Medication alone can help reduce the symptoms of bipolar disorder, but it can't cure the illness entirely. Nor can it help a child or teenager cope with the stress, alienation, and residual symptoms that remain. That's where therapy--the process of exploring feelings, motivations, strategies for change, and personal goals with a trained professional--comes in.

Therapy is also not a cure, but when it's done well, it contributes greatly to better personal functioning and happiness.

Lisa sees a wonderful therapist who uses mainly traditional psychoanalysis. The symptoms the therapist concentrates on are whatever Lisa bring in for that particular meeting. If she's had a particular problem in some area, like when her boyfriend broke up with her, or just in dealing with her bipolar symptoms at times, the therapist gives her hints, such as the coping skills Lisa learned while in the hospital, to help her get through a particular situation. --Donna, mother of 16-year-old Lisa (diagnosed bipolar II disorder, post-traumatic stress disorder, and anxiety disorder)

From time immemorial, people have known about the healing power of a listening ear, a shoulder to cry on, and wise advice. These resources have always been prized, whether they came from family members, friends, or religious advisors.

The industrial revolution of the late nineteenth century changed the way people relate to each other, and also made life more stressful and complex. Many people began looking for professional advisors, and often the person they turned to was a trusted physician. Some physicians did have a high level of expertise at helping people handle everyday emotional problems, and did so as a matter of course while they also treated physical troubles. Some, like Austrian neurologist Sigmund Freud, became fascinated with the serious life difficulties faced by people with major mental illness.

When Freud and his circle of European colleagues founded the modern practice of psychoanalysis in the late 1800s, not much was known about mental illness, and no effective treatments existed. Freud himself believed that bipolar disorder, schizophrenia, and some other major mental illnesses were biological in nature, largely because he found that long-term psychoanalysis didn't seem to help these patients very much. To benefit from psychoanalysis, it seemed to him, the patient had to have a great deal of insight into the roots of unusual thoughts or behaviors, not just a desire to change.

The Freudians identified many emotional disorders (most are like what today's psychiatrists call personality disorders) that he believed were based on unresolved sexual conflicts, ensuing life experiences, and other factors. The psychoanalytic process relied on conversations between patients and therapists about childhood memories and experiences, dreams, and current experiences to uncover the causes of problems and find avenues for healing. Because the thoughts and behaviors associated with major mental illnesses actually come from chemical imbalances, efforts at ferreting out their roots in childhood traumas were fruitless.

That's not to say that no one tried. Psychoanalysis was indeed touted as a treatment for major mental illness until very recently, and still is suggested by some doctors. Until very recently, some people with bipolar disorders who could afford it submitted to years of intense psychoanalysis. The process was sometimes enlightening on a personal level, but rarely afforded any reduction in troublesome symptoms. In fact, for some patients, analysis itself was so stressful that it exacerbated their symptoms! But until the advent of psychiatric medication in the 1950s and '60s, and the first glimmerings of other types of psychological therapy around the same time, psychoanalysis was simply the only treatment available.

The goal of psychoanalysis is deep personal understanding that eventually leads to positive behavior changes. The patient gains this understanding by forging a strong, trusting relationship with his psychiatrist, which allows him to bring buried feelings to the surface in their discussions. It's a very intensive process involving weekly or even more frequent visits with a trained psychotherapist. The therapist helps the patient look at how his life experiences, starting as early as the emotional trauma that some people believe is associated with the birth process, have created roadblocks to optimal personal development.

Today, it's a rare patient with bipolar disorder who would look at psychoanalysis as a first-line intervention ... or even at all. There are other therapeutic approaches that are more useful. These include:

• Cognitive therapy
• Play therapy
• Family therapy
• Group therapy
• Peer support groups
• Milieu therapy
• Counseling
• Behavior modification

All of these approaches share one basic characteristic with psychoanalysis: they rely on forging a strong relationship between the patient (who may be called a client) and a therapeutic professional to lay the groundwork for change. Unlike psychoanalysis, however, these methods rarely delve into the metaphysical or unconscious aspects of thought patterns or behavior. Instead, therapists in these disciplines address specific symptoms with targeted intervention techniques. Clients may even have homework assignments that involve applying the lessons learned in therapy to real life. In most cases, intervention is seen as a short-term process, although because of the chronic and fluctuating nature of their illness, many people with manic depression will need ongoing therapeutic help.

Some therapists are specialists in a particular method. Jungian therapists use psychoanalysis-like techniques based on the theories of Freud's contemporary, Carl Jung. Gestalt therapists specialize in helping people uncover and meet hidden needs (encounter groups and sensitivity training are two Gestalt-related ideas that were popular in the '60s and '70s), and fall into the general category of humanistic or experiential therapy. Holistic psychologists or therapists suggest diet changes, meditation, and other interventions. There are other specialized therapy styles. Most of these methods, while interesting, have not shown any particular usefulness for bipolar disorders.

Many therapists use an eclectic approach: they take the best ideas from each school of thought, and employ whatever methods and concepts seem most likely to work with each patient.

The goals of therapy are usually set by the client in concert with her therapist and, in the case of children, with the child's parents or other caretakers. Goals are as varied as individuals with bipolar disorders are.

Kara used to see a psychologist who worked with her on her self-esteem, and on coping techniques.
--Cindy, mother of 19-year-old Kara (diagnosed bipolar disorder)

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Vanessa sees a therapist, and the concentration is on anger management. Work is done in both group and family therapy.
--Sue, mother of 16-year-old Vanessa (diagnosed bipolar disorder, OCD, borderline personality disorder, passive-aggressive personality disorder)

•  •  •   •  •  

Billy sees a psychologist for a combination of cognitive-behavioral therapy and play therapy. The primary focus has been on coping with frustration.
--Marlene, mother of 8-year-old Billy (diagnosed cyclothymic disorder)

Your child's therapeutic goals might include:

• Discussing the nature of her illness and how it can be treated
• Identifying personal mood-swing triggers
• Identifying ways to prevent or shorten mood swings
• Identifying and stopping detrimental thought patterns
• Coping with problem symptoms and medication side effects
• Improving behavior at home, at school, or in the community
• Obtaining support for making positive lifestyle changes, such as maintaining sobriety
• Developing personal strengths, resiliency, and self-esteem to counter the detrimental social and personal effects of manic depression

If you don't think a therapeutic relationship is working well for your child, or if a therapist tells you something about your child that doesn't seem right, don't be afraid to seek a second opinion.

I saw a counselor when I was about 10. I was smart enough to outsmart him, but not smart enough to know that it was not in my best interest to do so. He told my parents I just had a bad attitude. For years after that, school personnel and family friends tried to get my parents to seek help for me, but they always relied on what that first guy said, and declined further evaluations. --Stephanie, age 32 (diagnosed with bipolar disorder at age 15 and now the mother of a bipolar child)

Who benefits from therapy?

Generally speaking, therapy cannot produce changes in people with bipolar disorders unless their most troubling symptoms are intermittent or starting to recede. A person who is actively psychotic, extremely manic, or depressed to the point of needing hospitalization usually cannot benefit from therapy, although they may seek out and greatly appreciate their therapist's support while weathering these storms. Once medication is starting to help or the state is receding on its own, there is a window of opportunity for therapeutic work.

Over a period of time, a bipolar patient in therapy should expect to develop better strategies for handling his mood swings and other symptoms. As these strategies begin to work, he will become even more able to benefit from therapy.

Even preschoolers can make gains in certain types of therapy. Play therapy was developed especially for the youngest children, and can be very effective. In fact, recent studies have shown that therapy may actually have long-term effects not just on how we feel, but in how our brains work physically, including which neurotransmitters are produced in what quantity. When therapy is undertaken in early childhood, it may change for the better how the brain develops.