Mar 29, 2020
Note: This episode was recorded before government guidance on restricting travel due to coronavirus.
We all experience ups and downs in mood, but what happens when the highs are so high and the lows are so low that it really interferes with your life? In this episode we hear from Cate Catmore and Professor Steven Jones about CBT for bipolar disorder.
Show Notes and Transcript
For more resources check out these links below.
Coping with bipolar disorder by Steve Jones, Peter Haywood and Dominic Lam
Overcoming Mood Swings by Jan Scott
NICE guidelines on bipolar are summarised here
Cate spoke about mindfulness. You can hear more about mindfulness-based cognitive therapies here
This BPS report is called Understanding Bipolar Disorder
Recovery toolkit for friends and relatives of someone with bipolar disorder based on research at Lancaster University
Guardian article on CBT for bipolar disorder by Lucy from a few years ago
If you’d like to read more academic journal articles this range of papers about bipolar disorder has been made free until 30th April 2020 from the BABCP journals
The photo is by Claire Satera on Unsplash
This episode was produced by Lucy Maddox.
Lucy: Hello and welcome to let's talk about CBT, with me, Dr Lucy Maddox. This podcast brought to you by the British Association for Behavioural and Cognitive Psychotherapies or BABCP is all about CBT. What it is, what it's not and how it can be useful. As an aside, if you listen regularly to this podcast and like it, please do consider rating and reviewing it, it helps other people to find it.
And if you have ideas for other episodes that you'd like to listen to, just let me know at email@example.com. Right then, I thought I'd start this episode with a quote from Kaye Redfield Jamison, who's a clinical psychologist and writer. She writes, "When you're high it's tremendous, the ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones.
But somewhere, this changes. The fast ideas are far too fast and there are far too many. You are irritable, angry, frightened, uncontrollable and enmeshed totally in the blackest caves of the mind." That was about Kaye's experience of bipolar disorder which is the diagnosis that this episode concentrates on.
For this podcast, I went to Lancaster and met Cate, who's experienced the highs and lows of bipolar disorder and what CBT can do to help. And Steve, whose research team works on a CBT-based intervention for bipolar disorder.
Cate: I'm Cate Catmore, I'm 64, and I live with my husband, got two children, two sons and two granddaughters. I did CBT a while ago and then I had a course of recovery-based CBT recently.
Steve: Hi, I'm Steve Jones, I'm co-director of the Spectrum Centre for mental health research at Lancaster University. The focus of our work is on trying to learn more about the psychological and social factors underpinning bipolar disorder and related conditions. And to use that information and learning to develop new interventions that are developed with the service user in mind. We've been in existence for about 11 or 12 years, and we've always had people with lived experience of bipolar disorder as colleagues as well as collaborators.
Lucy: Cate had her recovery-based CBT as part of a research study at Lancaster University, delivered by one of Steve's colleagues. It's not the first time Cate had CBT for bipolar disorder, but she felt she was more able to access it this time round.
Cate: In the very first place I had CBT when I was hospitalised about 10 years ago. I hadn't kept up with it, and I'd just let it slide, really. And then, I heard about recovery-based CBT through a bipolar support group at Lancaster University.
Lucy: I asked Cate about her experience of having bipolar disorder.
Cate: I didn't have too many manic episodes, but I have to say that was how it was diagnosed, and I must admit I did enjoy the manic phase.
Lucy: What did it feel like?
Cate: It felt free and exciting and I wanted to do everything that I could, and I felt that everything that I did I was doing very well. The main thing that I remember or being very enthusiastic at work and doing a lot more than I was called on to do. I was lucky that I didn't spend all that much, but I did give a lot of money away to charity.
But the best thing (laughs) and it sounds so self-important, but we went out a lot then, probably instigated by me. Me and my husband went out a lot. I used to say, "Oh got to get to this party early, because nobody will enjoy themselves if I don't get there."
Lucy: What a lovely feeling, though.
Cate: It was a lovely feeling, and sometimes I think I wish I could be a bit more like that. And I don't really get the highs anymore, I get the lows, but not the highs. And I know that they're dangerous and they're not healthy, but when you experience them, they are quite nice (laughs).
Lucy: Yeah, it sounds nice.
Cate: Mine wasn't destructive, I have to say, so I was lucky that I just had the nice inside feelings. I didn't gamble like some people do, and I didn't go out and buy a car or anything like that, just made me feel really good and bigger than I was.
Lucy: Yeah, that's a really nice way of describing. Bigger. Yeah. And what's the other end of the experience? So, the lower bit like?
Cate: Well, the lower bit was very low. Part of the manic bit eventually made things quite stressful because I was jumping from one thing to another. And so, work did become stressful and then home life became stressful because I was trying to do so much at home. And then, I got an eating disorder, and they both seemed to feed one another. So, losing weight so much made me more manic, I think.
And then, the more manic I was, the less I ate because I was doing so much, didn't have any appetite. So, it was that, really that led to me to be admitted to hospital. And then, I wasn't really high anymore after that. Then, the low bit started, which lasted a long time. So, I was in hospital quite a long time.
I think I left a lot of myself behind in that hospital. I don't really think I've ever been quite the same person that I was before. Even though I was assured I was, I think it does have a big effect. Yeah.
Lucy: Steve described the definition of bipolar disorder to me.
Steve: I guess bipolar disorder is typically defined in terms of experience of substantial variation in mood. So, most people with bipolar disorder will have experience of both periods of mania where mood is extremely elevated, people can feel very euphoric. They can have lots of energy, but often that can be mixed together with other things, which make it more complicated like feeling very irritable or frustrated.
And then, periods of depression, which are not unlike periods of depression, feeling rather hopeless and very down, and finding it really hard to get going and engage in normal life. And historically, bipolar has been seen as those two things, really. And what tends to be missed out is that often people are experiencing quite a lot of challenges in between those sorts of episodes, where they're not really experiencing mania and they're not really experiencing depression, but there's often quite a lot of mood variation going on.
And people are also working quite hard to make sense of the variety of experiences that they have. So, quite a lot of our work is targeting that middle period, which seems to be actually pretty crucial for people to then develop a platform for getting on with their lives.
Cate: Mood swings but extreme ones. Yeah, and they can last a varying length of time as well. So, people can be manic just for a short length of time, mine was relatively short, I suppose, two months. But then, I've found that the other side of it is quite dark, the depression can be quite dark. So, I think it's just like an exaggerated way of how a lot of people are, that just manage it normally in their day-to-day life.
I sometimes think that people are a bit wary of mood swings and think that something that they say that's wrong might cause a sudden up or a sudden down. And it isn't like that, at all. It's not so erratic as that.
Lucy: So, what does CBT for bipolar disorder involve?
Steve: An important part of any successful intervention with people with experience of bipolar and a core aspect of the recovery-focused approach is really working with the person initially, to get a shared understanding of their experiences that have brought them to the intervention.
Which isn't just a symptom history, because obviously with things like variable mood, the point, the continuum between something that's a problem and something that's normal experience and parsing those things out is one of the challenges people live with. So, people will often be able to for instance identify experiences where mood elevation has been in some ways amazingly good for them.
It allowed them to get a promotion or complete a task they otherwise might not have been able to complete. But then, there are also occasions when that's tipped over into something that's had a profound effect on their lives. And it's not hard to imagine how trying to pull all that together and make sense of it. Which bits do you want, which bits don't you want, which bits are you, which bits are some part of bipolar isn't something people find readily easily resolved without a bit of time and reflection, I think. So, getting that story clear and in a shared way can be a really useful platform for them working out, okay, so what do you want to change? And what do you want to have more of?
Lucy: So, anyone listening, who's thinking that they might want to try CBT for bipolar they could expect to have that kind of shared understanding at the start about what's happened for them and what they would like to work on?
Steve: We're not going to assume that it's about mood or it's about something else. We're going to work with you to find out what is the thing that's causing you difficulty and how shall we address that together.
Lucy: Cate told me a bit about what her most recent experience of CBT had been like.
Cate: Well, it was a talking therapy. We talked about issues that bothered me, and basically about ways to cope with those, identifying what they were, and what triggered them. And different ways of coming to terms with them and coping with them.
Lucy: If you were describing it to somebody who hadn't had it before, what would they see happening in the room? What was going on?
Cate: Well, two people talking together, basically in a chatting way, some writing going on to remind you what had been discussed with the therapist, and then to work on that during the week. I found it very helpful, I found it perhaps a bit stressful at first. And it did bring some things to the surface that were quite emotional, so sometimes there was a bit of crying going on.
But that was usually resolved during the course of the session, and then given ways to work on that. And why those feelings caused upset as well. The sessions lasted about an hour, sometimes a little bit over, not usually less. And it was a course of 12 weeks. And during that 12 weeks, I kept a diary of what we talked about. And then, kept a diary during the week, to keep a record of what had happened. And then, a memo to myself to talk to Lizzie about what had come up during the week.
Lucy: That's great, sounds really organised.
Cate: It was, yeah.
Lucy: And do you still use some of the techniques now?
Cate: I do, I was looking back at the diary that I'd made and yeah, I have kept it on board. It's not a therapy you do 12 weeks of therapy and that's it, it's finished, all your problems are gone, you get on with your life and it's all finished. You're cured sort of thing. It's something it's an ongoing process.
Lucy: Because recovery-focused CBT for bipolar disorder is focused on helping with whatever goals the person brings, it can include different CBT techniques, which help with different problems.
Steve: So, we use tools that we know from CBT for bipolar, CBT for anxiety, psychological approaches to substance use to bring together a package for that individual. So, the manual for recovery-focused therapy is quite a long document, because it encompasses all these possibilities. And it reflects what we were talking about, about quite individualised routes through therapy.
Lucy: What's your favourite kind of strategies to use from it? What sort of things do you use?
Cate: I use distraction, and something comforting that I find soothing, like sewing or seeing a friend or phoning my sister, but reading is a big thing as well. Sometimes even cleaning the cooker, something a bit mindless, really, just a distraction. But also, to remember that the feelings that I have aren't special to me. That not only people with bipolar or depression get feelings like that, that everybody does, the population does. And not to get too hung up on it, and I also use mindfulness as well, which is a big thing, yeah.
Lucy: Mindfulness is something that the episode on mindfulness-based cognitive therapy has loads more information about if you're interested. This is how Cate came to find mindfulness.
Cate: I did an online course in it which was great. It was to bring yourself back into the moment all the time, because so much time is spent thinking about the past, which I do and ruminating on things, which are big. That's gone, and if you're wasting your time now, now is all that you've got. And people miss so much in the moment. There was a lot of different ways to keep mindful.
A lot of it was just sitting and concentrating on breathing for two minutes. But also, when you're out walking, to look at the trees, to feel the ground underneath your feet, really ground yourself, literally to feel yourself walking. And I do notice things more while I'm out, and it makes it a pleasure. Exercise is often recommended for people, but you can go out for a walk and you can keep your head down and worry about things and just be walking.
You're in the fresh air and you're doing some exercise, but you're not really noticing what's going on around you, which is the soothing bit. Listening, mindful listening is a big thing as well. I tend to let my thoughts run away with me. So, when somebody's speaking I'm thinking about the next thing that I'm going to say rather than really listening to them. And that's been a big thing for me, to actually listen to somebody else properly.
Lucy: That's really interesting, have you noticed it makes a difference to the conversations you have?
Cate: Yeah, it has, I feel more involved with the person and what they're saying. And I think it probably makes me feel kinder towards the person, as well. Yeah.
Lucy: I've been reading some stuff about being kind to yourself recently, as well. Do you think that comes into it, too?
Cate: It does, yeah. I definitely think being kinder to yourself, not making too much of things, not thinking about all the bad things about yourself. But concentrate on the good things that you can do and the good things that you can do now and in the future. And not think about the bad things that you've already done, which are gone. You can't do anything about it now, it's finished.
Lucy: Cate talked about distraction, self-soothing and mindfulness strategies there. Other strategies that might be used in CBT for bipolar disorder might include trying out different behaviours to see what difference they make to mood. And sometimes gradually doing things that feel quite hard to do but that make someone feel better. There might also be ways of thinking that are getting someone stuck and Steve talked about some of these.
Steve: When people come in low mood, they may have a lot of negative thoughts and beliefs and tapping into those and looking at ways of finding alternative ways of thinking could be really useful. When somebody's mood is going up, you can also look at the patterns of thinking that are going on there. And work with the person to examine those in relation to how useful are they, how risky are they?
What elements of those do they feel that they want to retain? And how can some aspects that may be problematic be adjusted? I think one of the things that people will often struggle somewhat with is recalibrating. So, if somebody is at quite a low ebb when they come into therapy, and they've got an awareness of what they were previously able to do, which was often functioning at a higher level for anyone.
People will often come with a view that they either need to be there or nowhere. They either need to be right on top of where they were performing at their peak, or there's no point. And so, actually even fairly simple behavioural experiments, testing out, doing things that aren't meeting that criterion but are reasonable things to be doing. And the impact that that can have on subtle shifts in mood can be really useful on unsticking people.
Lucy: Cate told me a bit more about some of her experiences before and how she feels now.
Cate: I think I'm more on an even keel with some downs now. Yeah, and I try and think that everybody has that. And everybody finds a different way of managing it.
Lucy: I know you were saying you felt like you'd left a lot behind, but actually it sounds like you have gained a lot of different skills and strategies actually through your experiences as well.
Cate: Yeah, I think I have, and leaving work was a big thing, because I felt left work under a bit of a cloud, really, because it meant going into hospital.
Lucy: What were you working as?
Cate: I was a gynae nurse, and I worked on the gynae ward and in a bit of gynae oncology and in the outpatients as well. So, I did like my job and I had a lot of good friends, but I felt that I'd left under a bad situation, really. And I never did go back to work after, which used to worry me, because I didn't go back to work. Well, I stopped work when I was 51. So, it used to worry me, not working worried me for a long time. But then when all my friends started retiring, it felt a bit better (laughs).
Lucy: I asked Steve about that sense of loss that Cate had described earlier. Something Cate said really stuck with me, actually, just about how she really enjoyed some of the highs and actually not having those felt like quite a loss. How do you manage that in the therapy?
Steve: I think for a start, you deal with that by taking it seriously. So, I think a lot of people will have had the experience maybe with some other clinicians that they may have come into over the years of being slightly patronised in their valuing of these highs. That it's just you're not well, so that's just you not being well. You need to have something which makes you not go there.
I think working with the person to get a thorough understanding of actually okay, what does go on in those? Are there versions of that are dangerous to you and risky to you? And are there versions of that that are less so? And at what point do these things tip over? Can allow people to actually experience a range of mood states that are part of human experience.
So, on the one hand, yes being sleep deprived for three weeks while you do lots of things is probably for most people likely to lead them into challenging situations. But small amounts of changes in routine to accomplish a certain task, followed by a planned way of decompressing afterwards can actually work quite well for some people. So, that's why it's not a short therapy in a sense.
It's taking the time to be able to unpack those things for people, so that you're working together to see what you can take from that valued element of experience and what needs to be adjusted.
Lucy: Steve was really clear that someone shouldn't have to go to multiple services if they experience multiple problems. That CBT for bipolar disorder could flex to help people with not only ups and downs in mood, but also anxiety, substance misuse or other more functional goals. I was curious about how Steve measured change. Must be quite a challenge for measuring how effective therapies are, when there are quite a lot of different goals that each person might come with.
Steve: Yes, that's a very good point. And I think there's quite a debate about what's a good measure of an outcome. So, our position on that is that most people actually come for help because of subjective problems, their perception that they're experiencing something that's difficult. So, in the past, a subjective outcome has almost been regarded as not a proper outcome.
Whereas I think if it's done properly, they are absolutely important outcomes, because if people are happy with how they are functioning and where they're at, relative to where they want to be, in a sense they're doing what they need to do. And my view is as clinical psychologists, that's our job is to support people to get where they want to be.
Lucy: Cate now works in a range of volunteer roles.
Cate: With the voluntary work, I'm confident when I go out and do that.
Lucy: What's that? What sort of voluntary work are you doing?
Cate: Well, I'll go and read individually with the children at the local primary school. So, I did the five- and six-year-olds last year, but I was quite pleased really, because they said, "You're really confident with the children, and you know a lot about phonics. So, will you read with the little ones?" So, I've got four- and five-year-olds now. They're really sweet (laughs).
Cate: Yeah, I think you're really giving something, because learning to read is so basic to everything else. And then, the other voluntary work that I do is through church. And it's street pastors, you'll have street pastors in Bristol but you'll never have seen them.
Lucy: No, I don't know them.
Cate: So, it's run through all the churches in Preston. And it was started in Birmingham as a response to gun crime. The police asked could churches be around and about and talking to people. And gun crime did go down, and it spread out from there, from gun crime the people the street pastors were meeting homeless people. And then, helping people who were on a night out, who couldn't help themselves, they'd drunk too much. So, yeah, we try and get homeless people to go to services.
Lucy: I also asked Steve about the evidence base for CBT for bipolar disorder. He mentions NICE guidelines here, which are from the National Institute of Clinical Excellence. I've put a link in the show notes if you're curious.
Steve: So, the evidence is pretty good for the impact of CBT on mood and relapse. So, the NICE guidance for bipolar disorder in 2014 recommends that everyone living with bipolar has access to the opportunity to engage with psychological therapy based on their systematic review of the evidence.
The evidence on enhancing personal recovery is not as large, partly because it's an evolving field and it's more in the last eight years, I think, there's been a lot of interest in that. But certainly, as I mentioned with our recovery-focused trial, we've got evidence for that being beneficial. And it does seem as though there are a range of ways you can improve those sorts of outcomes.
Lucy: Cate described therapy as being like a river.
Cate: I've seen it described as a river, and the therapy is on one side, but one day you've got to swim across that river and get to the other side.
Lucy: I've not heard that before, I like that. Yes.
Cate: Yeah, it's quite nice, I did think at one time when I was still having therapy and thinking about getting to the other side, what if I get swept away? Which is a bit of a risk, but you've got to keep the image set in your mind that it will be calm waters that you swim across.
Lucy: I think there's something in that, though, isn't there? That fear of what are you stepping into? And is it going to be worse not better?
Cate: Yeah, I don’t think any therapy is a one size fits all. And I think you have to be in the right place to engage with it, as well.
Lucy: Steve thinks views on CBT for bipolar disorder have come a long way.
Steve: I remember when we were first doing one of the very early trials of CBT for bipolar. There was a lot of resistance to it from clinical colleagues in the sense that their argument was when people are manic, you can't work with them. When they're profoundly depressed, you can't work with them. And if they're not in either, what problem is left? It's a very simplistic view of people's experience, but that's where we were maybe in the mid 90s.
Now, there are a range of studies going on internationally in bipolar and I think there's a gradually increasing recognition that the psychological dimension to experiencing bipolar isn't a nice to have. But is a crucial aspect of both improving outcomes for people with bipolar, but also helping them with the human task of making sense of what's actually gone on.
Lucy: Cate was encouraging about trying CBT for bipolar disorder if you're considering it.
Cate: I'd definitely give it a go. I think perhaps the name cognitive behavioural therapy sounds a bit off putting. But it's a way of getting to understand your feelings, getting to understand different phases of bipolar and how to cope with them. They're actually quite simple, and it's good to have some help.
Lucy: I asked Steve why he likes working in talking therapies for bipolar disorder.
Steve: Bipolar if you like is pretty rare in terms of being a condition where some of the cardinal symptoms actually can confer an advantage. And I also find it personally fascinating working with people who are living alongside these experiences. I think actually living with the turbulence that bipolar can generate is pretty challenging.
And frankly, I admire the way a lot of people actually fold that into their lives and get on with a really engaged life. And if we can do something to support them in that, I think that's a worthwhile thing to do.
Lucy: That's all for today. Thanks so much listening. There are links in the show notes to more resources, and if you liked this episode, there are lots more you can listen to. Series one went through different types of CBT and series two is working through different types of problem that CBT can help with, including recent episodes on self-harm and perfectionism.
If you're thinking about having CBT and you want to find a BABCP accredited therapist, check out www.babcp.com and look for CBT register.
Thanks so much, lovely chatting with you.
Cate: Is that it?
Lucy: That's it.
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