How Cognitive Behavioral Therapy For Bipolar Disorder Can Help

Individuals living with bipolar disorder may experience symptoms that can cause serious disruptions to their lives, but there are a variety of treatment options available that can help, including cognitive behavioral therapy, also referred to as cognitive behavior therapy and CBT. Cognitive behavioral therapy (CBT) is a form of psychotherapy, or talk therapy, that is popular for treating various mental health conditions including depression, anxiety, bipolar disorder, and more with a large body of research that supports its effectiveness. In this article, we will discuss how CBT can help individuals with bipolar disorders manage depressive and manic symptoms. 

What is bipolar disorder?

Bipolar disorder is a mental illness that is characterized by intense emotions that fluctuate between extremes of “highs” and “lows”. The clinical term for these emotional states is “mood episodes”. Patients with bipolar disorder may experience depressive symptoms (hypomania) and manic symptoms (mania). 

During manic episodes, people with bipolar disorder feel elevated energy, clarity, and happiness on an extreme level. Their mood can then quickly swing in the opposite direction to feeling tired, sad, and confused. These mood episodes are distinct from each other and can last for days or weeks. 

This can cause significant distress for people as the fluctuations between extreme emotional states impact their behavior and disrupt their lives. A depressive episode or a manic episode may also affect someone’s interpersonal relationships with friends and family members. Even when people with bipolar are not actively experiencing a mood episode, their condition can still impact their mental well-being and cognitive function. If someone only experiences depressive episodes and does not experience manic episodes, they are considered to have unipolar depression and not bipolar disorder. 

The American Psychiatric Association outlines the symptoms of both manic episodes and depressive episodes that people with bipolar disorders may experience. During manic episodes, individuals with bipolar may experience symptoms like:

• Recklessness

• Speech changes, like being unusually talkative

• High-energy

• Reduced need for sleep

• Racing thoughts

During a depressive episode, symptoms may include: 

• Depressed mood

• Insomnia or sleeping too much

• Fatigue or loss of energy 

• Loss of interest or pleasure in typical activities 

• Feelings of worthlessness 

There are various types of bipolar and related disorders, including bipolar I disorder, bipolar II disorder, and cyclothymic disorder. The exact cause of bipolar disorder is not known, but some experts believe that brain structure and functioning may play a role. There may also be a genetic component, as bipolar disorder is more common in individuals who have a first-degree relative with the condition. 

Bipolar disorder treatment options 

Typically, treatment for bipolar disorder involves a combination of medication and psychotherapy interventions. Many people with bipolar disorder depend on medications to help them mitigate their symptoms. But research shows that treating bipolar with medication alone may not be as effective as when it is combined with talk therapy or psychosocial interventions, like mindfulness-based cognitive therapy. Treating bipolar disorder with medications can present multiple challenges. Some people may be non-obedient with medicine regimens, adverse side effects can occur, and because of the rapidly fluctuating emotional states of people with bipolar, it can be difficult to balance medications effectively to provide relief from symptoms long-term. 

A comprehensive treatment plan that considers the biological, psychological, and social factors impacting people with bipolar disorder may have the most profound benefits for treating acute depression, preventing relapse, and acting as a maintenance treatment for long-term symptom improvement. A good therapeutic relationship between the therapist and client can also increase the likelihood of the patient sticking with treatment and applying what they learn outside of sessions. 

One form of talk therapy that can be used in the treatment of bipolar disorder is cognitive behavioral therapy (CBT). The psychoeducation and coping strategies that are taught in CBT sessions can be beneficial for making behavioral changes, coping with intense emotions, developing problem-solving skills, and relapse prevention. Cognitive behavioral therapy is recommended as an acute treatment of depression, for the prevention of manic and depressive episodes, and to increase treatment adherence. 

Benefits of CBT for bipolar disorder

Cognitive behavioral therapy (CBT) is a type of therapy that combines cognitive therapy and behavior therapy to focus on identifying unhealthy thoughts and replacing them with more helpful thoughts and behaviors. According to the Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of bipolar disorder symptoms, cognitive behavioral therapy is an effective treatment, in addition to medication, when someone is experiencing a depressive episode and once a patient has achieved remission and has entered into the maintenance phase of treatment. 

CBT can help patients with bipolar disorder gain insight into how their symptoms impact their cognitions (thoughts) and learn how to replace negative thoughts and behavioral patterns with more positive ones. CBT therapists can teach healthy coping skills and behavioral strategies using a variety of evidence-based techniques. During CBT, patients may also learn to recognize triggers of a depressive episode, like stressful life events.

There are four main ways that CBT can benefit individuals with bipolar disorder:

• Ease the severity of elevated or depressive mood symptoms 

• Encourage adherence to medication regimens

• Learn to recognize the signs of an episode and take preventative steps 

• Treat comorbid mental health conditions like anxiety

How does CBT treatment for bipolar disorder work?

There are multiple types of therapy that can be used to treat bipolar disorder. Cognitive behavioral therapy (CBT) is regarded as one of the most effective treatment options because of its well-researched benefits. While the exact treatment approach can vary, CBT for bipolar disorder often includes the following aspects:

Assessment

For patients with bipolar disorder, one-on-one talk therapy with a trained CBT therapist generally begins with an assessment. During the assessment stage, the therapist and client work together to set expectations, identify symptoms and their severity, and create a plan of treatment. The assessment may include behavioral experiments, filling out questionnaires, and one-on-one discussions. 

Psychoeducation 

Psychoeducation often comes next. Psychoeducation (i.e., education about psychology) may be more effective for bringing about desired behavioral changes when taught in the context of CBT talk therapy. Bipolar disorder education can benefit patients by helping them learn how the symptoms of bipolar disorder impact them so that they can better identify when they are experiencing an episode and take steps to prevent it. The therapist may also explain to the client how cognitive behavioral therapy works and what to expect from treatment. 

Behavioral interventions 

The therapeutic interventions used in CBT focus on both behavior and cognition. Behavioral interventions for bipolar include inhibiting unhealthy behaviors during manic episodes and activating positive behaviors during depressive episodes. For example, certain behaviors like drug use (more specifically cocaine or amphetamine use) may trigger or prolong a manic episode. Integrated group therapy is a type of cognitive behavioral therapy developed specifically for people with bipolar disorder who also experience substance use disorder or substance addiction. During integrated group therapy, therapists teach strategies for incorporating behavioral changes and developing coping skills that can help people recover from and prevent relapse of both bipolar disorder and substance use. 

Cognitive interventions 

Cognitive behavioral therapy is largely about recognizing negative thought patterns (cognitive distortions) and reframing them into more positive thoughts. The idea is that by changing thought patterns, people can also change their behavioral patterns. This process is called cognitive restructuring. CBT therapists may use various techniques to achieve cognitive restructuring, including psychoeducation and guided discovery. During guided discovery, the therapist asks open-ended questions designed to increase the patient's self-awareness of their cognitive patterns. Another method that CBT therapists may use to aid in cognitive restructuring is exploring the patient’s schemas. Schemas are the core beliefs that are behind negative thought patterns and behaviors.  

Negative beliefs aren’t the only cognitive distortions that can influence patients with bipolar disorder, however. Researchers in the previously mentioned meta-analysis of randomized controlled trials noted that CBT can help participants address “hyperpositive thinking”, which can be a problematic feature of mania. For example, individuals with such thought patterns may believe that they’re invincible.

Relapse prevention

During the last stages of the therapeutic process, the focus is often on relapse prevention. This may include having discussions about the patient’s attitudes toward medications, identifying the signs of an onset episode of mania or depression, self-monitoring, and developing a daily routine. A structured daily routine paired with self-monitoring can help people with bipolar disorder identify when they are experiencing a change in thought patterns and other symptoms of mood episodes. The therapist may also help their client develop a safety plan to follow when they identify the warning signs of a relapse, such as taking medication, talking to a trusted loved one, or calling a professional for help. 

How online therapy can help

CBT can be a beneficial part of treatment for bipolar disorder, but for some individuals with this disorder, some of the symptoms may make it feel hard to seek help at times. For instance, if someone with bipolar disorder is experiencing a depressive episode, they may be feeling exhausted and low energy, which can make the idea of traveling to an in-person appointment feel very challenging. In these instances, online therapy may feel like a more convenient option, as you can match with an experienced therapist online and then meet with them wherever you have internet—including the comfort of home. 

Researchers have demonstrated the effectiveness of online therapy and online CBT, in particular, as a treatment option for a range of mental health conditions. For instance, one such study found that internet-delivered CBT was effective in the treatment and management of psychiatric disorders including bipolar disorder, as well as depression, generalized anxiety disorder, and more.