Frank and colleagues (1994,1997) have revised (almost completely) interpersonal psychotherapy for people with bipolar disorder. This version retains the main components of interpersonal psychotherapy: the focus is on the four interpersonal problem areas known to be associated with depressive episodes. A new component has been added: the regulation of social activities to manage symptoms. As social demands, social responsibilities and interpersonal relationships can disrupt social activities and lead to an unstable physiological situation, triggering bipolar symptoms in individuals who are more emotionally vulnerable. Behavioural techniques such as self-monitoring, action goal setting and the use of cognitive restructuring are used to regulate patients' lifestyles and establish stable social activities. A randomised versus controlled trial is underway to measure the effectiveness of this approach for patients who present stable under medication.
This treatment for patients with bipolar disorder integrates interpersonal psychotherapy and social activity behavioural therapy (SRT) to form Interpersonal and Social Activity Therapy (IPSRT).
The SRT component introduces the Social Activity Rhythm (SRM), a self-rating scale that measures 17 daily activities, such as waking up, breakfast, starting the day; whether they are alone or in company; and whether they are excited. This scale helps patients to recognise the relationship between the type of life they lead during the week and changes in mood. A high score on the scale indicates a high degree of regularity in daily activities; a low score means very irregular. Patients are encouraged to monitor their lives and avoid irregularity. The researchers hypothesised that regularity of life would lead to a more regular physiological rhythm, thus reducing the likelihood of relapse.
Frank et al. (1994) described the implementation of a four-stage IPSRT. Initially it was once a week, whether the patient was newly recovered from an acute illness or in a neutral state. The patient learns the interpersonal psychotherapy approach, followed by treatment once every 2 weeks and then once a month. SRM may be used during this phase.
The history contains symptoms, interpersonal relationships and episodes associated with the diagnosis, especially recent episodes. Following the time cue hypothesis that there is a social closure between the patient's life and the episode, the therapist asks the history to try to identify key times in the patient's regular life before the episode (the patient's pattern of episodes). Family members and close friends can assist during the interview phase, especially if the patient is less able to remember previous periods of agitation. For example, lack of sleep for more than a few days is also a sign of an early onset - in addition to external factors, such as preparing for an exam or taking a child to the emergency room.
This treatment develops a timeline of onset, significant life events, lifestyle changes, and other moments of mood vulnerability that patients may find. Interpersonal scales are administered as usual. Psychoeducation for bipolar disorder is imported into general interpersonal psychotherapy, with just a special emphasis on lifestyle changes that may influence onset. From this goal go the assessment of whether events, patterns or external stimuli in the patient's life may affect sleep duration. Patients are educated about the crisis that an irregular rhythm of life may cause an onset of illness. This will help to heal the condition and help the patient to make the necessary changes to identify situations such as meetings, films or situations where the patient may be overstimulated.
The second stage is to address interpersonal issues and develop a coping plan: looking for typical triggers for social interaction to stop, identifying and maintaining a balance of activities and stimuli, and making these changes a habit. Current information and SRM data are used to identify social stagnation issues. At each stage, the patient and therapist review the SRM to identify erratic social activity. The therapist tries to identify whether the instability is due to the symptoms of bipolar disorder or to changes in oneself. The goal is for the patient to establish more stable social activities: for example, going to bed at a certain time rather than staying up all night for a project, eating meals on time, etc. Maintaining the timing and quality of sleep is paramount; lack of sleep can lead to mania. The therapist can also help the patient to deal with symptoms caused by feelings and to identify and maintain sound social activities to avoid triggering a pause in life and daily activities.
The social activity aspect is dealt with in conjunction with interpersonal issues in the early stages of treatment.
Grief: In addition to unresolved grief, interpersonal psychotherapy also explores symbolic loss - the grief of losing a healthy self. fnmk et al. (1994) describe this as a self with good control over mood and behaviour. Grief may arise from the anticipation of a change in lifestyle following illness. The reader will note that interpersonal psychotherapy generally defines grief as complex grief, the grief of losing a close friend or relative. In interpersonal psychotherapy, symbolic loss is seen as a role transition problem for people with bipolar disorder.
Interpersonal conflict: Interpersonal arguments are a common problem for people with bipolar disorder and may be made worse by the effects of the bipolar disorder. People with bipolar disorder often need help to ease their arguments with others, as well as the urge to be critical and fussy.
Role reversal: Role reversal is seen as a setback to normal social activities. In and of itself, it can lead to emotional vulnerability and relapse. Role change may require extensive interpersonal adjustment.
Interpersonal deficits: Frank and colleagues (1994) found that people with bipolar disorder often have a large but unsatisfying number of relationships, particularly when the person has been alienated from close friends and family during a previous episode. Helping these patients to get to know others properly and to moderate expectations (without blowing off steam) is one of the tasks of interpersonal psychotherapy. frank et al. (1994) defined a new interpersonal deficit in patients with bipolar disorder that can arise after a bipolar episode. The patient may not want to reconnect with old friends or find a job. In standard interpersonal psychotherapy, this is usually seen as a role transition.
In the third phase of treatment, the therapist builds the patient's confidence by addressing the relationship between symptoms, social stagnation and interpersonal problems. At the end of treatment, after 4-6 months of monthly therapy, emotional weaknesses, early signs of illness, and symptom recurrence are reviewed. The eventual fourth stage is reviewed to provide an ongoing plan for the future.
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