Schema Therapy & Bipolar Disorder
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Q:  Schema Therapy & Bipolar Disorder

I am interested in the use of schema therapy for BP. I see it was designed to treat personality disorders but I remember from your website that you mention the similarities between the two. I am wondering what your thoughts are about it's use and effectiveness in BP individuals.

Dear Sam --

"Schema therapy" is a variation of cognitive therapy, I think most experts would accept. The focus is on not just "automatic thoughts", as it is in cognitive therapy, but rather on a deeper level, sort of the next layer down, namely the schema that lies behind the automatic thoughts. What is the worldview that leads to one's characteristic ways of thinking about emotional issues? That in some respects is an even better target than one's automatic thoughts themselves. It is more fundamental. For people with "personality disorders" (a term I much dislike, as at minimum it suggests a remarkable hubris on the part of psychiatry: "you have a personality disorder", whereas we are completely normal and therefore in a position to judge you), this therapy presumes that their schema will be very powerful and slanted in some way to produce the characteristic thoughts and behaviors of the condition.

In bipolar disorder, one might presume that there is no such underlying "slant" that needs attention in this way. At least it is not the fundamental basis of the problem, as would be the presumption in schema therapy for personality disorders. Therefore, in theory this therapy is not "on target" for bipolar disorder patients. They would be better off with a cognitive therapy which has been designed with the characteristic thoughts of bipolar disorder patients in mind, as it has been done by two independent research groups at least (their treatment manuals are available on my website on the page about
Psychotherapy for Bipolar Disorders, near the bottom of that page).

Nevertheless, one could surmise that many patients with bipolar disorder do indeed have some sort of underlying "slant" in their ways of viewing the world, perhaps belonging to them originally, or perhaps generated by their experiences due to their illness. For example, paranoia might be a particularly common such slant as quite a few people with bipolar disorder lean somewhat in that direction: they have very intense thinking around figuring out the causes of things, and can at times take more negative interpretations of their causal assumptions such that they see other people as somehow meaning them harm. To my knowledge, no one has ever tried to target that kind of thinking, that "schema", as part of treatment of bipolar disorder; but it might be quite appropriate in some people. On the other hand, sometimes that way of seeing the world is actually tied to the mood/energy cycling these people experience. In other words, it is not really a schema in the same sense, not something that is always there. Instead, this is more of a temporary schema which comes and goes with shifts in mood. In that case, such therapy might be rather a wasted effort; it might be a lot simpler to target the mood symptoms more directly, and stop the cycling, and then the need for such therapy would be moot.

All that said, I am sure that there are people with bipolar disorder who would benefit from a schema-focused therapy, just as many people who have neither bipolar disorder nor a "personality disorder" might. There: have I landed on nearly all the possible squares? I hope that is more useful than confusing.

Dr. Phelps

Published July, 2007

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