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TitleTreating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guides to Individualized Evidence-Based Treatment)
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Table of Contents
                            Front Matter
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Document Text Contents
Page 1


Page 2

Guides to Individualized Evidence-Based Treatment
Jacqueline B. Persons, Series Editor

Cognitive Therapy of Schizophrenia
David G. Kingdon and Douglas Turkington

Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal
and Social Rhythm Therapy
Ellen Frank

Page 112

his or her own schedule? What kinds of interpersonal stressors, if any, are likely to be
involved in the vacation?

In the case of a new job, you will want to know whether the patient’s work hours
will remain the same or change. Will he or she have to travel farther to get to the new
job? Will this job involve more or less out-of-town travel than the previous one? What
will the patient’s new responsibilities be? Is this position likely to be substantially
more, or less, stressful than the previous one? Does he or she have to learn a great deal
of new material in order to be competent in the new position—and, if so, how quickly?

In the case of a planned vacation or business trip, you and the patient can plan for
ways that the patient can maintain his or her regular sleep schedule and regular pattern
of meals and can modulate social interaction in the new environment so that he or she
becomes neither bored and lonely nor overstimulated.


Even a cursory review of Jill’s illness history timeline, which appears in Chapter 1,
would suggest how much mood disruption had been associated with taking a va-
cation. By the time Jill entered IPSRT treatment, she was positively vacation pho-
bic. Yet after a few months of therapy she began to understand why what was sup-
posed to have been good for her spirits so often turned out to be too good and,
therefore, disastrous. As she was feeling appreciably better and less fragile, she
also recognized how much she would benefit from a change of scenery and a bit of
relief from caring for her boys and her home around the clock. Her financial re-
sources were quite limited, but her husband was more than happy to take care of
the children and her brother and sister-in-law had offered to send her a ticket to
come to Seattle. As much as the idea of a vacation appealed to her, it also terrified

When she mentioned the possibility to her IPSRT therapist, he agreed that
there were some risks involved, but that if she planned carefully, she might be able
to minimize those risks. They discussed what time of day it would be best for her
to travel three time zones west (early in the day, so she could avoid being awake
much more than her usual 16 hours) and what time of day she should plan to re-
turn (pretty much anytime except on the “red-eye”). They talked about whether
she would have a room of her own to sleep in (essential) and what kinds of activ-
ity, and how much, were planned for her week there. Jill was then able to call her
sister-in-law and discuss what it would take to reduce her anxiety about the trip.
Not surprisingly, her sister-in-law was willing to do pretty much anything (includ-
ing sending her own children to sleep at their grandmother’s) to make Jill’s visit
safe and pleasant. They planned an agenda of activities that was interesting to Jill,
but modest in scope, and agreed that if it proved too much for her, they would just
take a day off and hang out at home.

By putting a lot of effort into the planning of her trip, Jill was able to get some
badly needed respite from her regular routine, enjoy the company of people she
cared about for the first time in months, and come back refreshed and more confi-
dent in her ability to manage her illness.

Because unanticipated life changes of major proportion, such as a death or marital
separation, often have much psychological meaning attached to them in addition to
representing dramatic alterations in social zeitgebers, considerable therapy time needs


Page 113

to be devoted to adapting to such changes. The IPSRT therapist must address both the
interpersonal and rhythm stability needs of the patient. Having first, of course, demon-
strated appropriate empathy and concern for the patient, the IPSRT therapist’s initial
emphasis is on the maintenance of stability in as many of the patient’s social rhythms
as possible despite the major role change or loss. This approach may seem callous, but
we have found it is actually much appreciated by patients, who report feeling that we
have given them an anchor to hang onto in a difficult time. Because working to stabi-
lize social routines is familiar to the patient and is not loaded with emotional meaning,
it is usually something they feel competent to attempt even when they are despondent
or demoralized by recent events. Once rhythm stability has been addressed, you can fo-
cus on the grief and/or role transition work using traditional IPT techniques, while
continuing to emphasize the importance of maintaining social rhythm regularity.


Stan had been fired from his job as a systems analyst, largely as a result of his
mood symptoms, a few months after entering IPSRT treatment. Following a mania
that did not negatively affect his work in ways that his superiors were aware of at
the time, he switched into a severe and incapacitating depression. Despite the fact
that he was in his mid-40s, everyone in his family agreed that it would be best for
him to return to living in his parents’ home, both for his safety and in order to con-
serve what little was left of his savings. He found unemployment to be very stress-
ful and became increasingly frustrated, angry, and disappointed, which led to a
further lowering of his mood. He yearned for employment not only for financial
reasons, but also because it would provide structure, meaning, and satisfaction to
his life. His IPSRT therapist has focused on helping him adjust to his unemploy-
ment while waiting for his depression to improve. He was no candidate for a job
interview at the time.

The initial sessions focused on teaching him the importance of structuring his
days and avoiding under- and overstimulation. He and his therapist discussed
various ways to structure his life, including helping his mother with regular
household tasks, volunteer work, and socializing. Stan was also able to talk about
the impact unemployment had on his sense of self and about the kinds of job pa-
rameters that would be important to maintaining his health when he is ready to
begin a job search.

As you are working with social rhythm regulation, it is important to keep in mind
that what may look like social rhythm disruption may actually be early signs of a new
episode of mania or depression. Did your patient stay up all night to finish a work pro-
ject because his boss insisted that it be completed by 9:00 A.M. the following day (social
rhythm disruption) or because he got so involved in and excited about the project that
he completely lost track of time (incipient mania)? Did your patient sleep until noon be-
cause her husband was going to be home that day and was happy to make the kids
breakfast and get them off to school (social rhythm disruption) or because she was too
lethargic and incapacitated to get out of bed and her husband, knowing that, stayed
home just to be sure that the children got to school (depression)? In either case, trying
to get your patient back on to a regular routine is likely to be beneficial—to prevent
new episodes and to ameliorate or short-circuit incipient ones.

Symptom Management 101

Page 223

long-term perspective, 146
case example, 146

poor outcomes, 145
seasonal mood variation, 148

case example, 148–150


Pamelor, 29
Panic spectrum disorder, and bipolar disorder,

Parnate, 29
Patient orientation to treatment, 84–85

behavior/education focus
alternative treatment approaches information,

symptom management (behavioral), 88
symptom management plan (individualized),

symptom management plan

(pharmacotherapeutic), 87–88
treatment plan description, 86

interpersonal problem area focus
case example, 89–90
selection, 89

treatment contract, 190
Perfenazine, 28
Phenelzine, 29
Posttraumatic stress disorder (PTSD) and bipolar

disorder, 60
Progress monitoring. See also Outcomes of therapy

early warning signs of new episodes, 128
enhancing adherence to interpersonal problem

area work, 136–137
medication adherence, 132–133
Mood Disorder Monitoring Chart, 129, 130f,

SRM adherence, 133–136
symptomatic and functional change monitoring,

symptomatic and functional change in

treatment, 128–129, 131–132
Psychoeducation, 33, 35, 53–54, 67–72

assumptions about, 20
case examples, 68, 70, 71

Psychological/psychosocial theories of bipolar
illness, 20–21

Psychosocial treatment, 32–35, 36t–37t


Rescue protocol, 119–120
Risperidone/Risperdal, 29


Schizophrenia vs. mania, 54
Serotonin function, 17
Social Rhythm Metric (SRM), 10, 14, 76–78, 81

adherence monitoring, 133–136
case examples, 81–82
importance of social rhythm stability, 23, 48
Social Rhythm Metric-II—5, 164f

example, 78f
score calculation, 165

Social Rhythm Metric-II—17, 166f–178f
example, 79f
score calculation, 179–181

stabilization goals chart, 193
Stabilization Schedule, 192

Social Zeitgeber Theory. See Integrative theoretical

Social zeitgebers, 3, 19–20, 21
and entrainment of circadian rhythms, 24–25

SSRI drugs, 29
Support groups, 124–125
Symptom management, 92–93. See also Social

Rhythm Metric (SRM)
activity vs. inactivity balance, 94

case examples, 94–99
behavioral activation, 102
in initial phase of treatment, 88
lifestyle alteration benefits, 93
patient’s routine/adapting to changes, 99–100

case examples, 100–101
trigger(s) identification, 93

case example, 93–94


“Tad” case example. See Bipolar disorder/IPSRST
case example/adult onset (manic
symptoms in unstructured environment
with overstimulation)

Tegretol, 28
Texas Consensus Conference Panel on Medication

Treatment of Bipolar Disorder, 32
Therapeutic relationship (IPSRT), 138

case examples, 139–141
countertransference issues, 151

case examples, 151–153
management of suicidal thinking/behavior, 143–144
patient confidentiality issues, 143
present and future focus, 139
relationship problems/case example, 141–143

Topamax, 28
Topiramate, 28
Toranil, 29

Index 211

Page 224

Transmeridian flights, as example of zeitstörer, 25
Tranylcypromine, 29
Treatment phases of IPSRT. See also Interventions;

Symptom management
contract, 90–91
final phase, 157

contact after termination, 161
ongoing maintenance, 158–159
termination of therapy, 47, 159–160

initial phase, 44–45. See also Case formulation
history taking, 44–45, 64–67
Interpersonal Inventory, 45, 65
interpersonal problem area selection, 45, 74, 76
Social Rhythm Metric, 45
therapist checklist, 191

initial phase during crisis approach, 45–46
intermediate phase. See also Interpersonal

problem areas; Patient orientation to

interpersonal problem intervention, 46
social rhythms regulation, 46

maintenance continuation phase, 46–47. See also
Progress monitoring

modular approach, 47–49
Trilafon, 28


Valproic acid, 17, 28, 29, 30


Young Mania Rating Scale (YMRS), 59, 129


Zeitgebers. See Social zeitgebers
Zeitstörers, 3, 25–26
Zyprexa, 29

212 Index

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