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.
Published July, 2007