Client-led Online Therapy for People Diagnosed With Bipolar Disorder

Bipolar spectrum disorder (previously known as manic depression) is a diagnostic term used to describe experiences of extreme, and sometimes enduring, fluctuations in mood that interfere with a person's life or cause significant distress. Individuals diagnosed with bipolar disorder experience periods of depressed mood and periods of elevated or irritable mood. In many cases, this amounts to clinical depression, or mania that entails hospital admission. Periods of mood fluctuation usually involve extreme changes to usual thinking and behaviour. During a period of depression people might feel hopeless and suicidal, withdraw from social activities and have difficulty functioning, resulting in a neglect of self-care and basic needs. During mania people might experience delusional beliefs, become highly distractible and prone to engaging in high-risk activities such as excessive spending or drug-taking. Both mood states can result in significant impairment in work, social or daily functioning and may result in hospitalisation.

Many people with a diagnosis of a bipolar spectrum disorder experience multiple relapses, causing them significant long-term disability. Meeting the needs of this client group can pose a real challenge for services given the complexity of fluctuating mood states, high levels of impulsivity and associated risk, and additional difficulties that people can also experience (such as anxiety and trauma).

Current guidelines recommend that people who have received a diagnosis of a bipolar spectrum disorder are offered an evidence-based psychological intervention as well as medication. These interventions are typically time-limited and guided by a specific manual with emphasis on alleviating symptoms and relapse prevention. The quality of the evidence supporting such interventions has been questioned. There has also been doubt cast on the effectiveness of these interventions.

Treatment adherence is also considered suboptimal, with relatively high drop-out rates. Access to talking therapies for those with complex needs has been described as 'notoriously poor'. People diagnosed with a bipolar spectrum disorder often report reasons for distress other than symptoms and prioritise a fulfilling, purposeful life over remaining relapse-free. Talking freely to a caring, approachable therapist is valued, as are interventions that facilitate control over aspects of life beyond mood. Recovery is achievable when people are empowered to follow a self- determined path, take ownership and confront longstanding problems.

Recent advances in cognitive therapy have departed from traditional relapse prevention to offer a theory-based approach that helps people understand their individual experience of bipolar spectrum disorder and target current problems and control over life goals (rather than focusing on controlling swings). Although patients perceived the intervention to be beneficial, a trial did not find significant improvement compared to treatment as usual. Patients wanted more sessions and greater flexibility in scheduling, and many reported problems beyond their diagnosis.