How can cognitive-behavioral therapy work if your whole problem is simply that your brain doesn't have the proper balance of chemicals?

If you were a football team with a really, really good running back, wouldn’t you still want a great pass receiver to help move the ball down the field?

Seriously, mood disorders are not reducible to chemical imbalances—all of us, with mood disorders or without, live in a challenging world that does not promise to become any simpler any time soon. Plus, we all grew up with various psychological nicks and scratches (at least) along the way that sometimes make it difficult to maintain an even keel in the face of adversity. And that adversity can come from outside of us, in the form of stress from finances, relationships, work, physical challenges, and the like.  And, particularly for those of us with mood disorders, the adversity can also sometimes come from within, in terms of those turns of mood that come on often unexpectedly and often out of the blue.

So, who wouldn’t want to be better equipped to handle stress? Besides, if we rely solely on medications, it can actually weaken our personal strength by putting us in a passive position: “There’s nothing I can do but wait for the medication to work…to wait for my doctor to find the right dosage…to wait…to wait…to wait…”

Well then, what are the options for self-strengthening—what can I do besides taking medications for my mood disorder? Sometimes supportive therapy can be enough—simply having someone to talk with and brainstorm about problems—someone who is in your corner regardless. More often, what we call “evidence-based psychotherapies” are useful—that is, psychotherapies or related psychosocial interventions that have been tested in formal clinical trials and shown to be effective for mood disorders. Some evidence-based psychotherapies for depression have even to be shown to be equal to medications in head-to-head comparisons.

Cognitive-behavioral therapy is probably the oldest psychotherapy with a solid evidence base for mood disorders, having been developed in the 1960s. Sometimes this type of treatment emphasizes changing thought patterns (cognitive therapy) and sometimes it emphasizes changing the ways we act (behavioral therapy), but more often these days a mixture of the two is used. Another psychotherapy with a strong evidence base is interpersonal therapy which, as you would expect from the name, focuses on relationships. There is also substantial evidence supporting family therapies, therapies oriented toward strengthening circadian (daily) rhythms, problem-solving therapy, and a group of approaches sometimes called “psychoeducation” that focuses on developing a better understanding of one’s symptom pattern and improving coping responses to symptoms. There is also some evidence that certain types of psychodynamic therapies derived from classic psychoanalysis may help.

OK, so I’m convinced: I do need to draft or trade for that great receiver. Now how do I find an evidence-based psychotherapist? Ask around. Ask your prescriber, your friends and associates who are in treatment, your fellow DBSA support group attendees. When you speak with a potential therapist, ask “brand name” questions: What type of psychotherapy do you do? How did you get trained? How long will this treatment last? What kind of materials do I need, like workbooks and such? Will we work in a group or one-on-one?

Often university clinics will have mood disorder programs that include both medication and psychotherapy treatment. Sometimes these clinics will be staffed by psychiatry residents or psychology interns or fellows. This is not necessarily a bad thing, since these trainees are usually highly motivated to do the treatment well, and they must be supervised by experienced psychotherapists.

Note that there are various self-guided books and apps and web programs based on these evidence-based psychotherapies, but rarely have they been tested in clinical trials. Shop carefully.

So: build out your team. It beats sitting around waiting for a medication to work.

About the Doc

About the Doc

Mark Bauer, M.D., is Professor of Psychiatry at Harvard Medical School, Associate Director of the VA Center for Organization, Leadership, & Management Research, and Director of the VA National Bipolar TeleHealth Program.  He is on staff of the VA Boston Healthcare System and has served on the DBSA Scientific Advisory Board since 1990.

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