the content of psychoeducation revolved around whether they
could agree on what aspects of Stefan’s behavior were likely to be part of bipolar illness
and what behaviors were within his control. The clinician helped clarify what a mixed
episode was, how mood episodes differed from ordinary teen behavior, and what role
medications and effective family communication might have in relapse prevention.
Judy began to consider the possibility that his anger and irritability were part of a
manic syndrome. Stefan expressed some relief that his conflicts with his mother and his
peers might have a biological as well as a psychological explanation. They discussed
environmental triggers for his daily mood swings (e.g., being denied access to his
phone), how these swings were different from his full manic or mixed episodes, and
how Stefan and Judy might interrupt the sequence of events that precipitated or fol
lowed these mood changes and led to further family conflict.
The treatment “took off” at the introduction of communication skills training. The
duo avidly participated in role-plays designed to increase their use of positive interper
sonal feedback, active listening, and making positive requests for change in each
other’s behavior. Judy found the latter especially helpful; she noted that after a major
conflict, Stefan would want her to hug him and tell him that everything would be all
right, but she felt too alienated to do so. She was able to ask him to choose another
means of self-soothing or to at least give her time to cool down before he asked her for
comfort. In turn, Stefan expressed frustration that she would only listen to him for a few
minutes and then would begin criticizing him, no matter what the topic. The clinician
instructed him to express this frustration in a constructive way by tying it to ways she
might be more patient with him. In turn, Judy learned to rephrase her criticisms as positive requests for change (e.g., “I’d appreciate your talking to me in a more respectful
tone of voice”). With repeated practicing of these communication skills in the sessions
and at home, they both reported reductions in their level of family conflict and a greater
feeling of collaboration.
Toward the end of treatment, the focus shifted to Stefan’s schooling. He expressed
fear of telling others at school what had happened to him and avoided going as a result.
The clinician normalized these fears, explaining that the experience of social stigma is
common among people after a psychiatric illness episode. During problem solving, the
pair discussed various options regarding whom Stefan should tell (e.g., friends, teachers, school health staff) about his bipolar disorder and what details he should give
them. They role-played specific conversations he might have with friends. With the cli-
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463 Psychotherapeutic Approaches to Bipolar Disorder
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nician’s coaching, Stefan decided that he did not need to tell everyone that he had
bipolar disorder or that he took antipsychotics, preferring to say he took “attention
pills” and “mood medicines.”
Upon discharge from FFT, Stefan’s mood symptoms had largely stabilized, and he
had enrolled in a new school. He reported some residual depression but was able to
accomplish daily tasks with greater effort. His mother returned to her job at half-time.
Stefan and Judy were regularly implementing the communication and problem-solving
skills at home and reported that their original goal of reducing their level of conflict had
been largely achieved. Both also felt they had benefited from understanding bipolar
disorder as an illness that could affect one’s relationships. Although Judy expressed a
preference that Stefan continue with his medication regimen “for now,” she continued
to wonder whether he could get along without it. For follow-up care, Stefan was referred to his psychiatrist for further discussions of medication options and to a community mental health center for individual therapy. Judy was referred to a mindfulnessbased cognitive therapy group for parents of teens with mood disorders.
Cognitive and Functional Remediation
Cognitive impairments have been found in 42%–64% of those with bipolar disorder,
especially in the areas of executive functioning, memory, attention, and verbal learn
ing (Reichenberg et al. 2009). Remediating cognitive deficits may be associated with
improvements in social and occupational functioning and quality of life. Functional
remediation (FR) consists of 21 weekly individual and group sessions providing psychoeducation and cognitive skills training (attention, memory, executive functioning)
in daily life situations, plus communication, interpersonal effectiveness, and stress
management training (Martínez-Arán et al. 2011). A 10-site RCT in Spain compared
FR with psychoeducation (also 21 sessions) and TAU in 239 euthymic adults with bi
polar I or bipolar II disorder. Patients with bipolar disorder who received FR showed
greater improvements in social and occupational functioning than those in TAU, but
no differences were detected between FR and psychoeducation alone (Torrent et al.
2013). At a 1-year follow-up, functional improvements persisted only for the FR
group (Bonnin et al. 2016).
Computer-based cognitive remediation has also been evaluated. In a trial of 84
adults with bipolar disorder, patients were randomly allocated to a computer-based
cognitive remediation treatment or a computer-based control condition, both consisting of three sessions per week for 24 weeks (Lewandowski et al. 2017). The computerbased cognitive remediation was associated with significantly greater improvements
in cognitive domains (e.g., processing speed, visual learning, memory) over 12 months.
Improvements in community functioning, however, occurred in both groups. Thus,
both cognitive and functional remediation may reduce cognitive deficits for adults
with bipolar disorder, but their unique role in improving psychosocial functioning is
unclear.
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The Systematic Treatment Enhancement Program
Few studies have addressed a key question in this literature: what treatment works
best for whom? The Systematic Treatment Enhancement Program study, a 2-year
multisite randomized clinical trial, compared three psychotherapies for bipolar disorder (FFT, IPSRT, or CBT), given in up to 30 sessions over 9 months, with three
weekly sessions of individual psychoeducation guided by a self-care manual. Pa-
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tients were 293 acutely depressed outpatients with bipolar I or bipolar II disorder
who were treated by study psychiatrists with standardized pharmacotherapy algo
rithms. The study found that patients receiving intensive psychotherapy and medications had better outcomes than those in collaborative care across a range of measures
(Miklowitz et al. 2007a, 2007b). Over 1 year, patients in the intensive therapy condi
tion were more likely to recover from depression (64%) and recovered more rapidly
(mean=169 days) than patients in collaborative care (52% and 279 days, respectively).
One-year rates of recovery for the three intensive therapies, which did not statistically
differ, were 77% for FFT, 65% for IPSRT, and 60% for CBT. Patients receiving the intensive therapies were also more likely to remain well in any given month of the 12month study than patients in collaborative care, and had better overall psychosocial
functioning, relationship functioning, and life satisfaction (Miklowitz et al. 2007a).
Thus, the STEP-BD program validated earlier research indicating that intensive psy
chosocial treatments are more effective than brief psychoeducation for stabilization of
depressive symptoms, although it did not clarify whether one of the treatments was
more effective than the others.
Subsequent analyses of the STEP-BD data suggest the presence of moderating variables on these treatment outcomes. Notably, patients with comorbid anxiety disorders showed greater benefits from intensive therapy versus brief psychoeducation in
rates of recovery from depression compared with patients without anxiety disorders,
suggesting that comorbidity may be a selection factor determining who should re
ceive intensive therapy in community care (Deckersbach et al. 2014).
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Application of Psychosocial Treatments to Early-Onset
and High-Risk Patients
Psychosocial interventions have been evaluated in patients who develop the full bipolar disorder syndrome before age 18 years. Childhood onset is a reliable predictor
of a more pernicious course of bipolar disorder in adulthood (e.g., Perlis et al. 2009;
Post et al. 2010). Two trials have compared FFT with brief psychoeducation in adolescents with bipolar I or bipolar II disorder; one of the trials showed an impact on the
trajectory of depressive symptoms (Miklowitz et al. 2008), and the other showed an
impact on manic symptoms (Miklowitz et al. 2014). The latter trial did not detect differences between FFT and brief psychoeducation on time to recovery or time to recurrence. However, patients in FFT reported higher quality-of-life scores over 2 years than
patients in brief psychoeducation (O’Donnell et al. 2017).
For younger bipolar patients, psychoeducation given in an eight-session multifamily group format has been shown to improve the trajectory of mood symptoms among
bipolar spectrum youth (ages 8–12) with bipolar I or II disorder or a bipolar disorder
NOS diagnosis (Fristad et al. 2009). An 18-session protocol of individual CBT and FFT
(known as the “Rainbow” program; West et al. 2014) consisted of alternating childonly, parent-only, and family sessions. Children in the Rainbow program showed
greater improvement in parent-reported mania scores, lower parent-reported depression scores, and a steeper response curve for depressive symptoms at posttreatment
and 6-month follow-up compared with an active, dose-matched individual psychotherapy control condition (West et al. 2014).
465 Psychotherapeutic Approaches to Bipolar Disorder
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There has been increasing interest in the role of early psychosocial intervention for
youth who are genetically at risk for bipolar disorder and show early signs of mood
disturbance. The long-term goal of research studies is to determine whether early in
tervention can prevent or delay the onset of the full bipolar syndrome. In a 1-year
RCT, 40 youth (ages 9–17) with major depressive disorder or unspecified bipolar dis
order, all of whom had a first-degree relative with bipolar I or bipolar II disorder, were
randomly allocated into one of two treatment groups: 12 sessions of FFT–high-risk
(HR) version over 4 months, or 1–2 sessions of a brief psychoeducational control treat
ment. Compared with the control group, youth in FFT-HR experienced more rapid recovery from their initial mood symptoms, more weeks in remission, and greater
improvement in hypomanic symptoms over 12 months (Miklowitz et al. 2013).
In a second, larger trial (N=127) of FFT-HR for high-risk youth—those with major depressive disorder or unspecified bipolar disorder and a familial history of bipolar disorder—family intervention was associated with a longer time to prospectively observed
mood episodes (the majority of depressive polarity) than was seen with a 4-month psy
choeducational comparison treatment. FFT-HR was not associated with a lower rate of
conversion to bipolar I or II disorder, although the mean duration of follow-up (2 years)
was not long enough to observe many conversions (Miklowitz et al. 2019).
In a 6-month pilot trial, Goldstein et al. (2018) randomly assigned 42 high-risk adolescents to receive eight sessions of IPSRT plus referrals to community care, or referrals alone. The adolescents had parents diagnosed with bipolar I or bipolar II disorder
but, unlike the participants in the FFT high-risk trial, had not developed mood disor
ders themselves. None of the youth in either treatment group had had a mood episode
(mania, hypomania, depression) by the 6-month follow-up, nor were there group dif
ferences in subthreshold depressive symptoms. Three adolescents developed subthreshold hypomanic or manic symptoms at follow-up, two in the referral-only arm
and one in the IPSRT-plus-referral arm. Actigraphy data revealed that at baseline, the
IPSRT group had more time awake after sleep onset compared with the referral-only
group but had less time awake 6 months later. Thus, early intervention with IPSRT
may have altered a key risk factor for mood episodes (sleep disturbance), but its effects
on early symptoms were less clear.
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Summary of Findings
The evidence reviewed in this chapter supports the use of bipolar-specific psychotherapies as adjuncts to pharmacotherapy in the stabilization and maintenance
phases of bipolar disorder. Evidence is strongest for the long-term maintenance of bipolar disorder, including relapse prevention and restoring functioning for youth and
adults. FFT and group psychoeducation have the strongest support and may be suit
able for different phases of the illness: FFT for patients who are recovering from an
episode of illness and group psychoeducation for patients in remission. No comparisons of group psychoeducation and family therapy have been undertaken, but this
would be a potentially informative area for research.
The studies of CBT and IPSRT are less conclusive. However, there have been more trials of CBT across a broader array of settings than for other forms of psychotherapy. CBT,
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FFT, and IPSRT were all more effective than brief psychoeducation in the STEP-BD
study, although the trial was too underpowered to show differences between the treat
ments. A newer approach to adolescent bipolar disorder based on dialectical behavior
therapy (DBT), which includes family and individual skills training components, has
shown promise in a preliminary RCT (N=20). Adolescents who received DBT showed
greater reductions in depression—and especially in suicidal ideation—over 1 year compared with a group that received supportive care (Goldstein et al. 2015).
Limitations Across Studies
Certain limitations of the extant literature must be emphasized. First, for ethical reasons, most RCTs examining psychotherapy also allow pharmacotherapy for patients
in all treatment conditions, making it challenging to determine if improvements at
tributed to psychotherapy are due to different pharmacotherapy regimens (Yatham
et al. 2018). Second, there is substantial heterogeneity in terms of the populations
sampled (i.e., patients with bipolar I or bipolar II disorder vs. those with unspecified
bipolar disorder, or patients in remission vs. those in episode), the number of therapy
sessions (ranging from 6 to 30), length of follow-up periods (6 months to 5 years), and
outcome measures (e.g., remission or relapse rates, symptom trajectories, hospitalizations, functional outcomes [Geddes and Miklowitz 2013; Yatham et al. 2018]). Thus,
it is unclear whether certain approaches are more effective than others, whether cer
tain subpopulations are less tractable, or whether the treatments are being compared
on the same outcome domains. Third, in the majority of trials, notably several using
FFT, the experimental treatment groups received a greater number of sessions than
the control condition groups, raising the question of whether treatment gains can be
attributed to amount rather than type of therapeutic contact.
Meta-analyses of the psychotherapy literature, especially those that take into account differences in treatment components, may be able to address some of these
questions (Miklowitz et al. 2017). A recent meta-analysis of 39 randomized psycho
therapy trials in bipolar disorder concluded that psychoeducation and skills training
given in a family or a group format were more effective in preventing illness recur
rences than psychoeducation and skills training given in an individual format (Miklowitz et al. 2021).
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Future Directions
Identifying Active Ingredients
Few studies have examined the active ingredients of successful psychosocial treatment in bipolar disorder. Psychoeducation, which is common to all bipolar disorder
psychotherapies, is consistently more effective than standard care without psychoeducation. Virtually all of the protocols involve some form of mood monitoring, relapse prevention planning, problem-solving regarding social and occupational
reengagement, medication adherence monitoring, stress management, and intervening with substance use (Murray et al. 2017). The literature has not made clear how
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long psychoeducation needs to be in order to be effective, or whether effects differ as
a function of delivery format (individuals, groups, or families).
There are other therapeutic ingredients that may explain the efficacy of some interventions over others. Involvement of the family in psychoeducation and skills training,
stabilization of sleep/wake cycles, cognitive restructuring, and behavioral activation
may have therapeutic benefits at different phases of the illness. For example, stabiliz
ing sleep/wake cycles may play a greater role in mania stabilization, whereas behavioral activation may be more effective in alleviating depression. Clarification of the
effective components of treatment at different stages or polarities of the illness may
lead to the development of more effective forms of therapy.
Regarding treatment format, internet-based programs and phone apps are being
increasingly used to remediate gaps in treatment access in many mental health pop
ulations. Patients with bipolar disorder are relatively adherent to web- or text-message-based tracking of mood states, whether given as a self-monitoring component of
pharmacotherapy or as part of individual psychoeducation (Bilderbeck et al. 2016;
Miklowitz et al. 2012). Preliminary evidence suggests that smartphone psychoeducation is well accepted among patients and can be delivered with good adherence to
psychotherapeutic principles (e.g., Hidalgo-Mazzei et al. 2015; Leitan et al. 2015).
Mediation and Moderation
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Treatment mediation—the ways in which psychotherapies work in bringing about
clinical change—has received relatively little attention in the bipolar literature. Medi
ators are treatment targets that when modified help explain the statistical association
between treatment and improved clinical outcomes. There are several candidates for
mediators of psychosocial treatments for bipolar disorder: improvements in family
interactions (for FFT), improved sleep/wake cycle regularity (IPSRT), and increased
knowledge of coping strategies (psychoeducation). As an example of the latter, an
Oxford University trial with 121 bipolar outpatients compared a five-session facilitator-guided psychoeducational therapy combined with electronic mood monitoring
against an educational self-help guide with electronic mood monitoring (Bilderbeck
et al. 2016). Although there were no between-group differences in self-rated depressive symptoms or relapse/readmission rates, the individual psychoeducation was
associated with greater increases in knowledge about bipolar disorder from pre- to
posttreatment (3 months) compared with the comparison condition. Further, increases
in knowledge at 3 months were associated with more weeks in remission over the remainder of the study year. Identifying mediators of clinical improvement is an important direction for the next generation of psychosocial treatment studies, because there
may be ways of modifying these mediators that will make treatment more effective
and less costly.
We also know relatively little about whether various forms of psychotherapy are
more versus less effective in illness subgroups (moderation). The current literature has
yet to identify best-practice treatments for those with more severe forms of bipolar disorder—for example, patients with treatment-resistant depression who have active suicidal behaviors or self-harm, or patients with substance abuse, rapid cycling, or
comorbidity with personality disorders or other major psychiatric disorders (e.g.,
ADHD). There has been some attention to the stage of illness as informing choice of
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treatments. It may be that therapies most applicable in the disorder’s earliest stages
(e.g., group psychoeducation, family skills training) may be less applicable later in the
illness course, when patients may benefit more from functional remediation.
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