This section describes the types of therapy that appear to be most useful for people with bipolar disorders, and mentions which kinds of patients are most likely to benefit from each. As mentioned previously in this chapter, many good therapists use techniques and concepts from several of these disciplines.

Cognitive therapy

Insurance companies love cognitive therapy (also called cognitive-behavioral therapy), because it sometimes produces relief from troubling symptoms within a defined, limited period of time. Patients like that too, especially those who are strongly motivated to help themselves.

The cognitive therapist begins by helping the patient identify which negative behavior patterns he would like to work on. Together, they identify what kinds of thoughts and feelings precipitate these behaviors.

Next, the therapist helps the patient figure out strategies for replacing thoughts that have negative consequences with new thoughts that have positive consequences. In other words, the cognitive therapist helps you "think yourself well."

In addition to bimonthly visits with her neurologist and psychiatrist, Cass sees a therapist weekly for an hour. His focus is behavior modification, and he is her friend. She loves to see him. I have a distrust of therapists, but am very comfortable with him. He has helped me to work with specific goals in mind for her. --Stephanie, mother of 7-year-old Cassidy (diagnosed bipolar disorder, Tourette syndrome, OCD, ADHD)

Cognitive therapy works best for handling specific "thought errors" and behaviors. For example, if a teenager with bipolar disorder tends to catastrophize when depressed, seeing only the negative side of everything and then becoming further depressed as a result, cognitive therapy can help him find strategies for breaking this negative thought spiral. These strategies might include the use of affirmations, consulting with the therapist or another trusted adult to double-check negative thoughts, or mentally substituting positive thoughts for the negative ones.

Does it work? Not always, but more often than one might think. Cognitive therapy has helped many people identify and combat errors in thinking, and has even proved useful for stopping thoughts that can lead to troubling behaviors, including self-injurious behavior. It has a good track record for helping people with compulsive behaviors, those in recovery from substance abuse or dependency, and patients suffering from anxiety, panic, and other out-of-proportion reactions to daily events. Evidence is mounting that cognitive therapy produces actual physical effects, such as changes in the production and absorption of neurotransmitters.

In the hands of a professional who has strong rapport with young children, cognitive therapy can be a powerful tool, even for preschoolers. Not every therapist has the ability to work well with this age group, however. It has been well-tested for use with adolescents and teens.

Cognitive-behavioral therapy has also shown effectiveness for educating bipolar patients about monitoring their mood cycles and symptoms, and for encouraging treatment compliance.

Play therapy

Young children express their fears, desires, and emotions in play, and they can often be reached and helped through the medium of play when conversation with an adult is impractical. Play therapists are specialists in this kind of therapy, which can work powerful magic when done with skill and caring.

Play therapists can work with children as early as infancy to build and improve skills in the areas of attention, interpersonal relationships, perception, and mood. They can also help young children who have been victimized by abuse or who have experienced other kinds of life traumas, such as the death of a parent.

Michael's therapist does play therapy, which is what works best with my son. At the beginning she concentrated on his sexual abuse issues. When that got better, the focus was whatever was going on at the time. If he was paranoid, they would talk about that. Self-esteem is always an issue. They discuss bipolar disorder and what it means for him. --Lynn, mother of 11-year-old Michael (diagnosed BPI with mixed states and psychosis, OCD, tic disorder)

There are many tools for play therapy, and many schools of thought. One of the most interesting types for use with young children is called floor-time play therapy, and is championed by Dr. Stanley Greenspan. The techniques of floor-time play involve creating structured play sessions with a client--or with your own child, because this is one kind of therapy that parents can deliver with ease--that help him overcome deficits in attention and relatedness. Filial therapy is another type of play therapy that uses similar ideas, and involves parents or other caregivers taking turns at initiating structured interactions.

Most play therapists work in a clinic or school setting, and use toys, games, and art supplies in their practice. For example, they might employ dolls or stuffed animals to help a young child talk about conflicts in the home, or they might use animal figures and a sand table to model desirable behaviors. With older children, art-based activities may be more interesting and a better communication tool. Communication, of course, is the goal. Parents might or might not be part of the play therapy session.

Because it's play-based, this type of therapy is best suited for preschool or grade school children. Activity choices should be based on the child's developmental level.

Be sure that your child is comfortable with the play therapist, or not much will get done in their sessions together. Talk to the therapist in advance about your child's diagnosis and what areas you hope can be worked on. Many play therapists are highly experienced at working with traumatized children, but may not know how to work with a child whose problems are neurological in nature.

Incorporating some floor-time play therapy techniques into your daily activities with a young child is a great idea. If your child's therapist uses this method, ask if she can train you as part of her work with your child. If not, see if training is available from a parent education group, or consult Dr. Greenspan's books for ideas.

Family therapy

A family is a group formed by individuals for their mutual benefit, with each member having his or her own personality, needs, and desires. Whenever one member of the group is ill or in emotional distress, it affects all the other members.

Family therapists work with the entire family together, although they may also see some members individually. They see the family as a system; probably not a perfect one (whose is?), but a system that at least tries to meet everyone's needs. The therapist helps each member express his or her fears, angers, and wishes, and then helps the family restructure itself in healthier ways.

You don't have to be the classic dysfunctional family to benefit from family therapy. Meeting as a group with a therapist can help a lot, even if only one person's behavior is seriously disordered. In fact, this approach is strongly recommended for the families of children with bipolar disorders, even if the child is seeing an individual therapist. In family therapy sessions, you'll have a safe place to talk about your frustrations, and to develop strategies for helping your child without neglecting the needs of parents and siblings. Without this opportunity, family members can undergo severe stress.

My mother said she almost had a nervous breakdown watching me disintegrate from a 4.0 student-body president to someone who couldn't finish a single verbal sentence, choose something to eat, or really do much at all except stay in bed and complain a lot. I think I was putting a lot of pressure on her by constantly turning to her for help that she could never give. Our relationship went through the toughest time when I was hospitalized. It took years to heal the wound that occurred from this. It wasn't until years later that I found out they weren't at all accurate with the information they were giving her. --Troy, age 30 (diagnosed bipolar I disorder at age 17)

Manic depression is very hard for families to handle, and yet a strong support system is essential for bipolar children. Clinical experience has shown that the more patients, their parents, and even their siblings know about bipolar disorders, the better their prognosis is. That should mean fewer hospitalizations, better medication compliance, and fewer serious legal and educational problems.

A good family therapist will be someone who is supportive and who is also knowledgeable about the biological nature of bipolar disorders and any co-morbid conditions. The last thing you need is a therapist who blames your child for her own difficulties. You also don't need to see someone who blames your parenting skills.

That said, some parenting styles and behaviors are especially detrimental to bipolar kids. Physical, sexual, and emotional abuse are just the most obvious examples. Children with bipolar disorders are emotionally fragile, and may be affected more strongly by family stresses such as financial difficulties, marital discord, and divorce. Family therapy can provide a venue for putting these issues on the table, for healing the pain caused by errors and misunderstanding and, perhaps most importantly, for setting family ground rules that ensure they don't happen again.

Another area where family therapy can help is identifying other family members who may have undiagnosed bipolar disorder or another related condition. Because of the genetic nature of manic depression and the low rate of appropriate diagnosis, it is fairly common for a parent to be diagnosed after their child. The thought styles and symptoms associated with bipolar disorder can then become a focus of family therapy, helping all family members understand each other better, improve how they relate to each other, and become a more cohesive and supportive unit.

As in any type of interpersonal treatment, there are a few common pitfalls to family therapy. Misplaced assumptions are one. Although piles of self-help books have been written about family relationships, the truth is that every family is a unique blend. Although knowledge of common personal behavior patterns and family structures can certainly be useful, watch out for a therapist who instantly labels your family as having typical adult children of alcoholics (ACOA) problems or who uses some other quick pop psychology explanation. The assumptions that accompany labels can prevent appropriate therapeutic work, and may lead the therapist away from concentrating on those of your family's needs that are specifically related to bipolar disorder.

Families also need to know that therapy is not a cure-all, although it will sometimes be presented that way by well-meaning professionals. If your child's difficulties are such that medications, therapy, and even hospitalization do not help much--and although these cases are the minority, they do exist--the goals of family therapy will need to be identifying survival strategies for coping with unmanageable symptoms, or it will probably be a useless exercise.

We went to family therapy religiously, to no avail. I do know that when Nathan was hospitalized, we were a happy family with him out of the picture. (Doesn't that sound awful?) When he is here, he is the cause of the turmoil, and if he does not want the help, then it does not make any difference what approach they use or how much family therapy you attend. --Cindy, mother of 16-year-old Nathan (diagnosed bipolar disorder, OCD, ADHD, post-traumatic stress disorder, chemical dependency, bulimia)

Group therapy

Group therapy brings together several people who are dealing with the same or similar problems, placing them under the guidance of a professional therapist. Within the group meetings, they can help themselves and each other.

Like family therapy, group therapy can be a very positive experience. Your child can form supportive relationships with peers as well as with her therapist, and will get the benefit of the other participants' real-life experiences and insight. Group therapy also tends to be less expensive than individual therapy sessions.

You may be able to take part in therapy groups for parents of bipolar children, or your child may be able to be in a group for bipolar kids around the same age. As long as the therapist in charge is knowledgeable and supportive, group therapy can be very useful for almost any patient and family. It is especially powerful with adolescents, who are often more likely to listen to their peers than to an adult therapist. Most residential centers, day treatment facilities, and hospitals use some form of group therapy with their young patients.

Some people never feel comfortable being open in a group situation, however. For these very introverted types, individual therapy is a better fit--although ability to function in a group may be one of the goals of that therapy, leading to group therapy later on.

Peer support groups

Peer support groups are a little like group therapy--but without the therapist. These range from ad hoc support groups formed by parents to professionally mediated support groups that may be available through a mental health clinic or public agency. Usually peer support groups do not charge participants, although a collection for snacks or meeting-room expenses might be taken up. Clinic-run groups, of course, may carry a fee.

Alcoholics Anonymous, Narcotics Anonymous, and other programs that use the 12-step model or a similar self-help approach are a particularly advanced kind of peer support group. These well-known programs bring together people with a common problem, and use methods for effecting personal change and supporting all members of the group that can be very effective. If substance abuse or dependency, eating disorders, or compulsive behavior disorders are additional problems for your bipolar child, you may want to look into the resources available along these lines.

The support experienced and friendships made in a peer support group can be very helpful for almost any family. Peer support groups for patients themselves can also be great--but without adult supervision, they can also be dangerous for bipolar teens. Before your child joins a support group, find out more about the program and the other participants. Some support groups provide a wonderful healing environment where young people with bipolar disorders can share their experiences with others who have been there. In a few strictly patient-run support groups for youth, however, solid information can go missing and misinformation can be spread. That can turn support group meetings into parent-bashing sessions, or lead participants to stop taking their medications due to peer pressure.

Local support and advocacy organizations, such as the National Alliance for the Mentally Ill (NAMI) and the National Depressive and Manic-Depressive Association (NDMDA), are often involved in setting up, sponsoring, and helping parents find peer support groups for bipolar children.

Milieu therapy

If your child is in a day treatment center, residential center, or hospital, milieu therapy is probably one of the program's underlying concepts. "Milieu" is a French word for site and setting. Milieu therapy endeavors to make the site and setting of everyday activities in a school, hospital, or living center therapeutic. This requires paying close attention to physical characteristics, such as making sure that the classrooms and dorms are not dingy and depressing, and ensuring that toys, games, and activities are available that build positive experiences and help to eliminate negative behaviors.

Of course, careful structuring of interpersonal relations in the milieu is of prime importance. Every interaction between a patient and a staff member has therapeutic potential, whether that staffer is the cafeteria cook or an actual therapist.

This is obviously a thoughtful, intelligent premise for constructing a program to support and enhance the lives of young people with mental illness. If a program promises to follow the precepts of milieu therapy, that's usually a good sign. Parents may also be able to take some ideas from milieu therapy and use them at home; see "The therapeutic home," later in this chapter.

Counseling

The most common place for children to see a counselor is at school. School counselors usually have a dual role: they advise students on academic issues and guide them through the college admissions process, and they also help them with personal problems. In the latter role, their focus is on maintaining wellness rather than on treating psychiatric disorders.

Accordingly, most school counselors are not equipped to provide regular therapeutic help to a child with a bipolar disorder--but they can be a key part of your child's therapeutic team. The counselor's office may be your child's designated safe place at school, a place where he can go if the stress is building up too high and he feels a crisis coming on. The counselor (or a school nurse) may be able to control as-needed medication for symptom exacerbations at school. She can be the person the student or his teacher comes to in case of immediate problems. She may also be able to act as a sort of resource broker, helping the student and family get hooked into more intensive help through the school district or through community-based programs.

Outside of schools, other professionals may provide counseling services in private practice or in a clinic. As discussed earlier in this chapter, the title of counselor may or may not have a legal meaning in your state or province.

Behavior modification

Behavior modification, also called behavior therapy, focuses on identifying problem behaviors, finding out what causes them, and eliminating them. That's far less simple than it sounds on paper.

You are most likely to encounter "behavior mod" experts, also called behaviorists, in more restrictive settings, such as day treatment centers, hospitals, and youth corrections facilities. The quality of their training and expertise varies widely. Their role in your child's treatment might include analyzing behavior and its antecedents and helping to develop a behavior plan to address problem areas (in a school setting, this is called a Functional Behavior Analysis plan). Some behavior therapists work one on one with bipolar youths, using techniques that are very similar to the related practice of cognitive-behavioral therapy.

One area where behavior therapy has proved particularly effective is the reduction of compulsive behavior, including self-injurious behavior. Another is the reduction of anxiety and panic. The exposure-reduction approach to phobias is an example that many people are familiar with. A child who has a severe school phobia, for example, would begin treatment by meeting with the therapist to discuss her fear. Then the therapist and patient would devise and carry out a plan to gradually and safely expose the child to the fearful situation or place, increasing the exposure over time.

Unfortunately, some behavior therapists are purists who feel that all human activity is based on conditioned responses to environmental stimuli. It's important to find a professional in this discipline who understands, accepts, and works with the role of neurochemistry in the origin and treatment of bipolar symptoms. In the case of school phobia, for instance, medication can play a role in both causing the problem and in solving it.