This document describes the development and testing of a recovery-focused cognitive behavioral therapy (RfCBT) for early-stage bipolar disorder. RfCBT was designed to explicitly target personal recovery rather than just symptom reduction. A pilot study found that RfCBT showed promise in improving personal recovery outcomes, increasing time to relapse, and enhancing quality of life compared to treatment as usual. The results provide preliminary evidence to support further evaluation of RfCBT in a larger definitive randomized controlled trial.

2. Recovery focused CBT for Bipolar
Disorder
Steven Jones
This study was funded by the National Institute for Health Research (NIHR)
under its Programme Grants for Applied Research funding scheme. The
views expressed are those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health.

3. Acknowledgements
• Sally Higginson
• Lee Mulligan
• Tony Morrison
• Gina Smith
• Mary Welford
• John Mulligan
• James Kelly
• Fiona Lobban
• Recovery Bipolar SURG

4. Background
• Traditional focus for intervention = symptom
reduction/relapse prevention
• NICE recommends structured psychological
interventions to help reduce relapse
• But what about other outcomes?
• Relapse is not a binary outcome
Geddes, Burgess et al. 2004; Colom, Vieta et al. 2009
Lam, Hayward et al. 2005

5. Case for Recovery
• Clinical vs personal recovery
– Can overlap but no synonymous
• Consumers value personal recovery
– Recovery ≠ symptomatic change
• Recovery reflected in government mental health
policy
• But therapies do not focus on personal recovery
outcomes
DOH 2001; DOH 2009
Mead and Copeland 2000
Russell and Browne 2005; Mansell, Powell et al. 2009

6. Case For Early Intervention
• Delayed treatment associated with worse outcomes in general both functional and
symptomatic
• Later episodes
– Triggered by life events previously linked to mood changes
– Less likely to be mediated by cognitive processes
• Thus psychological interventions potentially more powerful when applied earlier
in the illness course
– CBT benefit only for those with fewer episodes ?
– Earlier onset of bipolar disorder = worse clinical outcomes
Post et al 2010
Drancourt et al 2012
Barnard et al 2004
Jones et al 2001
Scott et al 2006
Lish et al 1994
Baldessarinin et al 2012

7. • Recent survey by Bipolar UK, Bipolar Scotland
and Royal College of Psychiatrists
• N=706
• Time to BD diagnosis 13 years
• 85% wrongly diagnosed initially – mainly depression
• 71% felt condition made worse by inappropriate
treatment
• Over half of clinicians wanted tools to help screen for
mania history

8. • So that people access the right treatments in a
timely fashion
• So that people don’t receive potentially
harmful interventions
• Duration of untreated bipolar disorder is
associated with more mood episodes, more
• suicidality and more mood instability
Drancourt et al. 2012

9. RfCBT for Early Bipolar
• Intention to provide a flexible but structured
intervention
• Benefits from current evidence base but
matches intervention to client’s priorities
• Targets individuals early in BD course to
hopefully improve trajectory
• Focus on service user valued outcome –
personal recovery

10. RfCBT Development
• Pilot case series data
– Jones and Burrell-Hodgson, 2008
• Importance of
– flexible engagement
– consideration of meaning of diagnosis
– coping skills reviews
– role of appraisals of fluctuations in affect.

11. RfCBT Development
• Therapy manual development was also
informed by:
– qualitative interviews about personal experiences
of recovery in BD
– focus groups to consult on content, format and
supporting materials

12. Jones et al., in prep
Mood experiences as
understandable and
manageable
Recovery as a life long
process
Access to personally
meaningful activity
Developing resources to
self manage health

13. Focus Group Outcome
• Importance of
– Focus on hope and opportunity
– Flexibility – timing and location
– Good quality supporting materials including
recovery stories
– Documented recovery plan
– Client control of sharing with wider MH team
– Measurement of functional outcomes

14. RfCBT Intervention
• Delivered by mental health professionals
trained to BABCP accreditation level in CBT or
equivalent.
• Duration of therapy is up to 18 h over six
months
• Sessions are weekly-fortnightly

15. RfCBT
The therapy approach differs from standard CBT for
bipolar disorder in the following ways:
• Explicit focus on eliciting client focused goals rather
than presuming a target of relapse prevention.
• Formulation driven idiosyncratic approach rather than
applying a very similar model of bipolar experience
across clients.
• Freedom to work within whatever model the client
brings.
• Openness to address functioning and comorbidity
issues as well as mood problems.

16. How to identify recovery goals
• Can be done by structured
qualitative interviews with clients
• Usually clinicians do not have time to do this
• Recent development of a quantitative measure
of recovery (Bipolar Recovery Questionnaire)
• Can indicate patterns of recovery goals and also
whether treatment is delivering recovery gains

18. Tools and Choices
• Section 1 Therapy information and appointment log
• Section 2 Useful information – Contacts, website,
groups, service user poetry
• Section 3 Recovery stories
• Section 4 Understanding my experiences –
Formulations, mood charts, life charts
• Section 5 Tools and Choices – Sleep diaries, EWS and
coping skills, recovery plan
• Section 6 – Future thoughts and ideas – Anything else
relevant inc own recovery story

19. Current Study
Recovery focused CBT (RfCBT) intended to
• enhance personal recovery
• reduce relapse
Participants:
Individuals <= 5 five years since onset of bipolar
disorder
Meet SCID criteria for BD

20. Primary Outcomes
• Feasibility and acceptability
– retention of participants
– adherence to the intervention
• Personal recovery
– BRQ
• Time to relapse
– SCID Life

21. Secondary Outcomes
• Quality of life and social functioning
– QoL.BD
– PSP

23. Feasibility
• 32/33 participants in therapy received at least 6
sessions RfCBT
– Mean 14.15 (s.d. 4.21)
• Recovery Fidelity Scale
– Mean adherence 91% (sd 9%)
• CTS-R
– Mean CTS-R (35.4 s.d. 7.9)
– Above established training threshold
Keen & Freeston 2008

24. Recovery
Better recovery outcomes at follow-up in RfCBT gp p =
0.01
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
Baseline 6 months 12 months
TAU
HAMD-RfCBT

25. Time to First Recurrence

26. Time to First Depression

27. Time to First Mania

28. Quality of Life
Trend towards better QoL for RfBT at post therapy
p =0.054
30
32
34
36
38
40
42
44
Baseline 6 months 12 months
TAU
RfCBT

29. Personal and Social Performance
Differences in PSP NS p = 0.151
50
55
60
65
70
75
80
85
Baseline 6 months 12 months
TAU
RfCBT

30. Conclusion
• RfCBT feasible in terms of
– Recruitment
– Retention
– Engagement in therapy
• Clinical outcomes
– Increase time to relapse for both poles of mood
episode
– Improved recovery
– Improved QoL
– Impacts of mood and PSP NS

31. Conclusion
• Results promising for this novel therapy
• Next stage to explore in a definitive trial
– Large scale – more precise effect estimates
• Crucial to test cost-benefits of this therapy

32. Thanks for your attention
• Please contact me if you want to know more:
s.jones7@lancaster.ac.uk