Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy

The newest addition to the growing collection of interpersonal psychotherapy treatment (IPT) manuals is Treating Bipolar Disorder . In the tradition established by cognitive-behavioral therapy (CBT) researchers, IPT is being adapted to the treatment of a variety of psychiatric disorders. Ellen Frank has been at the vanguard of the empirical testing of various IPT models, including the use of IPT as a maintenance treatment and as an intervention for depressed patients with panic spectrum disorders.

Unlike other IPT textbooks, this text describes an intervention that is a deliberate hybrid of IPT and social rhythm therapy (IPSRT). The SRT component was developed by Frank's research group and rests on the premise that disruptions in social rhythm—for example, time of waking, sleep onset, and eating—lead vulnerable individuals to be at higher risk for onset of depression or mania. SRT relies heavily on activity scheduling and behavioral interventions and resembles the initial stages of CBT or behavior therapy. It is the use of these techniques with patients who have bipolar disorder that is novel.

The elements of IPT described in the manual mirror those in the standard IPT textbooks for depression. The interpersonal formulation and a focus on the problem areas of role transitions, interpersonal disputes, grief and loss, and interpersonal deficits or sensitivities form the foundation of the intervention. Frank has added another problem area labeled "grief for the lost healthy self," which she describes as useful in assisting patients to cope with the chronic life changes that often accompany severe bipolar disorder. Many wonderful case examples illustrate the use of IPT with these problem areas.

The unique aspect of IPSRT is the coupling of the general behavioral approach with IPT. This allows a sequential approach in which behavioral interventions are aimed at regulating social rhythms. This focus is maintained throughout, but as the patient's daily routine becomes more firmly established, treatment focuses on the interpersonal ramifications of bipolar disorder and works on recognizing and accepting the limitations imposed by the illness.

The book is a superb manual for beginning therapists and those with limited training. The intervention relies very heavily on the use of scales and self-report forms that are used both to monitor the patient's concrete behavior and as behavioral interventions. These are reproduced in the appendix and are a resource all clinicians will find useful. IPSRT also provides a clear structure that is of benefit both to difficult patients and to their therapists.

For the more experienced therapist, however, it is not entirely clear that IPSRT differs from interventions that a seasoned clinician might provide. The SRT component relies heavily on psychoeducation, on enhancing compliance with medication, on recognizing and avoiding stressors, and on straightforward behavioral interventions that should be in the armamentarium of all well-trained clinicians. Interventions directed toward the "loss of the healthy self" bear much similarity to acceptance and commitment therapy, with a focus on accepting the limitations imposed by bipolar illness and positive adaptation to them. Moreover, there is little empirical data supporting the specific elements of IPSRT, though there is a wealth of clinical experience that undergirds it.

This should not be seen as criticism but as a reflection of the reality that all of the empirically validated psychotherapies are far more similar than different. It is also clear that adaptations such as IPSRT, which provide a structure for the application of good general psychotherapeutic techniques to specific populations and individual patients, are moving the field forward.