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Review

Psychoeducational and cognitive-behavioral strategies in the management of bipolar disorder

Michael W. Otto*, Noreen Reilly-Harrington, Gary S. Sachs
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Abstract Despite advances in the pharmacologic treatment of bipolar disorder, it is clear that additional strategies are needed to provide patients with longer-term mood stability. Recent years have witnessed the development of a number of psychosocial strategies for bipolar disorder that are design as adjuncts to ongoing pharmacotherapy. In this article we describe psychoeducational and cognitive-behavioral approaches to the management of bipolar disorder, with emphasis on broader treatment packages that can be offered by cognitive-behavior therapists working in specialty bipolar clinics, as well as specic strategies that can be integrated into standard pharmacotherapy for the disorder. A growing body of evidence documents the potential value of these interventions, and large-scale studies are underway, including the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), which will provide outcome on these interventions from the perspective of large, multicenter trials. 2002 Elsevier Science B.V. All rights reserved.
Keywords: Psychosocial strategy; Psychoeducational strategy; Cognitive-behavioral therapy; Bipolar disorder; Medication adherence

1. Introduction The purpose of this article is to provide an overview of the adjunctive use of cognitive-behavioral strategies for the management of bipolar disorder. Until recent years, this topic was relatively rare in the management of bipolar disorder, given the long history of attention to its biological substrate
* Corresponding author. Cognitive-Behavior Therapy Program, WACC-812, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114, USA. Tel.: 1 1-617-724-0814; fax: 1 1-617726-7541. E-mail address: motto@partners.org (M.W. Otto).

and somatic management. What then, is the role for psychosocial treatment in current management strategies? This discussion is best initiated by considering some of the limitations of somatic treatment. Despite the signicant pharmacopeia for bipolar disorder, the most common outcome continues to be a clinical course characterized by repeated episodes. For example, despite the use of mood-stabilizing agents, longitudinal data suggests relapse rates as high as 40% in 1 year, 60% in 2 years, and 73% in 5 or more years (Gitlin et al., 1995; see also OConnell et al., 1991). Resolution of bipolar depression is also characterized by poor outcomes for patients despite

0165-0327 / 02 / $ see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 01 )00460-8

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the regular application of mood stabilizers (Keck et al., 1998), and overall, adherence to medication treatment brings with it its own challenges, with poor medication compliance evident in one-half to twothirds of patients within the rst 12 months of treatment (Keck et al., 1998, 1996). All of these ndings encourage the search for additional modalities of intervention for bipolar disorder. A variety of evidence also suggests that psychosocial variables play a crucial role in inuencing the course of bipolar disorder. For example, it appears that dysfunctional and over-emotional family communication patterns can play a powerful role in inuencing relapse rates. Miklowitz et al. (1988) examined the outcome of 23 bipolar patients discharged to families characterized as either high or low in expressed emotion. Expressed emotion is characterized by critical, hostile, and emotional overinvolvement, and Miklowitz and associates found a striking vefold difference in relapse rates between the high and low expressed emotional families, with signicantly higher relapse in families characterized by high expressed emotion. The occurrence of negative life events has also been found to inuence the course of recovery from episodes in patients with bipolar disorder. For example, in a study of 67 patients recruited during hospitalization for mania or depression, negative life events were associated with a threefold increase in time to recovery (Johnson and Miller, 1997). Similar effects were evident in a study of relapse prevention. Ellicott et al. (1990) found that rates of relapse were 4.5 times higher among patients with high negative life-event scores during a 2-year follow-up study. Cognitive style also appears to play an important role in modulating the impact of life events on symptoms. For example, in combination with negative life stressors, bipolar individuals with dysfunctional attitudes or depressogenic attributional styles are more likely to develop affective symptoms (Alloy et al., 1999; Reilly-Harrington et al., 1999). These ndings support the rationale for utilizing cognitive-behavioral interventions aimed at modifying maladaptive cognitive styles and decreasing the impact of environmental stress. Finally, a number of studies suggest that disruptions in sleepwake cycles may place bipolar patients at risk for new episodes. In particular, negative

life events that trigger sleep disruption may be more likely to lead to mania than those that do not. For example, Malkoff-Schwartz et al. (1998) interviewed 39 bipolar patients and found that manic patients had signicantly more pre-onset life stressors characterized by social rhythm disruption (e.g., change in sleepwake cycle) than did depressed patients with bipolar disorder. Along these lines, Wehr et al. (1987) have argued that sleep loss may be a common causal pathway in the genesis of mania. Management of sleep cycles is likewise assumed to aid the control of episodes in bipolar disorder (Wehr, 1991; Wehr et al., 1998; Wirz-Justice, 1999). Psychosocial interventionsranging from adherence programs to promote sleep hygiene to strategies to reduce the impact of stressors on sleepcan play a role in this management. Given these studies documenting the potential inuence of psychosocial factorsi.e., family communication patterns, negative events, cognitive style, and sleep patternson the course of bipolar disorder, strategies to minimize the occurrence or impact of these factors is encouraged. Accordingly, one role for psychosocial treatments for bipolar disorder is to focus not on the disorder itself, but on the management of life circumstances that may inuence the expression of the disorder (Callahan and Bauer, 1999; Scott, 1996). There is also evidence encouraging a much more direct role for cognitive-behavior therapy (CBT) and other specialized treatment strategies in the management of bipolar disorder. CBT has a long history of successfully treating unipolar depression (for review see Deckersbach et al., 2000a), with a variety of studies suggesting that this efcacy extends to severe and treatment-resistant cases (Fava et al., 1997; Simons and Thase, 1992; Thase et al., 1991a,b). For example, Fava et al. (1997) applied CBT to a small sample of unipolar depressed patients who had failed to respond to adequate pharmacotherapy. Despite this history of treatment failure, Fava et al. obtained a 63% remission rate with brief CBT, and achieved high maintenance of these treatment gains over the next 2 years. CBT also appears to protect against relapse in patients with unipolar depression, with ndings that CBT offers relapse protection in the same range as maintenance pharmacotherapy (e.g., Evans et al.,

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1992; Fava et al., 1996, 1998; Murphy et al., 1984). Together these data encourage the application of CBT to the treatment of bipolar depression (e.g., Zaretsky et al., 1999), as well as the application of CBT to relapse prevention in bipolar patients. To date, at least three controlled studies have shown that CBT can benecially inuence the course of bipolar disorder. In an early study, Cochran (1984) examined the effects of brief treatment with CBT that focused on improving medication adherence. After only six sessions of treatment, patients were found to demonstrate better adherence and fewer hospitalizations over a 6-month follow-up period compared to a treatment-as-usual comparison condition. In a second study, Lam et al. (2000) examined the outcome of a sample of 25 bipolar outpatients who had a mean history of seven manic episodes and nine depressive episodes, but who were taking mood stabilizers and were not in an acute episode at the time of baseline evaluation. These patients were randomized to either routine care or routine care combined with a exible schedule (12 to 20 sessions) of CBT delivered over the next 6 months. The treatment emphasized education about the bipolar disorder and its management, as well as cognitiverestructuring, problem-solving and routine- and sleep-management interventions. Ratings by an independent assessor at 6 and 12 months indicated that treatment with CBT was associated with signicantly fewer manic, hypomanic, and depressed episodes than the comparison condition. Ten of 12 patients treated with CBT had no bipolar episodes during follow-up compared to only two of 11 control patients. In a third study, Hirshfeld et al. (1998) examined the effects of an adjunctive 11-session group program of CBT on the reduction of symptoms and prevention of relapse among patients with bipolar disorder. Interim analyses of this pilot study indicated that group treatment emphasizing psychoeducation, cognitive restructuring, assertiveness and problem-solving training, activity management, and medication adherence was successful in reducing the number of new episodes and increasing euthymic periods relative to a medication-alone comparison condition. This evidence for CBT joins other evidence for the

efcacy of psychosocial treatments in improving the course of bipolar disorder. Specically, family focused therapy (FFT; Miklowitz and Goldstein, 1997), and interpersonal therapy with a social rhythm component (IPSRT; Frank et al., 1994) have both been applied to bipolar disorder. In a randomized trial of 79 bipolar patients, Miklowitz et al. (2000) found that 21 sessions of FFT reduced both depressive and manic symptoms, and offered better protection against the recurrence of clinical depression, than a comparison condition that offered pharmacologic treatment and case management alone. IPSRT also holds promise for the management of bipolar disorder. Initial studies were equivocal (Frank et al., 1997, 1999), but a more recent study indicates that IPSRT may help promote periods of euthymia in bipolar patients (Frank and Hlastala, 2000). It is noteworthy that both FFT and IPSRT share in common a focus on psychoeducation and medication adherence, social or family problem-solving, and communication training. These elements of treatment are also part of CBT protocols for bipolar disorder (e.g., Otto et al., 1999). Thus, although these treatments differ signicantly in terms of theoretical assumptions and practical strategies, they do share in common some of the same targets and strategies for change.

2. Targets for CBT To benecially affect the course of bipolar, there are at least six separate targets for treatment. The rst ve of these concern relapse prevention, and the last directly targets the treatment of bipolar depression: (1) medication adherence, (2) early detection and intervention, (3), stress and lifestyle management, (4) treatment of comorbid conditions, and (5) treatment of bipolar depression. In the following sections, each of these applications of CBT for bipolar disorder is considered.

2.1. Medication adherence

The need for additional strategies for medication adherence in bipolar disorder is striking. Despite the planned, long-term use of mood stabilizers, a variety

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of evidence suggests that adherence often fails within the rst several months of treatment (Johnson and McFarland, 1996). The pharmacological management of bipolar disorders faces some of the same challenges of any preventive program of medication; at the time the pill is taken, there may be no disorder-related symptoms, and particularly no symptom relief, to either cue or reward pill taking. Under these conditions, pill use is primarily motivated by the memory of past symptoms and concerns that they may recur. Moreover, emergent side effects may sap this motivation and punish pill taking. Although all preventive programs may share in these basic factors, bipolar disorder brings additional challenges (Jamison and Akiskal, 1983; Keck et al., 1996). Patients may remember past hypomanic episodes fondly and may desire future episodes. Also, patients may not be convinced of the need for preventive treatment. Under these conditions, it is no surprise that adherence to mood stabilizers is so poor, despite the evidence for a clear link between non-adherence and relapse (e.g., Keck et al., 1998). A variety of social-psychological research suggests that compliance with requested behaviors is enhanced when an individuals assent to that action is elicited as his or her own opinion (see Cialdini, 1993). That is, it is not the psychiatrists task to tell the patient why medications are necessary, rather it is her or his task to elicit, with careful questioning, why the patient thinks that ongoing treatment may be helpful. Use of a life-history approach (Post) may be a useful strategy for eliciting relevant patient information on the impact of bipolar episodes on personal and family goals. The life-history method asks patients to construct a timeline of their disorder that depicts manic, hypomanic, and depressive episodes, and the life context that surrounded these episodes. This evidence can then be used to help the patient decide whether alternative treatments, or greater adherence to current treatments, is a reasonable strategy to adopt. In focusing on the patients recommendations in the context of a straightforward and dispassionate presentation of the facts about her or his history of disorder, the prescribing physician will be adopting strategies from Motivational Interviewing, an empirically supported strategy for enhancing engagement in treatment (Rollnick and Miller, 1995; Yahne

and Miller, 1999). Regular adoption of these techniques is encouraged for the treatment of bipolar patients. Moreover, repeated presentation of this information during the initial months of treatment appears to be indicated given evidence for memory and attention decits in bipolar disorder (Deckersbach et al., 2000b), and evidence that rates of non-adherence are at their average intensity at approximately three months of treatment (Johnson and McFarland, 1996). Enhancing motivation for medication use is only part of adherence interventions. Indeed a variety of cognitive-behavioral strategies are available to help patients establish a regular habit of medication use. For example, as part of a single-session intervention to improve medication adherence for outpatients with HIV, Safren et al. (2000) recommends the use of imaginal and role-play rehearsal of times and cues for pill storage and use, as well as the use of simple reminders to establish new pill-taking regimens (i.e., colored dots that are placed by the patient in everyday locationsin appointment books, on telephones, in the home bathroom, etc.that can be a cue for pill taking as well as for reviewing motivation for medication use). Certainly these strategies can be delivered by independent cognitive-behavioral therapists, but perhaps it is most important for pharmacologists to adopt these strategies directly. At the time of the review of symptoms and diagnosis, the pharmacologist can begin the process of offering expert information on bipolar disorder, combined with a review of the patients history of disorder and treatment, as part of a motivational intervention. The pharmacologist is engaged in helping establish the patient in the role of a responsible co-therapist on the case, seeking to help the patient dene the importance for him- or herself of medication use for control of bipolar disorder.

2.2. Early detection and intervention

The idea of establishing a cotherapist on the case also extends to other prevention efforts, particularly to efforts at early detection and intervention. In our specialty bipolar clinic, we routinely use a treatment contract and self-monitoring as part of standard pharmacotherapy to formalize the process of engag-

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ing the patient in planning for the management of future episodes. The treatment contract itself includes sections that review: 1. The purpose of the contract (aiding the patient in the management of bipolar disorder). 2. Names and contact numbers for other members of the treatment team (including friends or family members who may be asked to intervene at warning signs or crises associated with future episodes). 3. A patients characteristic symptoms of depressive or hypomanic episodes and the early intervention strategies the patient and her or his treatment team are to enact when faced by these symptoms (Reilly-Harrington et al., 2001). This contract is an outgrowth of previous work geared towards actively engaging patients in written plans for managing bipolar illness (Bauer and McBride, 1996; Hirshfeld et al., 1997). Without an organized treatment plan that includes the education and involvement of the patient and signicant others, care providers and family members are left to make decisions on behalf of the patient at times of crisis. A treatment contract provides both the patient and clinician with a forum for discussing what the patient would like her or his treatment team to do in the event of early signs of relapse (or a full relapse). The treatment team members should include people with whom the patient has regular contact, and may include healthcare providers, family members, signicant others, friends, or coworkers. Typically, patients invite family or support system members to sessions focusing on the development of the treatment contract. After identifying the treatment team, the contract instructs patients to identify specic thoughts, feelings, and behaviors that may serve as early warning signs for episodes of depression and mania. In addition, the patient is asked to outline personal actions to be taken in the event of an impending episode. Of particular importance is the identication of the initial signs of hypomania, to allow early detection and protective action against a potential manic episode. Next, patients develop a set of directives, stating ways in which they and their support systems can be helpful in preventing and

managing acute episodes. Strategies of this kind (early detection and intervention) have been found to signicantly reduce the rate of occurrence and number of manic episodes (Perry et al., 1999). Finally, all members of the extended treatment team are asked to review, ask questions, address concerns, and then sign the contract. Once the plan is in place, the clinician(s) and others who apply the contract become agents of the patients planning, rather than people imposing their own restrictions on the patient. Example contracts are available at the website, manicdepressive.org. Even though much of the contract is in a checklist format, it will take time to complete. However, clinicians should consider the contract as an investment against all the time and difculties associated with future episodes. With the contract in place and relevant contact information and actions prespecied, clinicians should be able to save time through efcient intervention at times of crisis, or through prevention of future crises. Current CBT protocols (Basco and Rush, 1996; Newman et al., 2001; Otto et al., 1999) also tend to emphasize early-intervention strategies to reduce the impact of hypomanic or manic episodes should they occur. These interventions are designed to reduce the likelihood of poor nancial, social, or sexual decisions that may occur in the context of an episode. These strategies range from specication of whom and under what conditions a member of the support network should be able to temporarily cancel a credit card to the specication of rules for risky action. For example, Newman et al. (2001) describe a TwoPerson Feedback Rule, where patients are taught to test out any new plan or idea with at least two trusted advisors. Patients are told of the hypomanic bias of ideas feeling good or correct even though they may not be correct. With the two-person feedback rule, patients are taught that if an idea really is that good, then two other people should be able to nd the idea at least reasonable. Newman et al. (2001) also discuss a 48 Hours Before Acting Rule in which patients are encouraged to wait two full days and get two full nights of sleep before acting on any new plan or idea. Patients are encouraged to think to themselves, If its a good idea now, it will be a good idea then. This two-day period of reection also allows an opportunity to put the Two-Person Feedback Rule into

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effect. Any interventions that can potentially disrupt spontaneous or risky decision-making are warranted when working with hypomanic patients.

2.4. Treatment of comorbidity

High rates of psychiatric comorbidity typify patients with bipolar disorder. For example, in a study of 288 outpatients with bipolar disorders, McElroy et al. (2000) found that 42% met criteria for a comorbid anxiety disorder, 42% for comorbid substance use disorder, and 5% for an eating disorder. These disorders were not differentially prevelant among those with bipolar one compared to bipolar II disorder, and in general these ndings replicated those from a number of epidemiologic studies (e.g., Chen and Dilsaver, 1995; Kessler et al., 1997). Treatment of comorbid conditions is an additional role for CBT. For example, anxiety comorbidity in bipolar disorder is associated with longer times to remission (Feske et al., 2000), underscoring the potential importance of managing this comorbidity as part of an overall treatment strategy. At present, CBT and pharmacotherapy (particularly, treatment with antidepressants) represent the treatment modalities with the best empirical support for efcacy with anxiety disorders. Specically, CBT has been shown to rival or surpass the efcacy of medication in meta-analytic reviews of the anxiety literature, and tends to offer longer-term maintenance of treatment gains (Christensen et al., 1987; Gould et al., 1995, 1997a,b; Otto et al., 1996). In many treatment contexts, patients can choose from these empiricallysupported alternatives based on preference and availability. However, patients with bipolar disorder may be greatly limited in the choice of pharmacologic strategies for anxiety disorders by the risk of induction of manic episodes associated with antidepressant use. Moreover, there is initial evidence that bipolar patients with signicant anxiety may have more difculties with medication side-effects. As a consequence, CBT has the potential to offer bipolar patients effective treatment without the risk of medication-induced manic episodes or the limitations associated with pharmacotherapy side effects.

2.3. Stress and lifestyle management

Activity monitoring and scheduling is a regular component of many cognitive-behavioral treatments of depression (Beck, 1995; Beck et al., 1979; Nezu et al., 1998). Monitoring is used to identify whether the patient suffers from under or overactivity, and whether the patient has a structure for providing breaks and pleasurable events during the week. In depression treatment, efforts are devoted to helping the patient construct a schedule that allows for rewarding activities in areas of both productivity and pleasure, and that helps a patient restart a program of activity if depression has waylaid this area of functioning. For the management of bipolar disorder, lifestyle management also includes attempts to protect the sleep / wake cycle, to provide a balance in the patients level of activities, and to monitor for increases in activity that may herald a hypomanic episode. For sleep management, therapeutic progress proceeds in two stages. In the rst, the clinician educates the patient about the role of disruptions in the sleep / wake cycle in heralding new episodes, and discusses with the patient what level of activity and sleep seems most reasonable for the patient. Once the desired hours of sleep have been identied, the clinician should help the patient calculate a regular bed time relative to daily demands and waking times. To aid compliance, the clinician should also identify cues for that target bedtime (e.g., if the patient nds herself watching television to the end of Letterman, the sleep time has been ignored). Also, to reduce the impact of other risk factors for episodesnamely, family stress and the impact of negative eventsstress management procedures that include training in problem solving, communication skills, and cognitive-restructuring may be valuable. Given that these procedures are a regular part of cognitive-behavioral treatments for depression, these skills may be introduced in the context of interventions for bipolar depressive episodes (see below).

2.5. Treatment of bipolar depression

As noted, CBT has a long history of success in the treatment of unipolar depression. These methods (e.g., Beck, 1995; Beck et al., 1979; Nezu et al.,

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1998) are also being applied to bipolar depression. For example, in a small pilot study, Zaretsky et al. (1999) found similar reductions in depressed mood for CBT applied to patients with bipolar depression as compared to patients with unipolar depression. Our own manual for the treatment of bipolar depression (Otto et al., 1999) initially emphasizes cognitive restructuring and activity management strategies. These core strategies are followed by a much broader package of emotional and social problem-solving strategies, combined with modules that target specic difculties patients may have with emotional regulation, assertiveness, or comorbid anxiety disorders (see also, Henin et al., 2001). Early in treatment, patients are provided with a model of the disorder and a rationale for treatment procedures, combined with instruction in a cognitivebehavioral model of the interplay between thoughts, feelings, and behavior. Patients are asked to then complement this didactic information by observing their own experiencing, testing the model, and identifying for themselves the role of thoughts in particular in inuencing mood. Each session is presented in a problem-solving format that includes review of the previous weeks learning, formulation of an agenda for the session, completion of the agenda with attention to in-session practice of concepts, and then assignment of home practice of skills. This format maintains a consistent focus on the step-by-step, goal-oriented, skill-acquisition approach that is at the heart of cognitive-behavioral treatments (e.g., Beck, 1995). To make treatment accessible to patients, attention is placed on the use of vivid metaphors and stories to crystallize important information on the nature of the disorder, the process of change, or a specic assignment or skill. In a review of the use of therapeutic stories and metaphors in CBT, Otto (2000) recommends: (1) the use of stories or metaphors that lead patients to draw on their own knowledge and experiences in their treatment efforts, (2) the use of voice modulation, theatrical pauses, and patient involvement to increase the salience of a story, and (3) the application of story icons to sum up a therapeutic concept for use in relevant moments in a patients life. For example, a story that has been incorporated into some of our manualized treatments (e.g., Otto et al., 1996, 1999) provides a primer for training in cognitive skills, by

introducing cognitive restructuring techniques in the context of a story about the coaching of a Little League Baseball player. A version of the core elements of the story (presuming that stories should change over time) was presented in Otto et al., 1999, pp. 167168, and is again presented here: This is a story about little league baseball. I talk about little league baseball because of the amazing parents and coaches involved. And by ]]] amazing I dont mean good. I mean extreme. But this story doesnt start with the coaches or the parents; it starts with Johnny, who is a little league player in the outeld. His job is to catch y balls and return them to the ineld players. And on this particular day of our story Johnny is in the outeld and crack one of the other players hits a y ball. The ball is coming to Johnny. Johnny raises his glove. The ball is coming to him, it is coming to him . . . . . . and it goes over his head. Johnny misses the ball, and the other team scores a run. Now there are a number of ways a coach can respond to this situation. Lets take Coach A rst. Coach A is the type of coach who will come out on the eld and shout: I cant believe you missed that ball. Anyone could have caught it. My dog could have caught it. You screw up like that again and you will be sitting on the bench. That was lousy! Coach A then storms off the eld. At this point, if Johnny is anything like I am, he is going to be standing there, tense, tight, trying not to cry, and probably praying that another ball is not hit to him. If a ball is hit to him, Johnny will probably miss it. After all, he is tense, tight, and may see four balls coming to him because of the tears in his eyes. Also, if we are Johnnys parents, we may see more profound changes after the game. Johnny, who typically places his baseball glove on the mantle, now throws it under his bed. And before the next game, he may complain that his stomach hurts, and that perhaps he should not go to the game. This is the scenario with Coach A. Now lets go back to the original event and play it differently. Johnny has just missed the y ball, and now Coach B comes out on the eld. Coach B says:

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Well, you missed that one. Here is what I want you to remember. Fly balls always look like they are farther away than they really are. Also, it is much easier to run forward than to back-up. Because of this, I want you to prepare for the ball by taking a few extra steps backwards, and try to catch it at chest level, so you can adjust your hand if you misjudge the ball. Lets see how you do. Coach B then leaves the eld. How does Johnny feel? Well, he is not happy. After all, he missed the ballbut there are a number of important differences from the way he felt with Coach A. He is not as tense or tight, and if a y ball does come to him, he knows what to do differently to catch it. And because he does not have tears in his eyes, he may actually see the ball accurately. Maybe he will catch the next one. So, if we were the type of parent that wants Johnny to make the Major Leagues someday, we would pick Coach B, because he teaches Johnny how to be a more effective player. Johnny knows what to do differently, and may catch more balls, and excel in the game. But if we dont care whether Johnny makes the Major Leaguesbecause baseball is a game, and one is supposed to be able to enjoy a gamethen we still pick Coach B. We will pick Coach B because we care whether ] Johnny enjoys the game. With Coach B, Johnny knows what to do differently; he is not tight, tense, and ready to cry; he may catch a few balls; and he may enjoy the game. And he may continue to place his glove on the mantel. Now, while we may all select Coach B for Johnny, we rarely choose Coach B for how we talk to ourselves. Think about your last mistake. Did you say, I cant believe I did that. I am so stupid. What a jerk! These are Coach A thoughts, and they have approximately the same effect on us as they do on Johnny. They make us feel tense and tight, and sometimes make us feel like crying. And this style of coaching rarely makes us do better in the future. Remember, even if you are only concerned about productivity (making the Major League) you would still pick Coach B. And if you were concerned with enjoying life, with guiding yourself effectively for both joy and productivity, you would denitely pick Coach B.

Remember that we are not talking about how we coach ourselves in a baseball game. We are talking about how we are coaching ourselves in life, and our enjoyment of life. During the next week, I would like you to listen to see how you are coaching yourself. If you hear Coach A, remember this story and see if you can replace Coach A with Coach B. Subsequent to telling the story, clinicians are to use the coaching metaphor to repeatedly examine the nature of a patients cognitions. This story can be told in approximately 5 minutes, and accordingly it is an intervention that can be provided as part of ongoing CBT or can be incorporated into the brief sessions that characterize pharmacological management.

3. Concluding comments The purpose of this article was to review the rationale, evidence, and some of the methods for the application of cognitive-behavioral strategies for bipolar disorder. Our goal was not simply to inform clinicians of some of the treatment options that may be available through local CBT providers, but to recommend a number of interventions for routine application by pharmacotherapists. In particular, we encourage application of motivational interviewing, treatment contracting, early intervention, and select stress management, activity scheduling, and cognitive-restructuring strategies to standard pharmacologic management. If some of these strategies are adopted, the physicians prescription for bipolar disorder will include both pharmacologic and psychosocial interventions. As we reviewed above, CBT has joined two other forms of psychotherapyfamily focused therapy (FFT; Miklowitz and Goldstein, 1997), and interpersonal therapy with a social rhythm component (IPSRT; Frank et al., 1994)in providing promising outcome data for the adjunctive management of bipolar disorder. More data on the overall and relative efcacy of these treatments will be forthcoming as part of the multisite, NIH-funded Sys-

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tematic Treatment Enhancement Program (STEP) for bipolar disorder, which will randomize up to 1000 patients in a controlled investigation of these treatments.

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