DBT for Bipolar Disorder: Informal vs Formal Mindfulness
By Dr. Kirby Reutter, DBTC, LMHC, MAC & Sheri Van Dijk, MSW, RSW.
This presentation is an excerpt from the online course “DBT Expert Interviews: From Trauma to Eating Disorders“.
Greetings and welcome to the first of 4 segments in this interview with Sheri Van Dijk on the topic of DBT and bipolar disorder. Sheri Van Dijk is a prominent psychotherapist with a private practice in Ontario, Canada. She’s also a prolific writer who has published extensively on the topics of both DBT and bipolar disorder, including The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder.
In the first segment of this interview, Sheri discusses how to teach mindfulness skills to clients with bipolar symptoms. She explains the unique challenges of teaching mindfulness to this population with specific recommendations to address these challenges. For example, Sheri explores the difference between formal vs informal mindfulness, the importance of emphasizing informal practice with smaller blocks of time, and the importance of teaching clients to hone their mindfulness skills before they’ve entered either a manic or depressive state.
Treatment Services Available
Kirby: Approximately 1% of Canadians aged 15 years and older report symptoms that meet criteria for bipolar disorder in the previous 12 months, and approximately 1 in 50 adults aged 25 and up reported symptoms of bipolar disorder at some point in their lifetime. But there’s not a ton of treatment services available.
Sheri: We’ve got specialized services in hospitals and we have a lot of support groups. We have a lot of other places that people can look for support. But there’s a real shortage of that for people with bipolar disorder. I remember working with various clients over the years who had bipolar disorders who tried out a mood disorder support program or support groups for depression. It was so interesting and heartbreaking because there was often a lot of invalidation that would happen in those kinds of support groups. What I came to learn in working with bipolar disorder is that it’s really like having apples being compared to oranges.
So, a person with bipolar disorder goes to a support group for depression. First of all, they’re probably the only person there with bipolar disorder. Second of all, the lack of understanding of bipolar disorder is still really prolific, for laypeople. If I’m in a support group for depression and I meet somebody with bipolar disorder, one of the things I hear quite often is, “Oh wow! You’re so lucky that you get those high episodes. I would love to have hypomanic episodes.” That is invalidating for the client with bipolar disorder.
There’s still a black and white perspective of what bipolar disorder feels like. People think that in the elevated episodes, it is good, fun, and energizing. But people don’t recognize the increase in suicidality and agitation. They also don’t see the psychic pain and other issues that people deal with when they’re hypomanic—and this is worse in manic episodes.
Emotional Dysregulation and Mindfulness
Kirby: You mentioned that you don’t know who is going to show up in the office, even if it’s the same person. How do you teach mindfulness when you don’t know exactly who is going to show up?
Sheri: That’s never been much of a struggle because, in my DBT work, my focus has always been not on borderline personality disorder but on emotion dysregulation. That’s what led me to look at applying DBT to this population. When I think about anybody with emotion dysregulation, we never really know where they’re going to be. With bipolar disorder, you think about somebody coming in with a hypomanic episode or somebody who is in a severe depression. But even a client without bipolar disorder, a severe depression could mean that they’re not able to do a 5-, 15-, or 30-minute mindfulness practice.
When I’m teaching people with bipolar disorder mindfulness it’s client centered, so I look at where my client is at. What kind of episode have they been in recently? And where are they at today? What’s their capacity right in this moment? Because they might be in a euthymic stable episode or a stable mood episode right now and yet maybe something fairly distressing has just happened. And so they’re not able to do a challenging mindfulness practice. A challenging practice would be, for example, to have them observe their thoughts for 5 minutes.
To go back to your question, I’m looking at making this client centered. How much experience does this client have already with mindfulness? Because quite often, we have people coming into our offices who are already practicing mindfulness or who have had some exposure to mindfulness. So what are they doing already? What’s their understanding of it?
If I have somebody come in who is already practicing 10-minute formal exercises every day, then I might want them to be practicing more informal exercises. So, I help them find a balanced way of practice. We have so much data and research on how helpful mindfulness meditation is for various mental health problems.
What people often don’t understand is that we also need them practicing in informal ways. It’s not just about sitting for half an hour every day. It’s also about being more aware of, for example, what’s going on in your body. Are your thoughts starting to get more racy? Are you feeling that little bit of agitation? It’s not about looking at those things for half an hour every day, it’s about doing those check-ins on an ongoing basis.
That is important—especially for people with bipolar disorder—because often we’re going to get very important information from those daily informal mindfulness practices. So I’d like people to start off with short practices, especially if they’re new to mindfulness. If they’re struggling with some kind of episode, it’s going to be more doable for them. When I say short, I mean a maximum of 2 minutes.
I always start people off with informal practices. For example, drive to your appointment mindfully. If you live 5 minutes away, maybe do 2 minutes of your driving to my office mindfully. If you have to check your email at work every day, check your first email of the day mindfully. Go for a walk mindfully for 2 minutes of your walk. Pet your dog mindfully. Have a conversation with your partner mindfully. That’s how I start people off.
Then we go from there depending on what their needs are and what they’re doing already. Some people will never get to the point of wanting to do formal practices and I don’t insist on that. I like to educate and provide the information about how formal practices can be helpful. But as long as my client is doing something mindfully, then that’s all I’m after. I think dialectically about mindfulness.
Mindfulness in Manic and Depressive States
Kirby: Does mindfulness practice look different if the client is in a manic state vs a depressive state?
Sheri: I typically clarify with my clients that probably if they are full-blown manic, they are not in a mindset where they’re going to be able to practice mindfulness. But I don’t want to be absolute. I don’t want to be non-dialectical about that. I don’t think I’ve yet met a client who in a full-blown mania was able to practice mindfulness, but there are always exceptions.
When I have a client in a hypomanic episode, that’s when it’s going to be more challenging. But definitely, it’s possible for them to practice mindfulness at that point. I’ve had a lot of feedback from clients over the years that when they are in or getting into a hypomanic episode and they’re able to practice mindfulness, it really helps to reduce the feelings of being overwhelmed. At times, when they’re taking on multiple projects all at once and the thoughts start racing, it often helps to calm them. It helps them to take a step back to see what’s actually going on right now and to help them think a little bit more about what they can do to help themselves.
Definitely, in a hypomanic episode, mindfulness is helpful. In manic episodes, I would say people are probably too unwell at that point to effectively practice. It’s not to say it’s impossible, but it’s unlikely.
Kirby: How about for a depressive state?
Sheri: Absolutely, more challenging, especially the more severe the depression, the harder it’s going to be to practice. This is also why, like any skill in DBT, we’re focusing on practicing a lot and especially when you can practice outside of distressing situations. Clients tend to come to us when they’re not feeling well, but the best time for them to be practicing skills is when they are feeling well.
So that’s going to make it more accessible. But it’s definitely doable. It’s just going to be more challenging in a depression. And I want to usually make it more engaging. When a client is in a deep depressive episode, a severe depression, that’s not usually the time when I want them to be doing a 15-minute observing your thoughts kind of exercise.
How about you go for a walk mindfully? Focusing on body sensations, on self-soothing kinds of things. Incorporating mindfulness with other skills to help improve the mood, I find, is what helps best.
Kirby: What you were just saying also applies very well to the DBT concept of coping ahead. In other words, don’t wait until you’re in a manic state or a depressive state to practice mindfulness. Do that ahead of time.
I also really like the distinction you made between the ability to comply with treatment. A lot of times, people assume that a manic state is great, like you mentioned before. Who wouldn’t want to be manic? And really that’s when patients tend to be less able to comply with treatment.
Sheri: Yes. Part of that is the illness fooling them into thinking that everything is okay. It’s a lack of insight, but it’s also inability. It’s like their thinking goes offline. They struggle to concentrate and remember. It’s emotion dysregulation what it comes back to. When we get that dysregulated, the thinking shuts down.
Kirby: And it’s a different type of emotion dysregulation than we normally think of when we think of applying DBT concepts. Because, like you mentioned earlier, we normally think of applying DBT to borderline personality and so we normally think of emotion dysregulation as primarily dysphoric. But euphoric states can also be states of emotional dysregulation, like you mentioned.
- When working with bipolar symptoms, it’s helpful to emphasize informal mindfulness practice over formal mindfulness practice (practical daily application vs traditional meditation).
- When working with bipolar symptoms, it’s helpful to teach clients to practice their mindfulness in much smaller blocks of time than with other clients. For example, doing just a few minutes of mindfulness practice at a time sprinkled throughout the day as opposed to one large block of time daily.
- When working with bipolar symptoms, it’s helpful for clients to practice coping ahead by honing their mindfulness skills when they’re relatively stable and between poles, before they’re actively immersed in either a manic or depressive state.
More DBT Expert Interviews: From Trauma to Eating Disorders
- DBT for Chronic Pain: Distress Tolerance and Emotion Regulation
- DBT for Substance Use: Radical Acceptance, Grief, and Recovery-Interfering Behaviors
- DBT for Teens: Teaching Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness
- DBT for Trauma: Dialectical Thinking and Distress Tolerance
- DBT Skills for Emotional Dysregulation in Psychosis: A Clinical Case Study
- Emotional Regulation, Interpersonal Conflict, and DBT Skills for Eating Disorders