Skip to main content
Submitted by PatientsEngage on 2 August 2019
A stock photo with scrabble tiles arranged with the word BIPOLAR

Psychiatric counselling and therapy for people with bipolar disorder can help reduce severity and number of episodes of depression and mania and improve understanding and coping abilities, says Dr Milan Balakrishnan, psychiatrist at Bombay Hospital.

Although medicines are the mainstay of bipolar disorder treatment, counselling and talk therapy also have an important role to play. How can a qualified therapist help someone in the treatment or control of bipolar disorder?

Bipolar disorder, as we currently understand, is primarily a neurobiological illness. So definitely in 99% of the cases, medication is prescribed. Mood stabilizers like Valproate, Lithium, Aripiprazole are the mainstay of treatment. But with bipolar comes so much of turmoil and extreme shifts in mood, feelings, energy. The world seems different at one time, and may seem diametrically opposite at other times, which for someone, who does not know anything about bipolar, can leave him very confused. And, the caregiver even more confused. The caregiver is led to think that this is some malicious intent. He was perfectly alright a while ago, why is he behaving like this suddenly. Or he can do much on his own, why is not doing anything now. So it is very difficult to understand a person with bipolar.

The first step for anyone is to consult a psychiatrist, psychotherapist, psychologist to understand the illness fully and to educate the patient and the family. Sometimes at the height of the episode, the patient may not be in a position to be educated. In that case, supporting the caregiver, and subsequently, as the patient stabilises, supporting the patient. Supporting the patient, I mean, psycho-education, helping him understand the illness, and how it functions and what it does it do to him, so that he can recognise those signs early and 1) seek help at the appropriate time 2) take care of himself better because he known the illness better and deeper. The better you understand the disorder, the more the patient and family will be equipped and empowered.

What are the different types of counselling for a person with bipolar?

There are various therapies that can be used at various stages of bipolar. It is very important for a therapist to be an expert in bipolar to be able to deal with it actually. Because it is not a one size fits all. What you do when the person is on the verge of a manic episode is very different from what you do in a depressive episode versus what you do when he is in a maintenance phase. It is important for a therapist to have full understanding and knowledge of bipolar. So the therapist needs to be educated first. It is not that I have trained in therapy so I can work with bipolar patients.

From experience, what form of psychotherapy proves to be most effective?

I’ll tell you for different phases.

Depressive Phase: For the depressive phase Cognitive Behaviour Therapy (CBT) or Rational Behaviour Therapy (RBT) that looks at cognition will help a lot. We also recommend Behavioural Activation (BA), which is also part of CBT, with little form of exercise, engagement, trying to meet people. I know right in the middle of a depressive phase, you can’t do all of that, but the earliest possible.

Manic Phase: In the manic phase, therapy would not be of much help because the priority would be to regulate.

Maintenance Phase: In the maintenance phase, yes, it is feasible because there is a lot of self-work, CBT, mindfulness based work, to identify, to be aware, to be able to see the shifts in your mind and body as you can pick it up early and treat it effectively, But I do come across patients, who are less psychological mindedness. With them CBT or RBT may not work in the form we know it. Counselling has to be more focussed on psycho-education and on family education. The family picks up symptoms quickly and brings the patient to us.

In bipolar, medications will always be a very important part of the whole treatment. So if someone says I am going to set this right only with therapy, that is very inappropriate. That is not evidence based.

According to your experience, what percentage of the treatment comprises medicines and what percentage comprises counselling?

Medications are more or less permanent, counselling is an add on.  The aim of counselling is get the patient resilient enough to deal with the illness. The therapist also needs to withdraw and say that you are now resilient enough to take care of yourself.

How difficult is it to identify and gauge symptoms like mania or hypomania in bipolar disorder?

Mania is very easy to gauge. Because is very obvious. Suddenly this person, who was demure, and quiet, becomes super excited, bubbly and hyperactive. He is going all over the place and talking to everybody, celebrating and dancing and spending money indiscriminately. So mania is very easy to identify. What is difficult to identify is this hypomanic and depressive phases. Hypomnania is a very subtle, baseline disorder. It is a very subtle form of mania. The patient could get loquacious, gregarious, full of confidence, but not reckless.

Which symptoms and forms of bipolar disorder are most debilitating?

The most debilitating could be the two extremes. So extreme mania where he can be aggressive, can pick up fights with everybody, can get beaten up or beat other people, or get into altercations or legal tangles. In the height of mania, most often, we have to admit the patient. Because he is so disruptive and he is spending so much money that if he is not admitted he could bring harm upon himself and others.  We come across manic phases all the time that require hospitalization. The other extreme case is severe depression. Depression is often accompanied with suicidal ideation, where the patient wants to harm himself and end his life.

How many patients do you see with bipolar in a month?

On an average, in a week, I see close to at least 20 patients. I work out of hospital (Masina Hospital, Mumbai) that predominantly sees psychiatric patients at a charitable rate.

What percentage of all your psychiatric patients would be bipolar?

So about 10 % of my patients would be bipolar. This among the patients who come to us at Masina. The prevalence of bipolar disorder among general population would be about 2-3 %. It is a highly undiagnosed, missed out kind of disorder.

Do you see an increasing awareness about bipolar and the need to approach a psychiatrists?

Awareness is definitely on the increase, particularly in the urban areas. Not so much in the rural or 2-tier cities. But when you start seeing manic episodes, there is panic and urgency because it is disruptive for the entire family and neighbourhood.

Are clients with bipolar disorder volatile and resistant to treatment?

Very often. Because of the things that they hear, that these medications are dangerous and there are so many side effects. And once you start these medications you’ll never get out of them. But that’s because of the nature of the illness.

Is it true that some of the medicines become lifelong.

It is because of the nature of bipolar. With bipolar disorder, with one episode you need to treat it for at least two years. With two episodes, you may need to treat upto five years. And multiple episodes, you may end up treating indefinitely. So it is like diabetes, if you don’t treat, it’ll come back.

What is the age group of your clients who visit you?

It ranges from 7 to 70. In the young ages, it is very tough to diagnose. With children, it is more difficult to control because it is a longer term investment.

Are family focused therapies advisable for bipolar clients, especially in the Indian setting?

Like I mentioned earlier, psycho-education also involves the family.