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.”1
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. Cognitive problems may account for the finding that a surprising 30% to 50% of patients with bipolar disorder remain impaired even when euthymic.2 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.3 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’s delivered in a group format over 21 sessions, which begin with cognitive exercises, such as mental arithmetic. Patients pair up to practice skills, such as 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 such as crosswords and Sudoku between sessions.4
Few communities offer this therapy, but a cognitive rehabilitation therapist might be able to do the work. Functional Remediation Therapy 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 employed in Functional Remediation Therapy, which is available free through the NIH. 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.
Dr. Aiken is the Director of the Mood Treatment Center and an Instructor in Clinical Psychiatry at Wake Forest University School of Medicine in Winston-Salem, NC. Dr. Aiken does not accept honoraria from pharmaceutical companies but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, which he coauthored with Jim Phelps, MD.
1. Logan L. The problem with how we treat bipolar disorder. New York Times Magazine. April 26, 2013.
2. Aiken C. Eight ways to improve cognition in bipolar disorder. Psychiatric Times. http://www.psychiatrictimes.com/bipolar-disorder/eight-ways-improve-cognition-bipolar-disorder. Accessed March 8, 2017.
3. Erikson E. Childhood and Society. New York: WW Norton; 1993.
4. Vieta E, Torrent C, Martínez-Arán A. Functional Remediation for Bipolar Disorder. Cambridge, UK: Cambridge University Press; 2014.