Specialized Services for Bipolar Disorder

Why I Treat Bipolar Disorder

A question I’m often asked by new patients is:  Why have you developed a specialization in providing psychotherapy to people with bipolar disorder?

I’ve always been interested in complex psychopathology. In the 1970s I spent four years working in an emergency services unit of a large community mental health center and another two on an inpatient psychiatric unit. Those experiences gave me amazing exposure to a broad range of psychiatric conditions.

In 1991 I was hired to create the East Carolina University Mental Health Services. The unit was separate from the University Counseling Center and its mission was to treat students who presented with more complex and acute psychopathology. The unit was small – 2.5 psychologists and one psychiatrist. Due to this unique configuration of clinical services, I saw many more students with bipolar disorder over the course of my nine years at ECU than I would have seen had I been a psychologist at a large counseling center where bipolar students would have been more evenly distributed across a larger clinical staff.

In 2000 I was hired as Director of Counseling and Psychological Services (CAPS) at the University of Virginia. I wanted to continue with some clinical work as opposed to being a full-time health services administrator. Given my previous experience at ECU, staff were glad to refer bipolar students to me and my experience with the population continued to expand.

From 2008 through 2013, I led the bipolar student support group at CAPS. In 2010 I co-authored a book on bipolar disorder. I also began writing a blog on bipolarity for Psychology Today. In 2013 I transitioned to full-time private practice where about two thirds of my patients are diagnosed with bipolar disorder.

Early in my career I had not identified bipolar specialization as a long-term career goal. It’s more like it’s gradually evolved in that direction, bit by bit, since the early 1990s.

There’s another factor that’s probably also had a strong influence. In 1951 I had polio when I was a year-and-a-half old. I mostly recovered though I was left with a very atrophied right leg. Through childhood and on up through my mid-adult years, I’ve worn a brace on one leg and have led a very physically active life. However, since the late 1980s my left leg has been gradually weakening due to the late effects of post-polio. I’m now able to walk some, but not well, and I mostly use an electric wheelchair to get around.

I don’t like living with the physical limitations brought about by polio, but it’s also something I can’t change. My only choices entail how well I accept and adapt to my limitations. It’s highly likely that my own personal journey with disability has had a strong impact on my capacity to understand and empathize with others who are faced with conditions that they do not want.

Clinical Assessment

Dr. Federman’s Approach to Bipolar Assessment

Assessment of new patients with bipolar disorder can vary greatly depending upon the extent of previous assessment and treatment already received.  When one comes in with a well-established diagnosis and treatment history, the assessment can be more streamlined than if the appointment represents a first meeting with a mental health professional.

That said, we also have to acknowledge that bipolar symptoms exist on a very broad spectrum and there are multiple other conditions that can be expressed through symptoms that look very “bipolar-like.”   I’m therefore cautious about assuming that previous diagnoses are always accurate.  My intent is to look at all the evidence including current symptom, established patterns of mood and behavior as well as previous treatment and to essentially ask – what’s really going on?

Initial Assessment Session(s)

Whenever possible I like to try to schedule 1.5 to 2 hours for an initial assessment meeting.  During that I’ll be trying to gather in-depth information about symptom patterns, current life circumstances, previous treatment, current medications and family background.  I will also give a fair amount attention to how an individual may feel about a potential or already existing bipolar diagnosis.  I find that if the bipolar diagnosis is accurate, issues involving acceptance of the diagnosis can be some of the stronger challenges that one is faced with.

Assuming that by the end of the first assessment session I’ve arrived at some definite conclusions and recommendations, they will be shared with you and we will discuss plans for going forward with treatment.  There may also be times when due to the complexity of presenting clinical issues, additional sessions may be needed before I’m able to be definitive about diagnosis and treatment recommendations.

Adjunctive Assessment

There are sometimes circumstances when further assessment may be needed from other mental health and/or medical professionals.  Examples would be when the contributing role Attention Deficit Disorder needs to be ascertained or when it’s suspected that some other physiopathology that may be responsible for the current symptom picture (brain injury, thyroid dysfunction, etc.).  These possibilities and referral options will be discussed with you if appropriate.

Individual Psychotherapy

Psychotherapy approaches for bipolar disorder can vary considerably. The work can be thought of as addressing one of the five areas outlined below. It is also frequently the case that multiple areas of focus are attended to concurrently.

A. Stabilization and psychiatric referral

When someone commences treatment and he/she is actively symptomatic, the first priority following assessment is to assist with lessening the acuity of current bipolar symptoms. This typically entails looking at lifestyle patterns and their impact upon day-to-day functioning.  Recommended modifications will be discussed while also looking at elements such as stress management, impact of current relationships, exercise, diet and substance use. Essentially, I take a very holistic approach towards stabilization.

In addition to therapy, psychiatric medication is often an essential aspect of achieving stability with bipolar disorder.  I work collaboratively with numerous psychiatrists in the Charlottesville area and if a new patient does not already have an effective psychiatric relationship, a referral will be made.  If a new patient is already receiving psychiatric treatment, I will obtain a signed release so that I can work collaboratively with a patient’s treating psychiatrist.

B. Acceptance of the disorder plus psychoeducation

This is one of the most important aspects of working with the disorder and the related therapy can span a broad range from as briefly as a few moths … up to a full year or more.

Each person reacts to his or her diagnosis uniquely.  For many this reflects where they’re at developmentally.  Accepting bipolar disorder is usually more difficult in late adolescence and/or early adulthood, particularly as many of the recommended lifestyle modifications are in conflict with lifestyle norms of the 17 to 25 year old.  However, if an individual has already been diagnosed and treated for bipolar disorder and has progressed beyond the initial adjustments, the issues of acceptance may be less problematic.

Regardless of one’s age when coming into therapy, improving one’s acceptance of their bipolarity is usually a salient aspect of psychotherapy.  An important aspect of acceptance involves developing an understanding of what the disorder is, how it can impact the individual (short term and long term) as well as what kinds of behavioral or lifestyle adjustments are needed to better manage one’s symptoms.  I think of this as the psychoeducational aspect of psychotherapy.  This this entails active teaching within sessions as well as directing individuals to reputable resources for their own learning about bipolarity. 

C. Psychotherapy for maladaptive personality patterns

People can have personality characteristics that are sometimes maladaptive.  Rather than facilitating one’s progression through life, they create their own set of issues or difficulties.  When these difficulties coexist with bipolarity they can certainly complicate the clinical picture.  The salient questions for the diagnostic and treatment planning become: What symptoms are being driven by bipolarity vs what symptoms are more reflective of underlying personality?  Hopefully, this distinction will be addressed during the initial assessment phase of therapy.  And if it is not clear early on, it will likely become apparent as therapy progresses and our understanding of one’s issues deepen. 

Maladaptive personality patterns are not a symptom of bipolar disorder, but they can definitely exacerbate the illness.  For the individual with bipolarity this can be like trying to extinguish a fire while repeatedly adding new dry kindling.  

Personality patterns don’t change easily.  They have evolved over many years’ time, and for most of individuals, they usually occur outside of conscious awareness and volition.  The work on these issues typically reflects a psychodynamic or psychoanalytically oriented approach where we are repeatedly looking at the impact of childhood and adolescent development upon personality.  It’s important to recognize that personality traits typically represent an individual’s efforts towards adaptation in response to early life influences.  These adaptations become interwoven within personality style and it’s not uncommon to find that they become maladaptive as one progresses through the lifecycle.  In other words, adjustments that the four-year-old had to make within their family of origin may no remain adaptive in their adult life.

In the course of working with bipolar disorder I do my best to discern whether personality issues are contributing to an individual’s difficulties.  Where this is the case, I work collaboratively with the individual to identify areas of personality change that are desired.  If the patient has sufficient motivation and resources (good insight, capacity to tolerate emotional discomfort, adequate finances for ongoing psychotherapy), then the work on “personality” may become a central part of treatment.

D. Supportive psychotherapy

Life with bipolar disorder can sometimes be a bumpy ride.  Even when doing all the right things, individuals can still find themselves struggling with mood instability.  Supportive therapy for the bipolar individual provides a time to feel heard and understood without having to worry about burdening friends or family.  Supportive psychotherapy helps the patient to maintain perspective while also providing supportive guidance in facing the challenges that come with bipolar disorder.

And if a patient is in the midst of one of those times when insight, behavioral adjustments and support don’t facilitate sufficient change, then therapy can also provide opportunities to explore feelings of frustration and helplessness. Essentially, therapy is a time and place where any and all feelings are permissible.  It’s part of what distinguishes the experience from typical day-to-day interactions.

E. Brief treatment for relapses

Intermittent relapse is a given for many with bipolar disorder.  The question isn’t so much – will relapse occur, but more – how often will it occur and what degree of symptom acuity will the individual be faced with.  The good news is that for many with bipolar disorder, maturation and life experience generally helps to lessen the highs and lows of bipolar disorder.

When one has achieved a relatively good degree of stability, then ongoing psychotherapy is usually unnecessary.  However, when mood does destabilize it can be helpful for a patient to come in for several sessions in order to receive brief assistance in getting back to mid-range mood.  Think of this like intermittent visits to a family practice physician. Once symptoms have returned to a manageable level, then continued sessions become less necessary and can be spaced out at broader intervals.

Support Group for Professionals Diagnosed with Bipolar Disorder

The support group meets every other week and is limited to six individuals with bipolarity, all of whom are currently employed or have the capacity to be employed within professional roles. This unique group provides a safe space to be able to discuss one’s struggles with others who share the diagnosis and can offer empathy and understanding of the bipolar experience.  Respect, safety and confidentiality in relation to identity and disclosed information are strongly emphasized throughout the group process.

Criteria for Participation

  • Group members must already have the diagnosis of bipolar I, II or Cyclothymia and be accepting of the diagnosis (should not attend if they are doubtful about it).
  • Group members must be able to assure confidentiality with other members’ identities and the content of self-disclosure that will occur in the group.
  • Group members must have the capacity for trust and open sharing of personal information.
  • Group members must have a current relationship with a prescribing psychiatrist and/or a psychotherapist (these can be the same). If a therapy relationship is not currently in place, a group member must have the capability/willingness to commence individual psychotherapy if warranted. 
  • Group members must have the capacity to commit to consistent attendance.

Couples and Family Work

Bipolar Disorder doesn’t occur in a context of interpersonal isolation.  Changes in mood, thinking and behavior can certainly affect loved ones, family members, friends and even co­-workers.  While it isn’t realistic to consider doing therapy with co-workers, it is very appropriate to involve those who share a strong relational commitment with the bipolar individual. Typically this involves family, spouses, significant others and/or even best friends.  A few therapy sessions with those individuals can often help all to better understand the impact of the disorder and to more effectively manage those aspects of the relationships that are most affected by recurrent bipolar symptoms.

Psychoeducational Consultation

If one has recently been diagnosed with bipolar disorder, the ensuing choices can be overwhelming for the diagnosed individual or for families (parents) of the individual.  These psychoeducational consults are focused upon providing bipolar-related information to individuals and families who are at the front end of the illness.  Topics may include: obtaining appropriate kinds of help, impact of the illness on the family system, arriving at decisions about school and/or work, recommendations regarding initial lifestyle adjustments as well as what to expect from the early course of the illness. 

These consults are not the same as accepting a patient into treatment.  Typically, they occur one to three times and are not reflective of an ongoing therapy relationship.  They are meant to provide helpful guidance so that people can become clearer about the choices they need to be making in response to a recently occurring bipolar diagnosis.  Costs are based upon my hourly fee of $200 per 60 minutes.

Extended In-Depth Assessment of Bipolar Disorder

Occasionally an individual may be interested in receiving a one-time in-depth consult and assessment pertaining to bipolar disorder.  The motivation for an in-depth assessment may reflect concerns about emerging bipolar disorder symptoms.  Alternately, an individual may previously have been diagnosed and is now seeking a second opinion regarding the diagnosis.

The in-depth consultation is approximately 1.5 to 2.5 hours in length, depending upon the extent of issues needing discussion.  The  benefit of scheduling an extended assessment entails the opportunity for thorough discussion and exploration without being limited by the constraints of a single session.  The cost for the assessment will depend upon the amount of time for the assessment. Fees are figured at $200/hr.

The assessment will cover the following areas:

  • Current symptoms and background
  • Course of presenting issues
  • Assessment of lifestyle and environmental influences
  • Psychiatric/psychotherapy treatment history
  • Family psychiatric history
  • Psychosocial history
  • Substance use history
  • Discussion of diagnosis
  • Treatment recommendations

If the individual being assessed would like to have a spouse, partner or family member participate in the assessment, he or she is welcome to do so.

If the assessment will serve as the foundation for subsequent treatment with Dr. Federman, a written report will not be generated unless specifically requested by the individual being assessed.  However, if the assessment is being done for an individual living outside the Charlottesville area and is intended for use by other mental health or medical professionals, a comprehensive written report will be provided.  Report cost will be based upon writing time.  It will usually be written and sent to the patient within two weeks following the assessment.