Introduction

The basic aims of therapy in bipolar disorder (BP) are to alleviate acute symptoms, restore psychosocial functioning, and prevent relapse and recurrence. The mainstay of treatment has been and currently remains pharmacotherapy. However, the use of anti-manic drugs can be accompanied by significant side effects (particularly if used in conjunction with mood stabilizers) and the treatment of acute depressive episodes with antidepressant medications carries a small but significant risk of 'switching' from depression into hypomania. Prophylactic treatment also has problems and there is a significant 'efficacy-effectiveness' gap in the reported response rates to all mood stabilizers (Guscott & Taylor, 1994; Scott, 2001; Scott & Pope, 2001). Even under optimal clinical conditions, prophylaxis protects fewer than 50 % of individuals with BP against further episodes (Dickson & Kendell, 1994). Given this scenario, the development of specific psychological therapies for BP appears a necessary and welcome advance. However, until recently, progress in this area was slow.

Historically, individuals with BP were not offered psychological therapies for three main reasons (Scott, 1995). First, aetiological models highlighting genetic and biological factors in BP dominated the research agenda and medication was not just the primary treatment but the only treatment considered appropriate. Second, there was a misconception that virtually all clients with BP made a full inter-episode recovery and returned to their pre-morbid level of functioning. Third, psychotherapists historically expressed greater ambivalence about the suitability for psychotherapy of individuals with BP than those with other severe mental disorders. Fromm-Reichman (1949) suggested that in comparison to individuals with schizophrenia, clients with BP were poor candidates for psychotherapy because they lacked introspection, were too dependent and were likely to discover and then play on the therapist's 'Achilles' heel'. Although clients with BP and their significant others argued strongly in favour of the use of psychological treatments (Goodwin & Jamison, 1990), these voices went unheard. Furthermore, the relative lack of empirical support (few randomized controlled trials have ever been published) meant that clinicians who believed adjunctive

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

therapy might be beneficial had few clear indicators of when or how to incorporate such approaches into day-to-day practice.

Over the last 20 years, two key aspects have changed. First, there is increasing acceptance of stress-vulnerability models that highlight the interplay between psychological, social and biological factors in the maintenance or frequency of recurrence of episodes of severe mental disorders (Goodwin & Jamison, 1990). Second, evidence has accumulated from randomized controlled treatment trials regarding the benefits of psychological therapies as an adjunct to medication in other severe mental disorders, particularly treatment-resistant schizophrenia and severe and chronic depressive disorders (Falloon et al., 1985; Paykel et al., 1999; Sensky et al., 2000; Thase, Greenhouse & Frank, 1997). Although research on the use of similar interventions in BP is still limited, there are encouraging reports from research groups exploring the role of 'manualized' therapies in this population (American Psychiatric Association, 1994).

This chapter briefly outlines the rationale for using psychological therapies in combination with medication in the treatment of adult clients with BP. Outcome data from randomized controlled trials is reviewed and the characteristics of therapies that are likely to be effective in BP are highlighted.

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