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Therapy for Cognition: Restoring the Self in Bipolar Disorder

Therapy for Cognition: Restoring the Self in Bipolar Disorder



In 2013 an article in the New York Times Magazine went viral. It was a personal story by Linda Logan, a talented woman whose life had been derailed by bipolar II disorder. Her concern was not the mania, depression, or psychosis she had lived through but something else: “the self.” She called on doctors to “ask about what parts of the self have vanished and . . . help figure out strategies to deal with that loss.”

Her words struck a nerve with many patients and left me a bit daunted. Thoughts of existential psychotherapy reflexively came to mind, until I looked closer at the parts of the self she found missing. “I lost my sense of competence . . . Word retrieval was difficult and slow . . . Clarity of thought, memory and concentration had all left me. I was slowly fading away.” These losses followed her even after her mood stabilized: “I still don’t have full days—I’m only functional mornings to midafternoons.”1

These problems are not outside the reach of treatment. They are the cognitive symptoms of bipolar disorder. My last column suggested that cognitive problems account for the finding that a surprising 30% to 50% of patients with bipolar disorder remain impaired even when euthymic. That disability isn’t limited to the workplace. Relationships are equally affected. Cognitive problems rob people of the roles Freud thought of as “the cornerstone of our humanness”—to love and work.2 It’s no wonder Ms. Logan called it a loss of self.

Functional Remediation Therapy focuses exclusively on the cognitive side of bipolar disorder. It is delivered in a group format over 21 sessions. There’s a lot of practice in this therapy. Sessions begin with cognitive exercises, such as mental arithmetic. Patients pair up to practice skills, like breaking complex tasks into workable steps or role-playing small talk. Sessions end with specific homework, and patients are also encouraged to read novels and newspapers and work on puzzles like crosswords and Sudoku between sessions.3

Few communities offer this therapy, but a cognitive rehabilitation therapist might be able to do the work. Functional Remediation was directly borrowed from that field, where it has been successfully used for schizophrenia, stroke, and traumatic brain injury.

Another option is to weave these skills into your own sessions. This is understandably less effective, but naturally more feasible. The first part of the therapy is readily translatable—assessment and education.

The Functioning Assessment Short Test (FAST) is a brief scale that’s employed in the therapy. It’s available free through the NIH (from that link, scroll to “Additional file 2”). From that assessment you can educate patients about the problem. Family education is equally important, to break the demoralizing cycle of frustration and blame these families often get caught in. Families should foster independence when it’s feasible, and lower their expectations when it’s not.


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