In this episode of Let’s Talk About CBT- Practice Matters, Rachel Handley talks to two expert guests – Professor Kim Wright from the University of Exeter and Associate Professor Tom Richardson from the University of Southampton – about bipolar disorder and the role of CBT in supporting people with this diagnosis.

Tom and Kim share their extensive clinical and research experience, alongside insights from Tom’s own lived experience of bipolar disorder. They discuss common myths, the importance of timely and accurate diagnosis, and how CBT can support people with bipolar in a meaningful and collaborative way.

They explore what CBT for bipolar looks like in practice, including work on relapse prevention, mood stabilisation, routine regulation and addressing beliefs about mania. The conversation also covers important systemic issues such as gaps in service provision, barriers to access and the need for more widespread training and implementation.

This episode is released to mark World Bipolar Day and aims to raise awareness and improve understanding of this often misunderstood condition.

Resources & Further Learning:

·        Richardson, T. (Eds). Psychological Therapies for Bipolar Disorder: Evidence-Based and Emerging Techniques. Spinger-Nature, 2024.

·        Bipolar UK Commission

·        Find out more about Kim Wright’s research and publications

·        Find out more about Tom Richardson’s research and publications

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If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy.

Credits:

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This podcast was edited by Steph Curnow

Transcript:

Rachel: Welcome to. Let's talk about CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients.

Today I'm delighted to be joined by not one, but two expert guests, my wonderful friend Kim Wright, Professor of Clinical Psychology at the University of Exeter, and the equally wonderful Tom Richardson, Associate Professor of Clinical Psychology and CBT at the University of Southampton. Both of our illustrious guests specialise in researching, treating, teaching, and training others in psychosocial interventions for bipolar disorder. Welcome guys.

Tom: Thanks for having us.

Rachel: I know you've both been working in this field of bipolar for many years. Kim, when I first met you, you were doing a PhD in bipolar, even before embarking on your doctorate in clinical psychology. And Tom, I know you have personal as well as professional reasons to be so committed, and passionate about the area. Can you tell us a little bit about your pathways into this work?

Kim: Yeah. Hello Rachel. It's really good to be here. So, I, started out quite a long time ago, when it was possible to finish your psychology degree and go straight into a research associate job and I was very fortunate to be able to do that and work with Dominic Lamb on his trial of CBT for people with bipolar, for relapse prevention. And that is at the, or was at, Kings College London and it was one of the early CBT trials in the area and it was really exciting to be involved in it and as part of that, again, this is a bygone era, it was possible to do a part-time PhD that was heavily subsidised for members of staff of the institution. So I did my PhD part-time with Dominic alongside my role, and that gave me the opportunity to meet hundreds of people with bipolar disorder and hear about their experiences. And then, after I finished, I did clinical psychology training and then worked in a community mental health team for a bit. And then I had a really wonderful opportunity to join the clinical research group at the University of Exter where I am now. And back then it was led by Willem Kuyken and Ed Watkins, who work in the area of depression. And they liked the idea of broadening out the team to include a focus on bipolar.

So that was a great opportunity for me to return back to research in the area of bipolar and also to work in the research clinic that we set up in the university not long after.

Rachel: What a brilliant opportunity to work with such amazing people, but also to be in there from the ground up, working on that first CBT trial in the area. Really exciting. How about you, Tom?

Tom: Yeah. Well, as you said, my research interests really has come a lot from my own experiences because I have Bipolar disorder type I. I haven't always been completely open about that. It's taken a few years of qualified life for me to feel comfortable with that, but yeah, I ended up having a manic episode just after my A levels, just before I started my degree, my undergraduate degree. I ended up in a hospital with a manic episode, so that got me interested in it. And then, when I was doing my undergraduate degree, actually I started doing a little bit, I started doing some stuff for kind of student journals and my thesis was actually about hypomania and how it relates to impulsivity and risk taking in the general population. So I actually became hypomanic about my dissertation, about hypomania.

So, and then I was working as a research assistant on sort of computer-based CBT at the University of Bath with children. But I did a little bit of stuff, a few bits of research and kind of papers around bipolar disorder, around like letters to the editor and reviews and that kind of thing. And then when I started my doctorate here in 2010, and that's when I started to get my kind of first real clinical experience, my first placement, I worked with a couple of people with bipolar disorder. And then, I was working in the NHS in Portsmouth community mental health teams for eight years. And that was a whole range of problems, but I did a lot of bipolar work there. I set up and ran a bipolar group, which was, which I really love doing. So it's gone from there. And then I joined the university in 2021, and this is a big part of my research here is about psychological therapies for bipolar. So influenced by my own experiences a lot of the time, as well as my service users.

Rachel: And I know that's naturally and rightly a very personal choice to share that information about your own mental health, but incredibly helpful, I think, for other mental health professionals as well as I'm sure your research to de-stigmatise that area and to be able to think about it from the inside out.

Tom: Thank you.

Rachel: We've recorded a number of podcasts recently on unipolar depression, and in fact, we've got a whole series of podcasts on depression coming out. This will probably be the first one because we've got World Bipolar Day coming up, but those conversations really underlined to me how common unipolar depression is. And our listeners will be not only aware of that, the massive numbers of people suffering from depression, but also probably seeing them in their practice’s day in, day out. But bipolar is perhaps a little less well recognised and understood. So, can we start with some of the basics? How might we recognise bipolar disorder or bipolar spectrum disorders outside of sort of dramatic portrayals, like the likes of Claire Danes on Homeland?

Kim: Yeah, so you're absolutely right. Bipolar is quite a lot less common than unipolar depression. I would say if you're seeing someone with recurrent depression and they report periods of consistently elated or irritable mood that go on for, say around four days or so, as well as some heightened energy and activation that's pretty persistent over that period, you could ask them a bit more about that time. A key thing is often sleep, people often talk about dramatically reduced need for sleep, but still feeling rested. They might also talk about that their mind's racing, that they're talking a lot more than normal and importantly, if they're around other people, noticing that they're different at those times and there isn't another obvious explanation like stimulating drugs or an overactive thyroid, for example. And I think it can be a tricky one because I think a lot of clinicians are quite reluctant to pursue diagnosis for the, supposedly the milder, subtypes of bipolar. But there is this concern in the prescribing community about the potential for SSRI drugs, antidepressants, to increase vulnerability to mania. So it can be important for people to know if they do have that tendency to periods of hypomania, in terms of treatment choice, in medication.

Rachel: Why? Why do you think clinicians are reluctant to pursue those diagnosis? What do you think is driving that?

Kim: I think it's partly to do with maybe concerns about people getting a stigmatising diagnosis, concerns about people being, particularly young people, being prescribed what are often seen as quite heavy medications with a considerable side effect profile. And also, the difficulty that there can be if people have quite a rapid cycling, mild or subtype of bipolar with distinguishing that from other potential explanations. So that can make people, some clinicians, maybe more reluctant to diagnose.

Tom: I think it's also worth saying that it also just gets missed a lot of the time. I was part of the Bipolar UK Commission, so we wrote some reports as part of that and that one of the key, really shocking findings was it was nine and a half years average to diagnosis. And nine and a half years after you'd been in touch with a mental health professional. Most people are originally diagnosed with unipolar depression, they're diagnosed with a depressive episode, but the hypomanic/manic side often gets missed because you're not likely to go and get help for that unless it's really severe. And then you might end up in hospital or contact with criminal justice or something horrible like that. But actually, a lot of the time people won't go and get help. So it does get missed for a long time because these episodes of hypomania/mania, they go on for a long time, they go on for weeks. That's an important distinction, we're not talking about daily ups and downs here. These go on for a long time, but they still don't go on as long as depression, people are depressed for months, people are hypomanic for a few weeks. So it's very easy to get missed even if you're under a mental health team.

Rachel: And Tom, Kim mentioned stigma and that being a barrier sometimes from a professional's point of view to diagnosing these problems. Do people suffering from these issues want diagnosis? What do you think about the whole issue of stigma for people who are presenting in services?

Tom: And I know there, there might be some therapists and clinical psychologists who, maybe don't agree perhaps with the term, but actually the research we did with Bipolar UK I think it was 85%, 87% that they found the diagnosis helpful. So we need to listen to that and we need to respect that. Yes, some people did say it increased feelings of stigma, but that was a real minority. And actually, other people were saying positive things like it got me the help I needed, it got me the medication, and it gave me an understanding from my experiences. Maybe there's a small risk of stigma, but I think it's improving. I think the awareness about bipolar disorder in the general public is better than it was a few years ago. And actually what the Bipolar UK Commission found people saying it, it helped make sense of my experiences, I think that's counteracting shame and internal stigma about this because the consequences of bipolar, how people act when they're manic in particular, spending money and changes in sexual behaviour, there's a lot of shame and stigma that can come with that internally, people being very hard on themself and that fuelling depression. So actually people having an understanding and knowing that, and if they're not alone with this and this is part of a condition, can be really helpful.

Rachel: I think at risk of finding very circular, diagnoses in general are helpful if they're helpful. So if they help people understand and also help them access appropriate help and treatment for the issues they're facing, which we will come on to, won't we? Is there anything that’s helpful for people to know about distinctions between subtypes of bipolar disorder or a spectrum of bipolar disorders?

Tom: Yeah, so there's the two main types are Bipolar I and Bipolar II disorder. Now this wasn't always made as a distinction and a lot of people who are listening to this with bipolar might not be aware if they are Bipolar I or Bipolar II, a letter from a doctor might just say Bipolar Affective Disorder. They might not be clear.

The main difference is mania versus hypomania. So Bipolar I, which is probably a little bit less common than Bipolar II. It's the more severe mania, full mania where these changes in energy and impulsivity really do get quite extreme and it causes all sorts of problems, people might end up in hospital. So Bipolar I is the more severe mania. Usually with depression, not always, there are some people who just get manic, but most of the time it's depression as well.

Bipolar II tends to be sort of more severe depression and then hypomania, which is less severe than full mania, won't cause as many problems, you're not likely to go into hospital with hypomania, but it still causes problems. I think that's important to say, I think hypomania can be dismissed as, oh, it doesn't cause any problems, but it does, and you don't meet the criteria for a hypomanic episode. So that's the main distinction, is mania versus hypomania. Sometimes people may get a diagnosis of cyclothymia, which is where people have these sort of milder hypomanic episodes and depression episodes that don't quite tick those boxes. So I'd consider them people who are high risk for bipolar disorder.

Rachel: Okay. That's really helpful. I wonder if there are any other, or any myths about bipolar and how it presents or is often understood that you'd like to bust that might be barriers to clinicians understanding or engaging well with people in this area.

Kim: I think a big one for me is the portrayal of the high periods as being times of extreme happiness or extreme positive feelings. Whilst they can be for many people, one of the kind of key symptoms of mania can be irritability rather than a kind of happy, high mood. And that can mean that it can be missed because it's the person isn't saying, wow, I feel really joyful and elated. It's more like this huge level of frustration often that things aren't happening quick enough, that people are getting in the way, the world isn't letting things evolve and goals to be met as quickly as the person might like. And also, even if people do start out feeling quite high and elated for some people, that it can become quite unpleasant. People talk about feeling I'm overactivated. I'm not even sure I really want to be, but there's nothing I can do to put the brakes on. Yeah, so that's one myth I would want to bust. Another one would be that some, and this is really important, that there can be a portrayal in the media that someone with bipolar is always up or down, when in fact lots of people with bipolar have very long periods of being feeling pretty stable, being well, and only occasional episodes.

Rachel: Yeah. I'm reminded of a recurrent dream. You know, we all have these recurrent anxiety dreams from time to time. One of mine is being in a car and not being able to put the brakes on. When you were talking about that feeling of just speeding up and not being able to stop, that's what that reminded me of and that horrible feeling of being out of control.

Kim: Yeah.

Tom: I agree with Kim. It's not all pleasant when people are manic people, it can feel very unpleasant, it can feel very distressing, out of control. I think a big one for me is, as I suggested a little bit earlier, a big misunderstanding is that this is daily ups and downs, which might be seen more with something more emotional sort of dysregulation. And when people are manic, they can have this dysregulation where the moods are quite up and down. But these episodes we're talking about are like weeks at a time. We're not talking about it changes one day to the next. We're talking about your hypomanic for a few weeks, and like Kim said, then you can be stable for a long time and then you might have an episode of depression that goes on for kind of a couple of months. So that's a really important distinction.

Rachel: Brilliant. Thank you so much for, enlightening us in those areas. What's the place then for psychological treatment with bipolar disorder? I guess we hear a lot about the biological vulnerabilities to bipolar disorder, or there's a sense that this is something that's genetic or biologically driven and I'm sure we'll talk more about that. Is it a presentation that really requires primarily or exclusively a pharmacological intervention, or does that differ depending on what stage you're at in terms or phase you're at in terms of the symptoms or you're experiencing.

Kim: So you're right, pharmacological treatment has historically been the main treatment offered to people with bipolar and in the NICE guidelines there are certainly plenty of recommendations about pharmacological treatment and there are differences depending on the phase of bipolar, but psychological therapies are also recommended and those include CBT. And they're recommended really for two main aspects; so one is for relapse prevention and the other is for acute bipolar depression, at least within the NICE guidelines. I think it's really important to say that unlike maybe with some other conditions, we don't have much in the way of trials of psychological therapy without medication compared to medication. Instead, it's usually psychological therapy in addition to medication or usual care compared to usual care. So the evidence base for psychological therapy as an alternative to medication is not well developed. However, what I would say is, I would hate to see a situation where somebody who can't take medication for bipolar, or chooses not to, is denied psychological therapy because there are just really good reasons to expect it will be potentially really helpful for people. So I would want to see that being an offer to people, who can't or don't want to take medication.

Tom: I think a lot of people might underestimate just how effective psychological therapies can be for bipolar. The biggest meta-analysis that's been done, it showed that CBT, group-based psychoeducation, which is often very sort of CBT informed and family interventions, family therapy, nearly halve the risk of relapse,

Rachel: Wow.

Tom: Which is really impressive. My take on the kind of literature so far is that if you add in medications like lithium, it halves your risk of relapse and then you add therapy on top, it halves the risk again. Which is pretty huge really. It really is. And I think that there, there's sometimes an issue about, maybe there's a little bit of, it's not as clear how much it reduces acute manic symptoms, but I think the evidence suggests maybe it does. And the same with acute depression symptoms. I mean, it is hard to do therapy with someone if they are really acutely manic and really acutely unwell. But actually, the evidence does say, well, it still might reduce kind of manic symptoms. So yeah, there's sometimes an issue about when you do it and what the motivation is cause it's really good for relapse prevention work. Sometimes I personally think that actually working with someone when they're quite stable is a good time to work with them. But there's, you've got to be careful of motivation because if someone's completely stable in mood, why would they want to engage in therapy? Trying to work with someone on a relapse prevention focus can be really useful time. And often people come to therapy after an acute manic episode, for example, and they're trying to pick up the pieces, they've been in hospital for a couple of weeks and they're trying to make sense of what happened and recover and move forward to their life, and that can be a really important time for therapy as well.

Rachel: So it sounds like there's really good evidence about this additive effect, about this relapse prevention, perhaps better times when you can do this, where maybe some of the good times to do it where people are less motivated, but perhaps could be really helpful. Do you think there's ever a time ahead where we might have a trial where it's psychological therapy versus medication? Or is that, would that be unethical given the…

Tom: I mean, we were talking about this Kim, weren't we? And we were talking about whether you could look back at the trials that had been done because maybe some people weren't on medication. I mean, I think it's been done with psychosis, hasn't it? I think Anthony Morrison did a trial for people who declined to take medication. I think, that would be an ethical way to do it, is you, the people who do decide that they don't want kind of medication, But I, yeah, I suspect it'd be quite hard to find people who weren't taking medication cause that usually is the treatment, the first treatment, and that's not what NICE guidelines say. NICE guidelines say that medication should be given an important weight as well. But yeah.

Rachel: Interesting, and perhaps maybe there is that group that you said, Kim, who people who don't want to take medication, that might be where some of this evidence comes from.

Kim: And certainly people do ask me that sometimes, is there, are there studies of psychological therapies for people who choose not to or can't tolerate medication? So I think that there is demand out there to know the answer to that question.

Rachel: And it's clear that psychological therapy, therefore, is very helpful, can be very helpful. How easy is it for people to get access to the evidence-based treatments that there are currently, and are there any particular barriers that people face?

Tom: So NICE guidelines are pretty clear that it should be offered in secondary and primary care but unfortunately the access isn't as good as it should be. So Bipolar UK Commission, again, we found, so 69% have been referred for therapy on the NHS and that might sound okay, but I suspect a hundred percent of them would've been offered medication on the NHS. Only one in five had been offered a group-based psychoeducation intervention, which are very evidence-based and very kind of cost-effective to run and very helpful for the individuals. What's more shocking is that 29% had never been offered therapy on the NHS, and about a quarter had been told they'd have to pay for it privately.

Rachel: Wow.

Tom: About a quarter had been specifically been told you can't get therapy on the NHS and up to half of people have had to pay for their own therapy at some point. So it, it definitely could be better. Now, I think with the positive side is that health education in England has put a lot of money into training for bipolar, and that's part of my role here is working on the CBT diploma. The Department of Health has been pushing training for CBT for personality presentation, CBT for psychosis, CBT, for bipolar. So, we are getting more and more people trained in this, which is great, so I do hope it will improve, but it is hard and myself and Kim have been looking at for NHS Talking Therapies, formally IAPT, we've just had a paper accepted about what the rules, what the guidelines are, what the kind of policies are about working with people with bipolar within these services because traditionally, officially you don't work with bipolar per se, but you can work with anxiety disorders, for example, or PTSD trauma work within these services. And one paper we did, we found that 33. 0% of people attending one IAPT service potentially had bipolar disorder that was undiagnosed. So there's a huge kind of iceberg of people who aren't diagnosed. So there isn't as good access as there should be. I mean, there is a lot of really great work going on there, there are more people being trained in CBT, which is great, but access to it is difficult. And I think it does vary. That's another thing unfortunately, that we showed with the Bipolar Commission is that there are, it's a bit of a postcode lottery. There are some services, there are a few specialist bipolar services, but then there are other services where you get you are in a mental health team with a lot of other people, and I think the reason people with bipolar can get missed and not get off with therapy is that because they can stay stable for a long period of time. That's one of the key findings we found in the Bipolar Commission is episodic care, which is, as well as just not being the clinically right thing to do. It's also a false economy where don't give people a lot of input and then they relapse and they're in hospital for two weeks and then it's, well, you're okay now, so we'll discharge you.

Rachel: And from various insights into Talking Therapy services, I imagine that those sort of time pressures can operate in different ways on the problems that you've raised. So even a good thorough diagnostic assessment and with a good history taking, sometimes it doesn't feel like there's time for that when you've only got so many sessions and asking these questions. But then there's also the rush to get people out the other end, isn't there?

Kim: And I think there's three pieces to think about in terms of this, the access question. One is, do we have the evidence-based protocols? Which for bipolar we do. Do we have the workforce? And as Tom said, there've been quite a lot of stride in that direction. But the third piece is the one we've been alluding to and just mentioned around NHS Talking Therapies is, do we have the place, the services in which these therapies would be delivered And at the moment, NHS Talking Therapies aren't really set up to deliver therapies for people with bipolar, and secondary care would be the place. But the barrier to getting or the threshold to entering secondary care where you can access these therapies is very high in a lot of areas. And so we're left with a gap and an absence of psychological therapies really often in that gap. And so I think that third piece for me is the piece that really needs attention. It's all very well to have the protocols and the workforce, but you need a place where the patients can come into contact with those two things easily.

Rachel: Do you have a sense of, and this is a big question to ask you, Kim, but do you or Tom, do you have a sense of where that place might be or what might work better?

Kim: I mean, I think there are different ways to address this. There are different models that could be used, but I suppose there's something about seeing psychological therapies as an important treatment that shouldn't be behind too many barriers. I think that's one of the things NHS Talking Therapies have done really well. They've put psychological therapies at the front and they're relatively easy for people to access, even if there can be a wait and we don't really have that situation for people with bipolar, although different parts of the country are trying different models of addressing this. For example, having teams that sit in between primary and secondary care or more reach down from secondary care or more reach up from primary care.

Tom: I think there's often a little bit of a change in mindset that is needed within services. Because, I mean, firstly, I think I'll just say that CBT for bipolar disorder is easily 10 to 15 years behind where CBT for psychosis is. And I think as a result, I've had people kind of saying, oh, I'm used to referring for CBT for psychosis, but I haven't really thought about it for bipolar disorder, which is slightly infuriating, but I do think it, people aren't aware of the psychological mechanisms, a lot of mental health professionals don't know about CBT, and so people aren't referred. And so it it's that combined with people are relatively stable for a long period of time, so maybe they're not ringing up and asking for lots of help so they can just get left to their own devices. So there is something about a change in mindset needed that, a lot of men's health professionals and service users really just think like, all I can do is take medication. And we really need to think about, well, there's more than that. Medication's really important, but there's a lot more to living well with bipolar than that. And yeah, these two kind of misconceptions that me and Kim have been talking about, which seem to be polar opposite, but people seem to buy into them. On the one hand, as I kind of said before, you are stable, you don't need therapy. But then also people can have this mindset that, well, someone's unwell now so they can't engage in therapy. You have it both ways where I've heard it. Yeah, you can't, you are too stable or you're too unwell, I've heard both. I have

Rachel: And when you say 10 to 15 years behind CBT for psychosis, Tom, is that in terms of evidence-based research or is that in terms of knowledge gaps and implementation?

Tom: Everything. I think, to be honest, I think, I mean certainly for the kind of the evidence base, like if you think about how many different models we have for psychosis and really big trials, we're just not, we're just not there with bipolar disorder. There's not as many trials, there's not as many people researching it as there are in psychological therapies for psychosis. In terms of actual kind of implementation in the real world, again, I think it's just CBT for psychosis is very well established, we have EIP services in the UK, early intervention in psychosis. So, it's just much more embedded into the culture of psychosis work that CBT is referred for. And I just don't see that being as embedded for bipolar-yet. We're working on it. This is part of it, right?

Rachel: Well, and it makes your work all the more important. So Tom, you said a little bit about your experience, your journey into bipolar. I wonder, if there is a typical, how does bipolar disorder develop for people and typically who suffers from bipolar disorder?

Tom: Yeah. So bipolar affects everyone. I mean, there are some research about differences in terms of different countries and that maybe more kind of western societies like here and the USA might have a slightly higher prevalence than some other countries, but it does affect everyone. Prevalence, gender differences, there's not that much way in the gender differences or ethnicity, but we know that, for example, and this makes my blood boil, analysis of South London, showed that black service users were less likely to be offered CBT. We know it seems to be a little bit more prevalent in younger people, and it does tend to peak in kind of late adolescents, early, early twenties.

How it develops, so in terms of risk factors, and again, there is a role of genetics, I think, and there's various research about how it might run in families to an extent. There's not like a bipolar gene, but there might be this risk and there might be something to do with the brain and the limbic system, how it processes emotions. But there's other risk factors as well, substance use is, there's one paper recently that found very heavy cannabis use in adolescence increases risk. But there's a lot of big role of trauma. We know that parental loss is quite common, parental loss in childhood, bullying and all sorts of childhood abuse. But emotional abuse in particular, emotional abuse is four times more likely in people with bipolar disorder.

So I think it's a combination of risk factors. They're never just one thing. There's often a combination of kind of, yeah, I always think of it like the nature and the nurture, stress, vulnerability, people might be vulnerable because of family history, a difficult childhood, et cetera. And then stresses, so life events are often a real trigger. There's evidence that stressful life events, negative life events can lead to depression. But also, a uniquely rubbish thing about being bipolar is positive, good life events can also make you manic, good things happening, getting a promotion, et cetera.

Rachel: That is highly disheartening, I would imagine, to realise that positive things can affect you negatively.

Tom: Yeah, it is. I mean, for me personally, there have been times where I'm going, oh, I wish I didn't keep getting good news about papers published and stuff because it fuels the mania. Yeah.

Rachel: You need to underachieve.

Tom: Wow. Well that relates to another thing about high standards and perfectionism, which is some of the stuff I've been researching about bipolar, because when you say you need to underachieve, there's part of me, core beliefs that goes, oh, I don't like that.

Rachel: Yeah. I know- and you won't be the only academic who feels that way. I am sure. I know that you've mentioned, previously Kim, other sort of biological systems that might be coming into play. I'm really interested in what Tom was saying about the limbic system. Is there more to say about those pieces interacting in the onset and development of Bipolar I.

Kim: Yeah, so I think a couple of these sort of biobehavioural models that have been looked at in the literature over the last few decades, have been particularly helpful for me to have in mind as a CBT therapist. So one of those is about circadian rhythm dysregulation, and this idea that in people who have a tendency towards bipolar episodes, the circadian system is somehow oversensitive or prone to dysregulation, which means that the system that's regulating the secretion of various hormones on a 24 hour cycle, might get thrown out. And when it gets thrown out, it can lead to an escalation into an episode. And the sort of things that might throw that out would be big changes to your routine, like taking a long-haul flight, for example. And there's quite a lot of circumstantial evidence that this circadian system is implicated in bipolar risk, at least for some people. And it chimes really well with research around sleep disruption as being a kind of a risk factor for relapse into a manic episode in particular. And also what lots of people say, I mean, when I talk to people about early warning signs of mania, sleep is there so often, sleep disruption and disturbance, not just as a sign but also as a kind of cause. So people will say, this happened, it disrupted my sleep and then that was it. So, the circadian system then that's, it's so useful to know about as a therapist, because you can think about then, what people can do to keep a stable, rhythm routine going. And that's a component of a number of the psychosocial therapies for bipolar work on routine stabilisation.

And then the other big biobehavioural theory that's around in the literature is around dysregulation of the system that organises our pursuit of rewards. So the approach system and the idea that this system might be, almost have a bit of a sticky switch in bipolar. So in all of us, when we see something or we know about something we need to work towards, strive towards in the environment, our approach motivation would go up and then it would return back to where it was once we've finished that piece of goal striving. Theres an idea with bipolar, that maybe firstly the system's more sensitive. So it might go up easier and higher and then it might get a bit stuck, people might find they've achieved the goal but they still feel that heightened approach motivation, which then forms a bit of a platform for further goal striving because people might feel they want to do something with that energy and that motivation. And that's really helpful to be aware of as a therapist. I never think this is definitely going to apply to everyone, but it's something, it gives you some pointers of what to look out for. And some people I've worked with have just found it really helpful to think about it. Oh, it's not necessarily everything positive that might trigger off some of these feelings, it's particularly when I'm striving towards something, and I feel that energy and that kick. And then they might think about, well, I still want to do that in my life. How can I do that in a way that isn't going to end up in a hypomanic place.

Rachel: It really makes me think about what you were saying, Tom, about this sort of interaction between these vulnerabilities and environment. And I'm thinking about you in a higher ed education institute where, it's institutionalised the sticky switch towards drive, isn't it? The more papers you publish, the more papers you need to publish, it must be hard for folk, as you describe, maybe with perfectionistic standards, maybe with kind of this reward striving and these underlying vulnerabilities, and then in an environment which really rewards that further.

Tom: Yeah. And I, I think some research I'm doing here, we're trying to, I'm trying to look at how high standards and perfectionism kind of interacts with these positive life events. because it makes sense to me that if you have very high standards and drive when something, as always described to my client when something bad happens, it's, oh, I'm going to criticise myself and go into a depression cycle when I don't meet my own high standards. But when you do meet them, you don't put your feet up and rest. You go, right, I'm on a roll. What's next? So yeah, that is, I mean, I love academia. I'm definitely in the right place with my fellow psychology nerds. But it is hard at times because a lot of bipolar folk, and I'm one of them, can really hang a lot of self-esteem to goals, very goal focused. And when people are manic, it becomes really goal focused behaviour and wanting to achieve. So people with bipolar have very high sort of dysfunctional attitudes, beliefs about achievement, needing to be outstanding, perfectionist, et cetera. So a really important part for me, therapy over the years has been to try and, well, for me, like a lot of it is focusing on values and what matters to me and why I do this rather than just these kind of goals because it is you can't win in academia, can you? Because there's always another paper to write. There's always someone who's got a bigger H index than you. And so part of me is trying to just a little healthy dose of who cares. But also, just the work-life balance is really important for everyone and certainly that's the case with me. And living well with this is just really being able to just go, I've done a good enough job, I've done enough for today, I'm going to go home. That's really important because that, that drive to wanting to do more is very powerful in bipolar. Yeah, trying to be a little bit more sensible and boring is a good thing.

Rachel: Well, well certainly in researching this podcast, I can see there's nothing boring or minimal about your research output and publications.

Tom: I mean, boring in a, I mean this in a, I use the term strategic boredom with my patients. I mean, hopefully my work isn't boring- I find it exciting. But I mean, sometimes there's that urge to, to work more, to do a big idea, to go out and socialise that drives mania. And actually, strategic boredom is, I need to go home and just binge watch some Netflix. It really is, can be as simple as that. So that work-life balance is really key, but it's very hard, a lot of the time for people with bipolar because there's this real pull to achieve, I need to do more. What's next?

Rachel: Okay. So to tap into your, both of your high achieving schema here, we've got challenge. You may or may not be aware of our Practice Matters podcast challenge, but as you'll know, we all love a good formulation of CBT and usually it has boxes and arrows, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about high bipolar disorder develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids? You can go individually, or you can help each other out, or you can fight it out up to you.

Kim: So I'd say, you could take a diathesis-stress model, where people may have a preexisting vulnerability, and that can be in the form of a tendency to the high and low mood states, potentially with a genetic component, family history that's more or less maybe important for different people as well as that alongside them might, there may be, as Tom's alluded to, particular beliefs that interact with that tendency or ramp it up, whether those are about achievement or are about mood itself and the implications of the mood itself and what you have to do with it to, to manage it or get the most out of it. And then when the early signs of a mood swing emerged, either because of a trigger or just out of the blue, how we meet that swing can affect how it develops. People might have thoughts like, this is my chance to show everyone what I can do when they experience some increase in activation and mood. And then that can lead to goals striving behaviours that can drive mood up further, potentially via sleep restriction or just more excitement or use of stimulating substances. And then on the other side, daily signs of depression might be interpreted as, oh, I'm getting low, I can't inflict myself on the world. I have to retreat, withdraw. And then as we know, in terms of the behavioural theory of depression, that can make the depression worse, and then either the high or the low episode as we've already talked about can create further problems for the person, further stress, which then can feed into future triggers, but also can reinforce some of the beliefs people might have. Like mood is dangerous and uncontrollable. Or if I don't try a hundred percent on everything, then hings are going to catastrophically fail. So there can be that sort of cycle in that respect.

Tom: Just to add to what Kim was saying there about how it can escalate from a trauma informed perspective, thinking about how trauma and these high standards interact. Let's imagine a diagram, longitudinal formulation, if your listeners can sketch it out in their heads. Early experiences, was a very high achiever at school, competitive athlete, and was very criticised when I didn't get top marks by my parents, I was someone who came from a background where there was a lot of pressure, they then developed beliefs that I need to be outstanding, I need to work really hard, I need to impress others. And then when they're starting to become manic, they're feeling very overwhelmed at work, they're feeling that they can't cope. They start to get these ideas and confidence, and then the way they make sense of it, the appraisals is, I can finally reach my potential. I can work really hard. I can get promoted. People will respect me. I can use this energy; I can use this confidence and mania. And then they go with it and they do all the things Kim was talking about that bring your kind of mood up, working more, sleeping less, taking drugs, et cetera, that maybe brings mood up more. So yeah, how people think about these when they're starting to become unwell really is important in whether it becomes a full-on relapse.

Rachel: So there's these background vulnerability factors, which include all the biological, and pieces that we've spoken about already. But there's also these beliefs which may have been formed and influenced by this early experience of having achievement rewarded and beliefs that have been developed around that about the need to strive and achieve. Mood changes or starts to change, there's interpretations of that which then lead to these behaviours depending on which, direction your mood might be changing in, maybe withdrawal, maybe striving further. And that leads into, again, of other stressors, other challenges and can strengthen some of these earlier beliefs we have about mood, which kind of see us cycling around the bipolar cycle.

Tom: And if people feel like they were very creative in a past manic episode, and we have to respect that actually, people think that they're very, you know, I'm really creative, et cetera and I get great ideas when I'm manic. There might be a bit of truth to that. There might be a bit of truth, certainly in early stage in hypomania, so we do need to listen to that. But the problem is, it can spiral out of control and what starts is maybe a sensible idea becomes very grandiose, very overly confident.

Rachel: I think you passed the challenge. I'm not sure whether you cheated slightly Tom in asking people to imagine arrows. I think I think we may have strayed from the rules, but I'll give it to you because it was such a clear explanation. So given this understanding of the maintenance of bipolar disorder, what are the key elements of standard CBT interventions for bipolar? And I know there are many, and we'll talk about sort of the family of interventions as we, we move on, but what are the key elements that we might see in CBT for bipolar disorder and how they link to this development and maintenance of the problem?

Kim: I suppose if you're thinking about relapse prevention work, then you're probably thinking about psychoeducation, about bipolar sort of looking at people's information needs in relation to bipolar, and around medication treatment. How the person, what their relationship is with medication, are they able to get the information, advice and support they need around that and with their prescriber? And then you're thinking about somebody's pattern of activities and their routine because you're thinking about this stabilisation idea with rhythms and routines and exploring that together. And if you are a kind of traditionally trained CBT therapist, then you've already got the skills for that in terms of activity monitoring and scheduling. So there'd be an element of that. You often would do a life chart with people to look at the patterns of relapse and what likely triggers might be, and also protective factors. And then there'd be a piece around looking at early warning signs of those episodes and how you might cope with those, what's worked, what hasn't worked, what you'd put in place and making a relapse prevention plan and thinking about how you would store it, revisit it, who you would share it with.

And then I guess another particularly cognitive piece in it might be around, not only the cognitions that come up when somebody's starting to get unwell and how you might work with those, but also there could be longstanding kind of cognitive patterns that increase vulnerability, as Tom's alluded to, if people have certain beliefs about, ongoing beliefs about, achievement, for example, or about what mood means and how dangerous it is. If those beliefs are there on an ongoing basis that might make people maybe more vulnerable to relapse. You'd look at factors in the person's life that could, that they could work on that would make them less likely to get unwell. That's in the kind of classic relapse prevention package, and I suppose for acute depression, you'd be very much doing in traditional CBT what's done for unipolar depression. So Beckian CBT for unipolar depression, but with some extra components, thinking about psychoeducation, about bipolar relationship to medication, bearing in mind this circadian rhythm potential idea. And then at the end of the, at the end of the course of therapy, thinking about doing some work around manic relapse as well as depressive relapse.

Tom: And for the manic side there really is some quite simple behavioural stuff that can be done. So your listeners will probably know, as Kim said, about behavioural activation for depression increasing activity, but really some fairly simple stuff around decreasing stimulation and activity if people are starting to become manic is really important. This is what I was saying about the term strategic boredom, we're actually trying to just watch a work life balance, reduce excessive socialising and all of that, and working on that sleep pattern. Some quite simple stuff can really have a really big impact.

Rachel: So it sounds on the surface of it, as you describe it, it's almost a bit like the kind of the standard protocols for depression. You might start working very much in the here and now, and then working backwards while solving those problems. Working backwards maybe to doing some more work on the longitudinal part of your formulation around these vulnerabilities and then thinking about relapse planning. But I guess from what you've already said that people present at very different times and stages, for therapy in this area. Is there a typical good course of therapy and if so, what does that look like?

Kim: So I'm a big fan of thinking about starting where the person's at. I think if you have somebody who's well and seeking advice and support around relapse prevention, if you start off with a depression protocol, it's probably not going to feel particularly relevant. So you're thinking, what does a person need and then sequencing the bits depending on what's most important. So if I'm working with someone who relapses very frequently, even if they're well when we start, we probably need to front load thinking about responding to a relapse, because it may well happen in the next couple of months. Whereas if you're working with someone who very rarely relapses, we can probably do that later on if the person wants to focus on that. So there's that sort of element of planning and moving things around to suit the individual.

Rachel: And Tom, I’m aware you were talking earlier about how sometimes the time to have therapy is when things are stable. That said, as a therapist I often find it's almost harder to work with people when they're well, because you don't have a kind of active symptom to get your teeth into for, that's a terrible expression I've just used, but I think you probably know what I mean, really seeing things in the here and now that you can be intervening with. Does that complicate delivering therapy?

Tom: Yeah, I think that can be the case sometimes. There's a certain amount of distress you need to have the motivation to engage in therapy because therapy's hard work. I think it doesn't come up too much because a lot of the time people will be stable, but they might be recovering from an episode, they're worried about a future episode. And some of the works Kim's done is even when people are stable in moods, they might have be a bit depressed or a bit emotionally up and down. So there's still stuff to work with. Anxiety, for example, a lot of people with bipolar have problems with kind of various anxiety problems as well. For me, a good course of therapy is about doing this relapse prevention work, the psychoeducation, what I'd say the more here and now, kind of surface level, like what you're getting right now, your thoughts and your emotions right now. And, for me, a good course of therapy goes a little bit deeper and that's what I'm really interested in and that's where it can be useful, even when people are stable in mood, if we're going at that core belief rules for living level, those high standards, those dysfunctional attitudes, beliefs about achievement and trauma often as well, like early trauma, I think that's a really good course of therapy if it goes a little bit deeper.

Rachel: So we've talked a bit about a standard CBT package if you like, and there's lots in there, which I think if people haven't been working with bipolar disorder, you can immediately see the transferable skills and knowledge that people have. But I know you've both been involved in developing and applying different approaches to treating bipolar disorder, including using dialectical behavioural therapy and behavioural activation approaches.

And Tom, you're the editor of a very recently published Handbook of Psychological Therapies for Bipolar Disorder, which seems like a really comprehensive and brilliant resource. Can you tell us a little bit more about the diversity of treatments, and when and why we might look to different psychological approaches.

Tom: Yeah, the book's out and it's a handbook, so it's trying to cover kind of everything and its 29 chapters I think. So it is pretty comprehensive.

Rachel: My favourite chapter, by the way, or the favourite chapter title I've seen is one that you've written, Gently Bursting Bubbles and Raining on Parades: a chapter on problematic positive beliefs.

Tom: Yeah. And according to my US colleagues, that's the most British chapter title they've ever had, apparently. But I really wanted to delve into that going deeper in the book. And it's called evidence-based and emerging because I've got chapters on the very strong evidence-base, like CBT and group psychoeducation but I wanted to give a platform to these kind of emerging therapies. Kim wrote a chapter about sort of behavioural, dialectical behavioural. We had a chapter about mindfulness, acceptance commitment therapy. But then there are also chapters on working with specific issues. So yeah, there's that book about positive beliefs about mania and challenging overly optimistic cognitions because that's a weird thing to do, because we're all used to challenging negative cognitions. But what about when someone's overly optimistic and you have to gently burst their bubble. It's a difficult thing to do as a therapist. So working with issues, so we did a working with anxiety, working with trauma and working in particular groups as well. So we had a chapter about how you might work with people who have a learning disability and bipolar disorder as well. So I wanted it to be comprehensive, for my sins. But it really to show that the relapse prevention work is key and it's really important, but there's a lot of work where you can go deeper and there's a lot of other work outside of relapse prevention work that is often needed if we're really going to give a comprehensive treatment to someone with bipolar.

Kim: I think that's a really important message that just because somebody has a bipolar diagnosis, not to assume that what they're going to want to work on is something directly about the bipolar symptomatology. Some people may want to work on other aspects of life and living alongside bipolar. Some people might want to work on an anxiety disorder or PTSD or relationship issues and when it comes to the balance of new versus existing treatments, I think there's still quite a bit of work to be done, as we said, to get access to existing evidence-based psychosocial treatments, and potentially some tweaks to those and improvements to make them more effective or to make sure they're delivered better. And then the investment in new treatments might be around where we feel there are gaps or there seem to be gaps that aren't being addressed by the new treatments. So I think we need to be thinking about both.

Rachel: What's your experience been like, Kim, of integrating some of those, for example, the DBT ideas or thinking about behavioural activation rather than a kind of full CBT type package?

Kim: So the work I've been doing has been for people with ongoing mood instability or residual symptoms in between episodes, and it came out of a feeling that, certainly as a clinician, using kind of standard CBT packages with people where their mood is up and down an awful lot, felt a little bit clunky, because it felt like there were chunks of work we had to do and if somebody came in a different mood state, it was maybe it was the way I was applying it, but it was like, oh no, we're going to have to put that on pause while we do this. And I guess I wanted something that was more like a set of principles that you could use whatever mood state somebody was in when they came to the session. And the work I'm doing at the moment is about integrating sort of behavioural activation with some emotion regulation concepts and techniques, primarily from dialectical behaviour therapy. So it's behavioural activation, but with more focus than usual on the person's relationship to affect and how they might think about their feelings or emotions or affect and how they might respond to it. Because finding, and there is evidence about this in literature, just in terms of people's relationship to their affect, people who've had like lots of extreme mood states can sometimes feel quite burned by that and quite scared of their increases in changes in mood and energy and maybe need to befriend it again and work out which of the feelings states I can trust in terms of my feelings and what I might need to take action with so that maybe people are not always catastrophising or avoiding changes in affect. And that, that has been really interesting work to do but what I found, as I've talked to clinicians about is people are doing this already. So I feel like what I'm doing is simply formal formalising what a lot of clinicians around the country and around the world are doing anyway in terms of integrating emotion regulation techniques into their cognitive or behavioural practice.

Rachel: And it sounds like importantly, really articulating those principles that you're coming back to. I know you work closely at Exeter with Barney Dunn, who's recently recorded a podcast with us thinking about ADEPT and working with positive affect and think targeting anhedonia. You know very much I'm hearing this theme come back through with all this depression work of coming back to principles and sessions because what can pop up in any session, even with unipolar depression can be so variable, can't it?

Kim: Yeah absolutely. I think when people have got major sources of instability in their lives, whether that's life events or relapsing, unpredictable physical health considerations or whether that's mood state being very back and forth. I sometimes, when I'm doing training with therapists, use the metaphor of a tent in the wind. You're trying to peg a tent out before it gets really windy, you don't want to spend ages on one peg. You want to get a couple of key pegs in so when the wind hits, you've got something to fall back on that's keeping things in place. So usually if I've got somebody whose mood is really up and down, usually what we'll try to do at the beginning is get a few key things in place so then we've got something to refer back to when they come back in and they're feeling differently than how they did before, or they're experiencing a real exacerbation of how they're feeling. And a practical example of that would be relapse prevention early warning sign work, when you do that in therapy it can take sessions and sessions. I think it can be really helpful to do a quick version of that right at the beginning so that when somebody comes in and their mood's suddenly going up, you can refer back to that and it took you 15 minutes in the session and you can go over it in much more detail later on in the therapy, but at least you've got that peg in there to help you keep things in place.

Rachel: That's such a helpful metaphor. And I think we're used to talking about therapists having tools in their tool belt. I love the idea of them having tent pegs that they can be working with their clients. So it sounds like there's a variety of approaches to treating bipolar disorder that, that, broadly fall under the CBT umbrella, like CBT/DBT/ACT, other related therapies but there are other therapies like family focused therapy, which we know are applied, and Tom you've talked about group approaches with different, maybe different modalities, but maybe some of those modalities, but applied in a different way. What do we know about the effectiveness and efficacy of these treatments?

Tom: I think I briefly mentioned earlier, so the biggest meta-analysis that's been done to date shows that CBT group, psychoeducation, family focused therapy reduce the risk of relapse by about half nearly. And also they do appear to reduce kind of acute symptoms as well. Individual studies have also shown benefits, like it reduces how long the episodes go on for, it reduces the risk of hospitalisation, but I think the evidence is really strongest for that relapse prevention focus certainly.

Rachel: And what does a good outcome for bipolar therapy look like?

Tom: Well, it's based on goals. I think definitely, it’s based on what the patient goals was. As Kim said, sometimes people might not be particularly bothered in, you know, they might not want to work too much on relapse prevention, there might be other focus about their relationships or their anxieties, for example. I think for me personally, a revised relapse prevention plan is always a good outcome because people will usually have one, but a more CBT kind of informed one is good. But then I think something that goes deeper than, like I said before, that relapse prevention, something if people are able to reevaluate some of their high standards and soften those up a little bit, that's a really good outcome for me I think as a therapist,

Rachel: So I guess all good CBT we're thinking about the individual's goals.

Tom: We are, we're thinking about the individuals’ goals, we're thinking about the here and now, but we're thinking back to a bit of a deeper core belief level as well. You want to see some of those rules for living and core beliefs sort of soften up at the end of therapy,

Rachel: Yeah, because this isn't a kind of one-off event that people are going to be experiencing. It's something that they need to be thinking about through their lifetime.

Tom: Yeah, there's the having a really good relapse prevention plan and knowing what to do if you're starting to become unwell. But the deeper stuff as well, that reduces your future vulnerability.

Rachel: And let's say you are sitting in front of a client with bipolar disorder for the first time. What can you reasonably say to that person about their outcomes? Because it’s one thing, thinking about the kind of these big trials, what do you say to someone presenting for treatment? Because the individual can benefit differently, can't they, depending on their own circumstances. What do we say to clients when they're presenting for therapy in terms of hope for outcomes?

Kim: So I would be honest that we can't predict for a given individual exactly how the therapy will affect them or work for them. Generally, these therapies are found to be helpful. It depends on what the target is obviously, but for example, in reducing risk of relapse, I might have drawn a diagram of the person's mood switches, and it might be that, it nips the tops off or the bottoms off the highs and lows rather than you end up with a completely flat line. And I'll be curious about what the person's own aims would be around that and what would be tolerable for them. Because I think there can sometimes be a perception that people without bipolar have very stable mood and that's normal to have very flat, stable mood and that isn't the case. So just being interested in where people think is realistic to end up and where they would like to end up. But always keeping that space open for the possibility that the episodes may recur, symptoms might recur- but does that mean that you can't live well and live a valued life alongside that.

Tom: Yeah, sometimes people will ask the question of can it be cured? And I think having just an open, honest conversation from a very recovery focused approach, is useful to say that it reduces the risk of relapse if you're depressed, it will hopefully help you get out that sooner. We're not saying it's going to stop it completely, just to sort of have these kind of smart goals and realistic expectations, but I think people take that on board if you say this can help,. It's like medication, it's not going to get rid of it, but it can help you live better with it.

Rachel: And I've heard what you said about one of the myths about bipolar being that the manic or hypomanic episodes not necessarily being experienced as entirely positive and they can actually be quite negative for people, but for some folk, is there a sense that there might be losses involved in this if I'm going to nip the top off my curve?

Tom: Yeah. It is hard. And again, that chapter you referenced, it's about there are positive beliefs about bipolar. I mean, not all, I say a minority of people, but there is evidence that some people with bipolar, they don't want to stop mania, in particular, or they don't want complete control over their moods. And that's often because they feel like they're more productive or they're more creative, for example. I remember once I was running a relapse prevention group that people had signed up for and 10 people who wants to stop getting depressed, all of them put up their hands. Who wants to stop getting manic? Like one person put up their hand? And this was a relapse prevention group. So this is part of the work. It is. And as we were talking about in that formulation diagram challenge, those beliefs that this is a positive thing and I can use this, that is often part of the process, and it spirals out of control. So sometimes having to work with these beliefs, which are often underlying by those kind of perfectionism and high standards is really important because there's no point doing relapse prevention work if the person isn't entirely convinced they need to stop getting manic.

Rachel: And talking about efficacy and effectiveness. Do we know much about different groups engaging with this treatment? Are there diversity issues around who benefits? Who doesn't?

Tom: I think we know in the UK certainly from one study that black service users were less likely to be offered CBT as I think I mentioned earlier, which, obviously it makes my blood boil. It isn't right. I don't think we really know about in terms of who kind of benefits the most really. I mean there was this one study that showed that the people who had positive beliefs about mania didn't benefit quite so much, as you'd probably expect. I don't think we know that. I think this is, this is one of the things that we're probably a little bit behind on is tailoring it a little bit more and seeing who benefits the most. I don't think we're there yet, to be honest.

Rachel: So an area for more work and more research. And in your, you've both got extensive experience of developing interventions, teaching, supervising, applying the therapy. Where do therapists get stuck? What are the questions that they ask most frequently or the tricky issues that people come up with?

Kim: So I think we've already mentioned about, that the issue of people may be having mixed feelings about letting go of high mood, and I think therapists do worry that it will come across like they're telling people not to be happy. So I think there's a couple of answers to this. I mean, firstly, not all positive mood is created equal, so I think it can be helpful to look at what different types of positive mood there are, and to work with people to discriminate between a kind of, okay, safe, high mood and one that is more indicative of the beginning of a relapse. And often people will say that the kind of more like contented happy feelings are not involved so much in a relapse, but the more energised, activated feelings are. But even within those, you wouldn't, I wouldn't want people to never, to be scared, to ever feel excited or energised. So what makes the difference? Because if we know what is particularly associated with those feelings heralding an episode, it means we can relax about the other times when we might feel excited and energised if it's unlikely they're going to lead to an episode.

I guess the other thing is, it's not actually really the mood that tends to cause the problem. It's usually what people do when they're manic. That's the thing that people tend to say, they feel a lot of guilt or shame about that tends to cause lots of stresses in life, like overspending and so on. So for me, the target to address around a manic episode isn't really the high mood, it's the behaviour. And what I tend to work with people on is increasing a sense of control over the behaviour so that if there's a high, they do experience a high, it's not as damaging as it might be. Sometimes that does mean downregulating, the high mood because it helps the person to think straight about the next best thing to do. If you're really in the grip of a feeling, it can be difficult to make a wise behavioural choice. So sometimes there is that downregulation, but not always necessarily. And I think that can be quite, in terms of training therapists, can be a helpful message. No, don't worry, your main job isn't to make people less happy. It's to help people feel more in control.

Rachel: That's really helpful because I imagine, as we've said earlier, that's quite, almost inhibiting for therapists thinking, my whole life I've been trying to make people feel better. I don’t want to take this away from them. So to focus, as you say, on the behaviour and the control rather than on taking someone's positive affect away from them.

Tom: I think when I'm training therapists, one thing that people struggle with is to formulate the mania. They can bind into this idea that a lot of mental health professionals and people with bipolar do; that mania comes out of nowhere and it's very biological and there's kind of nothing you can do about it. When actually it can escalate quickly, but it often builds up for sort of several weeks and there will be early warning signs. So I always say to people, formulating the mania is key, and once you've got that, the rest will follow. I've said before about this issue of working with people when they're stable, when there are people, when the people, when they are unwell, it can be done. It just needs to be done in a particular way.

Rachel: I know we spoke about high folk are often presenting for treatment, maybe not for the bipolar disorder, but sometimes for other comorbid issues that they're experiencing, so for example, presenting in services for treatment of an anxiety disorder or PTSD. And I think therapists can sometimes be nervous about treating those other presentations in that context if indeed they know about it. What do we know about the efficacy of standard evidence-based treatments for other presentations if they're the person's primary concern in the context of the bipolar disorder?

Tom: Yeah, well, unfortunately there's not a whole lot of evidence. That's why kind of my book was, that came within the emerging part rather than the evidence-base. So we know, for example, about half a people who have anxiety with bipolar, would meet the criteria for an anxiety disorder at some point in their life as well. And there's quite high levels of kind of drug and alcohol abuse as well. There is evidence that CBT can reduce anxiety within bipolar disorder, but not a whole lot of research, PTSD as well. There's disproportionately high levels of traumatic events and PTSD and bipolar. And there’s a little bit of evidence, there's a couple of small RCTs about trauma focused CBT and about EMDR and how that can be used with bipolar. But, really not a whole lot to go off at the moment. But we know that in NHS Talking Therapies, that's usually what's worked with is the kind of anxiety or the PTSD, rather than the kind of bipolar per se.

Rachel: So it sounds there's, as you say, it's emerging evidence, we don't know, but equally, it doesn't sound like there's a good rationale to withhold that treatment for folk. Importantly, we don't know that it doesn't work either.

Tom: Yeah, there's, what is it? The absence of evidence or evidence of absence? I can't remember what the term is, but yeah, the stuff with trauma work and anxiety, for example, is pretty promising. Some people did prolonged exposure with bipolar and they found that it was fairly effective, nobody became unwell. There weren't any people who became manic as a result, for example. No, it's not a reason not to withhold it at all. It just needs to be done with kind of a few slight tweaks really, and just being cautious and for trauma work the stabilisation- I know there's disagreement about how much is needed, but for bipolar, even if it's just doing a simple relapse prevention work before you do trauma work can be really important as a bit of a safety net for you and your patient.

Rachel: So we always like to take a moment in the podcast to think about self-care and self-reflection as working in mental health is so rewarding. I know we all love it, but it can also be very challenging on both a personal and professional level. If you really care about the people you're treating as hopefully most of us do, and bring not just your mind, but also your empathy, your whole self to the work- perhaps even more if you have lived experience of the challenges your clients are facing, as you've spoken about, Tom. How do you think therapists or as therapists, we might be challenged by working with bipolar disorder? What things might we have to examine, put under the microscope around our own assumptions, behaviours, how do we look after ourselves?

Kim: I think one thing for me that I notice is, is that sense of, we usually work with people who don't like their condition. They don't like being really anxious. They don't like being really depressed and they want to change it. And this isn't, as we said, always the case for high moods. I think it's really important as a therapist to make sure that your agenda isn't at odds with that of your patients, not going in thinking, right, what they need to do is they need to work really hard on never becoming even slightly high ever again, when actually that's not the person's agenda at all. I mean, obviously sometimes we have to do, I have different, agendas for safety, but generally speaking, we want those to line up.

Rachel: So it sounds in this work, it can really help actually think about when we're taking a stance towards therapy, that is what I'm doing to someone else rather than working with them and that kind of professional mindset is I know best for you, which I guess we don't want to have in place for any of the work we do, but it sounds like it really throws that into focus.

Kim: Yes, exactly. It would be the case with anybody but, I think it's particularly at the forefront when you have somebody who may think, actually, I enjoy being high and it's not something I want to change.

Tom: I think when someone is fully manic, like you'd see in Bipolar I, it can escalate quite quickly and it's very chaotic and scary and feels very out of control for the service user. And it's also the case for the therapist. It can be a scary time when people relapse like that. And it can be really emotional and sometimes clients can feel very anxious about the future. You will be as a therapist as well. So I think a lot of that when people are manic, it is difficult. And I think, just trying to remind yourself as your therapist, your own high standards, having smart goals, it's not a sign of therapy gone wrong or a failure from you or the patient's part if they do unwrap- that is the nature of the condition. And what we're hoping to do is that this is going to happen less often and you're going to be able to pick up the pieces quicker.

Rachel: I suppose it's important. We can really believe that and model that in our own work.

Kim: I agree so much with that, Tom. I think I've seen therapists feel like, oh, somebody's having a relapse or their mood's dipped, or it's gone up- I failed as a therapist. When actually this is, you are walking alongside them as they experience this. And it's an opportunity for you to learn more, for them to have an experience of the therapy during one of those phases and maybe learn how to relate to that episode and respond to it differently. It's a potentially a really helpful opportunity, even though you and the patient wouldn't have wanted that relapse to happen. So you know for therapists really not to catastrophise.

Rachel: So in fact, it's not the work gone wrong. It is the work.

Kim: It is the work, yeah.

Tom: Yeah.

Rachel: So one of the really great privileges of being a therapist is we get this window into the lives of others and, we get to benefit also from seeing their resilience and creativity and face of life's challenges. I wonder what you've learned from the people you've worked with and how this work may have made a difference, a personal difference even in your life, or the focus of your work.

Tom: I mean, I'm always in awe of the bipolar community and their wisdom. I think the bipolar community is a, it is that it is a community, and you get lots of people supporting each other, which is a lovely thing. And when I ran groups in the NHS, I think, what was great is that we had the content, but we also learned from each other. And I learned from my service users and all sorts of wisdom, the kind of early warning signs you just wouldn't really be aware of. And the coping strategies, the people that have already be developed, people are amazingly resilient. And I think that term strategic boredom came from someone who sort of said, I need to be boring in order to stay well, which has stuck with me. I think another thing I've just learned is just not to underestimate how powerful, quite a simple intervention as a CBT therapist can be, work with people who have never had therapy despite living with bipolar for years or decades, and just a few sessions doing a relapse prevention work plan can be so helpful for them. So not to underestimate the power of something simple like that.

Rachel: It may be a very simplistic parallel to draw and hopefully you'll correct me if so, but I'm struck when you're talking about that community and also earlier about, the perhaps the sense of ambivalence people might have around some of the work in terms of their goals. It reminded me a little bit of sort of the Alcoholics Anonymous movement, the idea that you're supported by people around you who will spot signs for relapse, who maybe have developed other strategies themselves to work with that. and benefit from that kind of wisdom when it's easy to see how the problem doesn't always feel like a problem.

Tom: Yeah, I think peer support is really important and that's something that Bipolar UK is trying to roll out more is more peer support.

Kim: Yeah, I think as therapists, we are, we're meant to be doing therapeutic interventions, but we don't have the monopoly on therapeutic interventions. So I really agree with Tom about the huge benefits that people can get from groups, communities around bipolar, but also I've done some work on lifestyle factors and bipolar and psychosis and hearing about the effects of nature exposure on people's wellbeing. There were so many therapeutic mechanisms in what people talked about with regard to time spent in nature. And it just helped remind me that formal psychological therapies are one small part of somebody's therapeutic journey and most of the therapeutic contacts actually really happen outside of the therapy room and we can help facilitate that and be open to that as therapists.

Rachel: And as we've hinted at throughout this podcast, you're both really engaged in research and on the cutting edge of what's happening with bipolar disorder. What do you think are the really important questions that need answering or the next big challenges in the field?

Kim: For me, it's that the main thing really in the UK is access  to evidence-based psychological therapies. I mean, that's around the world. In the UK we've got the benefit of a centralised, pretty centralised system. We've got quite a relatively high number of therapists trained in at least some of the approaches we need- but there are barriers around cost and resourcing that, so we might need to look at how we deliver the therapies to manage those issues, but also as I've said about the way that services are organised so that people don't find themselves in a different place in the system to where the therapy is available. I think that sort of systems-based research and development is really needed.

Tom: Like I said, I think we're quite behind where CBT psychosis is. So I'd like to see us play catch up a little bit. I'm interested in the, this going deeper. There is a bit of evidence that dysfunctional attitudes can improve, following CBT and bipolar, but I think we need more research on that. Same with kind of trauma work and these high standards as goal focused behaviour. And yeah, there really hasn't been much about these positive beliefs and how that can impact treatment so I think we need to dig into that and try and work on some of these positive beliefs about mania as well.

One thing that's really exciting is, I think the reason CBT for psychosis is there's better access and there's more research is because we have these early intervention in psychosis. It's not a guideline; it's a target to offer CBT and that's one thing the Bipolar UK report has called for is more of these targets and more bipolar specific care. One really important thing is, could we use this as early intervention? And there's a big trial up in Manchester led by Sophie Parker that myself and Kim are on the steering group for, which is essentially trying to do what those big trials for early intervention in psychosis did decades ago, years ago, for bipolar disorder. Can it actually prevent, can it actually improve outcomes for people who are at risk of bipolar disorder? And, that would be, yeah, that really would be a game changer if this shows some positive outcomes. So that's a definitely one to watch.

Rachel: And we see again and again, don't we in mental health that you can have the best treatments in the world. And it sounds like there's still plenty to be developed around that, but actually if they're not implemented, and if there isn't the policy and the infrastructure around that to make sure that people access it, it’s not doing its job. And I know that whole, environment is maybe getting more complicated to access to, to influence. Maybe not with, we're recording this just a couple of weeks after the announcement about NHS England being folded up. So it'd be really interesting to, to see in this space what happens around those policy decisions and that implementation. But really great to know that there's folk like yourselves with such a deep and wide-ranging knowledge that hopefully will be influencing the next stages in that.

If people want to learn more about your work, where can they access training or how can they get involved?

Tom: So I am chairing special interest group for bipolar disorder. So if you log onto your system, if you want to sign up to that, you'd be very welcome. It's been recently restarted, having been dormant for a few years. My book's called The Handbook of Psychological Therapies for Bipolar Disorder and, Yeah, I'm on kind of social medias @drtomrichardson. I'll often share about my work there.

Kim: And Tom and I are on the Psychological Interventions Task Force for the International Society for Bipolar Disorders. And we have in the task force, we have a working group at the moment who are putting together a web resource on evidence-based therapies for bipolar, trying to make it a one stop shop for clinicians internationally in terms of what should we be delivering, how should we deliver it, and links to useful resources. And we're hoping to launch that later this year.

Rachel: That's fantastic. That's so useful for therapists to have a place that they can go to, that they can trust also. So that, that sounds brilliant. And the book Tom looks like an incredible achievement. I'm sure. people want to get their hands on that after listening to this, if their appetite has been wetted or I'm working in this area, or indeed, if they're already deeply burrowed in there.

So in CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key messages or message would you like folk to leave with from this podcast regarding the work?

Kim: So I suppose mine would be if you're a fully trained CBT therapist, you've got 95% of what you need to work with people with bipolar. And the additional 5% is important, but it's not complicated.

Tom: I think A: it is possible to formulate mania and B: CBT techniques can reduce the risk of relapse, both for depression and mania.

Rachel: So there's hope. Nice to leave on a message of hope. Fantastic. Thank you both so much. It's been brilliant talking to you. I think we could have done a series of podcasts on this. So thank you so much for your time and all your wisdom and all that you've shared with folk at home.

Tom: You're welcome. Thanks for having us.

Kim: Thank you.

Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected]

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