Moshe S. Torem, MD

Psychiatric patients stand to benefit greatly from adhering to prescribed pharmacotherapy, but many patients typically do not follow their medication regimens.^1,2 Three months after pharmacotherapy is initiated, approximately 50% of patients with major depressive disorder (MDD) do not take their prescribed antidepressants.³ Adherence rates in patients with schizophrenia range from 50% to 60%, and patients with bipolar disorder have adherence rates as low as 35%.^4-6 One possible explanation for “treatment-resistant” depression, schizophrenia, and bipolar disorder may simply be nonadherence to prescribed pharmacotherapy.

Several strategies have been used to address this vexing problem (Table 1).^7,8 They include individual and family psychoeducation,^9,10 cognitive-behavioral therapy,¹¹ interpersonal and social rhythm therapy, and family-focused therapy. This article describes an additional strategy I call “participatory pharmacotherapy.” In this model, the patient becomes a partner in the process of treatment choices and decision-making. This encourages patients to provide their own opinions and points of view regarding medication use. The prescribing clinician makes the patient feel that he or she has been listened to and understood. This and other techniques emphasize forming a therapeutic alliance with the patient before initiating pharmacotherapy. The patient provides information on his or her family history, medical and psychiatric history, and experience with previous medications, with a specific focus on which medications worked best for the patient and family members diagnosed with a similar condition.

Getting patients to participate

One of the fundamental tasks is to encourage patients to accept a participatory role, determine their underlying diagnosis, and co-create a treatment plan that will be most compatible with their illness and their personality. There are 10 components of establishing and practicing participatory pharmacotherapy.

1. Encourage patients to share their opinion of what a desirable treatment outcome should be. Some patients have unrealistic expectations about what medications can achieve. Clarify with patients what would be a realistic expectation of pharmacotherapy, and modify the patient’s beliefs to be compatible with a more probable outcome. For example, Ms. D, a 46-year-old mother of 2, is diagnosed with MDD, recurrent type without psychotic features. She states she expects pharmacotherapy will alleviate all symptoms and allow her to achieve a new healthy, happy state in which she will be able to laugh, socialize, and have fun every day for the rest of her life. Although achieving remission is a realistic and desirable treatment goal, Ms. D’s expectations are idealistic. Helping Ms. D accept and agree to realistic and achievable outcomes will improve her adherence to prescribed medications.

2. Encourage patients to share their ideas of how a desirable outcome can be accomplished. Similar to their expectations of outcomes, some patients have an unrealistic understanding of how treatment is conducted. Some patients expect treatment to be limited to prescribed medications or a one-time injection of a curative drug. Others prefer to use herbs and supplements and want to avoid prescribed medications. Understanding the patient’s expectations of how treatment is carried out will allow clinicians to provide patients with a rational view of treatment and establish a partnership based on realistic expectations.

3. Engage patients in choosing the best medication for them. Many patients have preconceived ideas about medications and which medicine would be best for them. They get this information from various sources, including family members and friends who benefitted from a specific drug, personal experience with medications, and exposure to drug advertising.

Understanding the patient’s preference for a specific medication and why he or she made such a choice is critical because doing so can take advantage of the patient’s self-fulfilling prophecies and improve the chances of obtaining a better outcome. For example, Mr. O, a 52-year-old father of 3, has been experiencing recurrent episodes of severe panic attacks. His clinician asked him to describe medications that in his opinion were most helpful in the past. He said he preferred clonazepam because it had helped him control the panic attacks and had minimal side effects, but he discontinued it after a previous psychotherapist told him he would become addicted to it. Obtaining this information was valuable because the clinician was able to clarify guidelines for clonazepam use without the risk of dependence. Mr. O is prescribed clonazepam, which he takes consistently and responds to excellently.

4. Involve patients in setting treatment goals and targeting symptoms to be relieved. Actively listen when patients describe their symptoms, discomforts, and past experiences with treatments. I invite patients to speak uninterrupted for 5 to 10 minutes, even if they talk about issues that seem irrelevant. I then summarize the patient’s major points and ask, “And what else?” After he or she says, “That’s it,” I ask the patient to assign a priority to alleviating each symptom.

For example, Ms. J, a 38-year-old married mother of 2, was diagnosed with bipolar II disorder. She listed her highest priority as controlling her impulsive shopping rather than alleviating depression, insomnia, or overeating. She had been forced to declare bankruptcy twice, and she was determined to never do so again. She also wanted to regain her husband’s trust and her ability to manage her finances. Ensuring that Ms. J felt understood regarding this issue increased the chances of establishing a solid treatment partnership. Providing Ms. J with a menu of treatment choices and asking her to describe her previous experiences with medications helped her and the clinician choose a medication that is compatible with her desire to control her impulsive shopping.

5. Engage patients in choosing the best delivery system for the prescribed medication. For many medications, clinicians can choose from a variety of delivery systems, including pills, transdermal patches, rectal or vaginal suppositories, creams, ointments, orally disintegrating tablets, liquids, and intramuscular injections. Patients have varying beliefs about the efficacy of particular delivery systems, based on personal experiences or what they have learned from the media, their family and friends, or the Internet. For example, Ms. S, age 28, experienced recurrent, disabling anxiety attacks. When asked about the best way of providing medication to relieve her symptoms, she chose gluteal injections because, as a child, her pediatrician had treated her for an unspecified illness by injecting medication in her buttock, which rapidly relieved her symptoms. This left her with the impression that injectable medications were the best therapeutic delivery system. After discussing the practicalities and availability of fast-acting medications to control panic attacks, we agreed to use orally disintegrating clonazepam, which is absorbed swiftly and provides fast symptom relief. Ms. S reported favorable results and was pleased with the process of developing this strategy with her clinician.

6. Involve patients in choosing the times and frequency of medication administration. The timing and frequency of medication administration can be used to enhance desirable therapeutic effects. For example, an antidepressant that causes sedation and somnolence could be taken at bedtime to help alleviate insomnia. Some studies have shown that taking a medication once a day improves adherence compared with taking the same medication in divided doses.¹³ Other patients may wish to take a medication several times a day so they can keep the medication in their purse or briefcase and feel confident that if they need a medication for immediate symptom relief, it will be readily available.

7. Teach patients to self-monitor changes and improvements in target symptoms. Engaging patients in a system of self-monitoring improves their chances of achieving successful treatment outcomes.¹⁴ Instruct patients to create a list of symptoms and monitor the intensity of each symptom using a rating scale of 1 to 5, where 1 represents the lowest intensity and 5 represents the highest. As for frequency, patients can rate each symptom from “not present” to “present most of the time.”

Self-monitoring allows patients to observe which daily behaviors and lifestyle choices make symptoms better and which make them worse. For example, Mrs. P, a 38-year-old married mother of 2, had anxiety and panic attacks associated with low self-esteem and chronic depression. Her clinician instructed her to use a 1-page form to monitor the frequency and intensity of her anxiety and panic symptoms by focusing on the physical manifestations, such as rapid heartbeat, shortness of breath, nausea, tremors, dry mouth, frequent urination, and diarrhea to see if there was any correlation between her behaviors and her symptoms.

8. Instruct patients to call you to report any changes, including minor successes. Early in my career, toward the end of each appointment after I’d prescribed medications I’d tell patients, “Please call me if you have a problem.” Frequently, patients would call with a list of problems and side effects that they believed were caused by the newly prescribed medication. Later, I realized that I may have inadvertently encouraged patients to develop problems so they would have a reason to call me. To achieve a more favorable outcome I changed the way I communicate. I now say, “Please call me next week, even if you begin to feel better with this new medication.” The phone call is now associated with the idea that they will “get better,” and internalizing such a suggestion allows patients to talk with the clinician and report favorable treatment results.

9. Tell patients to monitor their successes by relabeling and reframing their symptoms. Mr. B, age 28, has MDD and reports irritability, insomnia, short temper, and restlessness. After reviewing his desired treatment outcome, we discuss the benefits of pharmacotherapy. I tell him the new medication will improve the quality and length of his sleep, which will allow his body and mind to recharge his “internal batteries” and restore health and energy. When we discuss side effects, I tell him to expect a dry mouth, which will be his signal that the medication is working. This discussion helps patients reframe side effects and improves their ability to tolerate side effects and adhere to pharmacotherapy.     

10. Harness the placebo effect and the power of suggestion to increase chances of achieving the best treatment outcomes. In a previous article,¹² I reviewed the principles of recognizing and enhancing the placebo effect and the power of suggestion to improve the chances of achieving better pharmacotherapy outcomes. When practicing participatory pharmacotherapy, clinicians are consciously aware of the power embedded in their words and are careful to use language that enhances the placebo effect and the power of suggestion when prescribing medications. Use the patient’s own language as a way of pacing yourself to the patient’s description of his or her distress. For example, Ms. R, a 42-year-old mother of 3, describes her experiences seeking help for her anxiety and depression, stating that she has not yet found the right combination of medications that provide benefits with tolerable side effects. Her clinician responds by focusing on the word “yet” (pacing) stating, “even though you have not yet found the right combination of medications to provide the most desirable benefit of beginning healing and restoring your hope, I promise to work with you and together we will try to achieve an improvement in your overall health and well-being.” This response includes several positive words and suggestions of future success, which are referred to as leading.

Not all patients will respond to participatory pharmacotherapy. Some factors will make patients good candidates for this approach, and others should be considered exclusionary qualities (Table 2).

Bottom Line

“Participatory pharmacotherapy” involves identifying patients as partners in the process of treatment choice and decision-making, encouraging them to provide their opinions regarding medication use, and making patients feel they have been heard and understood. This technique emphasizes forming a therapeutic alliance with the patient to improve patients’ adherence to pharmacotherapy and optimize treatment outcomes.

Related Resources

• Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;16(2);CD000011.

• Mahone IH. Shared decision making and serious mental illness. Arch Psychiatr Nurs. 2008;22(6):334-343.

• Russel CL, Ruppar TM, Metteson M. Improving medication adherence: moving from intention and motivation to a personal systems approach. Nurs Clin North Am. 2011;46(3):271-281.

• Tibaldi G, Salvador-Carulla L, Garcia-Gutierrez JC. From treatment adherence to advanced shared decision making: New professional strategies and attitudes in mental health care. Curr Clin Pharmacol. 2011;6(2):91-99. 

Drug Brand Name

Clonazepam • Klonopin

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychiatric patients stand to benefit greatly from adhering to prescribed pharmacotherapy, but many patients typically do not follow their medication regimens.^1,2 Three months after pharmacotherapy is initiated, approximately 50% of patients with major depressive disorder (MDD) do not take their prescribed antidepressants.³ Adherence rates in patients with schizophrenia range from 50% to 60%, and patients with bipolar disorder have adherence rates as low as 35%.^4-6 One possible explanation for “treatment-resistant” depression, schizophrenia, and bipolar disorder may simply be nonadherence to prescribed pharmacotherapy.

Several strategies have been used to address this vexing problem (Table 1).^7,8 They include individual and family psychoeducation,^9,10 cognitive-behavioral therapy,¹¹ interpersonal and social rhythm therapy, and family-focused therapy. This article describes an additional strategy I call “participatory pharmacotherapy.” In this model, the patient becomes a partner in the process of treatment choices and decision-making. This encourages patients to provide their own opinions and points of view regarding medication use. The prescribing clinician makes the patient feel that he or she has been listened to and understood. This and other techniques emphasize forming a therapeutic alliance with the patient before initiating pharmacotherapy. The patient provides information on his or her family history, medical and psychiatric history, and experience with previous medications, with a specific focus on which medications worked best for the patient and family members diagnosed with a similar condition.

Getting patients to participate

One of the fundamental tasks is to encourage patients to accept a participatory role, determine their underlying diagnosis, and co-create a treatment plan that will be most compatible with their illness and their personality. There are 10 components of establishing and practicing participatory pharmacotherapy.

1. Encourage patients to share their opinion of what a desirable treatment outcome should be. Some patients have unrealistic expectations about what medications can achieve. Clarify with patients what would be a realistic expectation of pharmacotherapy, and modify the patient’s beliefs to be compatible with a more probable outcome. For example, Ms. D, a 46-year-old mother of 2, is diagnosed with MDD, recurrent type without psychotic features. She states she expects pharmacotherapy will alleviate all symptoms and allow her to achieve a new healthy, happy state in which she will be able to laugh, socialize, and have fun every day for the rest of her life. Although achieving remission is a realistic and desirable treatment goal, Ms. D’s expectations are idealistic. Helping Ms. D accept and agree to realistic and achievable outcomes will improve her adherence to prescribed medications.

2. Encourage patients to share their ideas of how a desirable outcome can be accomplished. Similar to their expectations of outcomes, some patients have an unrealistic understanding of how treatment is conducted. Some patients expect treatment to be limited to prescribed medications or a one-time injection of a curative drug. Others prefer to use herbs and supplements and want to avoid prescribed medications. Understanding the patient’s expectations of how treatment is carried out will allow clinicians to provide patients with a rational view of treatment and establish a partnership based on realistic expectations.

3. Engage patients in choosing the best medication for them. Many patients have preconceived ideas about medications and which medicine would be best for them. They get this information from various sources, including family members and friends who benefitted from a specific drug, personal experience with medications, and exposure to drug advertising.

Understanding the patient’s preference for a specific medication and why he or she made such a choice is critical because doing so can take advantage of the patient’s self-fulfilling prophecies and improve the chances of obtaining a better outcome. For example, Mr. O, a 52-year-old father of 3, has been experiencing recurrent episodes of severe panic attacks. His clinician asked him to describe medications that in his opinion were most helpful in the past. He said he preferred clonazepam because it had helped him control the panic attacks and had minimal side effects, but he discontinued it after a previous psychotherapist told him he would become addicted to it. Obtaining this information was valuable because the clinician was able to clarify guidelines for clonazepam use without the risk of dependence. Mr. O is prescribed clonazepam, which he takes consistently and responds to excellently.

4. Involve patients in setting treatment goals and targeting symptoms to be relieved. Actively listen when patients describe their symptoms, discomforts, and past experiences with treatments. I invite patients to speak uninterrupted for 5 to 10 minutes, even if they talk about issues that seem irrelevant. I then summarize the patient’s major points and ask, “And what else?” After he or she says, “That’s it,” I ask the patient to assign a priority to alleviating each symptom.

For example, Ms. J, a 38-year-old married mother of 2, was diagnosed with bipolar II disorder. She listed her highest priority as controlling her impulsive shopping rather than alleviating depression, insomnia, or overeating. She had been forced to declare bankruptcy twice, and she was determined to never do so again. She also wanted to regain her husband’s trust and her ability to manage her finances. Ensuring that Ms. J felt understood regarding this issue increased the chances of establishing a solid treatment partnership. Providing Ms. J with a menu of treatment choices and asking her to describe her previous experiences with medications helped her and the clinician choose a medication that is compatible with her desire to control her impulsive shopping.

5. Engage patients in choosing the best delivery system for the prescribed medication. For many medications, clinicians can choose from a variety of delivery systems, including pills, transdermal patches, rectal or vaginal suppositories, creams, ointments, orally disintegrating tablets, liquids, and intramuscular injections. Patients have varying beliefs about the efficacy of particular delivery systems, based on personal experiences or what they have learned from the media, their family and friends, or the Internet. For example, Ms. S, age 28, experienced recurrent, disabling anxiety attacks. When asked about the best way of providing medication to relieve her symptoms, she chose gluteal injections because, as a child, her pediatrician had treated her for an unspecified illness by injecting medication in her buttock, which rapidly relieved her symptoms. This left her with the impression that injectable medications were the best therapeutic delivery system. After discussing the practicalities and availability of fast-acting medications to control panic attacks, we agreed to use orally disintegrating clonazepam, which is absorbed swiftly and provides fast symptom relief. Ms. S reported favorable results and was pleased with the process of developing this strategy with her clinician.

6. Involve patients in choosing the times and frequency of medication administration. The timing and frequency of medication administration can be used to enhance desirable therapeutic effects. For example, an antidepressant that causes sedation and somnolence could be taken at bedtime to help alleviate insomnia. Some studies have shown that taking a medication once a day improves adherence compared with taking the same medication in divided doses.¹³ Other patients may wish to take a medication several times a day so they can keep the medication in their purse or briefcase and feel confident that if they need a medication for immediate symptom relief, it will be readily available.

7. Teach patients to self-monitor changes and improvements in target symptoms. Engaging patients in a system of self-monitoring improves their chances of achieving successful treatment outcomes.¹⁴ Instruct patients to create a list of symptoms and monitor the intensity of each symptom using a rating scale of 1 to 5, where 1 represents the lowest intensity and 5 represents the highest. As for frequency, patients can rate each symptom from “not present” to “present most of the time.”

Self-monitoring allows patients to observe which daily behaviors and lifestyle choices make symptoms better and which make them worse. For example, Mrs. P, a 38-year-old married mother of 2, had anxiety and panic attacks associated with low self-esteem and chronic depression. Her clinician instructed her to use a 1-page form to monitor the frequency and intensity of her anxiety and panic symptoms by focusing on the physical manifestations, such as rapid heartbeat, shortness of breath, nausea, tremors, dry mouth, frequent urination, and diarrhea to see if there was any correlation between her behaviors and her symptoms.

8. Instruct patients to call you to report any changes, including minor successes. Early in my career, toward the end of each appointment after I’d prescribed medications I’d tell patients, “Please call me if you have a problem.” Frequently, patients would call with a list of problems and side effects that they believed were caused by the newly prescribed medication. Later, I realized that I may have inadvertently encouraged patients to develop problems so they would have a reason to call me. To achieve a more favorable outcome I changed the way I communicate. I now say, “Please call me next week, even if you begin to feel better with this new medication.” The phone call is now associated with the idea that they will “get better,” and internalizing such a suggestion allows patients to talk with the clinician and report favorable treatment results.

9. Tell patients to monitor their successes by relabeling and reframing their symptoms. Mr. B, age 28, has MDD and reports irritability, insomnia, short temper, and restlessness. After reviewing his desired treatment outcome, we discuss the benefits of pharmacotherapy. I tell him the new medication will improve the quality and length of his sleep, which will allow his body and mind to recharge his “internal batteries” and restore health and energy. When we discuss side effects, I tell him to expect a dry mouth, which will be his signal that the medication is working. This discussion helps patients reframe side effects and improves their ability to tolerate side effects and adhere to pharmacotherapy.     

10. Harness the placebo effect and the power of suggestion to increase chances of achieving the best treatment outcomes. In a previous article,¹² I reviewed the principles of recognizing and enhancing the placebo effect and the power of suggestion to improve the chances of achieving better pharmacotherapy outcomes. When practicing participatory pharmacotherapy, clinicians are consciously aware of the power embedded in their words and are careful to use language that enhances the placebo effect and the power of suggestion when prescribing medications. Use the patient’s own language as a way of pacing yourself to the patient’s description of his or her distress. For example, Ms. R, a 42-year-old mother of 3, describes her experiences seeking help for her anxiety and depression, stating that she has not yet found the right combination of medications that provide benefits with tolerable side effects. Her clinician responds by focusing on the word “yet” (pacing) stating, “even though you have not yet found the right combination of medications to provide the most desirable benefit of beginning healing and restoring your hope, I promise to work with you and together we will try to achieve an improvement in your overall health and well-being.” This response includes several positive words and suggestions of future success, which are referred to as leading.

Not all patients will respond to participatory pharmacotherapy. Some factors will make patients good candidates for this approach, and others should be considered exclusionary qualities (Table 2).

Bottom Line

“Participatory pharmacotherapy” involves identifying patients as partners in the process of treatment choice and decision-making, encouraging them to provide their opinions regarding medication use, and making patients feel they have been heard and understood. This technique emphasizes forming a therapeutic alliance with the patient to improve patients’ adherence to pharmacotherapy and optimize treatment outcomes.

Related Resources

• Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;16(2);CD000011.

• Mahone IH. Shared decision making and serious mental illness. Arch Psychiatr Nurs. 2008;22(6):334-343.

• Russel CL, Ruppar TM, Metteson M. Improving medication adherence: moving from intention and motivation to a personal systems approach. Nurs Clin North Am. 2011;46(3):271-281.

• Tibaldi G, Salvador-Carulla L, Garcia-Gutierrez JC. From treatment adherence to advanced shared decision making: New professional strategies and attitudes in mental health care. Curr Clin Pharmacol. 2011;6(2):91-99. 

Drug Brand Name

Clonazepam • Klonopin

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychiatric patients stand to benefit greatly from adhering to prescribed pharmacotherapy, but many patients typically do not follow their medication regimens.^1,2 Three months after pharmacotherapy is initiated, approximately 50% of patients with major depressive disorder (MDD) do not take their prescribed antidepressants.³ Adherence rates in patients with schizophrenia range from 50% to 60%, and patients with bipolar disorder have adherence rates as low as 35%.^4-6 One possible explanation for “treatment-resistant” depression, schizophrenia, and bipolar disorder may simply be nonadherence to prescribed pharmacotherapy.

Several strategies have been used to address this vexing problem (Table 1).^7,8 They include individual and family psychoeducation,^9,10 cognitive-behavioral therapy,¹¹ interpersonal and social rhythm therapy, and family-focused therapy. This article describes an additional strategy I call “participatory pharmacotherapy.” In this model, the patient becomes a partner in the process of treatment choices and decision-making. This encourages patients to provide their own opinions and points of view regarding medication use. The prescribing clinician makes the patient feel that he or she has been listened to and understood. This and other techniques emphasize forming a therapeutic alliance with the patient before initiating pharmacotherapy. The patient provides information on his or her family history, medical and psychiatric history, and experience with previous medications, with a specific focus on which medications worked best for the patient and family members diagnosed with a similar condition.

Getting patients to participate

One of the fundamental tasks is to encourage patients to accept a participatory role, determine their underlying diagnosis, and co-create a treatment plan that will be most compatible with their illness and their personality. There are 10 components of establishing and practicing participatory pharmacotherapy.

1. Encourage patients to share their opinion of what a desirable treatment outcome should be. Some patients have unrealistic expectations about what medications can achieve. Clarify with patients what would be a realistic expectation of pharmacotherapy, and modify the patient’s beliefs to be compatible with a more probable outcome. For example, Ms. D, a 46-year-old mother of 2, is diagnosed with MDD, recurrent type without psychotic features. She states she expects pharmacotherapy will alleviate all symptoms and allow her to achieve a new healthy, happy state in which she will be able to laugh, socialize, and have fun every day for the rest of her life. Although achieving remission is a realistic and desirable treatment goal, Ms. D’s expectations are idealistic. Helping Ms. D accept and agree to realistic and achievable outcomes will improve her adherence to prescribed medications.

2. Encourage patients to share their ideas of how a desirable outcome can be accomplished. Similar to their expectations of outcomes, some patients have an unrealistic understanding of how treatment is conducted. Some patients expect treatment to be limited to prescribed medications or a one-time injection of a curative drug. Others prefer to use herbs and supplements and want to avoid prescribed medications. Understanding the patient’s expectations of how treatment is carried out will allow clinicians to provide patients with a rational view of treatment and establish a partnership based on realistic expectations.

3. Engage patients in choosing the best medication for them. Many patients have preconceived ideas about medications and which medicine would be best for them. They get this information from various sources, including family members and friends who benefitted from a specific drug, personal experience with medications, and exposure to drug advertising.

Understanding the patient’s preference for a specific medication and why he or she made such a choice is critical because doing so can take advantage of the patient’s self-fulfilling prophecies and improve the chances of obtaining a better outcome. For example, Mr. O, a 52-year-old father of 3, has been experiencing recurrent episodes of severe panic attacks. His clinician asked him to describe medications that in his opinion were most helpful in the past. He said he preferred clonazepam because it had helped him control the panic attacks and had minimal side effects, but he discontinued it after a previous psychotherapist told him he would become addicted to it. Obtaining this information was valuable because the clinician was able to clarify guidelines for clonazepam use without the risk of dependence. Mr. O is prescribed clonazepam, which he takes consistently and responds to excellently.

4. Involve patients in setting treatment goals and targeting symptoms to be relieved. Actively listen when patients describe their symptoms, discomforts, and past experiences with treatments. I invite patients to speak uninterrupted for 5 to 10 minutes, even if they talk about issues that seem irrelevant. I then summarize the patient’s major points and ask, “And what else?” After he or she says, “That’s it,” I ask the patient to assign a priority to alleviating each symptom.

For example, Ms. J, a 38-year-old married mother of 2, was diagnosed with bipolar II disorder. She listed her highest priority as controlling her impulsive shopping rather than alleviating depression, insomnia, or overeating. She had been forced to declare bankruptcy twice, and she was determined to never do so again. She also wanted to regain her husband’s trust and her ability to manage her finances. Ensuring that Ms. J felt understood regarding this issue increased the chances of establishing a solid treatment partnership. Providing Ms. J with a menu of treatment choices and asking her to describe her previous experiences with medications helped her and the clinician choose a medication that is compatible with her desire to control her impulsive shopping.

5. Engage patients in choosing the best delivery system for the prescribed medication. For many medications, clinicians can choose from a variety of delivery systems, including pills, transdermal patches, rectal or vaginal suppositories, creams, ointments, orally disintegrating tablets, liquids, and intramuscular injections. Patients have varying beliefs about the efficacy of particular delivery systems, based on personal experiences or what they have learned from the media, their family and friends, or the Internet. For example, Ms. S, age 28, experienced recurrent, disabling anxiety attacks. When asked about the best way of providing medication to relieve her symptoms, she chose gluteal injections because, as a child, her pediatrician had treated her for an unspecified illness by injecting medication in her buttock, which rapidly relieved her symptoms. This left her with the impression that injectable medications were the best therapeutic delivery system. After discussing the practicalities and availability of fast-acting medications to control panic attacks, we agreed to use orally disintegrating clonazepam, which is absorbed swiftly and provides fast symptom relief. Ms. S reported favorable results and was pleased with the process of developing this strategy with her clinician.

6. Involve patients in choosing the times and frequency of medication administration. The timing and frequency of medication administration can be used to enhance desirable therapeutic effects. For example, an antidepressant that causes sedation and somnolence could be taken at bedtime to help alleviate insomnia. Some studies have shown that taking a medication once a day improves adherence compared with taking the same medication in divided doses.¹³ Other patients may wish to take a medication several times a day so they can keep the medication in their purse or briefcase and feel confident that if they need a medication for immediate symptom relief, it will be readily available.

7. Teach patients to self-monitor changes and improvements in target symptoms. Engaging patients in a system of self-monitoring improves their chances of achieving successful treatment outcomes.¹⁴ Instruct patients to create a list of symptoms and monitor the intensity of each symptom using a rating scale of 1 to 5, where 1 represents the lowest intensity and 5 represents the highest. As for frequency, patients can rate each symptom from “not present” to “present most of the time.”

Self-monitoring allows patients to observe which daily behaviors and lifestyle choices make symptoms better and which make them worse. For example, Mrs. P, a 38-year-old married mother of 2, had anxiety and panic attacks associated with low self-esteem and chronic depression. Her clinician instructed her to use a 1-page form to monitor the frequency and intensity of her anxiety and panic symptoms by focusing on the physical manifestations, such as rapid heartbeat, shortness of breath, nausea, tremors, dry mouth, frequent urination, and diarrhea to see if there was any correlation between her behaviors and her symptoms.

8. Instruct patients to call you to report any changes, including minor successes. Early in my career, toward the end of each appointment after I’d prescribed medications I’d tell patients, “Please call me if you have a problem.” Frequently, patients would call with a list of problems and side effects that they believed were caused by the newly prescribed medication. Later, I realized that I may have inadvertently encouraged patients to develop problems so they would have a reason to call me. To achieve a more favorable outcome I changed the way I communicate. I now say, “Please call me next week, even if you begin to feel better with this new medication.” The phone call is now associated with the idea that they will “get better,” and internalizing such a suggestion allows patients to talk with the clinician and report favorable treatment results.

9. Tell patients to monitor their successes by relabeling and reframing their symptoms. Mr. B, age 28, has MDD and reports irritability, insomnia, short temper, and restlessness. After reviewing his desired treatment outcome, we discuss the benefits of pharmacotherapy. I tell him the new medication will improve the quality and length of his sleep, which will allow his body and mind to recharge his “internal batteries” and restore health and energy. When we discuss side effects, I tell him to expect a dry mouth, which will be his signal that the medication is working. This discussion helps patients reframe side effects and improves their ability to tolerate side effects and adhere to pharmacotherapy.     

10. Harness the placebo effect and the power of suggestion to increase chances of achieving the best treatment outcomes. In a previous article,¹² I reviewed the principles of recognizing and enhancing the placebo effect and the power of suggestion to improve the chances of achieving better pharmacotherapy outcomes. When practicing participatory pharmacotherapy, clinicians are consciously aware of the power embedded in their words and are careful to use language that enhances the placebo effect and the power of suggestion when prescribing medications. Use the patient’s own language as a way of pacing yourself to the patient’s description of his or her distress. For example, Ms. R, a 42-year-old mother of 3, describes her experiences seeking help for her anxiety and depression, stating that she has not yet found the right combination of medications that provide benefits with tolerable side effects. Her clinician responds by focusing on the word “yet” (pacing) stating, “even though you have not yet found the right combination of medications to provide the most desirable benefit of beginning healing and restoring your hope, I promise to work with you and together we will try to achieve an improvement in your overall health and well-being.” This response includes several positive words and suggestions of future success, which are referred to as leading.

Not all patients will respond to participatory pharmacotherapy. Some factors will make patients good candidates for this approach, and others should be considered exclusionary qualities (Table 2).

Bottom Line

“Participatory pharmacotherapy” involves identifying patients as partners in the process of treatment choice and decision-making, encouraging them to provide their opinions regarding medication use, and making patients feel they have been heard and understood. This technique emphasizes forming a therapeutic alliance with the patient to improve patients’ adherence to pharmacotherapy and optimize treatment outcomes.

Related Resources

• Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;16(2);CD000011.

• Mahone IH. Shared decision making and serious mental illness. Arch Psychiatr Nurs. 2008;22(6):334-343.

• Russel CL, Ruppar TM, Metteson M. Improving medication adherence: moving from intention and motivation to a personal systems approach. Nurs Clin North Am. 2011;46(3):271-281.

• Tibaldi G, Salvador-Carulla L, Garcia-Gutierrez JC. From treatment adherence to advanced shared decision making: New professional strategies and attitudes in mental health care. Curr Clin Pharmacol. 2011;6(2):91-99. 

Drug Brand Name

Clonazepam • Klonopin

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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Patients with bipolar disorder (BD) have a high risk for suicidal ideation, suicide attempts, and suicide.^1-3 Approximately 25% to 50% of BD patients attempt suicide at least once, and their attempts often are lethal—the ratio of attempts to completed suicides in BD patients is 3:1, compared with 30:1 in the general population.⁴ Lithium has been shown to effectively stabilize BD patients’ mood and significantly reduce the rates of suicide attempts and completed suicides,^5-9 but does not reduce BD patients’ long-term suicide risk to that of the general population.

Literature on psychotherapeutic treatments for patients with BD primarily focuses on improving patients’ adherence to pharmacotherapy and achieving faster recovery and remission.¹⁰ Nonpharmacologic treatments for patients with BD include psychoeducation, family-focused psychoeducation, cognitive therapy, and interpersonal and social rhythm therapy (Table 1).¹¹ Literature on nonpharmacologic treatments to address suicidality in BD patients is limited,^12,13 and additional psychotherapeutic interventions to reduce suicide risk in BD patients are needed.¹⁴

In this article, I describe a novel psychotherapeutic intervention I use that integrates cognitive therapy principles with ideas derived from the psychosynthesis model.^15,16 It consists of teaching patients to “disidentify” from suicidal thoughts, followed by a guided-imagery exercise in which patients experience a future positive life event with all 5 senses and internalize this experience. This creates a “hook into the future” that changes the present to match the future event and acts as an antidote to suicidal thoughts. I have used this strategy successfully in many patients as an adjunct to pharmacotherapy.

Table 1

Nonpharmacologic interventions for bipolar disorder

A theoretical model

Roberto Assagioli, who established the approach to psychology called psychosynthesis, formulated a fundamental psychological principle in controlling one’s behavior: “We are dominated by everything with which our self becomes identified. We can dominate and control everything from which we disidentify ourselves.”¹⁵ According to the psychosynthesis model, it is easier to change thoughts we identify as foreign to “the self” (ego-dystonic) than thoughts we identify as being part of “the self” (ego-syntonic).

Patients whose suicidal thoughts are ego-syntonic identify with the thoughts as representing themselves and take ownership of these thoughts. Such patients are at a greater risk of acting on suicidal thoughts.

Patients whose suicidal thoughts are ego-dystonic consider the suicidal thoughts foreign to their core self and do not believe such thoughts represent them. In essence, they “disown” the thoughts and typically want to control and eliminate them. Examples of patients’ ego-syntonic vs ego-dystonic suicidal thoughts are listed in Table 2.

This construct calls for an intervention to help patients who have ego-syntonic suicidal thoughts restructure them as a manifestation of BD, rather then the patient’s core self belief. The intervention emphasizes the patient is not “a suicidal patient” but suffers from an illness that may manifest with suicidal ideation. Many BD patients overly identify with their disease, stating, “I am bipolar” or “I am suicidal.” The “I am” statement originates from the verb “to be,” which implies the disease is part of the patient’s identity. The goal of this intervention is to help the patient learn to disidentify from the disease and decide that suicidal thoughts do not represent their core self, but are a manifestation of the underlying disease.

The psychosynthesis model of helping patients disidentify and therefore disown suicidal thoughts is compatible with interventions that use mindfulness-based cognitive therapy training to teach patients to experience their thoughts as just passing through their consciousness without taking ownership of them.¹⁷

Table 2

Examples of ego-syntonic vs ego-dystonic suicidal thoughts

The intervention

Assessment of suicidality is a fundamental skill for every mental health clinician.¹⁸ The psychotherapeutic intervention I use integrates the cognitive therapy principles of reframing, relabeling, and restructuring patients’ thoughts with disidentification from dysfunctional thoughts, feelings, and desires, based on psychosynthesis principles.

First, I conduct a comprehensive mental status examination that includes an in-depth exploration of the patient’s suicidal thoughts to determine if they are ego-syntonic or ego-dystonic. I begin by asking patients to clarify and elaborate on their statements referring to suicide, asking questions such as “Is there a part of you that objects to these thoughts?” and “Is there a part of you that wants to live?” If a patient indicates that he or she does experience inner conflict regarding such thoughts, these thoughts are classified as ego-dystonic. If a patient does not have any counter thoughts regarding the suicidal thoughts and fully identifies with them, the thoughts are classified as ego-syntonic.

I follow this with a treatment plan that helps patients change their view of their suicidal thoughts. I ask the patient to change these suicidal thoughts to ego-dystonic by focusing on the following statement: “I, (patient’s name), am a human being and like all human beings, I have thoughts; however, I am not my thoughts, I am much more than that.” I ask my patient to read this out loud and to mindfully meditate on this statement several times a day to reinforce the new understanding that these suicidal thoughts are a manifestation of the chemical imbalance of the mood disorder, and do not represent the patient as a person.

This intervention is paired with a future-focused internalized imagery experience I have described in previous articles.^19,20 In this part of the treatment, the patient and I discuss a specific expected life milestone that is positive and for which he or she would want to be present (eg, children graduating from high school or college, a wedding, birth of a child/grandchild, etc.). Using guided imagery, the patient experiences this event with all 5 senses during the session. I instruct the patient to internalize the experience and bring it back from the future to the present. This creates a “hook into the future” that is coupled with this desired milestone event in the patient’s life.

The following 3 case studies provide examples of the application of this treatment intervention.

CASE 1: Disidentifying family history

Mrs. G, a 42-year-old mother of 2, suffers from bipolar II disorder with recurrent episodes of depression associated with ego-syntonic suicidal thoughts. She states that at times she feels she is a burden to her husband and children and believes they may be better off without her. She says she believes “ending it all” must be her destiny. After further investigation, I learn Mrs. G has a family history of BD and 3 relatives have committed suicide. This family history may partially explain her belief that suicide must be “in her genes.”

I discuss with Mrs. G the strategy of changing her thoughts. I tell her to write in her journal—which she brings to her sessions—the following statements: “I am a human being. I am an adult woman and mother of 2 children. I know I have thoughts but I am not my thoughts, I am much more than that. I know I have genes but I am not my genes, I am much more than that. I know I have feelings, but I am not my feelings, I am much more than that. I know I have cousins, uncles, aunts, and other relatives but I am not my relatives. I am uniquely myself, different from the others.”

I ask Mrs. G to read these statements out loud and repeat them several times a day to reinforce this new way of perceiving the suicidal thoughts and to disidentify from the thoughts and her family history as it relates to suicide.

Mrs. G and I talk about the future and expected family milestones. When I ask if her son would want her to be present at his college graduation, she says yes. We then discuss in detail the date, time of day, and location of this event, followed by a guided imagery exercise focused on the graduation. She is guided to experience this event with all 5 senses and describes the event in detail, including the expression on the faces of her husband and children, their voices, and the scent of their aftershave lotion. She hears her son saying, “Mom, I love you. Thank you for being there with me all these years. I could not have done it without you.” I ask Mrs. G to internalize these experiences and carve them into her memory. She is instructed to come back from this future-focused guided imagery experience. When her eyes open, she looks at me and describes her experience in great detail, at times using the past tense, which confirms that the future-focused event was internalized.

In her next session, Mrs. G reports an improvement in her sleep and a change in her suicidal thoughts, which now are only fleeting.

CASE 2: Experiencing graduation

Ms. J, age 17, was diagnosed with bipolar I disorder when she was 15. She has a family history of BD in her mother, 2 maternal aunts, her grandmother, and an older sister. All these women have a history of suicidal thoughts and suicide attempts requiring hospital treatment, but no completed suicides.

Ms. J has been taking an adequate combination of mood stabilizers. She has recovered from 2 previous depressive episodes and is experiencing a third relapse with suicidal thoughts. At times, she experiences these thoughts as ego-syntonic; at other times, they are ego-dystonic.

I first educate her about the nature of BD, explaining that her suicidal thoughts are a manifestation of a chemical imbalance in her brain as a result of the depressive relapse. I teach her to use guided imagery to focus on her favorite place of peace and serenity, the beach, which produces immediate relief of the intense anxiety she felt.

After we complete the disidentification exercise, I ask her to focus on her high school graduation ceremony, which is scheduled to take place in 1 year. In a state of guided imagery, she experiences her graduation from high school with all 5 senses. As she returns to a state of full alertness with her eyes open, she describes the graduation ceremony experience in detail using the past tense, as if it had already occurred, thereby creating her own hook into the future. I instruct her to write about this experience in her journal and bring it with her to the next session.

The following session, Ms. J reports that her suicide ideations have “disappeared.” She says this was accompanied by improvements in her overall mood and sleep.

CASE 3: Internalizing the future

Mr. C, a 38-year-old married father of 4 children, has bipolar II disorder and is in a depressed state. He has been treated with optimal doses of mood stabilizers and atypical antipsychotics but continues to have suicidal thoughts. These thoughts are at times ego-syntonic; he says, “My family would be better off without me.” When Mr. C’s mood improves, however, the suicidal thoughts become more ego-dystonic; he expresses fear that he might act out on the thoughts and states that he does not want to die, he really wants to live and get better. He has no history of suicide attempts.

During our session, I ask Mr. C to focus on a new perspective to understand his thoughts by repeating the following statements: “I, JC, am a human being. I know I have a bipolar mood disorder; however, I must remember I am not bipolar. I have suicidal thoughts; however, I am not my thoughts, I am much more than that. I know I want to live, to heal, and to get better. I want to be alive and well so I can see and participate in my children’s graduation from high school and be there when they get married and when my grandchildren are born.”

I teach Mr. C to use guided imagery, during which he experiences such future positive images and milestones in his life in all 5 senses and internalizes them by using the “back from the future” technique.¹⁷ By the end of the session, he reports feeling better, more hopeful, and confident in his abilities to control his suicidal thoughts. I instruct him to write in his diary about his experiences with the future-focused positive milestones and to bring this assignment to his next appointment.

At his next appointment, Mr. C reports that his suicidal thoughts have become more fleeting, lasting for 10 to 30 seconds, and then spontaneously change to focus on issues of the “here and now.” When I ask him to read what he’s written, what stands out is the use of past tense verbs to describe future-focused experiences. For me, this confirms that Mr. C has internalized the future, creating the desirable “future hook” that acts as an antidote to the suicidal thoughts.

Related Resources

• Rouget BW, Aubry JM. Efficacy of psychoeducational approaches on bipolar disorders: a review of the literature. J Affect Disord. 2007;98:11-27.
• Weinberg I, Ronningstam E, Goldblatt MJ, et al. Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals. J Clin Psychiatry. 2010;71:699-706.

Drug Brand Name

• Lithium • Eskalith, Lithobid

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Patients with bipolar disorder (BD) have a high risk for suicidal ideation, suicide attempts, and suicide.^1-3 Approximately 25% to 50% of BD patients attempt suicide at least once, and their attempts often are lethal—the ratio of attempts to completed suicides in BD patients is 3:1, compared with 30:1 in the general population.⁴ Lithium has been shown to effectively stabilize BD patients’ mood and significantly reduce the rates of suicide attempts and completed suicides,^5-9 but does not reduce BD patients’ long-term suicide risk to that of the general population.

Literature on psychotherapeutic treatments for patients with BD primarily focuses on improving patients’ adherence to pharmacotherapy and achieving faster recovery and remission.¹⁰ Nonpharmacologic treatments for patients with BD include psychoeducation, family-focused psychoeducation, cognitive therapy, and interpersonal and social rhythm therapy (Table 1).¹¹ Literature on nonpharmacologic treatments to address suicidality in BD patients is limited,^12,13 and additional psychotherapeutic interventions to reduce suicide risk in BD patients are needed.¹⁴

In this article, I describe a novel psychotherapeutic intervention I use that integrates cognitive therapy principles with ideas derived from the psychosynthesis model.^15,16 It consists of teaching patients to “disidentify” from suicidal thoughts, followed by a guided-imagery exercise in which patients experience a future positive life event with all 5 senses and internalize this experience. This creates a “hook into the future” that changes the present to match the future event and acts as an antidote to suicidal thoughts. I have used this strategy successfully in many patients as an adjunct to pharmacotherapy.

Table 1

Nonpharmacologic interventions for bipolar disorder

A theoretical model

Roberto Assagioli, who established the approach to psychology called psychosynthesis, formulated a fundamental psychological principle in controlling one’s behavior: “We are dominated by everything with which our self becomes identified. We can dominate and control everything from which we disidentify ourselves.”¹⁵ According to the psychosynthesis model, it is easier to change thoughts we identify as foreign to “the self” (ego-dystonic) than thoughts we identify as being part of “the self” (ego-syntonic).

Patients whose suicidal thoughts are ego-syntonic identify with the thoughts as representing themselves and take ownership of these thoughts. Such patients are at a greater risk of acting on suicidal thoughts.

Patients whose suicidal thoughts are ego-dystonic consider the suicidal thoughts foreign to their core self and do not believe such thoughts represent them. In essence, they “disown” the thoughts and typically want to control and eliminate them. Examples of patients’ ego-syntonic vs ego-dystonic suicidal thoughts are listed in Table 2.

This construct calls for an intervention to help patients who have ego-syntonic suicidal thoughts restructure them as a manifestation of BD, rather then the patient’s core self belief. The intervention emphasizes the patient is not “a suicidal patient” but suffers from an illness that may manifest with suicidal ideation. Many BD patients overly identify with their disease, stating, “I am bipolar” or “I am suicidal.” The “I am” statement originates from the verb “to be,” which implies the disease is part of the patient’s identity. The goal of this intervention is to help the patient learn to disidentify from the disease and decide that suicidal thoughts do not represent their core self, but are a manifestation of the underlying disease.

The psychosynthesis model of helping patients disidentify and therefore disown suicidal thoughts is compatible with interventions that use mindfulness-based cognitive therapy training to teach patients to experience their thoughts as just passing through their consciousness without taking ownership of them.¹⁷

Table 2

Examples of ego-syntonic vs ego-dystonic suicidal thoughts

The intervention

Assessment of suicidality is a fundamental skill for every mental health clinician.¹⁸ The psychotherapeutic intervention I use integrates the cognitive therapy principles of reframing, relabeling, and restructuring patients’ thoughts with disidentification from dysfunctional thoughts, feelings, and desires, based on psychosynthesis principles.

First, I conduct a comprehensive mental status examination that includes an in-depth exploration of the patient’s suicidal thoughts to determine if they are ego-syntonic or ego-dystonic. I begin by asking patients to clarify and elaborate on their statements referring to suicide, asking questions such as “Is there a part of you that objects to these thoughts?” and “Is there a part of you that wants to live?” If a patient indicates that he or she does experience inner conflict regarding such thoughts, these thoughts are classified as ego-dystonic. If a patient does not have any counter thoughts regarding the suicidal thoughts and fully identifies with them, the thoughts are classified as ego-syntonic.

I follow this with a treatment plan that helps patients change their view of their suicidal thoughts. I ask the patient to change these suicidal thoughts to ego-dystonic by focusing on the following statement: “I, (patient’s name), am a human being and like all human beings, I have thoughts; however, I am not my thoughts, I am much more than that.” I ask my patient to read this out loud and to mindfully meditate on this statement several times a day to reinforce the new understanding that these suicidal thoughts are a manifestation of the chemical imbalance of the mood disorder, and do not represent the patient as a person.

This intervention is paired with a future-focused internalized imagery experience I have described in previous articles.^19,20 In this part of the treatment, the patient and I discuss a specific expected life milestone that is positive and for which he or she would want to be present (eg, children graduating from high school or college, a wedding, birth of a child/grandchild, etc.). Using guided imagery, the patient experiences this event with all 5 senses during the session. I instruct the patient to internalize the experience and bring it back from the future to the present. This creates a “hook into the future” that is coupled with this desired milestone event in the patient’s life.

The following 3 case studies provide examples of the application of this treatment intervention.

CASE 1: Disidentifying family history

Mrs. G, a 42-year-old mother of 2, suffers from bipolar II disorder with recurrent episodes of depression associated with ego-syntonic suicidal thoughts. She states that at times she feels she is a burden to her husband and children and believes they may be better off without her. She says she believes “ending it all” must be her destiny. After further investigation, I learn Mrs. G has a family history of BD and 3 relatives have committed suicide. This family history may partially explain her belief that suicide must be “in her genes.”

I discuss with Mrs. G the strategy of changing her thoughts. I tell her to write in her journal—which she brings to her sessions—the following statements: “I am a human being. I am an adult woman and mother of 2 children. I know I have thoughts but I am not my thoughts, I am much more than that. I know I have genes but I am not my genes, I am much more than that. I know I have feelings, but I am not my feelings, I am much more than that. I know I have cousins, uncles, aunts, and other relatives but I am not my relatives. I am uniquely myself, different from the others.”

I ask Mrs. G to read these statements out loud and repeat them several times a day to reinforce this new way of perceiving the suicidal thoughts and to disidentify from the thoughts and her family history as it relates to suicide.

Mrs. G and I talk about the future and expected family milestones. When I ask if her son would want her to be present at his college graduation, she says yes. We then discuss in detail the date, time of day, and location of this event, followed by a guided imagery exercise focused on the graduation. She is guided to experience this event with all 5 senses and describes the event in detail, including the expression on the faces of her husband and children, their voices, and the scent of their aftershave lotion. She hears her son saying, “Mom, I love you. Thank you for being there with me all these years. I could not have done it without you.” I ask Mrs. G to internalize these experiences and carve them into her memory. She is instructed to come back from this future-focused guided imagery experience. When her eyes open, she looks at me and describes her experience in great detail, at times using the past tense, which confirms that the future-focused event was internalized.

In her next session, Mrs. G reports an improvement in her sleep and a change in her suicidal thoughts, which now are only fleeting.

CASE 2: Experiencing graduation

Ms. J, age 17, was diagnosed with bipolar I disorder when she was 15. She has a family history of BD in her mother, 2 maternal aunts, her grandmother, and an older sister. All these women have a history of suicidal thoughts and suicide attempts requiring hospital treatment, but no completed suicides.

Ms. J has been taking an adequate combination of mood stabilizers. She has recovered from 2 previous depressive episodes and is experiencing a third relapse with suicidal thoughts. At times, she experiences these thoughts as ego-syntonic; at other times, they are ego-dystonic.

I first educate her about the nature of BD, explaining that her suicidal thoughts are a manifestation of a chemical imbalance in her brain as a result of the depressive relapse. I teach her to use guided imagery to focus on her favorite place of peace and serenity, the beach, which produces immediate relief of the intense anxiety she felt.

After we complete the disidentification exercise, I ask her to focus on her high school graduation ceremony, which is scheduled to take place in 1 year. In a state of guided imagery, she experiences her graduation from high school with all 5 senses. As she returns to a state of full alertness with her eyes open, she describes the graduation ceremony experience in detail using the past tense, as if it had already occurred, thereby creating her own hook into the future. I instruct her to write about this experience in her journal and bring it with her to the next session.

The following session, Ms. J reports that her suicide ideations have “disappeared.” She says this was accompanied by improvements in her overall mood and sleep.

CASE 3: Internalizing the future

Mr. C, a 38-year-old married father of 4 children, has bipolar II disorder and is in a depressed state. He has been treated with optimal doses of mood stabilizers and atypical antipsychotics but continues to have suicidal thoughts. These thoughts are at times ego-syntonic; he says, “My family would be better off without me.” When Mr. C’s mood improves, however, the suicidal thoughts become more ego-dystonic; he expresses fear that he might act out on the thoughts and states that he does not want to die, he really wants to live and get better. He has no history of suicide attempts.

During our session, I ask Mr. C to focus on a new perspective to understand his thoughts by repeating the following statements: “I, JC, am a human being. I know I have a bipolar mood disorder; however, I must remember I am not bipolar. I have suicidal thoughts; however, I am not my thoughts, I am much more than that. I know I want to live, to heal, and to get better. I want to be alive and well so I can see and participate in my children’s graduation from high school and be there when they get married and when my grandchildren are born.”

I teach Mr. C to use guided imagery, during which he experiences such future positive images and milestones in his life in all 5 senses and internalizes them by using the “back from the future” technique.¹⁷ By the end of the session, he reports feeling better, more hopeful, and confident in his abilities to control his suicidal thoughts. I instruct him to write in his diary about his experiences with the future-focused positive milestones and to bring this assignment to his next appointment.

At his next appointment, Mr. C reports that his suicidal thoughts have become more fleeting, lasting for 10 to 30 seconds, and then spontaneously change to focus on issues of the “here and now.” When I ask him to read what he’s written, what stands out is the use of past tense verbs to describe future-focused experiences. For me, this confirms that Mr. C has internalized the future, creating the desirable “future hook” that acts as an antidote to the suicidal thoughts.

Related Resources

• Rouget BW, Aubry JM. Efficacy of psychoeducational approaches on bipolar disorders: a review of the literature. J Affect Disord. 2007;98:11-27.
• Weinberg I, Ronningstam E, Goldblatt MJ, et al. Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals. J Clin Psychiatry. 2010;71:699-706.

Drug Brand Name

• Lithium • Eskalith, Lithobid

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Patients with bipolar disorder (BD) have a high risk for suicidal ideation, suicide attempts, and suicide.^1-3 Approximately 25% to 50% of BD patients attempt suicide at least once, and their attempts often are lethal—the ratio of attempts to completed suicides in BD patients is 3:1, compared with 30:1 in the general population.⁴ Lithium has been shown to effectively stabilize BD patients’ mood and significantly reduce the rates of suicide attempts and completed suicides,^5-9 but does not reduce BD patients’ long-term suicide risk to that of the general population.

Literature on psychotherapeutic treatments for patients with BD primarily focuses on improving patients’ adherence to pharmacotherapy and achieving faster recovery and remission.¹⁰ Nonpharmacologic treatments for patients with BD include psychoeducation, family-focused psychoeducation, cognitive therapy, and interpersonal and social rhythm therapy (Table 1).¹¹ Literature on nonpharmacologic treatments to address suicidality in BD patients is limited,^12,13 and additional psychotherapeutic interventions to reduce suicide risk in BD patients are needed.¹⁴

In this article, I describe a novel psychotherapeutic intervention I use that integrates cognitive therapy principles with ideas derived from the psychosynthesis model.^15,16 It consists of teaching patients to “disidentify” from suicidal thoughts, followed by a guided-imagery exercise in which patients experience a future positive life event with all 5 senses and internalize this experience. This creates a “hook into the future” that changes the present to match the future event and acts as an antidote to suicidal thoughts. I have used this strategy successfully in many patients as an adjunct to pharmacotherapy.

Table 1

Nonpharmacologic interventions for bipolar disorder

A theoretical model

Roberto Assagioli, who established the approach to psychology called psychosynthesis, formulated a fundamental psychological principle in controlling one’s behavior: “We are dominated by everything with which our self becomes identified. We can dominate and control everything from which we disidentify ourselves.”¹⁵ According to the psychosynthesis model, it is easier to change thoughts we identify as foreign to “the self” (ego-dystonic) than thoughts we identify as being part of “the self” (ego-syntonic).

Patients whose suicidal thoughts are ego-syntonic identify with the thoughts as representing themselves and take ownership of these thoughts. Such patients are at a greater risk of acting on suicidal thoughts.

Patients whose suicidal thoughts are ego-dystonic consider the suicidal thoughts foreign to their core self and do not believe such thoughts represent them. In essence, they “disown” the thoughts and typically want to control and eliminate them. Examples of patients’ ego-syntonic vs ego-dystonic suicidal thoughts are listed in Table 2.

This construct calls for an intervention to help patients who have ego-syntonic suicidal thoughts restructure them as a manifestation of BD, rather then the patient’s core self belief. The intervention emphasizes the patient is not “a suicidal patient” but suffers from an illness that may manifest with suicidal ideation. Many BD patients overly identify with their disease, stating, “I am bipolar” or “I am suicidal.” The “I am” statement originates from the verb “to be,” which implies the disease is part of the patient’s identity. The goal of this intervention is to help the patient learn to disidentify from the disease and decide that suicidal thoughts do not represent their core self, but are a manifestation of the underlying disease.

The psychosynthesis model of helping patients disidentify and therefore disown suicidal thoughts is compatible with interventions that use mindfulness-based cognitive therapy training to teach patients to experience their thoughts as just passing through their consciousness without taking ownership of them.¹⁷

Table 2

Examples of ego-syntonic vs ego-dystonic suicidal thoughts

The intervention

Assessment of suicidality is a fundamental skill for every mental health clinician.¹⁸ The psychotherapeutic intervention I use integrates the cognitive therapy principles of reframing, relabeling, and restructuring patients’ thoughts with disidentification from dysfunctional thoughts, feelings, and desires, based on psychosynthesis principles.

First, I conduct a comprehensive mental status examination that includes an in-depth exploration of the patient’s suicidal thoughts to determine if they are ego-syntonic or ego-dystonic. I begin by asking patients to clarify and elaborate on their statements referring to suicide, asking questions such as “Is there a part of you that objects to these thoughts?” and “Is there a part of you that wants to live?” If a patient indicates that he or she does experience inner conflict regarding such thoughts, these thoughts are classified as ego-dystonic. If a patient does not have any counter thoughts regarding the suicidal thoughts and fully identifies with them, the thoughts are classified as ego-syntonic.

I follow this with a treatment plan that helps patients change their view of their suicidal thoughts. I ask the patient to change these suicidal thoughts to ego-dystonic by focusing on the following statement: “I, (patient’s name), am a human being and like all human beings, I have thoughts; however, I am not my thoughts, I am much more than that.” I ask my patient to read this out loud and to mindfully meditate on this statement several times a day to reinforce the new understanding that these suicidal thoughts are a manifestation of the chemical imbalance of the mood disorder, and do not represent the patient as a person.

This intervention is paired with a future-focused internalized imagery experience I have described in previous articles.^19,20 In this part of the treatment, the patient and I discuss a specific expected life milestone that is positive and for which he or she would want to be present (eg, children graduating from high school or college, a wedding, birth of a child/grandchild, etc.). Using guided imagery, the patient experiences this event with all 5 senses during the session. I instruct the patient to internalize the experience and bring it back from the future to the present. This creates a “hook into the future” that is coupled with this desired milestone event in the patient’s life.

The following 3 case studies provide examples of the application of this treatment intervention.

CASE 1: Disidentifying family history

Mrs. G, a 42-year-old mother of 2, suffers from bipolar II disorder with recurrent episodes of depression associated with ego-syntonic suicidal thoughts. She states that at times she feels she is a burden to her husband and children and believes they may be better off without her. She says she believes “ending it all” must be her destiny. After further investigation, I learn Mrs. G has a family history of BD and 3 relatives have committed suicide. This family history may partially explain her belief that suicide must be “in her genes.”

I discuss with Mrs. G the strategy of changing her thoughts. I tell her to write in her journal—which she brings to her sessions—the following statements: “I am a human being. I am an adult woman and mother of 2 children. I know I have thoughts but I am not my thoughts, I am much more than that. I know I have genes but I am not my genes, I am much more than that. I know I have feelings, but I am not my feelings, I am much more than that. I know I have cousins, uncles, aunts, and other relatives but I am not my relatives. I am uniquely myself, different from the others.”

I ask Mrs. G to read these statements out loud and repeat them several times a day to reinforce this new way of perceiving the suicidal thoughts and to disidentify from the thoughts and her family history as it relates to suicide.

Mrs. G and I talk about the future and expected family milestones. When I ask if her son would want her to be present at his college graduation, she says yes. We then discuss in detail the date, time of day, and location of this event, followed by a guided imagery exercise focused on the graduation. She is guided to experience this event with all 5 senses and describes the event in detail, including the expression on the faces of her husband and children, their voices, and the scent of their aftershave lotion. She hears her son saying, “Mom, I love you. Thank you for being there with me all these years. I could not have done it without you.” I ask Mrs. G to internalize these experiences and carve them into her memory. She is instructed to come back from this future-focused guided imagery experience. When her eyes open, she looks at me and describes her experience in great detail, at times using the past tense, which confirms that the future-focused event was internalized.

In her next session, Mrs. G reports an improvement in her sleep and a change in her suicidal thoughts, which now are only fleeting.

CASE 2: Experiencing graduation

Ms. J, age 17, was diagnosed with bipolar I disorder when she was 15. She has a family history of BD in her mother, 2 maternal aunts, her grandmother, and an older sister. All these women have a history of suicidal thoughts and suicide attempts requiring hospital treatment, but no completed suicides.

Ms. J has been taking an adequate combination of mood stabilizers. She has recovered from 2 previous depressive episodes and is experiencing a third relapse with suicidal thoughts. At times, she experiences these thoughts as ego-syntonic; at other times, they are ego-dystonic.

I first educate her about the nature of BD, explaining that her suicidal thoughts are a manifestation of a chemical imbalance in her brain as a result of the depressive relapse. I teach her to use guided imagery to focus on her favorite place of peace and serenity, the beach, which produces immediate relief of the intense anxiety she felt.

After we complete the disidentification exercise, I ask her to focus on her high school graduation ceremony, which is scheduled to take place in 1 year. In a state of guided imagery, she experiences her graduation from high school with all 5 senses. As she returns to a state of full alertness with her eyes open, she describes the graduation ceremony experience in detail using the past tense, as if it had already occurred, thereby creating her own hook into the future. I instruct her to write about this experience in her journal and bring it with her to the next session.

The following session, Ms. J reports that her suicide ideations have “disappeared.” She says this was accompanied by improvements in her overall mood and sleep.

CASE 3: Internalizing the future

Mr. C, a 38-year-old married father of 4 children, has bipolar II disorder and is in a depressed state. He has been treated with optimal doses of mood stabilizers and atypical antipsychotics but continues to have suicidal thoughts. These thoughts are at times ego-syntonic; he says, “My family would be better off without me.” When Mr. C’s mood improves, however, the suicidal thoughts become more ego-dystonic; he expresses fear that he might act out on the thoughts and states that he does not want to die, he really wants to live and get better. He has no history of suicide attempts.

During our session, I ask Mr. C to focus on a new perspective to understand his thoughts by repeating the following statements: “I, JC, am a human being. I know I have a bipolar mood disorder; however, I must remember I am not bipolar. I have suicidal thoughts; however, I am not my thoughts, I am much more than that. I know I want to live, to heal, and to get better. I want to be alive and well so I can see and participate in my children’s graduation from high school and be there when they get married and when my grandchildren are born.”

I teach Mr. C to use guided imagery, during which he experiences such future positive images and milestones in his life in all 5 senses and internalizes them by using the “back from the future” technique.¹⁷ By the end of the session, he reports feeling better, more hopeful, and confident in his abilities to control his suicidal thoughts. I instruct him to write in his diary about his experiences with the future-focused positive milestones and to bring this assignment to his next appointment.

At his next appointment, Mr. C reports that his suicidal thoughts have become more fleeting, lasting for 10 to 30 seconds, and then spontaneously change to focus on issues of the “here and now.” When I ask him to read what he’s written, what stands out is the use of past tense verbs to describe future-focused experiences. For me, this confirms that Mr. C has internalized the future, creating the desirable “future hook” that acts as an antidote to the suicidal thoughts.

Related Resources

• Rouget BW, Aubry JM. Efficacy of psychoeducational approaches on bipolar disorders: a review of the literature. J Affect Disord. 2007;98:11-27.
• Weinberg I, Ronningstam E, Goldblatt MJ, et al. Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals. J Clin Psychiatry. 2010;71:699-706.

Drug Brand Name

• Lithium • Eskalith, Lithobid

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.