Cognitive-Behavioral Therapy for Bipolar Disorder Cognitive-Behavioral Therapy for Bipolar Disorder SECOND EDITION Monica Ramirez Basco A. John Rush THE GUILFORD PRESS New York London ©2005TheGuilfordPress ADivisionofGuilfordPublications,Inc. 72SpringStreet,NewYork,NY10012 www.guilford.com Allrightsreserved Nopartofthisbookmaybereproduced,translated,storedina retrievalsystem,ortransmitted,inanyformorbyanymeans, electronic,mechanical,photocopying,microfilming,recording,or otherwise,withoutwrittenpermissionfromthePublisher. PrintedintheUnitedStatesofAmerica Thisbookisprintedonacid-freepaper. Lastdigitisprintnumber: 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Basco,MonicaRamirez. Cognitive-behavioraltherapyforbipolardisorder/Monica RamirezBasco,A.JohnRush.—2nded. p. cm. Includesbibiographicalreferencesandindex. ISBN1-59385-168-5(hardcover) 1. Manic–depressiveillness—Treatment. 2. Cognitive therapy. I. Rush,A.John. II. Title. RC516.B36 2005 616.89′506—dc22 2005008775 In memory of David Walter Savage 1957–2003 About the Authors Monica Ramirez Basco, PhD, is a clinical psychologist, author, lec- turer,andClinicalAssociateProfessorofPsychologyattheUniversity of Texas Southwestern Medical Center at Dallas. She is an interna- tionallyrecognizedexpertincognitive-behavioraltherapy(CBT)and a founding fellow of the Academy of Cognitive Therapy. Dr. Basco is the author of Never Good Enough: How to Use Perfectionism to Your AdvantagewithoutLettingItRuinYourLifeandcoauthorofGettingYour Life Back: The Complete Guide to Recovery from Depression. She is also the author of The Bipolar Workbook: Tools for Controlling Your Mood Swings, a CBT guide for patients, to be released in 2006. A. John Rush, MD, is Professor and Vice Chair for Research in the Department of Psychiatry at the University of Texas Southwestern Medical Center at Dallas. His work has focused on the diagnosis and psychotherapeutic, psychopharmacological, and somatic treatment of major depressive, bipolar, and other mood disorders. He has authored 10 books and over 400 journal articles. Dr. Rush’s internationally recognized work has received numerous awards. Most recently, his research has focused on longer-term disease management programs, includingmultisteptreatmentalgorithmsforbipolarandmajordepres- sive disorders. vi Preface Sincethepublicationofthefirsteditionofthisbookin1996,wehave had many opportunities to implement and evaluate our cognitive- behavioral strategies for containing the symptoms of bipolar disorder and for prevention of relapse. We have trained clinicians and researchersacrosstheUnitedStates,inSouthAmerica,andinEurope tousethesemethodsinclinicalsettings.Andotherinvestigatorshave worked with and modified our strategies for application to their unique patient populations with good results. Also over the 9 years since our original publication, new pharmacological treatments for bipolar disorder have been developed, tested, and found efficacious. Indeed, these are exciting and hopeful times. Several challenges remain for clinicians and researchers. Better detection methods are needed so that this illness can be recognized and addressed earlier in its course. Medical and behavioral strategies must be strengthened so that those with the illness will have fewer residualsymptomsofdepressionbetweenepisodesofmaniaandmajor depression. Methods are needed to help patients use their treatment resources more consistently so that they can receive the maximum benefit available. These include clinical strategies that enhance adherencetomedicaltreatmentsandimprovementsinpsychopharma- cological agents so that medications can be better tolerated. We must also aid the efforts to destigmatize mental illness so that people can feel more comfortable seeking psychiatric and psychological care. Taken together, these improvements will help people gain a better senseofcontrolovertheirsymptomsandhelpthemtoachievegreater quality of life. The methods presented in this second edition of Cognitive- Behavioral Therapy for Bipolar Disorder represent another step toward vii viii Preface the development of clinical methods for preventing relapse and for helping patients to live with this illness. Its organization is different from that of the first edition, to allow more flexibility for clinicians. Rather than providing specific session-by-session instructions, it guides clinicians toward selecting methods that address the stage of illness and treatment and tailoring the intervention to the specific problems and needs of patients. Our experience has shown us that people with bipolar disorder and their family members are often very active in seeking ways to improve their health, to stay abreast of recent developments in treat- ment, and to experiment with ways to control their symptoms. The membersoftheDepressionandBipolarSupportAlliancegroupsacross theUnitedStatesaswellasotherself-helpgroupscontinuetomakeit their mission to support and educate themselves and one another, to convey hope, and to challenge the fields of psychiatry and psychology toassisttheminfindingnewwaystoimprovethequalityoftheirlives. Becausepeoplewiththisillnessareabletoplayanactiveroleintheir care, they read about and make use of treatment methods available through therapy, in journal and magazine articles, through the visual media, and through books. As educated consumers, they often enter treatment already having implemented many of the methods we sug- gest in this book. The flexibility of the methods described herein will allow clinicians to bypass components of treatment about which the patient has knowledge and skills and move ahead to the more advanced methods offered for controlling depression and mania. Beforethecognitive-behavioralmethodsprovidedinthistextcan be of help, the patient must be ready to deal with the fact that he or shehasachronicandseverementalillness.Thisconceptisverydiffi- cultforpeopletoaccept.Ournaturalinclinationashumanbeingsisto pushawaybadnews.Thus,providingtherapyandmakingitasuccess- fulexperienceisasmuchaboutthetimingbeingrightasitisaboutthe methods being useful. If the patient is intellectually ready to learn to managehisorhersymptomsbutisnotemotionallyreadytofullygrasp themeaningofhavingthislife-longdisorder,therewillbemanyroad- blocks on the path to recovery. Steps toward managing the symptoms may be followed by periods of frustration and anger with the enter- prise, perhaps even the desire to give up on treatment altogether. It may be necessary to postpone psychotherapy or put it on hold while the person allows him- or herself time to grieve the loss of full mental health and of a life uncomplicated by depression and mania, medica- tions and therapy, and doctors and hospitals. Patience is needed by bothcliniciansandpatientstoallowthenormalprocessofacceptance to occur and adjustment to solidify. When the patient is ready, the Preface ix cognitive-behavioral methods presented in this volume can help him or her to regain control, to prevent succumbing to the peaks and val- leys of the illness, and to improve the quality of his or her life. Thereisstillmuchtobelearnedaboutthemanagementofbipolar disorder,andourpatientshavemuchtoteachus.Ifonlywecanmain- tain the sense of purpose as clinicians and researchers that brought us tothementalhealthfield,wecanperseveretofindanswerstothesig- nificant problems posed by this chronic and debilitating illness.