Category Archives: Bipolar Disorder

Diluted DBT Still Effective for Bipolar Disorder

University of Washington psychologist Marsha Linehan has a strict definition of her ground-breaking Dialectical Behavioral Therapy (DBT). If a client doesn’t …

  • attend a DBT skills group and …
  • receive individual therapy from a DBT-trained therapist …
  • who attends a weekly DBT consultation group and …
  • offers phone coaching,

… they aren’t really in DBT. The full program is what she researched; she won’t vouch for anything less.  A new study by Van Dijk, Jeffrey and Katz of the Southlake Regional Health Centre in Ontario, Canada suggests even a cherry-picked form of ‘adherent’ DBT may still help those with Bipolar Disorder.

T-shirts like this are why I love the internet

T-shirts like this are why I love the internet

The researchers enrolled twenty-six adults with Bipolar I or II Disorder in a psychoeducational group. The clients learned about their diagnosis, but were also trained in mindfulness practice and DBT’s emotional-regulation, interpersonal-effectiveness and distress-tolerance skills. After twelve weeks of ninety-minute group sessions, the clients scored higher on Beck Depression Inventory, reported greater awareness of their emotional states and less fear of the same. Six months later, they also had fewer emergency-room visits and hospitalizations. These findings echo other studies that found DBT skills group training – by itself – can be effective for depressive symptoms.

It’s tempting and dangerous to conclude DBT can be treated like a toolbox, instead of a unified whole.  Tempting, because DBT is a comprehensive therapy for challenging clients. That makes it dauntingly complex. Becoming fully versed is like learning another language. With all of its’ useful techniques, attitudes and approaches, it’s almost too simple to cherry-pick a few and call it DBT.

It’s dangerous because Linehan’s therapy depends so much on movement, speed and flow – rapidly shifting around all of those techniques, attitudes and approaches to meet a client’s needs.  Practitioners’ mailing lists often feature tales of clients firmly uninterested in DBT because of their previous experience – with non-adherent therapists whose treatment had some of the features, but none of the integrity of Linehan’s.

Carl Rogers’ use of reflective listening and Alfred Adler’s focus on the here-and-now were subsumed into the basic practice of therapy. Linehan’s DBT skills could be mindlessly assimilated the same way. Let’s have more research on how much and how little can be dropped before you no longer have an effective therapy.

Citation:

Sheri Van Dijk, Janet Jeffrey, Mark R. Katz. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders 5 March 2013 (volume 145 issue 3 Pages 386-393 DOI: 10.1016/j.jad.2012.05.054)

@ 2013 Jonathan Miller All Rights Reserved

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Filed under Bipolar Disorder, depression, Dialectical Behavioral Therapy

Icarus Project Seeks New Flight Plan for the Mentally Ill

In a 1963 clipping from the New York Daily Mirror, passers-by were asked, “If a Woman Needs It, Should She Be Spanked?” Strangely, none of the four interviewed were women.

It’s this kind of selection bias the Icarus Project stands against.  The Project is a San Francisco-based collective promoting the voices of the mentally-ill..  They organize peer support,  create on-line art galleries, and rally clients to speak out on their own behalf. One thing they don’t do? They don’t accept the idea that mental illnesses are solely impairments.

The Icarus Project’s logo: falling or flying?

Normally, mental health staff face-palm over calls to, “challenge standard definitions of psychic difference as essentially diseased, disordered, broken, faulty, and existing within the bounds of DSM-IV diagnosis.” Too often, treating mental health issues as a “dangerous gift” means a client goes off their meds, lands in the hospital, and disrupts their progress towards recovery. The  Icarians’ language is counter-cultural, but there’s nothing mindless in their anti-authoritarianism.  They aren’t against meds, diagnosis or treatment – only the belief we mental health professionals know the whole story. This balance is reflected in their name; Icarus, you’ll remember, perished when he flew too close to the sun.

Sophie Crumb’s self-care flyer for The Icarus Project

Talk of “societal oppression” and “urban shamanism” may induce woozy flashbacks of 1970s identity-politics and the backlash that followed.  Should we worry their printable pamphlets on self-mutilation  don’t urge clients to stop? A close reading shows the pamphlet promotes harm reduction, including many safer substitutes Marsha Linehan would endorse. When project members critique profit-seeking drug companies’ influence on mental health treatment, they have company in the highest and most respected levels of  psychology.

The project celebrates an impressive tenth anniversary this year. Whereas decentralized collectives usually veer from dialectical moderation to the ditches of extremism, Icarus continues to walk a narrow path: meds and therapy are okay, self-care and community are crucial, and mental illness, while no blessing, is not necessarily a curse. This quote from Scatter sums up the project best:

Our society still seems to be in the early stages of the dialogue where you’re either “for” or “against” the mental health system. Like either you swallow the antidepressant ads on television as modern-day gospel and start giving your dog Prozac, or you’re convinced we’re living in Brave New World and all the psych drugs are just part of a big conspiracy to keep us from being self-reliant and realizing our true potential. I think it’s really about time we start carving some more of the middle ground with stories from outside the mainstream and creating a new language for ourselves that reflects all the complexity and brilliance that we hold inside.

In the 1960s and 1970s, the Whole Earth Catalog provided tools for those ready to challenge social and economic norms. Today, Icarus does the same for those who question psychiatric norms. It also challenges mental health professionals to make “empowering clients” and “person-centered diagnosis” more than platitudes. “Mentally disturbed,”  is synonymous with “unreliable witness”, and yet  no one else can tell us what the experience is like.   If Freud hadn’t analyzed himself, would there be a field of psychology today?

@ 2012 Jonathan Miller All Rights Reserved

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Filed under Bipolar Disorder, Borderline Personality Disorder, The Client's Side

“Normal people don’t do everything perfectly.”

From: Madness: A Bipolar Life by Marya Hornbacher:

“See, the thing is, you’ve got this idea of normal that’s not normal. Normal people don’t do everything perfectly. You don’t have to do everything perfectly to be normal. To be normal, you’ve got to kind of relax and let some things go. Your problem is that you’re so used to being in crisis that your whole perception of yourself is as a fuckup, a permanent fuckup, never someone who gets to not be a fuckup, so you have to torture yourself and hate yourself just to be as good as everyone else. You’re having a hard time realizing that you’re not a fuckup anymore. You’re entering into a whole different period of your life where you are normal. And you’re having a hard time getting used to it.”

                I gaze out the window. “But if you’re not trying to be perfect, then how do you know if you’re doing things right?”

                “There is no right,” she says. “There’s the best you can do. And that’s fine. That’s normal.”

                “The best I can do is sometimes completely fail,” I say.

                She shrugs. “Fine,” she says. “The rest of us do it all the time.”

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Filed under Bipolar Disorder, The Client's Side

Is Bipolar Disorder a Thing?

"So, am I depressed, or Bipolar, or what?

When you have to diagnose a client with lots of depressive symptoms and a few, brief manic symptoms, you can be faced with a zebra riddle: is this a mild case of bipolar disorder? Or just a depressed person who gets very, very energetic when their mood improves ?

James Phelps, MD posts to the Psychiatric Times to suggest the problem may lay in the categories themselves. In a review of studies done with different definitions of hypomania (symptoms lasting at least four days… or three… or possibly two…) Phelps found hypomanic symptoms occur at lower and lower frequencies until they vanish altogether. He suggests Bipolar Disorder isn’t a ‘thing’, like a broken arm. Rather, he proposes it is a range along a spectrum of symptom intensity, the way doctors diagnose hypertension when their patient’s blood pressure gets up around 140/90.

What to do?  Dump the existing diagnoses? Start over by rating symptoms and personality traits on empirically-based scales?  It’s true that a switch to research-based constructs would bring us all closer to the reality we can know and measure. The downside is that it would produce chaos during the conversion. To know one’s diagnosis is a fundamental client right – how long would it take to explain diagnoses like, “5-2-6-2-1-7-8”? How would we file and reference the research on extinct disorders? Where will Borderline Personality Disorder support groups meet  if we declare there’s no such thing? To overturn established systems, one has to counter massive inertia. American therapists of a certain age will remember how the U.S. didn’t convert to the metric system in the 1970s – and it had a 200-year track record.

Phelps suggests we contain the collateral damage by taking a cue from physicists. They’ve understood for years that light sometimes acts like a particle and sometimes like a wave. They’ve conducted useful research (and kept their heads from exploding) by using the most appropriate model for the problem they face.  This “complementarity” principle means we can be more empirical without bewildering clients. For research, we’d use the ‘wave’ model, where it’s understood that ‘major depression’ and ‘bipolar’ mark points on a curve measuring the length and intensity of manic symptoms. When talking to clients, we’d use the ‘particle’ model, where we’d speak as though those conditions were as different as asthma and a hangnail. Would we lose specificity? Not enough to leave our clients uninformed. After all, even if Bipolar Disorder isn’t a ‘thing’, it shouldn’t take a psychology degree to get treatment.

@ 2012 Jonathan Miller All Rights Reserved

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Filed under Bipolar Disorder, Diagnosis