Behavioural experiments for bipolar disorder
One of the most important improvements in mental health that I’ve observed across the past 25 years is greater awareness amongst clinicians other than psychiatrists that a client presenting in a depressive episode may be suffering from Bipolar Disorder. There are several psychological approaches that could be offered to accompany pharmacotherapy but many clinicians have been trained in an era before these were taught in mainstream training programs. This week’s article by Jasper Palmier-Claus and colleagues (2020) is a great primer to get clinicians thinking about how they might apply a common cognitive behaviour therapy strategy – behavioural experiments - to this lower prevalence problem.
In order to use behavioural experiments effectively, the case formulation needs to be refined very specifically, which is helpful regardless of whether the clinician identifies primarily as a cognitive behaviour therapist. I’ve summarised Palmier-Claus et al’s (2020) article in the table below, highlighting both key assumptions that contribute to the distress and disability of bipolar disorder, and examples of experiments that might be used to test these beliefs.
Clinical Implications
The authors offered the following technical points when carrying out behavioural experiments:
Behavioural experiments should always test the key cognitions in the formulation, in contexts that are directly related to the client’s problem list and goals.
Experiments should be introduced collaboratively as a form of curious hypothesis testing.
Before undertaking the experiment, client and therapist should agree which belief is being tested, what the task would involve, what they predict will happen, and how different events would either confirm or disconfirm the predictions
Grade experiments that seem overwhelming; i.e., break tasks into smaller, more manageable steps
Take the risk of adverse outcomes seriously. Ensure clients have ways to manage or mitigate risks before undertaking the experiment.
Relaxation, breathing, or imagery exercises can help relieve client agitation before or during experiments
Use others to assist in experiments: therapist; family members; other members of mental health teams to increase clients’ awareness of multiple sources of support. Supportive others can help reinforce the ‘take home’ message of the exercise
During experiments with people with Bipolar disorder, balance praising bravery with offering reassurance when needed; these clients are likely to experience strong emotions during the exercise.
The therapist should check what the client is thinking or feeling throughout and revise the aims of the exercise in vivo as needed.
After the experiment, changes in the client’s mood might alter what they learn from the experiment, so debriefing is important to ensure the client remembers a helpful take-home message from the exercise.
Therapists should not be afraid of aspects of the exercise that don’t go as well as planned, but use this learning to inform the planning of future exercises. E.g., if a client experiences racing thoughts during an exercise that interferes with their ability to learn from the experiment, a future experiment might include more time to reduce arousal to improve mental clarity.
For the original article, go to:
https://onlinelibrary-wiley-com.access.library.unisa.edu.au/doi/full/10.1002/cpp.2415
REFERENCES
Palmier-Claus, J., Wright, K., Mansell, W., Bowe, S., Lobban, F., Tyler, E., Lodge, C., & Jones, S. (2020). A guide to behavioural experiments in bipolar disorder. Clinical Psychology and Psychotherapy, 27: 159-167.