Hi Dr. Phelps,

Thank you for all the valuable information online and in your book.

I have two questions:

1.) Do you know of any patients who have been able to effectively use mindfulness meditation to deal with severe depressive episodes? I think it is a valuable tool for OCD and other anxiety problems, but simply observing thoughts and feelings during depressive episodes drags me down and leaves me feeling even more overwhelmed by them. During depressive episodes, there is something to be said for distracting activities-exercising, knitting, reading, volunteering, etc-but I keep reading that if we stop fighting depressive symptoms and embrace them, it will soften the experience. I simply can not relate to that.

2.) How long is too long for a patient with bipolar disorder to stay in therapy? I am embarrassed that I have been going for six years. I have made great progress with general anxiety and OCD. For about 3 decades, I spent several hours everyday going through a lengthy list of compulsions, but that is history now. I keep thinking I should be doing as well with the bipolar disorder by now, but repeated bouts of severe depression and mixed states continue to be a problem. There is definitely nothing wrong with my therapist because she uses the same multi-faceted approach as you do and I continue to learn a lot in the sessions. I just can't get the bipolar disorder under control like I did with the OCD so it is very frustrating.

I apologize that this is so long. Thank you in advance for your answers to my questions if you choose my submission to post a response to. (I realize that given the number of submissions you probably receive, it may not be possible to post a response to everyone. If you choose mine, please omit my name.)

Sincere regards & thanks.  
                     
Dear Anon. --

As you are learning, there are different variations of "cognitive-behavioral therapy". Some of them work better for one given person than others. As you point out, "distraction" is regarded in some of these therapies as carrying the risk of being a form of "avoidance"; and as you are aware from your OCD treatment, avoiding avoidance is central to the treatment process.

However, as you also point out, the treatment of depression using cognitive tools can be approached somewhat differently. Several different variations of "mindfulness" have recently been injected into CBT. One of the first was described in a textbook called Mindfulness-Based Cognitive Behavioral Therapy for Depression, although this was more of a description of a research program than a description of any significant new form of therapy. Nevertheless, it was a remarkable synthesis of other work in psychotherapy (such as dialectic behavior therapy, which has a strong mindfulness component) plus the traditional CBT approach.

A variation of mindfulness melded with CBT which might feel more natural to you has recently been published in the form of a patient-friendly workbook called Get Out Of Your Mind and into Your Life, by Stephen C. Hayes. Dr. Hayes has been working on this method, which he calls Acceptance and Commitment Therapy, or ACT, for about a decade. He has published the method several ways, and has subjected it to randomized clinical trials, showing efficacy in treatment resistant depression.

Very few therapists are familiar with ACT, but the new manual makes it quite accessible. You might get hold of a copy and show it to your therapist and ask whether this might be a variation to try.

However, you raise another issue here, about "getting the bipolar disorder under control" as you did with OCD. Without knowing your case, I can't at all be certain about this, but I do generally operated under the assumption that psychotherapy alone cannot completely control mood swings (although there are some important non-medication ingredients, such as a regular pattern of sleep and exercise, without which one may end up needing much more medication than otherwise). In other words, it could be that you and your therapist have done everything which could possibly be asked of each of you, and yet still your symptoms are not sufficiently controlled, and that instead the focus would have to be on using additional mood stabilizers to gain that last degree of stability you might be seeking.

Finally, how does one know when one has had enough therapy? In your case comment it sounds as though you continue to feel that you are learning and gaining from the process. That might be enough right there to say that it is worth continuing (particularly if you were to add a new angle, such as described above).

In general, however,, knowing when to stop psychotherapy is a very complex issue. In theory, the result of such treatment is supposed to become integrated into yourself to such an extent that ultimately you can maintain the gains derived from it even after ending your ongoing relationship with a given therapist. This is particularly true of the more modern psychotherapies that emphasize acquiring skills as much or more than the relationship with the therapist. Nevertheless, that relationship is also quite crucial to the outcome in many cases and must be brought to a close with care and deliberate discussion. Indeed, that last sentence about ending the relationship is the subject of vast discussion in psychotherapy literature. Suffice it to say that in general, when contemplating bringing psychotherapy to a close, it is best to do so through an open discussion of the issue with your therapist, expecting that this might take quite a few sessions to work through.

Thank you for your interesting and very polite question.

Dr. Phelps



Published May, 2007