1. The programme at a glance
Indication. Bipolar I or II disorder in an adult, diagnosed, followed by a psychiatrist, in a period of relative stability or residual symptoms — not during an acute episode.
Reference model. Structured psychoeducation, supplemented by work on regular rhythms and by the involvement of someone close (Colom and Vieta, 2006; Frank et al., 2005; Miklowitz, 2019). These are the approaches that have shown a reduction in relapses alongside medication.
Format. Twelve 50-minute sessions, thirteen if session 2 is split in two (section 17), one a week up to session 10, then session 11 a fortnight later and session 12 a month after that. One session is held jointly with someone close, session 10; that person can also attend session 3. Three boosters, at three, six and twelve months, because the result is measured in years.
Mechanism targeted. Reducing the number and severity of episodes by acting on what can be changed: early recognition of the signs, regular rhythms, continuity of treatment, and what to do in the days before an episode.
| Session |
Subject |
Deliverable of the session |
| 1 |
Assess and situate |
Diagnosis clarified, frame set |
| 2 |
The history as a curve |
The chronology plotted, in their own hand |
| 3 |
Understanding the disorder |
Model explained, questions addressed |
| 4 |
The signs of elevation |
Personal list of the first signs |
| 5 |
The signs of depression |
Personal list, and distinction from what is normal |
| 6 |
The emergency plan |
Plan written, passed on to the psychiatrist and to someone close |
| 7 |
Rhythms and sleep |
Week regulated, times written down |
| 8 |
The treatment |
Obstacles to adherence identified |
| 9 |
What the episodes left behind |
Consequences listed, repairs dated |
| 10 |
Those close to the person |
Joint session, written agreement |
| 11 |
The life project |
Realistic goals, losses named |
| 12 |
Review, relapse, maintenance |
Maintenance plan, measures repeated |
What the person takes away. Seven printable worksheets, listed in section 39: my curve, my signs when it goes up, my signs when it goes down, my plan (the emergency plan), my rhythms, the corner for those close, my plan for what comes next.
What sets this programme apart from the other manuals on this site. Three things. In it, psychotherapy is explicitly a complement and not the main treatment. Its main aim is measured not in weeks but in years. And it asks for a written document intended to be read by someone other than the patient.
2. Before you start
When you start
Not during an acute episode. Neither manic nor severely depressed. A patient in a manic phase cannot do this work, and a patient in severe depression will retain nothing of it.
Not too late either. The most productive moment is the period following an episode, when the memory is fresh and the motivation is there. Waiting for six months of stability loses both.
And not on an uncertain diagnosis. After a first episode, you can start as soon as the diagnosis has been made and settled; a diagnosis that is still uncertain makes this programme premature.
The four preliminary decisions
Has the diagnosis been made, and by whom? Section 3. Bipolar disorder is both underdiagnosed and overdiagnosed, and you are not there to decide.
What is the psychiatric follow-up? Note the psychiatrist's name, how often the appointments take place, the current treatment, and how to reach the psychiatrist in case of an alert. If that follow-up does not exist, setting it up is the first aim.
What is the suicide risk? It is high in this indication, particularly in depressive and mixed states (section 4), and it is asked about explicitly.
And what substance use? Alcohol and cannabis are very frequent, they destabilise, and they change the prognosis.
What this programme does not treat
It does not treat an episode in progress.
It does not replace medication.
It does not make a diagnosis.
And it does not on its own treat a disorder with a severe, unstabilised comorbidity, which requires an integrated service, in which the two disorders are treated together and in a coordinated way.
How to use it
Read the whole before the first session, in particular sections 13, 29, 30, 31 and 32: the treatment, the early warning signs, the emergency plan, rhythms, and adherence.
Each session is described according to the same framework: the aim, the steps, what you say, common errors, and the criterion for moving on.
Three warnings specific to this reason for consulting.
The patient knows things you do not. They have lived through their episodes. Your hypotheses about their early warning signs are less good than theirs, and the programme is built on that.
Hypomania is not always unpleasant. Some patients are attached to it, and denying that is the best way to lose the alliance. Section 32.
And this work is measured in years. A programme that seems to have changed nothing at six months may have prevented a hospital admission at three years. You have to say so to the patient, and to yourself.
3. Four presentations not to be confused
The diagnosis belongs to the psychiatrist. What follows is for knowing what you are looking at, and for spotting the situations where an opinion needs to be asked for.
1. Bipolar I disorder
What defines it. At least one full manic episode, that is, an elevation of mood or an irritability with an increase in energy, severe enough to have a heavy impact, sometimes to require hospital admission, or to be accompanied by psychotic symptoms. Depressive episodes are frequent and they are not required for the diagnosis.
What that implies. This programme, with particular attention to the early spotting of elevations — a term which, in this manual, covers both manic and hypomanic episodes.
2. Bipolar II disorder
What defines it. At least one hypomanic episode — the same nature, lesser intensity, without major impact or hospital admission — and at least one major depressive episode.
What has to be known. It is not a milder form. The depressive burden is often heavier, the impact is comparable, and the diagnosis is made on average much later.
What that implies. The same programme, with more room given to depression and to discreet signs of elevation. When the history is made up of numerous, lasting highs and lows, without any manic or major depressive episode, the psychiatrist may diagnose cyclothymic disorder, and Cyclothymic disorder: steadying the waves without dimming the person — a therapist's manual then describes the protocol specific to it.
3. Unipolar depression
What points towards bipolarity in someone consulting for depression: an early onset, numerous short episodes, a family history, an unusual response to an antidepressant, such as an elevation occurring during treatment (section 7), atypical features — hypersomnia, increased appetite, physical heaviness (section 4) —, and above all a past episode of elevation — which nobody has ever looked for, because nobody consults for feeling well.
What that implies. A psychiatric opinion before any treatment.
4. Borderline personality disorder
What points to it. The instability is rapid, often on the scale of a day, it is triggered by relationships, it has been present continuously since adolescence, and it goes with a fear of abandonment and an unstable identity.
What points towards bipolarity. Episodes lasting days or weeks, with a change in sleep and energy, and free intervals, that is, periods without symptoms between episodes.
What that implies. The distinction is difficult, the two sometimes coexist, and an error in either direction has significant treatment consequences.
The three other things to examine
Each of them can produce manifestations that resemble an episode, or add to one.
A medical cause or a treatment. For example thyroid disease, corticosteroid treatment or certain neurological treatments.
A substance. Stimulants, including cocaine, high-dose cannabis, or withdrawal.
And attention deficit disorder. It shares impulsivity, distractibility and restlessness, it is chronic and not episodic, and it frequently coexists.
The three useful questions
"Have there been periods when you needed much less sleep without feeling tired?" Probably the most useful single question for spotting a past elevation, because it bears on an observable fact and not on a mood.
"Have there been periods when the people around you found you different, too fast, too driven?" It picks up what the patient does not report.
And "how long did it last?" It separates the episode from instability.
4. The episodes, in detail
The manic and hypomanic episode
What you observe. An elevated or irritable mood, an increase in energy and activity, a reduced need for sleep without tiredness, a flood of ideas, faster speech, distractibility, an increase in plans, and involvement in activities with damaging consequences — spending, sexual behaviour, work decisions, driving.
What misleads. Irritability, which is often the dominant form and which does not resemble the idea people have of mania. And hypomania, which is experienced as a good period and is almost never reported spontaneously.
What distinguishes mania from hypomania. The duration, the intensity, the impact, the possible presence of psychotic symptoms, and the need for hospital admission.
The depressive episode
What you observe. What is observed in any major depression, with a few frequent particularities: marked slowing, hypersomnia, increased appetite, physical heaviness, and a more abrupt onset than that of a unipolar depression (section 33).
What has to be known. It is the phase that takes up the most time over the course of the disorder, particularly in type II, and it is the one that weighs most on daily life. It is also, along with mixed states, the one in which suicide risk is highest.
Mixed episodes
What you observe. Features of both polarities at the same time: depressed mood with agitation, racing thoughts, insomnia and irritability.
What has to be known. These are the states with the highest suicide risk, the most distressing, and the hardest to recognise. Spotting them early is part of the work of session 5.
The intervals
They are not always free. Residual symptoms persist in a substantial share of patients, particularly depressive and cognitive ones, and they account for a large part of the impact.
And cognitive difficulties. Attention, working memory, executive functions: they are frequent, they sometimes persist between episodes, patients know little about them, and naming them is a great relief to many people who believed they had become incapable.
5. What triggers episodes
The disorder is not caused by events; the episodes, on the other hand, are frequently precipitated. It is those precipitants that can be changed, and they are the subject of half the programme.
Sleep
It is one of the best-established precipitants. A reduction in sleep time can precipitate an elevation, and that can be enough (Wehr et al., 1987).
The concrete situations. A flight with jet lag, a sleepless night, shift work, being on call, a newborn baby, a party, a house move, an exam period.
What that implies. Sleep is not a symptom to watch: it is a variable to protect. Section 31.
Disrupted rhythms
Changed working hours, job loss, retirement, holidays, a change of season, a house move. Anything that disorganises the time markers of a day.
Life events
Losses tend to precipitate depressive episodes.
Events that increase activation and goals — a promotion, a project, a success, the start of a relationship — tend to precipitate elevations. It is counter-intuitive and useful to know.
Substances
Alcohol, cannabis, stimulants. They precipitate, they aggravate, they complicate treatment, and they are very frequent.
Treatments
Stopping mood-stabilising treatment is the leading precipitant of relapse, and stopping abruptly carries particular risk.
Certain treatments can favour a mood switch, that is, a rapid shift from one polarity to the other, most often from depression to an elevation; that question belongs entirely to the psychiatrist, and your role is to report what you observe.
Times of year and times of life
Seasonal variations exist in some patients. The postpartum period is a very high-risk period, and it is prepared for well in advance.
Frequently asked questions
The patient does not believe in the diagnosis.
That is frequent and it is not an absolute obstacle. You work on what they recognise: the episodes themselves, their consequences, and the signs that precede them. The label can wait.
Should this work be done just after an episode?
It is often the best moment: the memory is fresh and the motivation is there. The episode just needs to be over.
An episode occurs during the programme.
You suspend, you support, you coordinate with the psychiatrist, and you resume afterwards. It must have been announced from the first session so that it is not experienced as a failure.
The patient wants to stop their treatment.
You do not give an opinion. You work on what lies behind it — side effects, meaning, loss, missing hypomania —, you take up their chart again, and you help them talk about it with the psychiatrist. The rule "you do not stop alone" is written into the plan.
He misses his hypomanic phases.
That has to be heard; then weigh that regret against what the episodes have cost (session 9), without denying what those phases brought.
How do I spot the start of an episode in someone I see once a week?
Through sleep, which comes at the top of every session, and through the lists drawn up in sessions 4 and 5. You are not the main detector: the patient and the person close to them are.
The person close wants to contact me directly.
That is settled in advance, with the patient's agreement, and it goes into the plan. Unplanned contact is experienced as a betrayal.
Should suicide risk be talked about?
Yes, explicitly, and in every low phase. It is high in this indication.
The patient is functioning very well and does not see the point.
That is a good moment to do this work, and it is also the moment when people stop their treatment. The chart from session 2 answers better than any argument.
Memory and concentration problems persist.
They are frequent and recognised. Naming them is a relief, and adjustments as well as cognitive remediation approaches exist (section 37).
He works nights.
It is a real question, and it is raised early. Some posts are hard to reconcile with stability, and it is better to talk about it before an episode than after.
She wants a child.
The question is prepared for long in advance and, where it touches on treatment, it belongs to the psychiatrist. What belongs to you: the arrangements for the nights, the partner's role, and a specific plan for the postpartum period.
How long does this work last?
Twelve sessions over about four months, then follow-up that goes on to twelve months. The effect is measured in years.
And if the patient has no psychiatrist?
That is the first aim of the programme. Without psychiatric follow-up, this work has no foundation.