Bipolar disorder (BD) has traditionally been heavily “biologized.” If one were to go to a bipolar specialty conference, one would find numerous talks about genetic and biological markers, cognitive impairments, sleep research, neuroimaging, and algorithms for prescribing mood-stabilizing and antipsychotic medications. One would not hear as much about how adjunctive psychotherapy can enhance medications in stabilizing mood episodes or preventing recurrences. Yet there is growing evidence of the power of structured psychosocial approaches in the outpatient treatment of BD.

Adjunctive psychosocial therapies for BD with supportive evidence include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family-focused therapy, and group psychoeducation. These treatments are usually initiated when the patient is recovering or has fully recovered from a manic or depressive episode and continue on a weekly or biweekly basis over periods of four to nine months.

A network meta-analysis of 20 randomized controlled trials of patients with BD (types 1 and 2) indicated that combining structured psychosocial therapies with medications is more effective than usual care (typically medications alone, with or without supportive therapy) in reducing rates of recurrence over one year (Miklowitz et al., 2021).

The Psychoeducational Approach

Virtually all of the psychosocial approaches with empirical support include psychoeducation. Psychoeducation involves acquainting the patient (and sometimes their family members) with the symptoms, course, causes, treatment, and self-management of BD, with guided practice of illness-management skills. These skills include learning to track one’s daily mood changes, regulate daily rhythms such as sleep/wake cycles, challenge and restructure negative (or overly optimistic) thinking, stay adherent to medications, communicate effectively with one’s family, and solve problems related to the disorder.

Psychoeducation is intended as an adjunct to medications rather than as a solo treatment. Clinicians must be aware that many patients with BD refuse medications, especially if they are adolescents or young adults who are not convinced that they have the disorder or that medications are effective. Collaboration with a treating psychiatrist is essential.

Family Matters

In family-focused therapy (FFT), the treatment we developed at UCLA and later tested at the University of Colorado, patients and their family members (parents, spouse, siblings, or extended relatives) meet together with a clinician and learn to recognize the patient’s “prodromal” signs of manic or depressive episodes (signs that emerge before the onset of major symptoms) and strategies for preventing their full-blown expression. Strategies may be straightforward, such as contacting the patient’s psychiatrist to review and adjust medications, or more complex, such as assisting the patient in managing money, keeping regular sleep/wake habits, or devising strategies to reduce substance use.

Family members often recognize prodromal signs well before the patient. In describing these signs, they use observations such as “she stands too close to me and speaks loudly” or “he gets full of himself.”

Once the patient and family have some level of agreement on what the early stages of episodes look like, the emphasis in FFT changes to strategies for preventing symptoms from worsening. Some sessions focus on the patient’s and family members’ beliefs about medications, with parents or spouses usually advocating for medication adherence and patients expressing resentment of what they perceive to be encroachments on their independence.

In a typical FFT session, clinicians recognize that the patient has a level of expertise in bipolar illness based on their personal experiences. They encourage patients to explain to their relatives what they experience during manic, hypomanic, or depressive episodes, how these states are different from ordinary mood swings, what environmental factors are relevant to new episodes, and when relevant, why they refuse medications.

Therapists coach family members to listen and validate the patient’s viewpoint while also adhering to their own view that the continuity of treatment is essential. Similarly, the patient is coached to listen and validate the caregivers’ viewpoint, with the clinician mediating these discussions. Patients and family members role-play the use of basic communication skills, such as listening actively or requesting changes in each others’ behavior.

Case Example

Karla, an 18-year-old woman in her senior year of high school, entered FFT with two older siblings (a brother, aged 27, and a sister, aged 30) and her mother and stepfather. She was clearly depressed and had a family history of BD. During an extensive diagnostic evaluation, she reported a history of brief (two- to three-day) and recurrent hypomanic episodes alternating with lengthier episodes of depression. She met DSM-5 criteria for “other specified bipolar disorder.” Karla was surprised to learn of this diagnosis and had many questions about the line between full BD and BD spectrum disorders.

The FFT clinician obtained Karla’s agreement to discuss the bipolar diagnosis with her family members. The clinician began by encouraging all participants to share their observations about Karla’s symptoms. Each family member had a different explanation for Karla’s depression: her older sister believed it was due to childhood trauma, her mother thought she had inherited it, and her brother simply shrugged, saying, “Hormones, probably.” Although they had heard the term “bipolar” before, no one in the family seemed to think that Karla’s short periods of increased energy, irritability, impulsive behavior, decreased sleep, and hypersexuality were in any way related to her depressive episodes.

The family was divided on Karla’s need for medications. Karla was open to a psychiatric evaluation but expressed fear that “there’s something wrong with my brain” and that taking a pill would ruin her chances of getting into a good college. Her mother wanted her to try Lexapro (escitalopram) but hadn’t considered the possibility that antidepressants might not be the first recommendation for a person with a bipolar spectrum disorder.

The clinician used the fact that more than one family member had been previously treated for depression and asked those members to tell Karla what their experiences of depression had been like. This intervention made Karla feel much less stigmatized within the family, a key issue hindering her willingness to access treatment. The discussion was especially enlightening for Karla’s stepfather, who had been assuming that she was being lazy and really didn’t want to go to college. Karla eventually agreed to an evaluation with a child psychiatrist in the same clinic and began a trial of lamotrigine, to good effect.

Most FFT focused on the family's difficulties with open communication: listening to each other’s expressions of emotional pain or confusion while also being able to request changes in each others’ behavior and balance positive with negative feedback. These exchanges involved role-playing new communication skills between Karla and her siblings or her stepfather or her siblings and their mother. At the end of the four-month treatment, Karla’s depression had stabilized. She remained on lamotrigine and was actively applying to colleges.

Format and Setting of Psychoeducation

Although the structure and length of psychoeducation vary from patient to patient, family and group formats appear more effective than individual formats in preventing new episodes of depression or mania (Miklowitz et al., 2021). When patients are experiencing prodromal symptoms, close relatives or friends can provide immediate input to the treatment team to inform preventative interventions.

In group settings, other individuals with BD can help the patient recognize when they are becoming ill, the importance of social support and avoiding substance abuse, and the role of medications and other “life hacks” in maintaining stability and quality of life. In the best circumstances, other group members provide companionship and hope, especially for patients who experience their lives as an endless series of doctor appointments, therapy sessions, and trips to the emergency room. For many patients, hearing that other people with BD experience the same types of family conflicts, stigma, and shame can be quite eye-opening.