CBT for bipolar disorder

1. Introduction

Version followed: individual relapse-prevention cognitive therapy (CT) as developed by Lam, Jones, Hayward & Bright (1999; 2nd ed. Lam, Jones & Hayward 2010) and tested in Lam et al. (2003), organised into the four-stage sequence described by Jan Scott (2001, 2007). Module topics from Basco & Rush (2005, 2nd ed., 20-session protocol) and Otto, Reilly-Harrington et al. (2009, Managing Bipolar Disorder, the STEP-BD-era CBT programme) are added where they cover ground the Lam/Scott sources do not. These manuals differ in order and emphasis; the source is named for each item below. The full manuals are not drawn on (only tables of contents and published descriptions); step detail beyond those is marked [synthesis] or [uncertain].

CBT for bipolar disorder is a structured, collaborative, educational therapy given alongside mood-stabilising medication, not in place of it [source: Scott 2001; Lam et al. 2003]. It rests on a stress-diathesis model: there is a biological vulnerability to mood episodes, and stressors, disrupted sleep and routine, non-adherence, and certain thinking and behaviour patterns can set off or speed up an episode [source: Lam et al. 2003; Scott 2001]. The theory of change is that people learn to (a) understand their own illness pattern, (b) spot the earliest signs of an episode (the "relapse signature") and act before the prodrome becomes a full episode, (c) keep sleep, activity and routine regular, (d) take medication consistently, and (e) change the depressive and hyperpositive thinking, and the underlying beliefs such as extreme goal striving or perfectionism, that drive mood swings and risky behaviour [source: Scott 2001, 2007; Lam et al. 2003; BYU CGRP summary of the Lam manual]. The main target is preventing relapse and improving functioning, with symptom management of current depression as a second focus.

2. Framework

Format. Individual outpatient therapy is the main form tested (Lam; Scott). Group and brief versions exist (see below). The therapy is usually started when the client is euthymic or only mildly symptomatic, not during acute mania [uncertain: inferred from the relapse-prevention aim and trial designs; exact inclusion criteria not drawn on]. Each session follows the usual CT structure: agenda, review of mood chart and homework, one or two targets, new homework, feedback [synthesis: standard Beckian CT structure, which Scott says this approach builds on].

Session counts by version

Lam (1999/2010; trial 2003): 12 to 18 individual weekly sessions within the first 6 months, plus 2 booster sessions in months 6 to 12. The trial mean was about 14 sessions. Sessions were about an hour, delivered by experienced clinical psychologists with weekly peer supervision of audiotapes [source: Lam et al. 2003; BYU CGRP].
Scott (2001; 2007): about 20 (2001) or 20 to 25 (2007) sessions, weekly to about week 15 and then tapering to fortnightly. Boosters come at about weeks 32 and 38 (2001) or 32 and 40 (2007) [source: Scott 2001, 2007; the two papers give slightly different booster timing, so treat timing as flexible].
Basco & Rush (2005): a 20-session protocol given in the book's appendix [source: Guilford table of contents; session contents uncertain].
Otto, Reilly-Harrington et al. (2009): 13 core sessions (introduction; mood charting and activity scheduling; cognitive restructuring I to IV; core beliefs, 3 sessions; treatment contract, 3 sessions; hypomanic cognitive errors). These are followed by a "problem-list phase" of optional modules and a closing well-being and relapse-prevention component [source: Psychology Tools listing of the therapist guide contents]. In STEP-BD the intensive psychosocial therapies for bipolar depression ran up to 30 sessions over 9 months [source: CNS Spectrums article abstract citing Miklowitz et al. 2007].
Brief technique-led packages: about 6 to 9 sessions without individual formulation, focused only on adherence or early warning signs. Examples are Cochran's 6 group sessions for adherence, Scott & Tacchi's seven 30-minute sessions, and Perry et al.'s early-warning-signs programme [source: Scott 2007].

Stages (Scott's four-stage sequence; Lam's components map onto it)

Stage	Goals	Main work	Typical timing	Move on when [synthesis unless cited]
A. Socialisation, formulation and goals	Shared understanding of the illness; engagement; agreed goals	Explore the client's own model of the illness; life chart; review past episodes for triggers and prodromes; psychoeducation; work on stigma and fragile self-esteem; individual formulation including maladaptive beliefs [source: Scott 2001, 2007]	Sessions 1 to about 4	A life chart and a shared written formulation exist; goals are agreed; the client accepts at least a working hypothesis of a recurrent mood disorder
B. Symptom management	Skills to manage current depressive and hypomanic symptoms	Self-monitoring (mood, thoughts, behaviour, symptoms, daily diary); self-regulation (regular activity, routines, sleep, time management, use of support); coping strategies for depression and mania; automatic thought diaries [source: Scott 2001, 2007]; sleep and routine emphasis [source: Lam et al. 2003]	About sessions 4 to 10	The client keeps a mood chart most days; can name two or three strategies that have shifted mood; sleep and routine are more regular
C. Adherence and beliefs	Remove barriers to treatment; start belief work	Attitudes to medication, pros and cons, risk factors for stopping; excessive self-reliance and attitudes to authority; begin core-belief work [source: Scott 2001, 2007]	About sessions 8 to 15 (overlaps B)	The client has a personal adherence plan; core beliefs and assumptions such as goal striving are named and linked to past episodes
D. Relapse prevention	Self-management after therapy	Relapse signature; at-risk situations and high-risk behaviours with a hierarchy of coping strategies; crisis plan and prior agreements; avoid major decisions during episodes; post-therapy self-management plan; core-belief modification [source: Scott 2001, 2007]	Fortnightly sessions toward the end, then boosters [source: Scott 2001]	A written relapse-prevention and crisis plan has been shared with the people named in it and rehearsed. Boosters check the plan, its use and any new triggers

In the Lam version the content is grouped by theme rather than stage: psychoeducation on the stress-diathesis model and medication; cognitive-behavioural skills to monitor mood and cope with prodromes; sleep and routine; and long-term vulnerabilities such as extreme striving and the urge to "make up for" time lost to illness [source: Lam et al. 2003; BYU CGRP]. The emphasis on routine links it with interpersonal and social rhythm therapy [uncertain: lineage not verified in a primary source].

Guideline context. NICE CG185 recommends that adults with bipolar disorder be offered psychological interventions developed for bipolar disorder (individual, group or family) [source: NICE QS95 statement 4, citing CG185 recommendations 1.2.5, 1.6.1 and 1.7.3]. CG185 also requires a published manual, and its long-term content list covers: information about the disorder; the effect of thoughts and behaviour on mood and relapse; self-monitoring; relapse risk and distress; crisis and staying-well plans; and problem-solving [uncertain]. For bipolar depression it recommends a bipolar-specific intervention or a high-intensity intervention (CBT, IPT or behavioural couples therapy) [uncertain: the CG185 recommendation wording].

3. Guiding principles

Adjunct to medication, within a stress-diathesis model. Present CBT as working with medication, and never set it up as a reason to stop medication [source: Lam et al. 2003; Scott 2001].
Collaborative and educational. Treat the client as co-investigator of their own illness pattern and share all charts and formulations with them [source: Scott 2001].
Formulation-driven. Choose and order interventions from the client's own formulation. Only the brief packages run a fixed sequence without one [source: Scott 2007].
Start from the client's own explanation. Write the client's causal beliefs (stress, personality, spiritual explanations) into the model instead of overriding them [source: Scott 2001].
Work on depression and mania alike. Plan explicitly for both poles, and also for idiosyncratic signs [source: Scott 2001].
Expect non-adherence. Assume the client will not always take medication or do homework; plan for it openly and respect beliefs about autonomy and control [source: Scott 2001].
Protect sleep and routine. Count sleep loss as a possible trigger and early sign. Regular sleep and daily rhythm are standing targets, not optional extras [source: Lam et al. 2003; Scott 2001].
Target the drive behind the swings. Work on extreme goal striving, perfectionism, need for approval and "making up for lost time" as relapse risks, not only on negative thoughts [source: Lam et al. 2003; Scott 2007; BYU CGRP].
Look past mood. Do not use "feeling good" alone as a warning sign, because it is easily mistaken for being well. Base the relapse signature on specific behavioural and cognitive changes [source: Scott 2001].
Self-management is the end goal. Use homework and self-monitoring every session so the client can run the plan without the therapist [source: Scott 2001].
Promote recovery from diagnosis. Convey that a meaningful life is possible, inside a supportive and empathic relationship [source: NICE CG185 rec. 1.1.1].
Fit the work to culture and beliefs. Adapt the work to the client's cultural background and beliefs about biological, social, psychological and family influences [source: NICE QS95 statement 4].
Plan for crisis while well. Make decisions about crises and prior agreements during euthymia, when judgement is intact [source: Scott 2001].

4. Intervention inventory

The entries follow Scott's stages A to D, then the extra modules. The source of each technique is given. Where only a chapter or session title was seen (Basco & Rush; Otto et al.), the steps are standard CBT procedure adapted to bipolar disorder and are marked [synthesis]. All example wording is illustrative and is not quoted from the manuals.

Stage A, 1. Eliciting the client's own model of the illness (socialisation)

Purpose / when: First sessions. Find out what the client believes about their diagnosis, its causes and treatment, so later education and formulation build on it [source: Scott 2001, 2007].
Steps: (1) Ask what they were told about the diagnosis and what they think causes their episodes. (2) Ask how they understand medication and what they make of past episodes. (3) Ask about family history and how the family understands the illness. (4) Write the client's causal ideas down in their own words for use in the formulation. (5) Note any disagreement ("it was just stress") as something to test together, not a debate to win [synthesis on 4 and 5].
Example language (illustrative): "Before I tell you anything, I'd like to hear your own theory. What do you think was going on before your last two episodes?"
Watch for: Rejecting the diagnosis outright, or accepting it fatalistically ("nothing I do matters"). Both feed into later adherence and self-esteem work. It is working when the client can say their own version of how episodes start.

Stage A, 2. Life chart

Purpose / when: Early sessions. Map the history of episodes so triggers, prodromes, treatment effects and patterns become visible [source: Scott 2001, 2007].
Steps: (1) Draw a horizontal timeline from first symptoms to now, with a mid-line for normal mood. (2) Mark each depressive episode below the line and each manic or hypomanic episode above it, with rough height for severity and length for duration. (3) Add life events, hospital admissions, medication starts and stops, substance use, sleep disruption, and changes in work or relationships. (4) For each episode ask what was happening in the weeks before, what changed first, and what helped or harmed. (5) Look for repeated sequences, such as sleep loss before highs or stopping medication before relapse. (6) Use family members or old records to fill gaps when the client agrees [synthesis on steps 1 and 6: a common life-chart method; the manual's exact format].
Example language (illustrative): "Let's put your history on one page. Where would you put the first time things felt really wrong, and was it a high or a low?"
Watch for: Distress or shame while reviewing past episodes, especially behaviour during mania. Pace the work and normalise it. Memories of manic periods may be incomplete. It is working when the client sees a pattern they had not noticed. The chart then feeds the relapse signature (Stage D).

Stage A, 3. Psychoeducation

Purpose / when: Throughout Stage A and revisited later. Give accurate information about bipolar disorder, its epidemiology, treatments and prognosis, framed in the stress-diathesis model and the role of medication [source: Scott 2001; Lam et al. 2003; BYU CGRP summary of Lam].
Steps: (1) Link each piece of information to the client's own life chart, not to generic facts. (2) Explain vulnerability plus triggers: biological sensitivity, with stress, sleep loss, substances and stopping medication as common triggers. (3) Explain what medication does and why maintenance treatment matters, and refer dosing questions to the prescriber. (4) Explain prodromes and why catching them early matters. (5) Check understanding by asking the client to summarise. (6) Give written or reputable online material [synthesis on 1, 5 and 6].
Example language (illustrative): "One way to think about it is a vulnerability, a bit like a sensitive alarm system. Medication turns the sensitivity down; sleep, routine and how you handle stress decide how often the alarm gets tripped."
Watch for: Information overload, and information heard as a life sentence. Pair facts with what the client can influence. It is working when the client can explain the model in their own words and link it to an episode of their own.

Stage A, 4. Individual formulation (cycle-of-change diagram)

Purpose / when: End of Stage A, revised throughout. Build a shared map linking cognitions, behaviour, mood, sleep, environmental stressors and biological factors, plus core maladaptive beliefs, to guide which interventions come next [source: Scott 2001 (figure based on Basco & Rush); Scott 2007].
Steps: (1) Pick one recent episode or near-episode from the life chart. (2) Draw boxes for trigger or stressor, thoughts, behaviour, sleep and activity, mood, and biological vulnerability, and draw arrows for how each fed the others. (3) Add the client's own causal beliefs. (4) Add the underlying assumptions or core beliefs that made the trigger matter, such as perfectionism, need for approval or excessive self-reliance [source: Scott 2007]. (5) Sort current problems into intrapersonal (e.g. low self-esteem), interpersonal (e.g. small social network) and basic (e.g. severity of symptoms, work difficulties) [source: Scott 2001, 2007]. (6) Agree where to intervene first.
Example language (illustrative): "So the deadline came, you started working nights, sleep dropped to a few hours, you felt brilliant, and then you took on even more. Where in that chain could we most easily put a brake?"
Watch for: A formulation the client does not recognise. Revise it with them. It is working when the client uses the diagram to explain a new event.

Stage A, 5. Addressing stigma and fragile self-esteem

Purpose / when: When the diagnosis triggers negative thoughts about the self ("I'm defective", "no one will employ me") or shame that blocks engagement [source: Scott 2001, 2007: challenging negative automatic thoughts and behavioural experiments on stigma and fragile self-esteem].
Steps: (1) Find the specific stigma-related thoughts and rate belief from 0 to 100. (2) Examine evidence for and against, and separate "having an illness" from "being the illness". (3) Design a behavioural experiment, for example telling one trusted person and predicting their reaction beforehand, or collecting evidence of competence over a week. (4) Review the result against the prediction and re-rate belief [synthesis on step detail: standard CT experiment procedure].
Example language (illustrative): "You predict your sister will pull away if you tell her. How could we find out, in a small and safe way, whether that's true?"
Watch for: Experiments that may really carry social or job risk. Choose safe tests. It is working when belief ratings drop and the client engages more openly with treatment.

Stage A, 6. Goal setting and problem list

Purpose / when: End of Stage A. Turn the formulation into agreed, measurable goals [source: Scott 2001 lists goals: accept the disorder and the need for treatment; manage stressors and interpersonal problems; improve adherence; cope with depression and hypomania; recognise early relapse; self-management; modify thoughts and beliefs].
Steps: (1) List problems by the three types. (2) Ask the client to rank them. (3) Turn the top three into specific goals with a sign of success. (4) Add relapse prevention as a standing goal even if the client did not raise it, and explain why [synthesis on steps 2 to 4].
Example language (illustrative): "If therapy works, what would be different in six months that you could actually see?"
Watch for: Goals that are themselves over-ambitious, a pointer to goal striving (see Stage C). It is working when goals are concrete and agreed.

Stage B, 7. Mood charting and self-monitoring (structured daily diary)

Purpose / when: From Stage B onward and continuing after therapy. Track mood, sleep, activity, thoughts and symptoms so changes can be spotted and links seen [source: Scott 2001, 2007; Lam et al. 2003; Otto et al. session 2 "Mood Charting and Activity Scheduling" (title only)].
Steps: (1) Agree a simple daily rating, for example mood from very depressed to very elevated around a neutral midpoint, plus hours slept and one or two key behaviours. Medication taken and substance use can be added [synthesis on the exact scale]. (2) Rate at the same time each day. (3) Review the chart at the start of every session. (4) Link peaks and troughs to events, sleep and thoughts. (5) Over time, mark personal threshold levels that trigger the coping plan.
Example language (illustrative): "Can we keep this to under two minutes a day? What time would you actually remember to do it?"
Watch for: Over-monitoring that raises anxiety. Patchy charts may themselves show mood change. During highs the client may stop charting or rate themselves as merely "good". It is working when the client keeps charting most days and starts drawing links without prompting.

Stage B, 8. Regulating sleep and daily routine (self-regulation)

Purpose / when: Core throughout, and urgent when sleep or routine is erratic. Sleep loss can trigger episodes, so keeping sleep and daily rhythm regular protects against relapse [source: Lam et al. 2003; BYU CGRP; Scott 2001, 2007 on regular activity, daily routines, sleep patterns, time management and use of support].
Steps: (1) Use the diary to find current bed and wake times, meals, work hours and evening stimulation. (2) Agree fixed wake and bed times that stay close at weekends. (3) Anchor meals and some daily activity at regular times. (4) Plan ahead for disruptions such as night shifts, long-haul travel, deadlines, parties and new babies. (5) Build a wind-down routine with less stimulation in the evening. (6) Agree what counts as a warning, such as a run of short-sleep nights, and what to do then (link to the relapse plan). (7) Add time management: cap working hours and plan breaks [synthesis on steps 2 to 7: Lam's emphasis on sleep and routine is confirmed, the specific procedure is not].
Example language (illustrative): "Looking at your life chart, the highs both started after weeks of very little sleep. How would you feel about treating your sleep as part of your treatment?"
Watch for: Clients who prize late-night productivity, or who see routine as dull or as giving in. Link this to beliefs about goal striving. It is working when sleep and routine times vary less on the chart.

Stage B, 9. Activity scheduling and coping strategies for depression

Purpose / when: Current or emerging depression. Rebuild activity, mastery and pleasure without over-scheduling [source: Scott 2001, 2007 "coping skills for depression"; Otto et al. session 2 (title); Basco & Rush ch. 7 "Trigger Control and Increasing Positives" (title only)].
Steps: (1) Use the diary to show the link between activity and mood. (2) Schedule a small number of manageable activities, mixing mastery and pleasure. (3) Rate predicted and actual mastery and pleasure. (4) Break avoided tasks into steps. (5) Find triggers for low mood and plan around them. (6) Keep the plan realistic so success does not depend on a burst of energy [synthesis on step detail].
Example language (illustrative): "Let's plan the smallest version of this that would still count. What would a five-minute version look like?"
Watch for: Over-correction into overactivity as mood lifts, which can tip into hypomania. Keep an eye on sleep and total load. It is working when mood lifts alongside activity while sleep stays stable.

Stage B, 10. Coping strategies for hypomanic symptoms

Purpose / when: When early hypomanic signs or mild elevation appear. Reduce the behaviour that turns a prodrome into an episode [source: Scott 2001 "coping skills for... mania"; Lam et al. 2003 on changing behaviour so prodromes do not progress; Basco & Rush ch. 8 "Controlling Negatives" (title only)].
Steps (synthesis): (1) Prioritise sleep: keep fixed bed and wake times and cut evening stimulation. (2) Reduce stimulation and commitments: fewer social events, projects and stimulants, and no alcohol or drugs. (3) Postpone new major commitments and big spending, and run them past an agreed person first (see the crisis plan). (4) Make a list of ideas instead of acting on them, and review it once mood is stable. (5) Contact the prescriber early about possible medication review. (6) Use the agreed hierarchy of coping strategies (Stage D).
Example language (illustrative): "Your chart shows less sleep and three new projects this week. That matches your early pattern. What's on your list for this stage?"
Watch for: Hypomania feeling good, so the client may resist or reinterpret the signs. Work this out while euthymic. It is working when the client acts on the signs before function is affected.

Stage B, 11. Automatic thought diaries and cognitive restructuring (depressive thinking)

Purpose / when: Negative thoughts about self, world and future that keep low mood, hopelessness or avoidance going [source: Scott 2001, 2007; Otto et al. sessions 3 to 6 "Cognitive Restructuring I to IV" (titles); Basco & Rush ch. 9 "Management of Cognitive Symptoms: Content Changes" (title)].
Steps: (1) Record situation, emotion and its intensity, and the automatic thought, rating belief. (2) Name the distortion (e.g. all-or-nothing thinking, overgeneralising, mind-reading). (3) Weigh the evidence for and against. (4) Form a balanced alternative and re-rate belief and emotion. (5) Test it behaviourally where possible. (6) Practise between sessions [synthesis: standard Beckian CT, which Scott says this approach builds on].
Example language (illustrative): "When you thought 'I've ruined everything again', how much did you believe it? And what does the evidence say about 'everything'?"
Watch for: Severe depression limiting what the client can do; simplify the forms. Thoughts about the illness itself ("I'll never be stable") need the same work. It is working when belief ratings shift and the client starts to challenge thoughts without help.

Stage B, 12. Recognising hyperpositive thinking and hypomanic cognitive errors

Purpose / when: In euthymia, preparing for highs; also at early elevation. Catch the overly positive thinking of rising mood, such as overestimating ability, underestimating risk and seeing ideas as uniquely brilliant [source: Scott 2001 describes hyperpositive thinking and positive distortions in mania; Otto et al. session 13 "Hypomanic Cognitive Errors" (title); Basco & Rush ch. 10 "Process Changes" (title; content may cover racing or disorganised thought: uncertain); BYU CGRP: Lam addresses overly positive thoughts].
Steps (synthesis): (1) From the life chart, collect real thoughts the client had when high, such as "I don't need sleep" or "this investment can't fail". (2) Name the errors: overestimating success, underestimating risk, discounting others' concerns. (3) Write a list of personal "high thoughts" as part of the relapse signature. (4) Agree reality checks for decisions made during elevation: wait, write down the risks, ask a trusted person. (5) Rehearse using these on a real current decision.
Example language (illustrative): "When you're well, looking back, which thoughts from last summer would you now call warning signs rather than insights?"
Watch for: Grief or defensiveness about losing "high" experiences, and the risk of sounding as if every positive feeling is suspect. Separate ordinary happiness from patterns tied to episodes. It is working when the client spots their own high thoughts and delays acting on them.

Stage C, 13. Medication adherence work

Purpose / when: Stage C, and whenever a client has stopped, skipped or wants to stop medication [source: Scott 2001, 2007; Basco & Rush ch. 4 "Enhancing Adherence" (title)].
Steps: (1) Explore the client's fears, attitudes and thoughts about medication, for example side effects, "being controlled", losing creativity or highs, or "needing pills means I'm weak". (2) Draw up the advantages and disadvantages of taking it and of not taking it, short-term and long-term. (3) Find the factors that raise or lower the client's own risk of non-adherence, such as feeling well, side effects, chaotic routine, or beliefs about self-reliance and authority. (4) Treat those beliefs with cognitive techniques and the practical barriers with behavioural ones, such as linking doses to routine, reminders, and agreeing to raise side effects with the prescriber [source for steps 1 to 4: Scott 2001, 2007; specific behavioural aids are synthesis]. (5) Assume lapses will happen and plan what to do after one [source: Scott 2001].
Example language (illustrative): "It makes sense that you'd want to stop something that dulls you. Let's put both sides on paper, and look at what happened on your life chart the last two times you stopped."
Watch for: Lecturing, which tends to push clients away. Respect autonomy. Never advise on doses; liaise with the prescriber. It is working when the client discloses missed doses openly and side effects are raised with the prescriber instead of medication being stopped quietly.

Stage C, 14. Treatment or compliance contract

Purpose / when: After the client has learned to identify symptoms. A written, agreed plan of what the client and named supporters will do as specific symptoms appear [source: Basco & Rush ch. 5 "Compliance Contracts" (title); Otto et al. sessions 10 to 12 "Drafting a Treatment Contract" (titles)]. Exact layout and contents in the manuals are [uncertain].
Steps (synthesis): (1) List the client's early signs for depression and for hypomania (from the relapse signature). (2) For each level of severity, write what the client will do, what they want named supporters to do or not do, and when to contact the care team. (3) Include treatment preferences and what supporters may say when they notice signs. (4) Invite the supporters to a session to agree the plan. (5) Sign, share copies and set a review date.
Example language (illustrative): "Let's agree now, while you're well, what you want your partner to do if she sees you sleeping four hours and spending fast, including how she should say it."
Watch for: Contracts that feel coercive. The client owns the wording. It is working when supporters and client describe the same plan and use it.

Stage C, 15. Identifying and modifying core beliefs and dysfunctional assumptions

Purpose / when: Stage C onward. Change underlying rules such as perfectionism, need for approval and excessive self-reliance that drive automatic thoughts, risky striving and stress [source: Scott 2001, 2007; Otto et al. sessions 7 to 9 on core beliefs (titles)].
Steps: (1) Use the downward arrow from recurring automatic thoughts ("if that's true, what does it mean about you?"). (2) Write the assumption as an if-then rule and trace where it came from. (3) Weigh its costs and benefits, including its role in past episodes. (4) Draft a more flexible alternative rule. (5) Test the new rule with behavioural experiments. (6) Keep a positive data log for the new belief [synthesis: standard CT belief-change methods].
Example language (illustrative): "The rule seems to be 'If I'm not exceptional, I'm worthless.' What has living by that rule cost you, especially around your episodes?"
Watch for: Belief work stirring strong affect in a mood-sensitive client. Pace it and watch the mood chart. It is working when the client acts against the old rule and mood stays stable.

Stage C, 16. Working with extreme goal striving and "making up for lost time"

Purpose / when: When the client pushes hard after an episode, sets very high goals or links self-worth to achievement. This is a specific feature of the Lam manual [source: Lam et al. 2003; BYU CGRP: regulating extreme goal striving; Scott 2007 notes research by Lam and Johnson on this theme].
Steps (synthesis): (1) Map past cycles of losing time to illness, then frantic catching up, sleep loss and relapse on the life chart. (2) Name the striving assumptions and rate belief. (3) Look at advantages and disadvantages, including how much has been achieved through steady pacing versus bursts. (4) Set graded, paced goals with a weekly limit on hours or new commitments. (5) Watch for a rise in goal-directed activity as a possible early warning sign. (6) Grieve losses caused by the illness openly, so catching up stops standing in for that grief.
Example language (illustrative): "After each low patch you've tried to win back the whole year in a month. What happened to your sleep and mood each time?"
Watch for: Ambition being heard as discouraged. The aim is sustainable achievement, not lower aspirations. It is working when goals are paced and new commitments are timed against the chart.

Stage D, 17. Building the relapse signature (early warning signs)

Purpose / when: Stage D, drawing on the life chart and monitoring. Identify a personal set of the earliest, most reliable signs of a coming depressive or (hypo)manic episode [source: Scott 2001, 2007; Lam et al. 2003; REACT toolkit module for common examples].
Steps: (1) For each past episode, ask what changed first, then next, then next, in sleep, activity, thinking, social behaviour, spending, irritability and appetite. (2) Ask supporters what they noticed first. (3) Sort the signs into depression-specific, mania-specific and idiosyncratic ones [source: Scott 2001]. (4) Pick two or three key signs for each pole. Avoid using mood alone, because it is easily read as being well [source: Scott 2001]. Common examples include feeling more energetic, talking more and feeling high for (hypo)mania, and low motivation, low energy and tiredness for depression [source: REACT toolkit]. (5) Order the signs by stage (early, middle, late) and set observable thresholds for action [synthesis].
Example language (illustrative): "Of everything on this list, which two showed up earliest and most reliably? Those are the ones we'll watch."
Watch for: Signs so common they cause false alarms, such as one bad night. Set a time threshold. Signs differ between people. It is working when the client and supporters can name the signature without notes.

Stage D, 18. Coping with prodromes: at-risk situations, high-risk behaviours and a hierarchy of coping strategies

Purpose / when: Stage D. Plan concrete responses so prodromes do not become episodes [source: Scott 2001, 2007 (at-risk situations, high-risk behaviours such as more alcohol use, hierarchy of coping strategies); Lam et al. 2003 (cognitive-behavioural skills for coping with prodromes)].
Steps: (1) List at-risk situations from the life chart, such as exams, bereavement, travel, conflict, anniversaries and stopping medication. (2) List high-risk behaviours, such as rising alcohol or drug use, all-nighters and spending sprees. (3) For each, build a graded hierarchy of strategies running from self-help (sleep, routine, cutting stimulation, activity scheduling) to involving supporters and then the care team or prescriber [the hierarchy structure is from Scott; the contents are synthesis]. (4) Rehearse them with scenarios in session. (5) Review past coping. Lam et al. measured how well clients coped with past prodromes on a rating scale [source: Lam et al. 2003; the scale is not reproduced].
Example language (illustrative): "Let's take your exam season as the test case. What's step one if sleep drops for two nights? What's step three if spending starts too?"
Watch for: Plans that rely on insight the client loses as mood rises. Build in steps that supporters trigger. It is working when real prodromes since the plan were noticed and acted on earlier than before.

Stage D, 19. Crisis plan, prior agreements and "no major decisions" rule

Purpose / when: Stage D, while euthymic. Agree in advance how a crisis will be handled [source: Scott 2001: crisis management, avoiding major decisions during episodes, prior agreements with family and clinicians].
Steps: (1) Agree that major decisions (jobs, relationships, big purchases, moving house) wait until mood is stable, and say who will help judge that. (2) Agree with family and clinicians who will act on which signs and how. (3) Record crisis contacts, treatment preferences and practical arrangements (children, pets, money, cards). (4) Include suicide risk steps and lethal-means safety where relevant, in line with local risk practice [synthesis on 3 and 4]. (5) Share copies with the client's consent.
Example language (illustrative): "While you're well, can we agree a rule for future-you: no decision over a certain size until you've had two weeks of steady mood and talked it through with someone on this list?"
Watch for: Ambivalence about handing control to others. Keep the client's choices central. It is working when the plan is known and used in a crisis.

Stage D, 20. Self-management plan, tapering and booster sessions

Purpose / when: Final sessions and boosters. Consolidate skills for life after therapy [source: Scott 2001 (planning self-management after discharge; fortnightly anti-relapse sessions; boosters); Lam et al. 2003 (2 boosters in months 6 to 12)].
Steps: (1) Space sessions out to fortnightly. (2) Compile a single written plan: formulation, relapse signature, coping hierarchy, crisis plan, adherence plan, routine targets. (3) Agree how long to keep monitoring. (4) Hold booster sessions to review use of the plan, new triggers and lapses, and to refresh skills [synthesis on 2 and 3].
Example language (illustrative): "In the booster, I'd like you to teach me your plan as if I were new to it, and we'll see what needs updating."
Watch for: Drop-off in monitoring once the client feels well. Boosters target this. It is working when the client has used the plan independently between sessions.

Across stages, 21. Involving family or supporters

Purpose / when: In assessment (family interactions and understanding) and in planning (prior agreements, contracts) [source: Scott 2007 (family interactions explored in Stage A); Scott 2001 (prior agreements with family)]. Note that the Lam and Scott CT is individual, and formal family therapy is a separate approach (family-focused therapy) [source: Scott 2007; CNS Spectrums abstract on STEP-BD].
Steps (synthesis): (1) With consent, invite a key supporter to one or two sessions. (2) Share the formulation and relapse signature. (3) Agree how the supporter will raise concerns, using wording the client chooses. (4) Give carers information and point them to carer support [source: REACT toolkit on information for relatives].
Example language (illustrative): "What would be the most helpful way for your brother to tell you he's worried, and what would be the least helpful?"
Watch for: Critical or over-involved family interactions, and confidentiality. It is working when supporters' feedback is accepted without conflict.

Optional modules (problem-list phase): what the manuals list

The following are module or chapter titles in Basco & Rush (2005) or Otto et al. (2009). Only titles were seen. The steps are standard CBT procedures adapted to bipolar disorder [synthesis], to be used when the problem list calls for them [source for module existence: Guilford contents; Psychology Tools contents].

Module 22. Stress management

Purpose / when: Stress is a recurrent trigger on the life chart [source: Basco & Rush ch. 11 (title); Scott 2001 lists managing stressors as a goal].
Steps (synthesis): (1) List current stressors and rate them. (2) Separate the controllable from the uncontrollable. (3) Problem-solve the controllable ones. (4) Plan coping and support for the rest. (5) Spread out predictable stressors in time. (6) Watch sleep during stressful periods.
Example language (illustrative): "Which of these three can you actually change this month, and which do we need to plan to get through?"
Watch for: Stress management turning into another striving project. It is working when stress peaks pass without changes in sleep or mood.

Module 23. Interpersonal communication and social skills

Purpose / when: Conflict, irritability, or a damaged or small social network [source: Basco & Rush ch. 12 "Addressing Problems in Interpersonal Communication" (title); Otto et al. ch. 18 "Social Skills Training Module" (title); Scott 2001, 2007 list interpersonal problems].
Steps (synthesis): (1) Choose a recent difficult exchange. (2) Look at what was said and heard, and the thoughts on each side. (3) Teach specific skills: listening and reflecting, "I" statements, specific requests, timing (not when mood is high or angry). (4) Role-play. (5) Practise with a real person and review.
Example language (illustrative): "Let's replay that argument. This time, say what you'd ask him to do, in one sentence."
Watch for: Irritability that is part of a prodrome, not a skills gap. Check the chart. It is working when there are fewer escalations and requests are clearer.

Module 24. Problem-solving

Purpose / when: Practical problems that drive stress or follow episodes, such as debt, work or housing [source: Otto et al. ch. 17 "Problem-Solving Module" (title)].
Steps (synthesis): (1) Define the problem in concrete terms. (2) Brainstorm options without judging them. (3) Weigh pros and cons. (4) Choose one and plan the steps. (5) Act and review. Slow the process down if mood is elevated.
Example language (illustrative): "Let's list every option, even silly ones, before we judge any of them."
Watch for: Impulsive solutions chosen during elevation. Use the no-major-decisions rule. It is working when problems are tackled step by step.

Module 25. Comorbid anxiety

Purpose / when: Co-occurring panic, social anxiety, GAD or similar [source: Otto et al. ch. 19 "Management of Comorbid Anxiety Disorders Module" (title)].
Steps (synthesis): Use standard CBT for the specific anxiety disorder (psychoeducation, cognitive work, graded exposure). With exposure, explain the rationale, get consent, agree the client controls the pace, and avoid doing intensive exposure during mood episodes or with acute risk. Watch whether disrupted sleep from late-evening exposure work is affecting mood.
Example language (illustrative): "We'll build a ladder of steps, you decide each step, and we'll pause if your mood chart starts to move."
Watch for: Anxiety that is part of a mixed or depressive prodrome. It is working when avoidance falls and mood stays stable.

Module 26. Breathing and relaxation strategies

Purpose / when: Arousal, tension, sleep onset problems, or as a step in the coping hierarchy for agitation [source: Otto et al. ch. 20 (title)].
Steps (synthesis): Teach slow breathing and progressive muscle relaxation in session, practise daily, then use them in the wind-down routine and at early arousal.
Example language (illustrative): "Let's practise this now so it's ready before you need it."
Watch for: Relaxation used in place of acting on a clear prodrome. It is working when the client uses it without prompting and arousal drops.

Module 27. Anger management

Purpose / when: Irritability and anger outbursts, common in mixed states and hypomania [source: Otto et al. ch. 21 (title)].
Steps (synthesis): (1) Build an anger log of triggers, thoughts and body cues. (2) Practise early time-out. (3) Challenge hostile interpretations. (4) Plan assertive alternatives. (5) Add rising irritability to the relapse signature if it predicts episodes.
Example language (illustrative): "What's the first thing your body does before you snap?"
Watch for: Risk to others. Follow local safeguarding procedures. It is working when time-outs are used and incidents fall.

Module 28. Managing extreme emotions

Purpose / when: Intense emotions beyond a mood episode [source: Otto et al. ch. 22 (title); contents uncertain].
Steps (synthesis): Name and rate emotions, use distress-tolerance and self-soothing strategies, delay acting on intense urges, and ask for support.
Example language (illustrative): "On a 0 to 10 scale, where is it now, and what has brought it down even one point before?"
Watch for: Self-harm urges; assess risk. It is working when urges pass without harmful action.

Module 29. Well-being and relapse-prevention close

Purpose / when: Ending phase in the Otto programme, building positive functioning as well as reducing symptoms [source: Otto et al. ch. 23 "Well-Being Therapy and Relapse Prevention" (title); contents uncertain].
Steps (synthesis): Track moments of well-being and what cuts them short, build on strengths and valued activities at a sustainable pace, and fold this into the final relapse-prevention plan (item 20).
Example language (illustrative): "Alongside watching for warning signs, let's track what a good, steady week looks like for you."
Watch for: Positive-mood work being confused with chasing highs. Keep the link to steady routine. It is working when the client reports satisfaction with stable mood.

Brief formats (6 to 9 sessions)

Purpose / when: Limited resources, or a narrow target. A fixed package on adherence or on early warning signs, without individual formulation [source: Scott 2007, citing Cochran (6 group sessions), Scott & Tacchi (seven 30-minute sessions), Perry et al. (early warning signs)].
Steps: Deliver items 3, 13, 17 and 18 in condensed form. Groups add peer sharing [synthesis on selection].
Watch for: Scott notes these mainly reduce mania, with little effect on depression, so add depression-focused work when depression dominates [source: Scott 2007].

5. Handling problems

Most of what follows is [synthesis], built from the principles above. Where a source supports a point, it is cited.

Client becomes hypomanic or manic during therapy. Shorten sessions and focus on the coping hierarchy, sleep, cutting stimulation, safety and contacting the prescriber now. Postpone cognitive restructuring and belief work. Bring in agreed supporters under the prior agreement [source for prior agreements: Scott 2001]. Resume the planned work after the episode, and add the episode to the life chart as a learning event [synthesis].
Client resists or disputes the diagnosis. Work from the client's own model [source: Scott 2001]. Agree to test hypotheses using the life chart and mood chart, and frame the work as reducing what the client sees as disruptive (lost jobs, fights) without needing agreement on the label [synthesis].
Non-adherence to medication. Expect it and plan for it [source: Scott 2001]. Explore the beliefs behind it non-judgementally (autonomy, self-reliance, missing highs), review the pros and cons and the life chart, and support raising side effects with the prescriber. Never advise on doses [source: Scott 2001, 2007; synthesis on liaison].
Homework or monitoring not done. Make the task smaller (one rating a day), link it to an existing routine, and find out what got in the way. Notice whether non-completion tracks mood. Agree a minimum to keep doing between sessions [synthesis].
Missing highs, grief and loss. Clients may miss the energy and creativity of elevated periods, or grieve years lost to illness. Name this openly and look at the costs and benefits honestly. Connect it to the "making up for lost time" pattern [source: Lam et al. 2003] and to valued goals reachable at a steady pace [synthesis].
Overwhelm or worsening during belief work or life-chart review. Stop, ground, and switch back to behavioural work (routine, activity). Return to the material when mood has been stable for a while [synthesis].
Stuck depression. Check medication with the prescriber, adherence, sleep, substance use and possible mixed features. Go back to activity scheduling with smaller steps. Consider the intensive formats used for bipolar depression in STEP-BD, which ran up to 30 sessions [source: CNS Spectrums abstract citing Miklowitz et al. 2007; synthesis on the rest].
Suicidal thinking. Assess risk at each session when depressed, mixed or after a rapid shift in mood, following current local standards. Make a collaborative safety plan, involve the care team, and counsel on lethal means (restricting access, safe storage of medication) [synthesis; standard practice].
Substance use. Treat increased alcohol or drug use as a high-risk behaviour and a possible prodrome [source: Scott 2001, 2007]. Add it to the relapse signature and coping hierarchy, and refer to substance services where needed [synthesis].
Rupture: client feels policed (e.g. "you think every good mood is mania"). Acknowledge it, separate ordinary happiness from signature patterns, and hand the client control over what supporters may say and how. Check the alliance at the end of sessions [synthesis].
Rapid cycling or mixed states. Use shorter monitoring intervals and set action thresholds on sleep and behaviour, not on mood alone [source: Scott 2001 on mood as an unreliable signature]. Work closely with the prescriber and focus on stability before restructuring [synthesis].
Cognitive difficulties during or after episodes. Use written summaries, repetition and shorter sessions, and simplify forms [synthesis].
Family conflict or critical comments. Use a joint session to align on the plan. Consider referral to family-focused therapy when family stress drives relapses [synthesis; family-focused therapy is a separate manualised approach].
Therapist pitfalls. Belief work started too early, before monitoring and routine are in place. Over-scheduling clients who strive too hard. Acting as prescriber [synthesis].

Sources

Sources

Further reading (not drawn on)

Lam, D.H., Jones, S.H., Hayward, P. & Bright, J.A. (1999). Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice. Chichester: Wiley. (2nd ed.: Lam, Jones & Hayward, 2010.)
Basco, M.R. & Rush, A.J. (2005). Cognitive-Behavioral Therapy for Bipolar Disorder (2nd ed.). New York: Guilford. (1st ed. 1996.)
Otto, M.W., Reilly-Harrington, N.A., et al. (2009). Managing Bipolar Disorder: A Cognitive Behavior Treatment Program, Therapist Guide. Oxford University Press (Treatments That Work). [uncertain: full author list and exact year not verified]
Newman, C.F., Leahy, R.L., Beck, A.T., Reilly-Harrington, N.A. & Gyulai, L. (2002). Bipolar Disorder: A Cognitive Therapy Approach. Washington, DC: APA. (Not drawn on; none of its specific techniques are used in this guide.)
Miklowitz, D.J. et al. (2007). Intensive psychosocial intervention enhances functioning in patients with bipolar depression (STEP-BD). Archives of General Psychiatry. (Cited via the CNS Spectrums abstract.)
National Institute for Health and Care Excellence (2014, updated 2020). Bipolar disorder: assessment and management (CG185).

Gaps and uncertainties. The full wording of the CG185 psychological-intervention recommendations (1.5.x, 1.7.x) could not be loaded. Session-by-session contents of the Basco & Rush 20-session protocol and the Otto et al. modules are not drawn on, so steps for those items are [synthesis]. Hypomania-specific delay rules credited to other manuals were not verified and are left out.

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