Is Therapy Pointless for the Unmedicated Bipolar Patient?

Kind of in conjunction with yesterday’s post, I want to take things back about a year before my quest for trying out modern medicine for the second time.

I was un-medicated and working a full time job in the fashion industry. “Yikes” is about the only way I can put it. That is a rather unforgiving industry, and though I was being pushed past my own limit by the horrendous actions of a couple of bad apples, I was somehow managing to hang on by a thread. My plan of attack was to find a good therapist that could weather the storm with me in an attempt to ride it out.

Unfortunately that plan crashed and burned.

I attempted to cultivate relationship with three different therapists, all of whom dumped me in one way or another.

I use the word “dumped” because there are few other words to describe sitting in the waiting room at my designated time, only not to be fetched by my associated therapist. With no call or explanation, beyond this:

The benefits of therapy are not significant enough for our relationship to continue if you plan to remain unmedicated.

Yep. Therapy, denied. Unless I was willing to also find a psychiatrist and take whatever I was prescribed, none of those therapists were willing to see me on a weekly basis. And mind you, was paying them.

I’ll admit, at the time, I really took it personally. What, I was somehow able to navigate roughly 60 hours a week of work but was suddenly too “crazy” during the hour I was in their office to be able to help without some kind of sedation? My seeming “non-compliance” with the psycopharmalogical world meant I would also reject listening to their perspectives, even though I sought them out? Ridiculous. I assumed I must be farther gone than I had originally thought.

Then, I was furious at these women. Didn’t they get into this field to help people? What, do they only take the easy cases? Why wasn’t anyone willing to rise to the challenge, if I was so nuts? And why were they all so flaky and blowing me off that way, didn’t they think I could handle an actual mature conversation?

So I gave up.

And I don’t have any desire to work in the fashion industry anymore.

There was a third explanation, a third possible reason for these interactions that I was completely unaware of until the Bipolar Disorder in Focus conference two weeks ago.

A woman there gave a presentation on the benefits of psychosocial therapy, and included a number of studies done on the subject. At the end, she said something that made all kinds of bells and whistles go off in my head:

There have been no studies on the impact of psychosocial therapy without the use of medication, in regard to the treatment of bipolar disorder.

HA!

There it is, there’s a big ol’ hole in our knowledge there. Would therapy alone be beneficial to those with bipolar disorder? Technically, since it hasn’t been researched, we don’t know.

I just want to take a second to point out that I realize the last couple posts may have seemed a little anti-drug, and I don’t want people to take that away, and nothing else.

It isn’t that I’m anti-drug, I am just pro-knowledge.

It isn’t that psychological medications are bad, they’re actually quite good for a lot of people. Personally, though, they do not react well with my body. I have a very sensitive body chemistry, which makes taking most of the medications that are out there for bipolar disorder today impossible. Clearly this has made things pretty difficult, especially when trying to find someone like a therapist, because they seem to have a pre-conceived notion of what will or wont help me.

Thankfully since that terrible time I had, I’ve found a therapist who is quite wonderful and doesn’t drive me absolutely bananas.

Anyway, since hearing that there hasn’t been much to tell us if therapy would help without the drugs (which, spoiler alert, I spent roughly seven years unmedicated so I can tell you it does), I decided to do a little snooping around online myself.

I contacted The Royal College of Psychiatrists‘s library in London to gain access to one of their publications (notably The Psychiatrist) which is available to (you guessed it) those working in the field of psychiatry for free, and pretty much everyone else for a modest fee. To my surprise, they allowed me free access to the article I wanted based on the fact that I am a patient. UK, you’ve just gained some favor in my book!

I try not to go all citation-crazy on this blog because as soon as medical jargon starts getting thrown around, I know a lot of folks lose interest. It can be hard to understand at times, and I usually find myself thinking, “alright, well what was the point of that?” It isn’t that I discount intellectualism, but I do try to write to a broad audience of people. I’d like to include a couple excerpts today though, so you can see exactly what I’m referring to, straight from the horse’s mouth. Or the horse’s keyboard, anyway.

The specific piece I was curious about is entitled, “Psychological Therapies for Bipolar Disorder: addressing some misunderstandings”, and is actually a letter published (by the original authors of a study) in reply to a letter published about the authors’ originally published work. If you can follow that. Right. (See, that’s why I usually don’t venture here!)

The excerpts I have pulled are authored by a team led by Steven H. Jones, Professor of Clinical Psychology, Spectrum Centre for Mental Research, Lancaster University, UK, including Fiona Lobban, Anne Cooke, Warren Mansell, Kim Wright and Joanne Hemmingfield, at the Spectrum Centre for Mental Research, Lancaster University.

We do not argue against the use of medication treatments, but we do discuss the fact that they are not necessarily helpful for everyone and that choice in relation to this, as well as other forms of treatment, is an important consideration. We accept that the evidence for psychological interventions is based mainly on participants who are currently receiving medication as well. This could mean that the sole ingredient offered by psychological interventions is an increase in adherence, but this is no more proven than other possible explanations. P.433

Be sure to replace “psychological interventions” with the word “therapy”, if you feel so inclined, because that is what they’re basically saying. The last sentence suggests there may be others who believe that the only reason therapy is helpful for bipolar disorder is to keep patients on their medications, but that the idea is not more proven than any other ideas of what therapy adds to the mix.

…there are no drug-free studies of psychological interventions in bipolar disorder. Such studies prove an enormous challenge, given the present readiness to prescribe. However, it is encouraging that psychological therapies appear to be superior to medication in the long term for a range of other psychiatric disorders, including unipolar depression, post-traumatic stress disorder and panic disorder. Nevertheless, our approach sees a key role for medication in services, particularly in situations of acute risk, and for clients for whom the benefits are clear. P.433

I find this portion incredibly encouraging. There are obvious situations where medications are necessary, but the fact that therapy is superior to medication (in the long term) for a number of other psychiatric disorders should be some indication of the potential for success with bipolar disorder.

…we provide extensive reports from large numbers of people with bipolar disorder, reporting on how they have learned to cope with their mood swings. We regard such evidence as primary rather than secondary in the pursuit of a scientific understanding of emotion regulation and how it becomes a problem for many people, just as early psychiatrists utilised a phenomenological stance in building their initial categorisations of mental illness. P.433

All I can say here is: awesome. I feel so often that the focus seems to be on eradicating symptoms, but I personally would rather just be better able to cope. I believe bipolar disorder does offer some benefits, and mere eradication usually includes both the benefits and the drawbacks. How better to gain a better understanding of how people cope than to talk to them? Seems deceptively simple, no?

So, just a little nugget, there. After going to that conference I am hungry for more science, more research, and more medical professionals I can actually agree with. It is important to me that I can feel hopeful about what is being done in the mental health field, even if it is only occasionally, and the politics here in America have a tendency to stifle that for me, to some degree.

I also wanted to take the time to say that I really do believe that a partnership with a therapist can do wonders. Medicated or not, as long as you’re willing to be open, honest, and receptive, it really shouldn’t  matter. And if someone tries to give you flack? Me and these 6 psychiatrists, we’ve got your back!

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13 responses to “Is Therapy Pointless for the Unmedicated Bipolar Patient?

  1. Very interesting post. I think different therapists might have different ideas on the matter. My therapist wanted me stable of meds first but then encouraged me to look into mindfulness and bipolar disorder without medications. I felt encouraged by that.

  2. “…there may be others who believe that the only reason therapy is helpful for bipolar disorder is to keep patients on their medications…”

    Fascinating! My therapist recently told me that there’s no apparent reason for me to stay in therapy since my symptoms are well-controlled by medications and I’m at low-risk for noncompliance. But he also said I have good insight, know when to intervene, and don’t have other major issues to work on.

    Not to be a total contrarian, and I know I’m an exception, but…

    I was told to start therapy in the first place to learn coping strategies for depression. Why? They assumed that after 20 years of battling depression and mostly managing to keep my act together that I didn’t know how to handle it. I already knew all of the recommended strategies, use them appropriately, and figured it out all by myself. Knowing how to cope when I feel awful and therefore being able to appear functional made everyone assume that I don’t really have serious problems – including the mental health professionals.

    I know a lot of people have issues related to experiences or behaviors from bipolar, even when symptoms are under control, but I worked through that stuff during periods of remission. To top it off, nearly all of the therapists I’ve seen were more damaging than helpful, despite my attempts to cooperate fully. They did a real number on my self-confidence and some of them invalidated and dismissed distressing experiences of symptoms over and over. No bitterness. Oh wait. Yes. Lots and lots of bitterness.

    So I’m not entirely convinced that everyone needs therapy. Like everything else, there’s no one-size-fits-all solution. I’m glad it helps a lot of people, but I don’t think it should be considered a blanket requirement.

  3. This is so interesting, because it leads right back into conversations about overmedicating and medication non-compliance.

    Doctors are eager to throw medication at people. Just like House said, the problem depends on the specialist. If you go to a Endocrinologist, it’s going to be a hormonal problem. If you go a Gynecologist, it’s going to be gynecological problem (I can’t tell you how many times I had an OB / Gyn tell me that my mood swings were PMS). If you go to a Psychiatrist, it’s going to be a disorder.

    I was on Yaz for six months before I decided that it clearly wasn’t PMDD. I was on various antidepressants for years and years before I decided that it didn’t work, and maybe it was just the way I was. (Which is never something anyone should start to think when it’s psychological). I had an Internal Medicine doctor tell me it was a vitamin deficiency of some kind, only to be knocked down when I asked for tests. And I had another doctor tell me it was because my blood sugar was everywhere. (Thank god I didn’t let them medicate that!)

    No, I don’t think doctors should be eager to throw medication at people. Medicating a psychiatric disorder is like playing Wheel of Fortune, except it’s more like, Wheel of Torture. How many people have been through slews of medication before they found the right one? If this were a science, then they would know your biochemistry and know the right prescriptions. But, no. It’s trial and error. So what if a person doesn’t really need medication?

    I think that if a person can find a way to manage their disorder in their life without medication, well that’s great. Not that I’m discouraging the use of medication, because it’s often necessary. I really think that might be the first route that someone should go through. Think about intake appointments. They are an hour long, and they want you to go through every symptom you’ve had in your entire life. Well, if you aren’t aware of the symptoms, then you might have difficulty identifying them. This is the exact reason that there are a plethora of misdiagnoses.

    Now, if a person comes in with extreme discomfort, demanding medication for relief, I don’t think that should be eliminated because a person didn’t complete the “therapy requirements”. I have had that happen on the flipside. One clinic required that I meet with a social worker before I could see a psychiatrist before each appointment. Yup, med checks too. I had to see this useless social worker who didn’t want to talk about my feelings or behaviors and the problems that it was causing in my life. She wanted to focus on the problems and “ways to solve them”. None of which were remotely feasible. How am I supposed to do everything I need to do in a day when I can’t get out of bed? “Well, you just have to will yourself to do it.” HA! Easy for you to say!

    I am surprised by the lack of research done on this topic. There is a wealth of it in unipolar depression. Why not in other disorders?

  4. Personally I am skeptical of any therapist that says they can’t work with a client until they are on medication. It may be more frustrating for the therapist but it is possible for the client to benefit. Take a look at Aaron Becks book “Cognitive Behavioral Therapy for Schizophrenia.” Not specifically about bipolar, but most professionals would think someone with Schizophrenia is more impaired than most people with Bipolar disorder. Lots of therapists don’t want to work with people who are drunk or on drugs but I can tell you from those of us that have worked on locked facilities, we don’t wait until people are better before we try to help them. There may be periods when the mania is so strong that you can’t follow the conversation but other than that there is good evidence that therapy helps all mood disorders, bipolar disorder included. The other side of that coin is people who take meds and don’t do therapy often find their symptoms return because they have the same thinking patterns which cause the same changes in brain chemistry as before.
    If your provider is not helpful, I hope you keep looking and trying. Just my opinion. David

  5. Wow, this really sucks. I’ve been depressed and unable to take any anti-depressant on the market for years, it was recently suggested to me – by a psychiatrist, 15 minutes after meeting me – that I was bipolar, I dropped him after telling him that I didn’t have manic periods – aren’t you supposed to get manic periods if you’re bipolar? – and now I’m seeing a social worker for therapy, starting tomorrow, having been unable to find a shrink who accepts my insurance. Now you’re saying that’s going to be worthless? If so, maybe I’ll skip the 30 mile drive each way and stay depressed. I’m probably overdue for a manic period, maybe one will hit soon and be just he pick me up I need!

    • I think you may have misunderstood, the point of the post was that therapy isn’t worthless. I would definitely still check out what that social worker has to offer, you never know, right?

      And in regard to bipolar disorder, you don’t always have to have manic periods to be diagnosed. There are several categories of the disorder, and in many no manic phases need to be present in order to be diagnosed. It sounds like this isn’t particularly what you want to hear, but for the most part it is very common for folks with bipolar disorder to have poor reactions to anti-depressants as well. Granted, there are other possibilities of what could be going on and I’m not a doctor, so I couldn’t tell you anything for sure.

      I know the potential labeling of having bipolar disorder is a little terrifying, but even if you aren’t on board with the diagnosis, there is the possibility that one of the medications used to treat bipolar disorder could work for you. If nothing else has worked so far, would it hurt to try a new approach?

  6. I will begin by saying that I can empathize with you. My body is extremely sensitive to medications, has even been ravaged by them to the point of emergency room visits and continued monitoring for potential permanent damage.

    But you have to keep in mind that we are the minority. Most patients suffering from bipolar disorder are able to find medication(s) that, while not necessarily free from side effects, are tolerable. They can adjust to the downsides, because they, the patients, decide that life with side effects is better than life with uncontrolled manic-depression.

    And despite my personal experience, I will unequivocally assert that I believe it is irresponsible, and often dangerous to encourage or give unconditional approval to most individuals suffering from manic-depression to try to manage their symptoms and episodes completely medication-free.

    There are obvious exceptions: when medications cannot be tolerated, or when symptoms are minor enough to meet diagnostic criteria but not cause serious difficulty in the functioning of the individual. But bipolar disorder is an illness, and just like any other illness, it needs to be managed.

    Managed, not obliterated or eradicated. I don’t disagree with you that so many doctors and other professionals seem to want to obliterate manic-depression and everything that is part and parcel, and that is not a productive mindset. But proper medication management is crucial for most who are dealing with bipolar.

    Speaking to the question in you post’s title, I don’t think that therapy is pointless, I think it can be extremely beneficial – providing that the therapist and the patient are on the same page. The therapists you wrote about handled things despicably. At the very least, they should have sat you down, face-to-face, and told you they were not comfortable continuing the therapeutic relationship and why. But therapists have rampant insecurities just like everyone else, and it probably came down to them not having the guts to admit, ‘I can’t help you.’

    More research definitely needs to be done on this topic. But until it is (and I suspect it won’t be any time soon), the best that can be done is to find a therapist who is accepting of you, your choices, and your lifestyle, and who you can communicate with openly and comfortably.

    Aren’t those pretty much the qualities you should be seeking out in a therapist anyway? 🙂

    • I try to describe the management of bipolar disorder to people as a pie. Yes, it is true that for many of the people I talk to, psychiatric medications make up a portion of that pie, and they are quick to admit that it is an important piece of that pie. Still, they don’t take up the entirepie.

      My intent here wasn’t to suggest everyone drop the medication portion of their pie, just to point out that there is something unfair going on based on a lack of knowledge.

      There are lot of reasons folks might not be medicated, sure -they might not like the idea of medications, or maybe they just can’t take them, but I find that it is more often that they don’t have insurance and can’t afford them, or they don’t have access to a doctor to prescribe them. Should these people be denied therapy based on the fact they aren’t medicated? Heck no. It is like telling them that since they can’t have the medication portion of the pie, they can’t have any pie.

      I think a little help can go a long way, and for the most part these can be some of the most appreciative folks out there, in regard to getting any help with mental illness.

      I absolutely agree with you about finding the right therapist, and you can expect to read a little more about that topic later on this week!

      Thanks!

  7. On Psychotherapy

    In my mind, meds are the hand reaching over the gunnel to pull you out of the water. After that, you need a buddy to help you learn how to stay in the boat. That may include putting a life preserver (meds) on you. A good buddy will always be a friend indeed, especially when you are in need of one.

    You lie to them, betray them, insult them, and fight them tooth and nail. And when you know that they will never leave you even through all of that, therapy can begin.

    It takes months. After more than ten years and 6 doctors, I finally found someone that I love and trust. I say love because it is a professional relationship, but nothing is more personal than pulling you up from a cold end in the deep waters. She’s 60 years old.

    I keep coming back and she keeps being there for me. I have the lowest pill load I’ve ever had, and no polypharmacy.

  8. This is a fascinating piece, well thought-out and reasoned. It piques my interest even more because I just today published a post on talk therapy for bipolar (http://wp.me/p22afJ-1Rx), and while there are good results about the value of psychotherapy, you are quite correct that I couldn’t find a piece separating the therapy out from medication. Good searching work–and fascinating quote-by Steven H. Jones.

    I’m still sold on medication for the vast majority of people with bipolar, but it’s totally intriguing to hear alternative views. Thanks for the legwork on this one–and good luck on wherever your path ultimately leads you. Candida

    • Thank you Candida, I certainly appreciate the fact that you have taken the time to research this gap in our knowledge as well!

      Since I wrote this piece I have been in therapy (and though medicated it is very clear that I am not having any improvements in mood due to the medications I’ve tried) several months, and in that time alone I have lessened the number of anxiety/panic attacks I have been having by a staggering amount. I would take this to be an indication that some aspect of therapy is helping me, despite the instability of my moods.

      While I understand the world of medical professionals not wanting to suggest (by any means) bipolar patients go unmedicated, the result of these studies is somewhat misleading, in my opinion.

      Glad you liked it, thanks for stopping by!

  9. Back again. I was fascinated enough by this to add it as an addendum to my original post. You really lend an alternative viewpoint I feel I was missing. Thanks!

  10. Pingback: Talking Your Way to Health?: Psychotherapy for Bipolar | candidaabrahamson

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