Social Rhythm Psychotherapy for Bipolar II

While most mental health professionals and doctors turn to medications first to treat bipolar disorder, they miss an opportunity to treat it naturally, through the use of psychotherapy. And while medication may be an appropriate first-line treatment for bipolar I disorder, where the mood states are more well-defined and severe, it’s less clear that it is as beneficial in bipolar II disorder.

It’s probably most accurate to describe bipolar II as a condition of complex mixed mood states. Sadly, because bipolar II isn’t as easily recognized as bipolar I, it is often misdiagnosed and goes untreated. People present most often with clinical depression while suffering from bipolar II, leaving the hypomanic episodes undiscovered unless a person is specifically asked about them.

Psychotherapy can be a beneficial, effective treatment method for bipolar II, with or without the use of adjunct medication. Here’s how it works.

In bipolar II disorder, mixed moods are “typically experienced as dysphoric, uncomfortable, energized states that one patient aptly described as “tired-wired.” Mixed mood states make it more difficult to track mood changes, evaluate outcomes in clinical trials, and recognize onsets of new episodes,” according to the researchers of a recent review article that examined psychotherapy’s effectiveness in the treatment of bipolar II (Swartz et al., 2012).

The review found “preliminary evidence for cognitive therapy, cognitive — behavioral therapy, psychoeducation, family focused therapy, case management, and IPSRT as treatments for [bipolar II] disorder.”

IPSRT is a form of psychotherapy called Interpersonal and Social Rhythm Therapy. At the time of this review, it was the “only psychotherapy to demonstrate feasibility of treating individuals with BP II with psychotherapy alone.” Which is quite an achievement, given that many professionals and most laypeople have probably never heard of it.

What is Interpersonal and Social Rhythm Therapy (IPSRT)?

Interpersonal and Social Rhythm Therapy has three components: psychoeducation, social rhythm therapy (SRT), and interpersonal psychotherapy (IPT). Here’s how the researchers describe these three components:

• Psychoeducation focuses on the illness and its consequences, pharmacotherapeutic options and potential side effects, and detection of prodromal symptoms and early episode warning signs.
• Social rhythm therapy (SRT) focuses on developing strategies to promote regular, rhythm entraining social cues and to reduce the impact of events that disrupt rhythms. This is accomplished by reviewing the patient’s social routines using the Social Rhythm Metric (SRM), an instrument used to measure rhythm regularity, by identifying behaviors that negatively influence rhythm stability and areas where rhythms could be regularized, and by working toward rhythm stability through graded, sequential lifestyle changes. Patients are encouraged to have as regular a schedule as possible.
• Interpersonal psychotherapy (IPT) interventions are used to help patients recognize the reciprocal relationship between interpersonal problems and mood dysregulation. Patients focus on one of five IPT problem areas in their efforts to ameliorate interpersonal and social role problems. Four of these come from the original IPT manual (grief, role transitions, role disputes, interpersonal deficits), and one has been added specifically for IPSRT, grief for the lost healthy self, in which patients have an opportunity to mourn the person they might have become if not for BP disorder.

So what is the basis for these social rhythms? The underlying zeitgeber (“time keeper”) hypothesis is that there are environmental factors that help us set and keep our circadian clock — such as the rising and setting of the sun. But there are also social cues in our daily lives that also help set and keep our circadian clock humming along smoothly. When one or more of these social cues gets disrupted, it disrupts our core biological (circadian) rhythms and throws us all out of whack. Something along the lines of:

People who are vulnerable to mood disorders (perhaps due to an underlying genetic component or simply a psychological deficit) get “stuck” in their biological rhythms being thrown off. So social rhythm therapy seeks to re-train your biological rhythms, to help speed recovery from the mood disorder.

Measuring Your Social Rhythms

Social rhythms are tracked daily using something call the Social Rhythm Metric (SRM), a simple journal worksheet that notes the target time, actual time, and number of people involved in 5 core daily activities: getting out of bed; first contact with another person; starting work, school, housework, volunteer, child or family care; dinner; and going to bed. It also tracks a person’s daily mood.

Previous research suggest maintaining rhythms such as these are more predictive than psychological stress in predicting a new episode of bipolar or bipolar depression:

How it Works: Goals & Techniques of IPSRT

The goals of IPSRT can be summarized as social rhythm therapy (SRT) seeks to make regular one’s daily routines, while emphasizing the link between regular routines and moods. It does this through the use of the SRM to monitor the patient’s routines, and suggest changes to help improve the regularity of those routines.

The goals of the interpersonal psychotherapy component is to emphasize the link between mood and life events, while focusing on interpersonal problem areas — grief, role transition, role disputes, and interpersonal deficits.

Specific techniques identified by the researchers of IPSRT include providing a rationale for making changes to one’s social rhythms — providing psychoeducation and the the background as to why these rhythms are important. Then the therapist will help the patient identify and track their mood states over time. This is important because, “of the subtlety of hypomania and the complexity of mixed states,” and so “it may be quite challenging for patients with [bipolar II] to ascertain mood states correctly.”

Next, an IPSRT therapist seeks to help the person regulate levels of stimulation in their daily lives, “increasing stimulation when their mood drops and decreasing stimulation when vulnerable to hypomania. Because individuals with BP II disorder commonly experience mixed or rapidly cycling mood states, they may feel like they live their lives in tangled states that alternate between “high gear” and “low gear.””

In addition to regulating levels of stimulation, the therapist will also help the patient learn how to better manage their grandiosity and sense of entitlement — two symptoms that often are a part of bipolar II. They will also help the patient minimize their emotional dysregulation, psychobabble for helping people become less emotionally reactive. This is done through techniques similarly used in dialectical behavior therapy, such as breathing exercises, distraction, and self-soothing.

Last, therapists keep tabs on a patient’s use of mood-altering substances, included alcohol, cigarettes, caffeine, and others. For instance, the use of caffeine may help boost a person’s energy while suffering through a depressive episode, but it also can play havoc on a person’s sleep quality and length.

 

In short, Interpersonal and Social Rhythm Therapy is a scientifically-validated treatment for people with bipolar II disorder. And it’s the only psychotherapy that has been shown to work sans medications, so it’s definitely worth giving a try. Look for a therapist who specializes in the treatment of bipolar II and is an IPSRT therapist (or has been trained in its use).

 

References

Swartz, HA. (2013). Getting in the rhythm: A key to practical treatments of mood disorders. Slideshow (PDF).

Swartz, HA, Levenson, JC, Frank, E. (2012). Psychotherapy for bipolar II disorder: The role of interpersonal and social rhythm therapy. Professional Psychology: Research and Practice, 43.