Conquering Common Challenges in Psychotherapy
Various obstacles can impede therapy, but all of them can be overcome. Common ones include:
- Dismissing the diagnosis. The biggest challenge for patients is accepting their diagnosis. “If you disagree about the diagnosis, get more information,” Basco said. She suggests thinking about what kind of evidence you need to be convinced. Educate yourself about the disorder and talk to patients and professionals.
- Resisting the lure of mania. Many patients don’t want to give up their euphoric episodes—which can feel pleasurable and intoxicating—and can resist or discontinue treatment. To work through this, Basco has patients contemplate how mania affects them, listing the pros and cons. In her experience, “they decide it isn’t worth it in the long run.”
- Having the time. Making the time to attend weekly sessions can be challenging, said Reilly-Harrington. Though there is much variability in the length of necessary sessions, Reilly-Harrington suggests attending at least 12 sessions.
- Continuing treatment. Once patients start feeling better and symptoms subside, they tend to want to discontinue therapy (and medication), and some even believe they’ve been misdiagnosed, Reilly-Harrington said. However, bipolar disorder is episodic and chronic, requiring continuous treatment. When patients stop treatment and deny the disorder, “that is when we see people start to relapse,” she said.
- Separating life from symptoms. It can be very difficult to distinguish between typical life events and bipolar symptoms. For instance, one of Brondolo’s patients would get very anxious when taking her daughter to sports practice 25 minutes away from home. She was embarrassed that such a seemingly simple task was so alarming to her. When Brondolo asked her patient to explain the directions to the practice, the patient was stumped, even though she relied on GPS. It turned out that, because the GPS was instructing her to take numerous turns, she could never retain the directions. It wasn’t that she was experiencing anxiety; instead, the disorder was depleting her information processing. “You may not realize how much bipolar disorder affects your ability to manage the details in your life,” Brondolo said.
- Understanding it’s a process. Brondolo likens bipolar treatment to a rehabilitation model. After you’ve been in a car accident, returning to your regular functioning is a step-by-step process that takes time. The same is true for bipolar, which requires mastering many skills.
Medication for Bipolar Disorder
It’s common for patients to try several medications before finding the best combination, which often includes a mood stabilizer and an antipsychotic (to help with sleep) or an antidepressant (if depressive symptoms are debilitating), said Melvin McInnis, M.D., a psychiatrist and professor of mood disorders with the Department of Psychiatry and the Depression Center at the University of Michigan. It’s important to note that “about 20 to 30 percent of patients will develop some mood instability” when taking an antidepressant, he said.
When choosing medication, many physicians and patients dismiss lithium, “because it’s an older medication that has largely fallen out of favor,” Dr. McInnis said. Years ago, doctors administered lithium at higher doses, which caused more side effects. Nowadays, however, patients take lithium at lower doses, minimizing side effects, he said. In fact, Dr. McInnis views lithium as “singularly one of the best medications for bipolar disorder” and uses it as the first line of treatment.
How quickly medication takes effect depends on the type. For instance, antipsychotics “work relatively quickly” and “often there will be a calming effect that is appreciated in a few days,” Dr. McInnis said. Achieving mood stability, however, can take several weeks or even months.
Using the following strategies can help you maximize your medication’s effectiveness:
- Communicate with your doctor. “The key is to have an open dialogue with the person who is treating you,” Basco said. All experts emphasize that finding the right mix of medication is a collaborative process, and doctor and patient should work as a team. Before starting medication, talk to your doctor extensively about the side effects and what you can expect.
- Give feedback. Once you’ve started taking your medication, “you should feel comfortable about giving the doctor feedback,” and “you shouldn’t feel like a passive participant,” Reilly-Harrington said. “It helps if you can say what you don’t like upfront rather than not taking your medication secretly because you’re unhappy with it,” Basco said. It can be something as simple as saying, “This medication is making me gain weight and I don’t like that.”
- Monitor progress. The reality is that doctors might not have much time to evaluate your progress with a medication. Instead, track your own progress. Dr. McInnis suggests keeping a diary of your mood, quality of sleep and energy levels and finding a good self-report scale to monitor your symptoms (such as the Beck Depression Inventory or the Patient Health Questionnaire, which assess depression). You can also record symptoms on scale of 1 to 10. Show these materials to your doctor, who then will have a better barometer of your progress.
- Take medication consistently. Patients might stop taking medication because they can’t tolerate the side effects or because they’re feeling better. However, “If you miss doses or fiddle with how much you take, you don’t maximize the medication’s effectiveness,” Basco said. Even worse, not taking your medication puts you “at high risk for relapse,” Dr. Swartz said.
- Be disciplined. If you often forget to take your medication, Reilly-Harrington suggests using behavioral tools to remind you. This can include setting alarm clocks and packing medication in your carry-on luggage.
- Combat weight gain. Because medication can cause significant weight gain, Reilly-Harrington recommends weighing yourself regularly. It’s much easier to manage your weight after gaining five pounds vs. 30, which might seem overwhelming. Also try to maintain an exercise regimen and avoid emotional eating.
- Avoid drugs and alcohol. Whether you’re self-medicating or kicking back with a few drinks, these substances can interfere with your mood and medication. They dilute the efficacy of medication and destabilize the individual, sending moods swinging, Dr. McInnis said.
- Attend support groups. People share their own experiences with medication along with tips to get around side effects, so patients see they aren’t alone, Brondolo said.
Combating Common Triggers
Two triggers common to both manic and depressive episodes are stress and stopping or reducing medication, Basco said. Even everyday stress or excitement can incite an episode. Most startling to people is how seemingly low-stress the event can be, Brondolo said.
Triggers for mania include sleep loss — whether it’s pulling an all-nighter or skipping several hours — different time zones and seasonal changes (typically springtime). Fall and winter tend to trigger depression. Substance abuse can also encourage, extend and exacerbate mania.
In addition to these common triggers, every person has a unique set of stressors, said Basco. If certain life events, such as relationship or financial problems, seem to trigger your depression, then you know these are your unique stressors. At first, these triggers might seem arbitrary; however, you can learn to anticipate episodes. Here are several strategies:
- Even if you aren’t sure why a previously simple task is now a stressor, consider the reasons it was so tough or unnerving for you, Brondolo said.
- Try to maintain the same sleep schedule every night. Remember the importance of keeping a regular routine for all daily activities.
- “Don’t abruptly reduce your medication, unless you work out a safe way to do this with your doctor,” Basco said.
- Learn how to problem solve, so when a stressor comes up, those skills are ready, Basco said. It’s also good to learn techniques to relieve tension and calm your thoughts and emotions.
- Know yourself well enough to identify the early signs and get help quickly; don’t try to tough it out, Basco said. Controlling mild symptoms increases the chance they won’t become major ones.
Suicide and Bipolar Disorder
Suicidal thinking is common in bipolar disorder, particularly during deep depressions and mixed states, when a person is agitated, depressed and energized. Though suicidal ideation can be tough to ascertain, some indicators that an individual is at imminent risk include: being depressed, a history of attempts, talk of harming oneself, putting affairs in order and an active plan, Dr. McInnis said.
If you’re experiencing suicidal thoughts, this means your symptoms are getting worse. Call your doctor, therapist or loved one immediately or go to the ER. It’s important to take such thoughts seriously and to realize that suicide is a permanent solution to a temporary mood.
General Tips for Living with Bipolar Disorder
- Think tasks through. Tasks that seemed simpler in the past might be much tougher now, partly because of bipolar’s strain on information processing. Brondolo’s student patients notice they have more difficulty taking tests, even though previously they had no trouble. She suggests using a scale from 1 to 10 to think through the difficulty of the task. If the task is over a 4, consider what it is about the task that trips you up and anticipate what you need to do to complete it successfully.
- Become an expert. Educate yourself about bipolar disorder by reading everything you can, looking at valuable Web sites like dbsalliance.org and Psych Central and attending support groups. You can find many books with excellent tips and tools. The key is to become informed and active, Basco said.
- Recognize your own courage. “Give yourself credit and respect for managing your illness” and acknowledge your hard work, said Brondolo. She notes the “tremendous courage and strength” it takes to live with bipolar disorder.
- Focus on your health. Every healthy lifestyle requires regular exercise, a wholesome diet and adequate sleep.
- Avoid caffeine and cigarettes. Whether it’s an energy drink, cup of coffee or anything with nicotine, stimulants can change your mood and cause sleep loss.
What Loved Ones Can Do
Often, family and friends are eager to help, but they aren’t sure what to do. Basco suggests:
- Keeping an open mind. Loved ones also can have difficulty accepting the diagnosis. However, keep in mind that an accurate diagnosis leads to effective treatment.
- Educating yourself. “Become knowledgeable about bipolar disorder so you can understand what the person is going through and how you can help,” Basco said. Even if the person isn’t ready to seek treatment, Basco still suggests learning about the disorder.
- Becoming an active ally. “Show support in an active way, go to support groups and meet with the therapist (with the patient’s permission),” Basco said. Establishing a relationship with the therapist is tremendously helpful for loved ones, who can ask the therapist what to do in specific situations, she said. You might ask, “When should I take suicidal thoughts seriously?” “Do I force my child out of bed when he’s depressed?”