The Development of a Cognitive Analytic Therapy (CAT) Relational Framework for Bipolar Disorder (BD)

Shannon, K. and Swarbrick, R., 2010. The Development of a Cognitive Analytic Therapy (CAT) Relational Framework for Bipolar Disorder (BD). Reformulation, Summer, pp.17-25.

1.1 Psychological Interventions

Traditionally, there are limited psychological approaches to support individuals with a diagnosis of Bipolar Disorder (BD). Historically, these have been underpinned by the dominant neurobiological approaches and pharmacological treatment (Goodwin, 2003). However, poor compliance with medication is commonplace in as much as 50% of individuals with a diagnosis of BD (Adams & Scott, 2000). Increasingly clinicians have identified the limited effectiveness of such a unitary approach and have started to recognise the increasing need for psychological input as an effective adjunct (Jones, Sellwood & McGovern, 2005). More recently, approaches have targeted social and environmental factors, for example, family interventions (Milkovitz et al., 2000); psycho education (Colom, Vieta, Martinez-Aran et al. 2003); interpersonal and social rhythm therapy (IPSRT, Frank, Kupfer, Thase, et al., 2005) and relapse management (Lam, Watkins, Hayward, et al., 2003).

Individual therapeutic interventions such as Cognitive Behavioural Therapy (CBT), have promoted individuals to develop new ways of coping and exploring cognitive thinking patterns with associated levels of disability (Scott, Paykel, Morriss et al., 2006). However Scott and colleagues highlight the limited effectiveness of brief CBT with individuals who have experienced a very high number of previous and frequently occurring episodes. Moreover, Castle, Berk and Murray’s (2009) review of psychosocial interventions for BD, emphasise that research on interventions to date have focused upon amelioration of one, as opposed to both poles of the disorder; with more efficacy demonstrated for the depressive phase. There appears to be an unmet need for a comprehensive psychological model, which can respond effectively to the complexity of manic, depressive and other states, levels of disability and distress elicited by BD. From a psychotherapeutic perspective, work such as by Frank and colleagues (2005), have explored the interpersonal and social dynamics associated with conflict, loss and transition. In terms of Cognitive Analytic Therapeutic (CAT) interventions, there has been increasing interest in developing therapeutic services for individuals with severe and enduring mental illness. Kerr, Birkett and Channen, (2003) identified that psychotic experiences and symptoms were the manifestation of distorted, muddled enactments of normal reciprocal role procedures. They stipulated that damage occurred at the metaprocedural level of the self and that the person was internally and externally ‘out of dialogue’. In 2001, Kerr explored CAT interventions in terms of staff development and service provision. The therapeutic aims included to develop alliances, concordance, reduce distress and to support and manage staff dynamics. This work was supported by the development of a contextual reformulation informed by iatrogenic factors within the system.

From the conceptualisation of these early innovative pieces of research within the CAT field, this suggested framework was also informed by the lead author’s previous work on The Broken Egg; a CAT framework of male aggression and violence (Shannon, 2002; Shannon, Willis and Potter, 2006), that is the similarities in hierarchical structure of the preferred and dreaded self states, associated societal status (e.g. high achieving, special, superior, successful) and identity positions (e.g. winner, unique, pinnacle); overlap of narcissistic and borderline features; disruptive nature of dissociation, ambivalence and difficulties in effecting persistent change. On this basis, we started to re-examine our historical and current clinical experiences, to aide our understanding of individuals presenting with BD.

With an awareness of the difficulties from a service perspective of providing effective and responsive services for this complex and distressed group of people, we started to conceptualise a CAT framework of BD over the past 4 years. An initial stage, involved the identification of unifying themes from different client groups across a wide array of clinical settings (such commonalities included consistent levels of damage to the self, the diversity and range of relational and illness states, the dynamic and often abrupt movement between distinct self states, levels of dissociation and the difficult and unhelpful elicited responses from others). 2006), high rates of attrition (e.g. Miklowitz et al., 2000) and the potential damaging impact on the psychological wellbeing of staff groups can be noted with a recognition of the need for competent staff involvement (see Roth and Fonagy, 2006). From a systemic and societal perspective, there has been evidence of an uninformed and dissociative response toward this client group in terms of paucity of both research and an underdeveloped array of psychological interventions. In our view, there is lack of metaprocedural conceptualisation of the difficulties experienced and therefore, a failure to provide appropriate, multi systemic responses. For example the NICE guidelines, which aim to examine the complex levels of disability, associated with BD, primarily focus upon pharmacological intervention, psycho education, family work and relapse prevention.

1.2 Nature and Impact of Bipolar Disorder

BD is associated with significant levels of damage at the individual, familial and societal levels. For example, there is an 80% likelihood of suicidal behaviour throughout an individual’s lifetime, with sufferers most likely to commit suicide in comparison to any other psychiatric group with a severe and enduring mental illness (Rihmer & Kiss, 2002; Valtonen 2005,). Substance and dependency rates are higher in Bipolar Disorder than in any other Axis 1 disorder (Goldberg, Singer and Garno, 2001) and result in greater suicide risk and suicidal behaviour (Dalton, Cate-Carter, Mundo, Parikh & Kennedy, 2003). Individuals who are in their manic phase of illness are four times more likely to commit acts of physical violence than an individual with Unipolar Depression (Graz, Etschel, Schoech, and Soyka, 2009). Thirty five percent of individuals with a conviction for sexual offending have a diagnosis of BD (Dunsieth, Nelson, and Brusman-Lovins, et al., 2004).

The United States Department of Health, Education, and Welfare (1979) conceptualised the levels of loss in all domains of functioning when they calculated that the average 25 year old woman with a diagnosis had “lost 9 years of life, 12 years of normal health, 14 years of major activities, such as schooling, work and child rearing”. This is in addition to the “ $199 million per annum indirect treatment costs and the $2 billion in total societal costs” (p 82.) as Das Gupta and Guest (2002) note and point to the fundamental need to develop appropriate services.

There appears to be a sense of fragmentation and neglect of this client group as evidenced by the limited research database and the poor provision of flexible, specialised clinical care which fails to address the complex diverse presentations and needs of sufferers. In conjunction with pharmacological treatment, it is essential to develop psychological models which can accommodate the complexity of the illness (Jones, Sellwood and McGovern, 2005).

2.0 Process of Development of a Cognitive Analytic Therapy Bipolar Disorder Reformulation

Both authors explored their clinical and process notes reflecting on individual and group therapy experiences to refine a consistent and reliable understanding of the CAT aspects of a BD reformulation. Subsequently after repeated review, informed by clinical practice and re-conceptualisation, the framework was presented in poster format at the ACAT North Conference: Innovations in Clinical Practice (June, 2008) at which the authors identified their alignment with other research groups. Conference delegates identified with the generic reformulation and linked this to their understanding of client and service perspectives. At a second stage, the framework was presented to a wider national psychological audience at the Division of Clinical Psychology (DCP) Conference at the Symposium for New Innovations for BD (December, 2008). Again, clinicians received the poster positively, and engaged in dialogue around their own feelings of isolation and uncertainty in managing this client group. Importantly, within this forum it appeared to be one of the only pieces of work to address the complex relational dialogues and multiple states of distress.

Following these formal discussions, and ongoing dialogue with senior management within the authors’ respective NHS Trusts, the framework was shared with clients and carers in an open forum within the Manic Depression Fellowship (MDF). The framework was introduced as a potential relational template to include an understanding of service provision and the care and therapeutic responses of adult mental health agencies. The forum aimed to provide a safe and respectful space for individuals from a range of socioeconomic backgrounds and generational positions, to converse, support and reflect on their experiences of distress, difficulty and illness within the provision of care.

The framework was described in stages, mapping the circularity of the reformulation. In doing so, the authors experienced powerful transference in the room, which altered and mirrored the different self-states as they were discussed (enactments). For instance, the clients and carers described a lack of understanding and appropriate and timely responses from services; a withholding of care. In relation to this, they expressed a sense of loss, helplessness and hopelessness. In the clients’ descriptions of this state, the authors experienced an ‘avalanche of sadness’ in the room, with powerful transference to be protective of the individuals and critical and potentially attacking of service provision.
Carers and clients were also noted at times, to be at different reciprocal poles and in differing self-states. For example, one marital couple who acknowledged the considerable negative impact of the illness on their relationship, and the lack of appropriate support and communication from services, appeared to be individually located in differing positions of partial dissociation; the client in an escalating, thrill seeking procedure to aim to access the grandiose, fragile, euphoric state (see figure 1 below). His partner however, was left in a voiceless, ‘sucked dry’ state where the overwhelming counter transference was of ‘flatness’ and absence.

There was a significant amount of information gathered around differing omissions in care provision and potential requirements and adaptations for future NHS interventions. Although we were originally invited by the MDF for a forty-five minute slot, we were asked to remain, and actively discussed issues for over two and a half hours. On leaving, we were overwhelmed by the reported paucity of timely, effective support this group of people appeared to have received, or have been able to make use of through the NHS. However, it was apparent that this informal meeting at the MDF forum allowed for recognition of shared experiences, beginnings of a shared understanding and a sense of solidarity and hope within the group. This was a validating experience as, without exception, the framework accounted for both carers’ and clients’ repeated dialogues and those with health care agencies. A second meeting with the MDF took place one year later with some of the original members present. The focus of this was to develop an understanding of the masked remission state (see figure 2) which had been outlined previously but continued to remain fully unformulated. Mirroring the first, the accuracy of the overall framework appeared to be significant. The specific changes to the framework were centred on the reciprocal roles and procedures of the masked remission state for both carer and client and the differing and potential conflictual interpersonal positions of client, carer(s) and services.

3.0 Different States of Bipolar Disorder

Figure 1 shows a brief overview of a suggested CAT framework for BD at this current point in time, which will continue to be developed following ongoing clinical work and a potential case series. There are a number of dominant states of mind: manic euphoria, controlled superiority, masked remission, critical shaming psychotic anger, dismissing and rejected depression. These will be discussed within the reformulation below, accompanied by the integration of the underpinning research evidence and knowledge currently available.

3.1 Yearned For and Preferred States

The state located at the top of the Sequential Diagrammatic Reformulation (SDR) indicates the preferred ‘special’ state of euphoria, mania and feeling “high” which is perhaps the most recognisable state characterising BD both from an epidemiological and societal perspective. Descriptions of this state from clients are powerful and evocative. For example “walking on water”, “on top of the world”, “invincible”, “chosen”, “enveloped by an angel” and “a giant amongst pygmies”. These descriptions demonstrate not only the special, almost unique quality of this state of mind, but also the higher status or rank over others (Gilbert, McEwan, Hay, Irons and Cheung, 2007), which reciprocates the ‘special’, and hence desired nature of the state. The desirability has particular relevance in understanding securing engagement from clients, lowering attrition rates and ensuring the efficacy of interventions.

In order to occupy this position and state of mind, there needs to be a disconnection from emotions which are at odds with, or which may puncture euphoria. This dissociation occurs at both intrapersonal and interpersonal levels, described by one client as “separate worlds”. By its very nature, this yearned for state is fragile, and hard to sustain, despite the introduction of more extreme and escalating acts [e.g. thrill seeking (Gilbert et al., 2007; Thomas & Bentall, 2002), sleep deprivation, drug taking (Comtois, Russo, Roy-Byrne & Ries, 2004), gambling (McIntyre, McElroy, et al., 2007), excessive interest in sex, spending lavishly (Rymaszewska, Andrzej, Tomasz, Aleksandra and Rybakowski, 2007)] and other risky behaviours in an attempt to prolong it. Such acts eventually result in a chaotic loss of control leading to a tumbling out of this preferred position. This is accompanied by a desperate scrambling, to avoid slipping further, and successive attempts to return to the preferred position. When this is not possible, the chaotic nature of the individual’s vulnerability, desperation and exhaustion, lead to exposure to themselves (insight) and transparency to others, including services.

3.1.1 Elicited Responses From Others and Systems

As a result, societal governing agencies are triggered into action e.g. sectioning under the Mental Health Act and acute care provision, social care input and/or involvement from the Criminal Justice System (CJS). This causes significant stress for the carers and families with respect to the wellbeing and management of their loved one. However, there is also an associated sense of relief that the client’s difficulties are explicit, transparent and are deemed sufficiently significant to warrant statutory agency and CJS responses. Via this process, the overwhelming pressure, vigilance and responsibility that families and carers have been managing is transferred, albeit temporarily.

3.1.2 State Shifts For The Individual

Through this process of falling from the preferred position, comes the potential accompanied increased emotional connection and increased awareness of the self and others; “a reality check”. Following the “bubble bursting”, the individual is painfully flooded with humiliation, loss, stigmatisation (Hayward, Wong, Bright and Lam, 2002), realisation of their fragility, and awareness of their psychiatric symptoms (Cheng-Fang Yen, Chung-Ping Cheng et al., 2008). This is mirrored in the shaming process experienced by the families and carers.

3.2 Fall to Differing States

The individual may find themselves in hospital or a prison cell, and experience being “overwhelmed” by service responses. After the chaos and bedlam has died down, the client may find himself or herself in a dreaded or endured state (see section below). They experience removal from society, rejection, stigmatisation and a sense of being discarded and valueless, with accompanying guilt, humiliation (Hayward et al., 2002) and distress.

To cope with these intolerable feelings, the client acts upon their desperate distress by enacting a critical attacking state. Individual differences result in self-attack in the form of on the one hand self-criticism or self-loathing i.e. “bad me” paranoia with accompanying accusatory or derogatory hallucinations, low self-esteem, the increased possibility of depression and potentially deliberate self-injurious behaviour and suicide (see Chadwick, Birchwood and Trower, 1996). Alternatively, the critical attacking state can be externally focussed and manifest as agitation, paranoia and self pity; “poor me” paranoia resulting in anger and the psychological or physical attack of others. Factors which increase the likelihood of abuse, either verbal or physical, by the client appear to be linked to younger age, level of drug and alcohol misuse and importantly, yet unsurprisingly, a poorer pre-episode relationship between client and carer (Vaddadi, Gilleard and Fryer, 2002).
These uncomfortable states are then exited by striving for the preferred states, by attempting to gain a sense of status through striving (Johnson, 2005) and grand gestures. These state shifts depend upon the other; to be the admirer, to bow to superiority, to be used by superior others in attempts to gain reflected admiration. These state shifts have some support in the work of Bentall and colleagues and the notion of a ‘manic defence’, where the seemingly elevated self esteem characterised in the manic phase, conceals the fragile underlying poor sense of self worth which is more transparent in the depressive state of mind (Lyon, Startup, Bentall, 1999).


Such a ‘manic defence’ enables the individual to be less permeable, and more robust to the influences of others; less sensitivity to high levels of stress or conflict. Therefore, in this phase, high Expressed Emotion (EE) interactions which are experienced in families do not directly or consistently affect a depressive outcome (Yan Hammen, Cohen, Daley & Henry, 2004). The partial dissociation of this state protects the individual, albeit temporarily. The sense of superiority from striving, competing and winning, can “spill into invulnerability, no need to listen to (inferior) others and elevated risk taking” (p.52) (Gilbert et al., 2007) and other forms of thrill seeking. As opposed to these state shifts being directly determined by interpersonal or psychosocial elements, manic episodes are better instigated and predicted by alterations in intrapersonal states (i.e. self to self) this achieved in the form of alterations to bio-psychosocial variables such as the sleep-wake cycle (Johnson et al., 1999).

2.3 Initially Endured Moving to Dreaded States: Masked Remission

This masked or ‘remitted’ state appears to be more stable, with seemingly less acute fluctuations in comparison to the extreme, polarised positions. Access to this initial endured position requires social competency, significant psychological and physical resources to maintain “agitated, temporary suspension” from the persistent striving and the inevitable falling when exhaustion overrides the facade.

Within this state, the individual has recognition and realisation of their situation, and has difficulty in coping with re-surfacing feelings which are inevitably painful (Cheng-Fang Yen, et al., 2008). There are feelings of guilt and embarrassment for their erratic and perceived irresponsible behaviours. They are also fearful of exposing their own imperfections and receiving subsequent criticism, and rejection by friends and carers, leading to relapse and hospital admission. Scott, Stanton, Garland et al. (2000) found increased interpersonal dependency with a perceived belief in the need for social approval and perfectionism in individuals who were in this euthymic phase. There is the aim and attempts by the individual to gain reassurance; a “need to be wanted”, “to be heard”, to be soothed forgiven and, not to be burdensome.

2.3.1 Assumed Solutions

The individual therefore attempts to gain positions in the bottom reciprocal roles of the upper part of the SDR, and achieve this via compliance, ingratiation, and ‘giving over’ of themselves to be forgiven, accepted and cared for in an attempt to gain ideal care and to be perfect (see Figure 2). To achieve this there are assumed fears that the other will be unable or unwilling to accept, or cope, with the emotional and physical burden generated by the client. Within this state the client is also sensitised to any perceived lack of response from carers, partners or friends (Solomon, Shea, Lea et al., 1996), which is personalised and interpreted negatively (Teasdale, 1988). Therefore in a bid to maintain contact with the other, they conceal or mask their own distress and anxiety and ingratiate or over-give of themselves in relationships. In doing so, the client discards and forgets their own needs, or, experiences, being overly controlled of themselves in their benevolence to others.

The client eventually feels engulfed and enmeshed or overly dependent (Gilbert, et al., 2007), with building resentment at increasing restrictions. Despite this, for fear of the other’s rejection, the client is unwilling to risk communicating their changing position and hostile emotions and therefore the enmeshment is unsustainable (Benazzio, 2004). The building pressure and eventual experience of critical rejection and potential rage results in a fall to the critical depressive bottom of the SDR and a sense of ‘being used up’ and ‘sucked dry’. This is descriptive of the high familial EE, which is associated with and predictive of relapse and depressive recurrence (Yan, Hammen, Cohen, Daley & Henry, 2004). Rosenfarb, Miklowitz, Goldstein et al. (2001) emphasise the observable transactional relationship between clients and relatives which may undermine client’s clinical stability. Clients living within high EE families (care characterised by critical and/or emotional over-involvement i.e. subsuming of the client’s self to others), report more manic symptoms and show a statistical trend toward having more depressive symptoms (Simoneau, Miklowitz and Rakhshanda, 1998); thus demonstrating the important influence of family relational patterns on symptomatology and the shifting states of mind of the client. In such instances the vulnerability of the individual within this central state is overwhelming, triggering a move to more robust poles.

Another consequence of the individual’s pattern of aiming to maintain closeness via dependence or enmeshment is subsequent psychological withdrawal (Coyne & Calarco, 1995); a pretence and concealment that things are functioning ‘normally’. The use of both avoidant and support-seeking coping styles in individuals who are in remission (Havermans, Nicholson, Marten and de Vries, 2007) may be initially functional. However, whilst avoidance and withdrawal and a sheltered, lifestyle may reduce exposure to daily stressors and feelings of criticism, these restrictive patterns also limit the positives of engagement in activity and relating to others (Coyne & Calarco, 1995) and leads to eventual depression and learned helplessness (see depressed state).

From the perspective of families and carers, the experience is one of being suspicious that there is a problem with their family member and constantly vigilant for clues of change. With the absence of meaning making and communication, feelings of being ‘sucked dry’ and exhaustion result, along with moderate or severe levels of caring burden (Perlick, Clarkin, Sirey, et al., 1999). Where the client has not been managed or cared for by the surrounding systems, the carer can feel unseen, abandoned and forgotten in response, or criticised and perceived as incompetent by others, and, inevitably by themselves contained within the assumption they are “not coping”.

2.3.3 Lack of Response of the Caring other

As a result of the individual’s concealment of distress, there is assumed remission and euthymia, in the sense that there is an explicitly lessening in intensity of symptoms and extremes of behaviour, relative to the highs and lows of mania and depression. The apparent disappearance of the client’s distress and symptoms is deemed as an efficacious outcome, by health agencies, carers and families, labelled as “remission” and characterised by a sense of safety. The role of services is deemed to be complete for this episode.

Clients describe the state of remission as a veneer; “putting on a mask” (see figure 2). However, as described for the client, there is still a “cycling” (state shifts), albeit less extreme, which requires internal resources at a time when the individual’s reserve is depleted and this remains unrecognised. The collective subjective description and experience of this masked remission state, reveals that its relevance, importance for wellbeing and risk management, may have been previously unrecognised or unappreciated. Carers and service providers are in danger of having a shared collusion, that stability is regained and the individual is safe within their remission.

2.3.4 Behind the Mask; a Move to the Dreaded state

Over time, within this “masked existence” both carer and individual can begin to lose a sense of themselves and feelings of “facelessness”, “dampening [self] down” , hopelessness, exhaustion and feeling valueless return. There is also a loss of individuality, vitality, and stimulation, which is in sharp contrast to the other states. Instead, clients in this state merely “pretend to exist” in masked agitation. Over time this is experienced as exhausting, “unbearable” and dreaded.

By this time, due to assumed remission, services have disconnected and shut off from supporting either the client or carer at this time of vulnerability and exhaustion. Any attempt to gain care is experienced as demanding by carers or services and the individual is rejected or unheard.

An awareness of the negative social consequences, heightening levels of hopelessness for potential change and meaningful recovery (Kim, Jayathilake & Meltzer, 2003) coupled with increasing levels of agitation (Benazzio, 2004) and impulsivity (Swann, Steinberg, Lijffijt, Moeller, 2008) can increase the client’s risk of suicide (Cheng-Fang Yen, Chung-Ping Cheng et al., 2008). Suicide can be seen as a final escape to this seemingly tortuous existence. At this point there are also significant, unrecognised risks for the carer; such as anxiety, depression and an increasing lack of resources to manage. From a societal perspective there is dissociation from and a neglect of understanding and provision for the everyday needs of individuals with mental health problems; this is mirrored in the experience of carers. All can fail to hold a valued position within society, feel socially excluded and experience deprivation in many domains of their lives.

2.3.5 Bipolar Spectrum Disorder

We postulate that the aforementioned self-state highlights the overlap of BD and Borderline Personality Disorder; that includes emotional instability, yearning for ideal care, and critical/rejecting positions. This overlap, referred to as a Bipolar Spectrum Disorder, has been the focus of considerable clinical and research interest (see Akiskal, 1994; Smith et al., 2005) The subthreshold for BD is common, clinically significant, and underdetected in treatment settings (Merikangas, Akiskal, Angst, Greenberg et al., 2007). There is a pejorative response by services, whereby a significant number of people who could be supported by psychiatric services are excluded because their symptoms fall outside of the clinical threshold and are deemed to be more consistent with a diagnosis of Personality Disorder. This ‘pre clinical rumbling’ and delay or absence of service response, results in the compounding of damage referred to in section 1.2 and may shape the individuals investment in the extreme two poles of the disorder. Solomon, Shea, Leon et al.’s (1996) work on personality traits in individuals with BD who are in remission also demonstrated increased neuroticism (hypersensitivity & shallow expression), hysteria (neediness), reduced ego resilience (diminished self assurance and poor composure) emotional stability (affective lability) and ego control (self control and impulsivity). Such personality factors are evident in this state and mirror the differing reciprocal roles and procedures identified within this CAT framework.

2.3.6 Depressed state

With the experience of exhaustion in the central masked state, the individual eventually expires into a depressed state of mind and behaviour. However, perhaps surprisingly, at this stage, in comparison, to the masked remission state, the depressed state has a certainty, comfortable familiarity and tangibility. The individual and the carer describe a ‘relief’, assurance and certainty in their roles within this state. Similarly services feel confident and activated in their role and expertise to assist.

Within this state, the individual feels able to remove their mask and give over of themselves and complete responsibility to the other in terms of their safety and wellbeing. This has been described as an almost meditative, destimulated and infantile existence, where there is no sense of agency; the person’s needs are nurtured by an attentive, dependent and responsible other. This is a time to recuperate with no responsibilities or demands on physical or cognitive resources. Such a state of almost meditation maybe mirrored in mindfulness based approaches to therapy; which have been successful in preventing the recurrence of depression in recovered patients with multiple depressive episodes (Ma and Teasdale, 2004). The lack of sense of agency may also be manifest in the avoidant and support seeking strategies enacted during such phases of illness (Coyne and Calarco, 1995) and the sheltered and passive lifestyles evident in Bipolar sufferers (see Havermans et al., 2007).

However, the empowered, caring and responsible role of the carer may change to powerlessness and devolution of role as a result of exclusion from nurturing, if the client is admitted to acute services. Also for the individual there is increased powerlessness, uncertainty, dependence and enforcement of therapeutic change through hospitalisation and medication regimes. The system takes control and feels a sense of worthiness, efficacy and pride. For the individual, the external agencies temporarily take responsibility before attempts to support and empower the individual to self care lead to ejection out of the dependent state, and hospital, into the unknown.

4.0 Summary

In our view, this suggested framework highlights the previously unformulated nature of all phases or self-states of this illness which maintain the cycle of BD. By the very nature of the masked remission, due to the relief for others and concealment by the client, it has been out of dialogue, (including at times the development of its formulation within this paper), and therefore the importance of this has potentially been unrecognised or underestimated. This framework is not implied to be an ‘off the peg’ reformulation for all individuals with BD, and there will be individual variation which should be carefully and collaboratively reformulated. Rather, this suggested framework attempts to highlight some of the psychological theories and influences underpinning the disorder, which may not be explicitly apparent. The sensitive and timely understanding of what is out of dialogue, that there is a lack of synchronised relational experience of the client, carer and service and the presence of underwhelming or overwhelming responses , is in our view, key to working with individuals with this diagnosis.


We postulate that it is the concealed or unrecognised masked remission existence, which sabotages stability and which should be the starting point for risk assessment and consideration for therapeutic change. The lack of recognition of the subtleties of Bipolar Spectrum Disorder is mirrored by the less than urgent responses by services to the masked state and points toward the invisible experience of the sufferer and this phase in their illness.

Familiar, narrow solutions spiral the individual downward to depression or attack or propel him or her upward toward grandiosity and mania, as the only perceived means of escaping this subjectively experienced inadequate existence. The separate self states remind us not only of the different phases of the illness, with associated treatment needs, but also differing levels of dissociation, fluctuating levels of motivation and reflective ability. Fluctuating levels of dissociation also highlight the degrees of damage to the sense of self and the lack of self-awareness, knowledge, integration of the selves and clear self-identity. The pulls of mania or depression are likely to be enticing for the individual due to the definite sense of self in relation to others and the clear and predictable reciprocation from others and society. The CAT reformulation enables a Level Three perspective, which allows the client, relatives and services to gain an informed and shared understanding of the relational dynamics associated with each specific state. This enables the development of collaborative care plans, advanced directives and risk management plans to scaffold the individual; which essentially are triggered responsively and proportionately.

Importantly, CAT’s reformulatory framework does not compete with other efficacious interventions. It enables pharmacological and other psychological approaches such as CBT which aim to address and support areas of change and recovery (e.g. improving social skills; decreasing self stigmatisation and acceptance of disorder; increasing external social and treatment supports; increasing medication adherence; stabilising wake/sleep cycles and daily routines and improving ability to identify and intervene early with relapses). This would ensure that individuals suffering from BD would be offered interventions within a robust and comprehensive psychological framework.

Whilst the evidence base of psychological approaches (cognitive therapy, interpersonal therapy, family therapy) is positive, Scott & Pope (2003) emphasise that without improved clarity about the theoretical underpinnings of these models, such psychological interventions will be perceived as non-specific supportive approaches, rather than targeted psychological treatments. We suggest that CAT and the current framework, can provide an integrated psychological theory which can identify, track and sensitively and compassionately respond to the needs (and collusions) of the client and the carer, depending on their reciprocal roles and poles, self states and levels of damage.

5.0 Conclusion

We plan to continue to research this suggested framework, via consultation and a case series, with the aim to improve understanding, and to refine and reformulate, where required. Importantly, the BD research community emphasise that any work in this area needs to clarify the mediators of outcome and variables of change to explain how psychotherapy prevents relapse, or stabilises symptoms (Milkowitz and Scott, 2009). We would suggest that utilisation of relational, integrative psychological models such as CAT can offer more than an adjunct to pharmacotherapy, mood stabilisation and relapse prevention, but can offer an integrated understanding of aetiology, maintenance and point to appropriate and timely exits for change. Without an accurate and shared reformulation which captures the restricted role repertoire, relational nature, hidden and explicit self states, plus the potential secondary gain for all the self states associated with the disorder, there are likely to be contraindications for an efficacious outcome. The cyclical, recurring nature of the disorder, which hijacks clients, relatives and services, is likely to continue at enormous psychological, societal and economic costs. Dr Karen Shannon is a Clinical Psychologist, Accredited CAT Practitioner, Supervisor and Trainer who is currently the lead for developing Forensic Psychological Services for people who have offended or who have the potential to offend in the Community, within Secure Services, Lancashire Care Foundation Trust.
Dr Rebecca Swarbrick is a Clinical Psychologist, Accredited CAT Practitioner who is currently lead psychologist for Women’s services, Rehabilitation and High Dependency for Secure Services within Lancashire Care Foundation Trust.


We would like to extend our thanks and gratitude for the warm welcome, trust, honesty and constructive input received from all at Southport Manic Depression Fellowship (MDF) Bi-Polar Group. This has helped us look behind the mask.


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