https://orcid.org/0000-0003-2843-8939
ABSTRACT
Background
Participant experiences of transdiagnostic bipolar disorder treatment groups has been largely under-explored. The present study aimed to explore the experiences of people living with bipolar disorder who participated in a pilot study of a transdiagnostic cognitive behaviour therapy for comorbid anxiety.
Methods
Ten participants (five male) diagnosed with bipolar disorder took part in an interview at the completion of the programme. Participants were asked open-ended questions about the programme and their experiences of participation in the group. Data were analysed using thematic analysis.
Results
Key themes identified included: (1) “Content and techniques – applications outside of the group”, where participants reported using the content learnt for the management of anxiety and other symptoms, including co-occurring conditions; (2) ‘Being part of the group – “feeling normal”, where participants reported feeling supported within a group that was specific to bipolar disorder; and (3) “Group structure – enabling process, content and research”, where participants reported that structural elements, such as participation in research, added meaning to their experience.
Conclusions
This research provides evidence for the value of transdiagnostic approaches in the treatment of bipolar disorder, with participants reporting that they applied the skills learnt to anxiety, substance use and bipolar disorder-specific symptoms.
KEY POINTS
What is already known about this topic:
Anxiety is an important co-morbidity in bipolar disorder than can impact illness course.
Group interventions can be helpful in the management of bipolar disorder.
Participants value the group experience.
What this topic adds:
Group programs targeting anxiety can assist people living with bipolar disorder.
Participants used techniques for a range of co-occurring conditions.
Value was obtained by participants through contributing to research and the group.
Introduction
Anxiety co-morbidity is common in bipolar disorder, and it is estimated that around 60% of the people living with the condition will also meet diagnostic criteria for a co-occurring anxiety disorder at some stage in their lives (Kinrys et al., Citation2019). Anxiety may also be part of the disorder itself (American Psychiatric Association, Citation2013) and associated with the onset of the illness (Duffy et al., Citation2019). In addition, anxiety may also contribute to poorer psychosocial outcomes for people living with bipolar disorder, making this an important co-occurring condition to treat (Bennett et al., Citation2019).
Although the presence of co-occurring anxiety in bipolar disorder is recognised, there are few psychological programmes that have been specifically developed to address anxiety in bipolar disorder. A systematic review of psychological interventions that assessed anxiety as an outcome noted that only 22 studies included an anxiety-related outcome measure, with only seven studies reporting on targeting specific anxiety disorders, and an additional seven targeting more general anxiety symptoms (Stratford et al., Citation2015). Therapies such as cognitive behavioural therapy (CBT) have been trialled in several studies, whilst other therapies such as mindfulness-based cognitive therapy have also been trialled, with improvements in anxiety being noted (Perich, Manicavasagar, Mitchell, Ball, et al., Citation2013; Manicavasagar, Mitchell, & Ball, Citation2013).
Group therapy programmes developed for the treatment of anxiety disorders in those with bipolar disorder are newly emerging (Pankowski et al., Citation2017) with transdiagnostic programmes showing promise (Ellard et al., Citation2017). Transdiagnostic programmes may be particularly useful in the treatment of anxiety for people living with anxiety and bipolar disorder, given the rates of multi-morbidity being found in this population (Pavlova et al., Citation2017), as it may allow for the application of the skills learnt across a range of situations. A pilot assessment of the transdiagnostic Unified Protocol, which addresses features common to a range of emotional disorders, has noted that benefits for anxiety for people with bipolar disorder (Ellard et al., Citation2017). The study assessed 18 sessions of individual therapy in a small sample of 29 participants diagnosed with bipolar disorder randomised to either treatment as usual (TAU) or the active intervention, and found that anxiety and depression symptom scores significantly decreased compared to treatment as usual in the treatment group (Ellard et al., Citation2017).
A qualitative study assessing an individual CBT-orientated transdiagnostic programme for bipolar disorder that has also aimed to address co-occurring anxiety in addition to mood disturbances more broadly also noted that participants reported content features as important (Joyce et al., Citation2017). Participants reported that content elements of the programme such as cognitive reappraisal were helpful in addressing symptoms, whilst other features, such as feeling empowered and less anxious in social situations, featured as important (Joyce et al., Citation2017). Therapist features also were considered, with participants noting the role that the therapist played including taking a kind and calming stance in the therapy itself as being helpful (Joyce et al., Citation2017).
Previous qualitative studies of bipolar disorder participants who were participants in group psychoeducation programmes have noted that participants reported themes such the “treatment of bipolar disorder, perception of others, and learning from the group” as being part of their group experience (O’ Connor et al., Citation2008). Themes relating to the process included the “perception of others”, where common experiences of groups were reported that involved feeling less alone with the illness as part of their outcomes. Other research of inpatient psycho-education group for bipolar disorder in China has also noted that the theme “Perception of participating in a group” which also included participants feeling less alone with their illness, whilst benefits of the content of the group programme was also noted (Chen et al., Citation2018).
The present study aimed to explore the experiences of a pilot study of a 9-week group-based transdiagnostic CBT for anxiety for people living with bipolar disorder. Previous research has found this programme feasible and acceptable (Perich et al., Citation2020); however, this study aimed to explore participant experiences of programme content, group process and their interaction with group members and to determine which features of the programme were useful for participants using a qualitative design.
Method
Participants
Participants were recruited via advertising on Facebook to take part in a face-to-face programme designed to treat anxiety in bipolar disorder at Western Sydney University. Advertising was targeted at people living in the broader Sydney region, including the Blue Mountains. Inclusion criteria included a diagnosis of bipolar disorder, under the care of a general practitioner (GP) or psychiatrist, not experiencing a current episode, over the age of 18 years. Individuals who did not meet the inclusion criteria were excluded.
Fourteen participants (eight males; six females; aged 23–73 years – mean 47 years) undertook the screening for the study and progressed into the programme. Ten participants (five males; five females) completed all aspects of the study, including the post-group interviews. For the four participants who discontinued the group intervention, reasons for leaving the study, included being unwell (n = 2), issues with travel to the university (n = 1) and other non-disclosed reasons (n = 1). Demographic characteristics of the completers (n = 10) are outlined in .
Table 1. Participant demographic details of the completers (n = 10).
Procedure
Participants were required to complete a telephone interview confirming their diagnosis of bipolar disorder and whether they currently met criteria for a mood episode using the SCID V (Research Version; First et al., Citation2015) prior to study entry. Any current or lifetime anxiety disorder diagnoses were also assessed (panic disorder, agoraphobia, simple phobia, social anxiety disorder and generalised anxiety disorder) by a trained interviewer. Participants were then asked to complete an online set of demographics and other measures of mood, quality of life and recovery measures, which comprise the quantitative arm of the study (Perich et al., Citation2020). Participants then completed the 9-week group therapy pilot programme facilitated by the first author (TP). At the end of the programme, participants were asked to complete the same online survey and then asked to participate in a qualitative interview (approximately 1 hour) asking about their experiences of the programme. The semi-structured interviews contained questions that were designed to assess the content and overall experience of the group therapy programme (see interview questions in Appendix).
The interviews were conducted via phone by a research assistant (EW) and recorded on a separate voice recorder and then transcribed. The study was approved by the Western Sydney University Human Research Ethics Committee (H12690). All participants gave informed written and verbal consent to participate in the study and the qualitative interviews.
Intervention
The intervention was a 9-week-long CBT programme designed to address symptoms of anxiety from a transdiagnostic perspective. The sessions covered a range of areas common in CBT programmes for anxiety, such as psychoeducation, relaxation and cognitive therapy. Behavioural experiments and exposure were also covered in the content, along with avoidance and safety behaviours. Participants were taught generally about these skills and encouraged to apply them to their individual circumstances and situations. Each session lasted up to 2 hours weekly, with a 10-15 min break each session. Session 1 contained the introduction to the programme, Session 2 – relaxation training, Session 3 – cognitive thinking styles and automatic thoughts, Session 4 – challenging automatic thoughts, Session 5 – behavioural experiments, Session 6 – graded exposure, Session 7 – problem solving, Session 8 – assertiveness, Session 9 – conclusion.
The intervention was administered by a registered psychologist (TP; she/her) with over 10 years’ experience and training in CBT and working with bipolar disorder populations, while a research assistant was also present in the session to take notes of homework compliance and other content issues to inform the development of the content for further use in bipolar disorder group programmes and also to assist with administrative features of conducting the group programme (EW). No adverse events were reported by participants due to participation in the intervention.
Data analyses
The interviews were transcribed verbatim, de-identified, quality checked by TP and analysed using inductive thematic analysis (KK; Braun & Clarke, Citation2006) in N*Vivo (QSR International Pty Ltd, Citation2019). TP was the therapist on the intervention, and KK was not a part of the therapy or interview process. Using this method, the authors KK and TP re-read the interview transcripts several times for familiarity to explore the initial code of the data independently. After initial codes had been determined, groupings that were associated with the research question were established with authors KK, TP and JC discussing these in collaborations and themes were defined and named. A consensus agreement was then obtained with KK and TP regarding the key themes. At the final stage, agreement was met with KK, TP and JC in collaboration and review of the results. JC was not part of the therapy or interview process. The data were interpreted with a social constructionist approach (Burr, Citation1995) using positioning theory (van Langenhove & Harré, Citation1999). This theory considers the data in relation to self-positioning both in relation to other people and the positioning of the person by other people. This approach was used to assess how people engaged with the CBT content, others and the group process itself. Pseudonyms were used for participants throughout the analysis, and participants did not review the transcripts. Due to the type of study and overall sample size data saturation was not considered in this study. EW, KK, TP and JC are all trained in CBT and are either registered or clinical psychologists.
Results
Three key themes were generated in the analysis: “Content and techniques – applications outside of the group”, ‘Being part of the group – “feeling normal”; and “Group structure – enabling process, content and research” (see, for thematic map).
Figure 1. Thematic map of participant experiences of group intervention.
Theme 1: impacts of programme components – life and identity shifts
Participants indicated that the impacts of the programme included the application of techniques that had notable impacts on their lives and sense of themselves. For example, Paula noted, “I found it very helpful. I don’t know what I would’ve done with my work situation if I didn’t do the programme”. The following extracts highlight the impacts of various aspects of the programme on different participants whereby they transported their learnings into their everyday lives.
I was anxious about opening my letterbox today but I went ahead and did it. So, there’s some parts of the programme that’s embedded in my daily life.
So instead of just having the repetitive thoughts, I’m actually trying to address the issue or the problem.
I can decide whether or not to take the thoughts seriously or discard them, or at least become aware of the pattern within myself when I start to let my mind wander and that can sort of arrest it.
Mark also noted that the cognitive group interventions contributed to a greater sense of personal agency to “choose” ways to respond to “the thoughts”. Psychoeducation regarding negative thinking styles also proved useful, with several participants noting they had not previously made a connection between their cognitions and their impact on their levels of anxiety.
Although many noted that homework was a positive feature of the programme, some participants noted finding it difficult to incorporate homework into their busy lives so would not formally complete it. Therefore, participants reported using the programme content and embedded it into their lives outside of the formal homework allocation, applying the techniques that were learnt outside of the group programme into their day-to-day routine.
In addition to impacts on their lives, some participants highlighted how changes in their lives had impacts for who they understood themselves to be.
I’m sober and I haven’t taken any drugs or alcohol in six months, but I have tons and tons of friends that still partake in either of those. And I had a Christmas party and I got offered some drugs. And in the past, I would have been more likely to say yes because I would have been really passive and sort of – they were forcing it on me, so I would have just said yes, and then had anxiety and done the wrong thing. Whereas I clearly told them, “No, why are you doing this? …… ”. I didn’t let someone else really trample over me because I was too anxious or indecisive. I knew what I wanted to do and I knew what my thoughts and opinions were.
That really helped [Progressive Muscle Relaxation techniques] me because it helped me to – I can feel my body because sometimes I feel like I don’t exist, like I don’t feel – it helped me to feel more grounded. It helped me with my – helped me to have my reality thoughts because sometimes, I have my delusions and that, I don’t feel that I’m real or I exist. So, these exercises helped me to realise that I’m alive, that I have a body, and these are my muscles that I have to really work. So that one exercise really helped.
The transdiagnostic nature of the content in the group and the manner in which the content was presented allowed for the participants to apply the skills across different experiences when they felt it was needed. Simon also spoke specifically of the use of the techniques in the group, including assertiveness training, had the following significant impacts on his life and identity formation. Simon’s stance to align his actions with what “I wanted to do” was a strengthening of a sense of identity through clarifying and standing for his own self-reflected values in the face of pressure from his social network to join them in substance use. Significant for Paula in the group was progressive muscle relaxation (PMR) exercises that were effective in the management of delusions and grounding herself in her body and connecting her with the sense that “I exist” that was at risk when bipolar disorder was dominating of her life.
Theme 2: programme process: inclusion and belonging
Participants in the programme spoke of the significance of the group process of being with others diagnosed with bipolar disorder that contributed to a sense of inclusion and belonging. Feeling as though they were not alone in their diagnosis of bipolar disorder was reported by participants as being an important part of beneficial aspect the programme with many noting that they felt this was a key feature. Many participants reported that this was the first group that they had attended either a group therapy programme, or a group with participants who had also bipolar disorder. The unique nature of the group as being bipolar-specific had an effect of participant’s feelings about the group and participation.
… no one around me has bipolar disorder … . and my friends and my immediate family don’t really care about bipolar disorder or they don’t believe that it exists. So, it’s a bit hard. You can’t talk about it to other people. So it was a very safe space to me, to actually be free and be myself, because they would understand, ‘cause no one else will understand. My friends and family don’t understand.”
I still have self-doubt and one of the questions that I ask myself occasionally is, “Do I really have bipolar or am I just imagining it or misinterpreting it as being bipolar?” And I guess hearing other people describe their experiences with it and being able to go, “Yes, I’ve experienced a similar thing”, … helped confirm for me that – yes, I do have bipolar and – yes, these symptoms or experiences are common.
These experiences included a group process that supported non-judgement, respect and safety that contributed to identity shifts including “showing the real me”, “feeling normal” and being “free to be myself”. Within this context, the participants experienced opportunities to also claim their voice and be heard. Implicit within these stretches of the text is the stigma experienced by those living with bipolar disorder where the diagnosis positions the person on or outside the boundary of normality (Gergen & McNamee, Citation2000) and recruited into both silence and concealing aspects their identity from others. On the other hand, both Paula and Peter experienced a validation of their symptoms of bipolar disorder in the group context that contributed to a shift away from the minimisation of their symptoms (by self and others).
Within the group context, participants experienced themselves as insiders to the shared experience of bipolar disorders that included support, knowledge and understanding.
And it made me feel like I wasn’t alone. … . I’m newly-diagnosed and quite young. It’s good to hear from people who are a lot older and have had a lot more episodes and – or maybe have been diagnosed for 20 years and then hearing them say, “Oh, well, when I first got diagnosed, I felt like this. And over the years, I’ve gotten used to it”.
I talk to them about it and say, “Yeah, ok, I get my really bad depressions and maybe you have them. I’ve had more suicide attempts than most of you”, which tend to pop out and so, yeah, I found that invaluable … You talk to a normal person about it and they’re like, “Oh … ”, whereas to these people, it was like, “Yeah, me too, but I still get out of bed every day and go to work just like you. And this is what I do to make sure I can do it. And this is what I do when I can feel the walls closing in … ”.
The participants observed their unique and individual points of difference in their illness when compared to the other group members and the importance and value of this comparison to others when understanding bipolar disorder symptoms and experiences. Central to these experiences, was a sense of hope that was realised through hearing other stories of living with bipolar disorder, including adjustment to living with (“gotten used to it”) and making a life around the symptoms (“this is what I do when I feel the walls closing in”).
However, one member reported concern about safety for other members, “I was concerned why one person had dropped out because I thought maybe it may have triggered things for him”, whilst some noted concerns about another member's behaviour in the group. As noted by one member who suggested additional screening, “We had an incident with one of the guys, and I think perhaps screening, because I got the feeling that the guy had a lot more issues than bipolar disorder – the way he went off. … ”.
Overall, these concerns were balanced with the benefits obtained from being with other members, “But apart from that one, everyone’s pretty friendly and listened to each other”, suggesting that the benefits overall that were obtained outweighed negative experiences, or concerns, with other group members.
Theme 3: validation through two-way contribution
Structural features of the group and the nature of the therapist’s facilitation of the group process was described by all participants in the programme as being a central feature of the experience of taking part in the programme. Participants spoke of the value of having free time to discuss areas of the experience of bipolar disorder with each other, but also the need for additional structure to allow for conversations around the content of the programme. These features of the programme were attributed to the way in which the therapist conducted the group whereby the facilitation allowed this process to occur. Some reported that they wished for more therapist input “I would have loved to hear more … ”, whilst others reported a good balance, “she let the conversation roll in a particular direction, but at the same time if we kind of got off track she’d be like ‘Alright, well let’s just pull it back and we’ll go back here’. So it was just a really good balance”.
The physical nature of the group, and that it was face-to-face, was also mentioned as relevant by some members. Several participants noted depressive episodes during the therapy period and that they felt they were shortened by their desire to attend the group, as Simon notes, “I feel like just coming somewhere every Saturday helped me because it got me out of bed no matter how I was feeling”. That the programme was not self-help and instead had specific content and structure was reported as being beneficial to participants, as it cultivated the valuing of the sharing of knowledge as two-way between the researcher/facilitator and the research participants.
it wasn’t a self-help group. The group wasn’t there to help me. I was there to help the group. The fact that it was a research thing and I felt I was contributing to more understanding – you know what I mean – that I was giving. I wasn’t getting. That meant something to me. I was contributing to something.
She’s a lecturer or a teacher in psychology [i.e., group facilitator] and she’s also now doing a study into bipolar. I was part of that group and I know for a fact being part of that group, answering her questions, I educated her.
These extracts highlight the value for these participants in sharing their insider experiences, wisdom and knowledge of bipolar disorder with the researcher. These participants took up the role that they were in a position to be able educate and inform the researchers about bipolar disorder and this had some key impacts. Implicit in this sense of personal contribution was that their experiences and perspectives mattered and were valuable, thereby cultivating a sense of self-worth, meaning and purpose in their lives.
Discussion
Three key themes were noted in the study when assessing participant experiences of the group therapy programme. The transdiagnostic CBT content featured as helpful for participants, with participants reporting the use of the strategies outside of the group programme and describing benefits that were obtained. This is consistent with previous research that has reported benefits as a result of group therapy programmes, such as mindfulness programmes (Chadwick et al., Citation2011) and was expected as part of the group programme.
However, participants also reported the use of techniques outside of the application to anxiety symptoms, to symptoms of bipolar disorder and also in managing substance use concerns. This highlights the value of the transdiagnostic approach in treating bipolar disorder and shows support for previous research in this area (Ellard et al., Citation2017; Joyce et al., Citation2017) which has indicated early promise for the role that these interventions may play. This current study also may suggest that further research is needed to assess the impact of these types of interventions on other comorbidities, such as substance use, in addition to anxiety.
Process-related themes also emerged, where participants noted benefits specific to being part of a group that was designed for people living with bipolar disorder and “feeling normal”. The reported benefits included features such as feelings of inclusion and belonging, feeling safe and understood. Although members had been previously diagnosed with bipolar disorder and were familiar with their diagnosis, the confirmation of experiences unique to bipolar disorder from those taking part in the programme was a positive feature of the group experience for some in the programme and provided confirmation of the validity of the bipolar experience. This supports previous research regarding group process in the bipolar disorder area (Chen et al., Citation2018; O’ Connor et al., Citation2008) and in other group therapy research more broadly.
The theme “Validation through two-way contribution” contained several key elements that were noted by participants as being important features of the experience of participating in the group therapy programme. Whilst therapist facilitation featured as important, the face-to-face nature of the programme held specific benefits for members, particularly those experiencing depression. Although contemporary intervention research is shifting towards connecting people with bipolar disorder using online methods (e.g. Fletcher et al., Citation2018), the specific benefits of live face-to-face interventions should be continued to be explored in research as these may hold additional behavioural activation benefits.
Although this was not expected as part of the study, participants in this study spoke of the value of taking part in a research study of bipolar disorder. Specifically, some participants spoke of the meaning of participating by sharing their experiences with the researcher and also in taking part in educating those working in the university. Community-based participatory research, where those with lived-experience co-design research ideas and programmes, has been highlighted as an area of growth and need in bipolar disorder research (Michalak et al., Citation2016); however, more research is still needed using these designs. Further exploration of how participation in research may be beneficial for both researcher and participants is required in bipolar disorder research and to explore how people living with bipolar disorder may also contribute to teaching, learning and education in a university setting.
Limitations of the study include that the sample of participants in the study were self-selected and were not symptomatic at study entry. Three participants also did not meet diagnostic criteria for a co-occurring anxiety disorder. In addition, the programme was restricted to people living in Sydney, Australia. More research is needed to explore the impact of mood states on the group experience for people living with bipolar disorder and how the group experiences may be influenced by other factors, such as cultural background, which was unexplored in this research.
Overall, several themes emerged as important when considering group therapy programmes in the treatment of bipolar disorder. Themes relating to the content of the programmes were identified in the thematic analysis where participants reported benefits from using CBT techniques in the management of anxiety and other symptoms of bipolar disorder. Other themes also highlighted the value of participation in both the group and in research with unique benefits being obtained by participating in a group of members with bipolar disorder.
Acknowledgments
The authors would like to acknowledge the contribution of Edward Wynter (EW) to the data collection and intervention.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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Appendix 1
Qualitative Interview Questions.
In thinking about your anxiety programme experience:
1. What about the programme had the most impact on your anxiety?
2. Tell me more about what happened, some examples, or what was done in the programme that helped?
3. How did that impact your bipolar disorder symptoms and how you managed them?
4. What else had a significant impact on you during the programme?
5. Tell me more about how that was done in the programme?
6 .What other aspects of the programme did you find most useful?
7. What aspects of the programme did you find least useful?
8. What, if anything, would you change or improve about the programme?