Functional remediation therapy addresses the cognitive problems of the nearly 50% of patients who remain impaired even when euthymic.
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.
“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."
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.
Inform patients that their cognitive symptoms-as bad as they are-are not likely to worsen. There is often a palpable relief after hearing this, especially in those over 50 who feared they were developing dementia. Emphasize that the problem is caused by the chronicity of the illness, rather than the medications that treat the illness. Encourage lifestyle factors that enhance cognition: exercise, sleep, diet, and sobriety.
The rest of the therapy involves skills to either sharpen cognition or compensate for the deficits that persist. Of these 2 approaches, compensatory skills are probably more important. Despite all the puzzles and brain games, Functional Remediation Therapy did not improve objective measures of cognition, but it did improve functioning, which points to compensation as the vehicle of change.
There’s an advantage to learning these skills in a group setting, with the enriched interactions it offers to practice them. On the other hand, individual work allows a closer tailoring of the skills to fit the patient’s needs and goals. Some of the skills I have found most useful, along with links to patient handouts, are:
1)Attention. When working, reduce external distractions, allow adequate time, and schedule regular breaks. When reading, pause to summarize the material to yourself. If the reading is dull, find ways to apply it to your life. Reward yourself after completing a task, eg, with a bite of chocolate or a visit to your favorite website.
2)Memory. Every morning and night, record important events and an updated to-do list in a journal. Organize your space so that things are easy to find. Use reminder systems such as alarms, calendars, and apps.
3) Problem-solving. Consider all aspects of the problem before reacting to it. Brainstorm solutions, and rank them according to how feasible, effective, and risky they are.
4) Social skills. The therapy includes sessions on reflective listening, small talk, and assertiveness.
Parts of this therapy are highly technical, and there are movements to replace some of it with computer exercises. Before we get that far, let’s not forget Ms. Logan’s reminder to first ask our patients about their losses. Put down the EMR, drop the FAST scale, look your patient in the eye, and ask if any part of his or her self has gotten lost in the symptoms or the treatment. It may lead down the path of Functional Remediation, or it may go somewhere else entirely.
This article was originally posted on 2/8/2017 and has since been updated.
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, MartÃnez-ArÃ¡n A. Functional Remediation for Bipolar Disorder. Cambridge, UK: Cambridge University Press; 2014.