Individual Therapies for Bipolar Disorder

Cognitive Behavior Therapy

Cognitive Behavior Therapy refers to a type of treatment in which a therapist works alone with a child to help him learn to challenge his negative thoughts and misperceptions. It is a therapeutic way (if a child's mood is not too unstable) to approach the rigidity we sometimes see in bipolar children—by teaching him the relationship between his thoughts and his behavior. The premise of cognitive behavior therapy is that by mastering particular ways of thinking, a child can learn to help himself function more effectively in the world around him.

Consider the following example. Suppose Frank is walking down the sidewalk and sees his classmate John walking down the other side of the street from the opposite direction. John looks down at his feet instead of making eye contact. Frank decides John isn't looking at him because John doesn't like him. He feels angry that John doesn't like him. Frank then goes home and sends an e-mail message to his friend Greg saying that John is a miserable, stupid kid who didn't even have the decency to look at him and say hello.

A cognitive behavior therapist would work on trying to get Frank to think about the other possible reasons John may have had for looking down and not making eye contact. Was it that he had a bad cramp in his toe? Maybe there was a nail in his shoe? Or was he worried about math class? The fact is, it's possible the reason he looked down had absolutely nothing to do with Frank. If this last explanation was what really was going on, Frank begins to learn that he might have jumped to conclusions and misinterpreted the situation, which led to his bad feelings and subsequent behavior.

Cognitive behavior therapy requires work. Not only does a child have to want to get better, he also has to commit to doing daily or weekly exercises designed to help change his behavior. For example, a bipolar child might be asked to practice deep breathing three times a day as part of his treatment program. Next, he would be instructed to use this technique whenever he feels anxious. Not all kids, and sometimes not even adults, are motivated to put forth this kind of effort. This type of therapy requires that a child have a certain maturity and the willingness to examine his own behavior. As you can imagine, this might not be the most appropriate treatment in young children or in children whose moods are labile.

But CBT can have good results for those who are motivated to give it a try. The Treatment of Adolescent Depression Study, a twelve-week study conducted in 2004 by John March, MD, MPH, director of the Division of Child Psychiatry at Duke University School of Medicine, and his colleagues, compared 439 depressed adolescents who were divided into four treatment groups: those taking Prozac (fluoxetine) alone; those using CBT alone; those taking Prozac with CBT; and a placebo group. Rates of response for Prozac with CBT were 71 percent; Prozac alone, 61 percent; CBT alone, 43 percent; and placebo, 35 percent. Therefore, it was the combined group that used both CBT and medication that experienced the most improvement.¹ Cognitive behavior therapy has also been found to be a useful tool for medicated bipolar adults as compared to a medicated group without CBT. The combined-treatment group had significantly fewer and shorter bipolar episodes and better social functioning.²

Cognitive therapy can have a number of variations. One type uses a treatment technique known as contrasting visual imagery. The idea is that if you think of and visualize something positive, you will be unable to focus on something negative at the same time. Ian's mother explains how visual imagery helped in her son's treatment:

A child with significant anxiety and a phenomenal imagination is often his own worst enemy. But one day not long ago, we discovered that it was also my son Ian's own best defense.

As we sat in the doctor's office with Ian, then age eight, we watched him put on a brave face as he explained some of his worst anxieties. He told us how alone he feels when he goes upstairs at night or when he arrives at school on days that he has "worries." It was heartbreaking to listen to him confess his discomfort at falling asleep (even while he was denying that it was so bad) as he blinked back the tears and described the monster that plagues his dreams.

We were at a crossroads of sorts. Then, the doctor came up with an idea. She suggested that he think of the funniest animal he could think of—something that would really make her laugh. Ian immediately thought of a cow in a pink tutu with matching lipstick; the cow was revealed to have clog dancing shoes on and a passion for juggling and riding the unicycle.

After the two of them had a good laugh, the doctor asked my son the cow's name, to which he responded, "Bob." The laughing resumed, only this time, it was almost uncontrollable. When they both calmed down, the doctor asked Ian to try to practice thinking of "Bob" a few times a day and right before he fell asleep. Ian did this for a week and was having an easier time drifting off to sleep. The next week, the doctor asked Ian to bring "Bob" to school with him and picture him anytime thoughts came into his mind that he didn't want.

"Bob" has given my son a way to talk about feelings that he had previously denied. It gave him back a sense of control, and he now feels empowered to banish the bad feelings. It has been several months since "Bob" came into our lives. If you ask Ian about him, he will smile …and tell you that this silly-looking cow in clogging shoes helps keep the bad thoughts away.

CBT can be used with children as young as five, if the child is cognitively able to use this approach. Michael Osit, PhD, a psychologist in Warren, New Jersey, describes using this therapeutic technique to help five-year-old Shawn conquer his fear of being kidnapped from his bedroom at night. The doctor showed the little boy a box filled with hundreds of pebbles, but only one of them was gold. He had Shawn close his eyes and pick up one of the stones. Then, he had him repeat the exercise over and over again. Shawn never got the gold pebble. The psychologist used this example to show the youngster that being kidnapped was as unlikely as getting the gold pebble. By working at the youngster's level, he was able to help alleviate Shawn's fears.

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