Transcript Bipolar poster Presented by Karen Shannon and Rebecca

A Cognitive Analytic Approach to Making Sense
of Bipolar Disorder
Shannon& Swarbrick©
Rebecca Swarbrick and Karen Shannon
[email protected] and [email protected]
A comprehensive understanding of severe and
enduring mental illness (SEMI) and specifically
bipolar disorder demands for a differing biopsychosocial
approach.
Cognitive
Analytic
Therapy (CAT) offers useful concepts and tools
to develop a relational and dialogical perspective
and new ways of conceptualising & working with
this overlooked client group.
A CAT approach will capture the three-way
dialogue between the internal world of
experience (self-self), interpersonal and group
relations (self-others, others-self) and the
influence of culture and society on accepted and
valued social identity (self-society-self); thus
providing a greater depth of understanding.
Exploring a different approach to bipolar
disorder has been significant. Generally, a lack
of psychological models appears evident (see
Sorenson, Done & Rhodes, 2007) and the
overall conceptualisation of the illness less
sophisticated than for other difficulties within
the SEMI umbrella. Systems appear to lack an
appreciation of distress experienced by service
users, and teams feeling overwhelmed and
unresponsive to the distress occurring.
One question to be asked is, why such social
dissociation? What drives the lack of empathy
and societal concern? Evident is a reduced sense
of pathology and increased awareness of social
acceptance. Culturally, the illness is partially
glamorised; a “media friendly” mental illness.
Our aim in developing a CAT-based explanation
involves trying to gain some sense of how it
works
from
clinical
experience.
The
conceptualisation is based on innovative models
of other psychological difficulties recently
adapted within CAT framework. Such an
approach allows for the expansion of the
framework incorporating
inter, societal and
intra-individual understanding, thus providing
level 3 overarching explanation.
A relatively consistent and cross cultural lifetime
prevalence rate of 0.4% has been identified within
the literature (Kessler, Rubniow, Holmes et al.,
1997). Illness sufferers experience a severe
progressive course, which is manifest in multiple
episodes. Over a lifetime, between 8 and 12
depressive episodes, and 4 to 7 manic episodes
occur (Lam et al., 2000). The first onset cycle lasts
approximately 40-60 months, reducing to a stable
rate of 5-10 months from the 5th to 7th acute
episode (Goodwin and Jamieson, 1990). 60% of
individuals
usually
have
other
co-morbid
difficulties. Yet, Kessler’s cohort study indicates
that as few as 45% of sufferers are in receipt of
therapy. The overriding conclusion is that
prognosis generally appears poor, with a limited
option for effective therapy.
Ways of Coping
Differing factors can trigger and exacerbate the
illness, including drug and alcohol misuse; comorbidity can be as high as 35% (Goodwin and
Jamieson, 1990). Motivations for use include self
medication or attempts to stabilise mood states
(e.g. amphetamines to maintain periods of hypomania). Levels of social, occupational and overall
psychological disability are also significant (e.g.
Prien and Potter, 1990). Levels of deliberate self
harm and suicide exceed those for other forms of
SEMI, noted to be as high as 30% (Chen and
Dilsaver, 1996).
Sense of Self and Damage
Significant periods of partial/full dissociation are
experienced (e.g. Hanstock, 2007); fragmentation
of the individual, their social networks and this can
manifest at inter-generational level (Milklowitz et
al, 1988). The sense of self is often unstable and
interconnected with levels of symptomatology
(e.g. Bentall, Kinderman and Manson, 2005;
Knowles et al., 2007; Taylor, Morley and Barton,
2007). This lack of integration results in a myriad
of inconsistent responses to stressors, a lack of self
What
is
bipolar
disorder
and
its
recognition and an inability to revise unhelpful
epidemiology?
relational patterns.
Bipolar disorder can be characterised
by a
number of possible symptom states, namely The desirability of specific self states, reduces
depression, mania, hypo-mania and mixed motivation on the individual’s behalf for change, as
they either hold relationally prized status (e.g.
affective episodes.
grandiose manic states) or an effective means
of care receiving (e.g. needy dependent
other). The array of healthy roles is restricted,
leaving a limited repertoire of polarised options
for the individual to maintain psychological
well being. Shifts in states can be rapid and
the individual lunges between extreme moods,
mirrored symptomatology and in the elicited
responses of others.
Traditional Approaches
Traditionally, psychological approaches seem
restricted and rather unformulated (see
Warren, 2005) and appear to focus on states
characterised by observable distress and
therefore a degree of negative societal impact.
Bipolar disorder management has centred
upon pharmacotherapy processes. Lithium
carbonate has been seen as an effective
prophylactic agent. Although widely used
within the clinical field, its preventative benefit
for certain symptom relapse states is limited
(Geddes et al., 2004). Implementation models
appear to fail to understand the state shifts
and the transition process (i.e. level 1
understanding) clinically evident . A paucity of
research exists into a range of therapeutic
alternatives. The majority of psychological
input has until recently focused on relapse
prevention (following periods of remission)
and family work. Physiological models of the
disorder
have
supported
expanding
psychological techniques to explore biological
and social instability systems. Recently with
growing
dissatisfaction
in
variety
of
approaches, there has been an exponential
rise in innovative models for the management
of both prodromal and acute phases of the
illness (e.g. CBT: Lam et al., 2000), providing
greater support for sufferers.
Levels of Damage
As clinicians, we wished to explain the
variation in disability, levels of social rejection,
exclusion and stigmatisation and the damage
inflicted by the person to their social world.
With this in mind, we explored case studies
from community and forensic services to
understand the differing levels of damage to
the intra and inter social self.
Factors
Community Forensic
Early
childhood
experiences with main care
giver: enmeshed, prized and
discarded aspects of self,
exclusionary to others, intergenerational disorganisation,
anxiety
provoking
child
behaviours, fear of impotence
and loss of control, discarded
by others though expressed
emotion.
Empty
sense
of
self:
suggestibility,
over
representation
of
external
others,
acquiescence
and
vulnerability, few delineations
to self.
present
present
present
present
Self and other expectation:
Striving perfectionism, goal
and achievement orientated,
pressured lifestyle.
present
present
Social cognitive skills: poor
theory
of
mind,
limited
empathy and social skills, lack
of
self
awareness
and
reflective thinking.
present
present
Levels of care required:
demanding input, use of risk
strategies (e.g. expression of
potential offences), high levels
of risk behaviours gaining
response or dissociating from
distress, higher levels of rage.
absent
present
Coping:
defensive,
externalised and projected
absent
present
Relationships:
ingratiation fluctuating
and prizing status, levels of dependent
superiority, higher levels of on levels of
self efficacy, self directed and
social
insatiated, feelings of being
cognitive
invaded and depleted, degree
skills
of dissociation.
Present
Costs:relationships/
networks, sense of self, risky
behaviours/offending,
drug
and alcohol use, finances,
recovery.
higher
lower
Table 1 provides A CAT-informed summary of the clinical differences
between service users in community and forensic services
A Cognitive Analytic Approach to Making Sense
of Bipolar Disorder
Karen Shannon and Rebecca Swarbrick
Shannon& Swarbrick©
[email protected] and [email protected]
Diagrammatic Formulation CAT approach to Bi-Polar Disorder
.
J
Elevating risk:
Increasingly
extreme acts
Drugs,
Intimidation,
manic activity,
sleep deprivation,
hunger
Invincible, special
manic untouchable
Out of control
perfect delusional, 3
unreal, and grandiose,
Overvalued, idealised,
Superior dominant
caring, owning 1
controlling 2
Engulfed
and
enmeshed
Controlled admired,
subservient
H
A
D
Drugs,
alcohol,
exercise
empty,
Paranoid self:
Other focussed
anger, pitying,
feels real, external
attributions
4
G
Paranoid self: self
focussed, self
loathing humiliated
shamed, inferior:
depression, lack of
responsibility, empty
Status driven:
ingratiate,
striving, grand
gestures
Needy and
desperate to
gain
intimacy/care
Escape
distress and
bleakness
welcomed nothingness,
vacuum, not thinking,
zoned out, numb,
E
I
Overly
dependent
disposing
B
Fear of falling, too
superior, becoming
increasingly out of touch,
easily discovered,
transparent
Psychotic
depression
C
F
Response of self
and other: pulled
down , start to be
aware
This is a Multiple Self States diagram (MSSD) which provides a dynamic
reformulation. It comprises of 6 separate self states, maintained by a complex
array of procedures.
Observable Idealistic states
The most sought after states are those in the top of the broken egg denoting
(1)idealised and deserving care, (2) a superior, admired, dominant controlling state
and (3) a psychotic grandiose invincibility.
These states are at best only
temporarily experienced and their fragility, is vulnerable to internal (actual/
perceived) and external assault or intrusion (actual/perceived). From these
positions there is the ‘soft landing’ (A) of dissociation and detachment state (4)
(but with an eventual fall either to depression or attacking criticism due to the
untenable nature of dissociation), the scrambling to maintain the sought after
positions through humiliation, psychological intimidation of others (B) or the ‘crash
landing’ of psychotic paranoid depression (C) or disposal and rejection (D).
Enduring/routine states
These are experienced as more stable, with less fluctuations yet they are deferred,
interim positions between more extreme states. Whilst they enable a degree of
social existence/functioning, the psychological (emotional numbness, anxiety,
resentment and anger, poor self concept), interpersonal (isolation, dislocation, poor
attachment) and social costs (exclusion stigmatisation, discrimination) are
extremely disabling.
Whilst endured, for some, there is additional
preoccupation with the premise that they will either fall
to dreaded or they need to climb to move toward
idealised states. Ascending out of a critical attacking and
paranoid state (5) involves the utilisation of artificial
aids to induce superiority and elation e.g. stimulant
drugs, measured intimidation, sleep deprivation and
manic activity (thrill seeking, financial risk taking,
promiscuity) (J). Increasingly extreme and desperate
acts are sought to reduce attenuation, habituation and
to achieve access to the sought after states.
Maintenance characteristics of the critical attacking state
are two different types of paranoia. On the one hand a
‘self pitying’ paranoia (E) in which the social other is the
focus of anger and attack. The feelings the individual
experiences are real, however a sense of responsibility is
absent through externalisation. On the other hand a self
directed loathing paranoid voice (F) can be evident
which, although feels “real” through depression, is in
fact avoidant of emotional assimilation. Both shield the
individual from the dreaded state (6) (see below)
through functional and potentially care eliciting
depression. A negative or ambivalent response from the
other or increased sense of responsibility and guilt, leads
to a fall into this dreaded state.
Unbearable/Dreaded states
These states are the most defended against due to their
intolerable and unacceptable nature by the individual,
psychiatric systems and society as a whole. In these
positions the individual experiences rejection, being
discarded and disposed of by self and others and a sense
of being used up and sucked dry (6). Notable is the
dissociation between desired and dreaded aspects of the
self; the former acknowledged and instrumental to early
care givers and the latter is discarded and abandoned as
worthless. Such a state can be avoided using
behavioural and substance strategies (G) which allow
for
temporary
escape
from
difficult
emotions.
Alternatively, the person can use two differing strategies
to gain some control and receive care. Either, a
narcissistic solution which demands greater cognitive
resources in an attempt to ingratiate the self with others
and gain a sense of status through striving and grand
gestures (H). Or, those with less adept interpersonal
skills will utilise a victimised, needy presentation to
access to care & intimacy (I).
Others may shimmer
between the two procedures, dependent on their levels
of disability.
Utilisation of the Model
This practice based conceptualisation provides Level Three
understanding of the difficulties experienced. Such an
approach brings into awareness the unconscious intentions
of procedures; care, recognition eliciting, status gaining,
escaping dreaded feelings. This is through the use of CAT
tools such as prose and diagrammatic reformulation. It
provides a cohesive narrative of the process and the
symptoms of the illness and as part of this captures a
consistent framework to track the sequences, dynamics
and state shifts. In addition to the observable symptoms,
it encapsulates the interpersonal and dialogic nature of the
illness. CBT research has shown threats to effectiveness
including problematic
therapeutic alliance (due to
significant levels of irritability, elation, fluctuations in the
dynamics) and self ambivalence towards symptoms and
any change potential (see Lam et al., 2000).
Societal assumptions demand the seeking of prized states
which further reinforces the status quo. A CAT approach
demonstrates the fundamental importance of the cultural
and social conceptualisation needed by services providing
support and intervention. The model postulates a
collaborative and empowering approach to therapy both
in acute and remission stages of illness. This provides an
active and non-symptom focused approach. It allows both
service and client to be reflective of complex interpersonal
process factors including levels of ambivalence, potential
self sabotaging mechanisms, emotional “hot spots”,
therapeutic ruptures and risk potential; all of which can
disable any active therapeutic strategies. All these may
impact upon treatment adherence and retention rates. A
greater sense of efficacy and control is provided for both
the person and the underpinning system surrounding
them. Importantly the model highlights for the self and
the group the ambivalence of change and the sense of loss
this may evoke.
The model can be utilised as a self and/or team
supervisory tool for conceptualising group dynamics;
teams, family and consultancy for indirect intervention
and risk management. Criticisms of CBT (see Sorensen et
al., 2007) describe the expenditure and expertise needed
to implement individualised packages, however a CAT
approach may provide other therapeutic options for the
NHS to look towards. By formulating all the self states and
providing an observing eye perspective there is a sense of
hope and optimism for all parties.