Professor Goodwin's recent blog post on the mental health elf blog is very helpful in terms of summarising some of the problems we have with structured psychological therapies across most psychological disorders not just bipolar disorder. He is also a much respected figure and scientist in the field of Bipolar disorders in UK and internationally. It is also very encouraging that despite his significant involvement and contribution to pharmacological treatments of bipolar disorder, more recently he has been involved in the therapeutic role of psycho-education.

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However, it is very disconcerting to read that psychoeducation as a psychosocial treatment modality in bipolar disorder is based on some coherent model of Bipolar disorder, whereas the other structured psychosocial treatments (CBT, IPSRT, FFT) are lacking in this respect.

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The truth of the matter is that only the opposite is true. Even though there have been some trials with psychoeducation with positive results, we have yet to see any model that this approach is based. It is even more problematic and worrying when highly respected figures in the field support a psychosocial intervention that indeed has no model (coherent or not).

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CBT therapies on the other hand for Bipolar disorder may have started from Beck's model of unipolar depressive disorders but later evolved and continue to evolve through Dominic Lam's model, Steven Jones work, and more recently Warren Mansell's model, or even through schema therapy. I would indeed agree that as of yet no one has produced a coherent CBT model for Bipolar disorder, and there are many experimental developments in progress in terms of basic cognitive theory and behavioural practice. The different CBT models of Bipolar disorder are being developed by different and competing teams, but all in all they provide continued progress in the field. Hence, the argument that the CBT model of Bipolar disorder is based just upon the model of unipolar depressive disorders does not hold well to evidence. We have at least 2 decades of model development in CBT for Bipolar disorder, whereas with the "psychoeducation" treatments we have only a few trials that demonstrate some level of too good to be true effectiveness without having any sense of any underlying model.

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The psychoeducation field needs to develop some sense of a model and to decide on its primary treatment targets. It is yet unclear how psychoeducation helps? Does it increase medication compliance? Does it increase knowledge and relapse prevention skills? Do patients become more knowledgeable? Is psycho bipolar knowledge the critical factor or what? These would be some basic questions that would help the necessary modeling work that psychoeducation would need to have before it can be called an evidence-based treatment and to stand on its own.

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Of course, not to do injustice to the other psychosocial treatments for Bipolar disorder, they also have much more theory and more coherent models of Bipolar disorder than psychoeducation does. Helen Frank's IPSRT therapy is based upon IPT and the bipolar models she has developed along with behaviour therapy and social rhythm therapy. David Miklowitz's Family-Focused Therapy is based upon the Expressed Emotion model and Communication Enhancement therapy. But they all do have evolving models. They are incomplete but they were developed and continue to develop based upon their own models of Bipolar disorder.

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I am looking forward to any kind of modeling work from the psychoeducation developers and proponents.

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Yanni Malliaris

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