Rachel Cruz

By Dr. Alisha Brosse

Sutherland Center Associate Director

Two newsletters ago I wrote about our Sutherland Seminar Series, an 8-week program to better educate people about bipolar disorder. Now you are hearing us talk about our recently launched “on demand” format of the seminar series. You may be wondering:  Why all this focus on psychoeducation?

We use the term “psychoeducation” to describe education offered to individuals with a mental health condition and/or their families to help them optimally manage their condition. Psychoeducation (PE) has been tested as a stand-alone psychotherapy for bipolar disorders. It also is a significant component of other psychotherapy programs, like cognitive behavior therapy (CBT) and family-focused treatment (FFT) for bipolar disorders. PE usually includes information about the symptoms that comprise mood episodes, factors that increase or decrease risk for mood instability, the effect of various behaviors on mood, and how treatments work. I think it’s safe to say that bipolar treatment experts around the world agree that psychoeducation is a critical part of the successful treatment of bipolar disorders.

A 2011 review summarized data from 13 randomized controlled trials of PE for bipolar disorders (Batista, Von Werne Baes & Juruena, “Efficacy of psychoeducation in bipolar patients: systematic review of randomized trials,” Psychology & Neuroscience, 4.3:409-416). A majority of these studies delivered PE in a group format to individuals with bipolar disorders, though a couple offered individual PE or targeted caregivers. Taken together, these studies suggest that PE:

• Improves both patients’ and caregivers’ knowledge of the illness
• Significantly improves clinical course
• May improve adherence to medication treatment
• Significantly improves patient functioning
• Reduces the number of relapses and recurrences
• Lengthens the time until the next mood episode
• Decreases the number and length of hospitalizations

So, why do we at the Sutherland Center focus so much on psychoeducation? Because we know from research – and from our clinical experience – that increased knowledge can have dramatic positive effects on peoples’ ability to manage their symptoms.

by Dr. Alisha Brosse, Sutherland Center Associate Director

If you are at all familiar with the Sutherland Center, then you probably know that our mission is to provide clinical services to people who can’t afford them in the community. You may be less familiar with our other commitment: to train clinicians in research-supported psychotherapy for bipolar disorders.

We are passionate about this! Through this training we have a much broader impact, not only along the Front Range of Colorado, but all across the country. To date we have trained 32 advanced doctoral students. Five of these student therapists are now licensed clinical psychologists who provide clinical care along the Front Range. Because of their training with us, they are able to provide high-quality, evidence-based psychotherapy to people in our community who can afford treatment in the community. When people call the Sutherland Center seeking referrals, it is wonderful to know where to send them!

Other former graduate student therapists have taken their skillsets to various states throughout the country. One has even brought his skillset back to his native country of Iceland. In this way, the Sutherland Center has indirectly impacted the treatment of bipolar disorder in a much broader geographic region.

Our training mission doesn’t only broaden our reach. It also is what makes it possible for us to treat so many with relatively few financial resources. In one hour I can either see one patient myself, or I can supervise four hours of clinical service delivered by student therapists. In addition, it is our student therapists who run our therapy group in which we treat up to 10 clients simultaneously. Student therapists are paid an hourly wage far, far below the average community fee of $140 per session. Thus, our training mission confers to us tremendous cost savings and greatly increases our treatment capacity.

You may wonder how proficient our student therapists are. After all, bipolar disorders are serious and complex illnesses. Are such inexperienced therapists up to the task? Yes they are! First, you should know that it is the select few who get admitted to the doctoral program at the University of Colorado Boulder; we get the cream of the crop here. Then there’s the fact that the Sutherland Center is not folded into the general training clinic. Interested students apply to work with us, and we select those we believe are the best fit for the Center. Most importantly, our patients regularly tell us that our student therapists are proficient. Here are a few examples:

“You have a very talented group of young professionals there… [They are] wise beyond their years.”

“I couldn’t ask for much better… [My therapist] has been understanding, resourceful… He’s gone over and above. He really listens.”

“Very pleased with [my therapist]… [I have an] excellent relationship with him.”

“She’s deeply compassionate…she’s excellent…very flexible. [I have] only positive feedback.”

“[The group therapists are] really sharp. Very impressed with them. Very open, flexible – not strict/rigid.”

“I really enjoy their [the group therapists’] style. Those ladies are going to change many lives.”

“[My therapist’s] done an amazing job of providing me with a foundation to work through my current difficulties. She’s tuned in. Such a blessing”

“Your therapists here are incredibly good – smart and intuitive… non-judgmental and very human.”

“…None of these good things would have happened without the help of the people of the Sutherland Center. They have been unfailingly warm and friendly whether in a class, therapy or crossing paths in the waiting area. I have told many of the people with bipolar disorder I’ve encountered in the last year about Sutherland, hoping that they will come there and find help. I am convinced that I am getting better treatment than anyone with bipolar that I have talked to in depth.”

We hear equally glowing reviews from the therapists we train. Here is a sample of what some have written about their experience training at the Sutherland Center.

“I just wanted to write and let you know that there are many times on internship when I am so grateful for my training through Sutherland… I often think about your words of wisdom during many types of situations (i.e., how would Alisha handle this?).”

“The training and supervision I received at the Sutherland Center was without a doubt the most thorough, intensive, and important training experience I received in my five years of predoctoral training at CU.”

“I worked as a clinician in the program for three years, and it was without exaggeration, the best clinical training experience I had while a graduate student at the University. I have benefited professionally from my training at the Sutherland Center, and find my knowledge of diagnosis and treatment of bipolar disorder to be in high demand.”

“My experiences at the Center were a profoundly important aspect of my clinical training at CU, and have contributed to my professional success in myriad ways… Many MUSC [Medical University of South Carolina] faculty told me that my experience at the Center in assessing and treating individuals with bipolar disorders made me a unique and desirable internship
candidate. The opportunity to treat individuals with severe psychopathology, and to do so under the remarkable clinical supervision offered at the Center, is very rare in clinical psychology Ph.D. programs.”

“The training I have received through the Sutherland Center was unique because of its emphasis on evidence-based treatment of Bipolar Disorder, a disorder that is frequently misdiagnosed and undertreated in the mental health field at large. Many individuals who do receive treatment often do not receive the kind of evidence-based treatment that would be most effective in alleviating symptoms and improving functioning. In addition to superior training in treatment provision, I
received unparalleled training in differential diagnosis, coordination of care, and interfacing with client support services. It was the only training opportunity offered directly through CU that provided this degree of training. Furthermore, it was the only experience available to me through my training program to gain expertise in working with individuals who may have psychosis, suicidal ideation, or extremely impaired functioning. My experiences through the Sutherland Center helped me to achieve a top-ranked internship and have helped shape me as a clinician. To this day, as a faculty-level clinician in a highly respected medical center, I still rely on skills that I learned through this training.”

“I benefited greatly from some of the best clinical supervision I have received to date at the Center—and learned much about assessment and treatment—and no other experience at UCB prepared me better for internship. But more than anything, it was the privilege of meeting so many people with bipolar disorder that I remember most vividly and most fondly.”

“Last night I had the opportunity to attend a former Sutherland Center client’s graduation from an alcohol recovery program. I was touched when the client asked me to stand and stated, ‘I would not be here today without your support. You saved my life.’ It is an honor to be a treatment provider at Sutherland Center, where I have the opportunity to witness individuals, such as my former client, transform their lives.”

We are very fortunate that most of our student therapists elect to work with us for more than their initial one-year commitment. This provides their patients with continuity and allows us to greatly benefit from their ever-increasing expertise. I am sad to be saying good-bye to two of our most experienced graduate student therapists, both of whom have been with us for three years. A big shout out to Lauren Landy and Andrea Pelletier-Baldelli, who have combined to provide over 800 hours of clinical care to Sutherland Center patients!

by Dr. Alisha Brosse, Sutherland Center Associate Director

The Sutherland Seminar Series (SSS) is an 8-week educational series open to anyone in the community who wants to learn more about bipolar disorders. The SSS covers topics such as: What is bipolar disorder? How is it diagnosed? What is the relationship between bipolar disorder and other disorders, like anxiety, ADHD, and substance use disorders? If you have bipolar disorder, what are some things you can do to improve mood stability? What professional treatments are available, and how does one shop for a therapist or medication prescriber? What is the impact of bipolar disorder on relationships, and how does social support and relationship stress affect bipolar disorder? Finally, what can you do in a true crisis? And, how can you use a wellness plan to help you or your loved one prevent relapse?

We started to offer the SSS in January 2008, and just started our 17th series. Over 950 people have attended a seminar! Participants have included people who have (or suspect they have) a bipolar disorder, family members, friends, therapists, and probation officers. The SSS is consistent with our mission to educate the public and train mental health providers.

The information provided is geared towards adults with bipolar disorder. Some parents of adolescents with bipolar disorder, and a few adolescents themselves, have attended and said that they benefited from the information. However, parents should be forewarned that we discuss some of the risky behaviors and dire consequences that sometimes go along with bipolar disorder (such as suicide, risky sexual practices, substance use, hospitalization, financial ruin, and being arrested). If you think your child is not old enough or not mature enough to hear this information, we encourage you to come without your child.

People can come to any or all of the seminars. No registration or commitment is required. Like all of our services, we don’t want money to get in the way of someone getting the resources they need. That’s why we have a donation can available, instead of a set fee.

People regularly tell us how valuable the SSS has been to them. Here are a few quotes from people who put their thoughts in writing:

“Thank you ~ Very grateful for your work!”

“Dear Alisha + Renee,
Thank you so much for providing the seminars on Mood Disorders at the Sutherland Center. It is a real contribution to the community and was well presented and well organized. I’m certainly appreciative of having participated!”

“I want to thank you for your bipolar seminars… I find the information you provide giving me essential information about this disease which is present in my family. And equally important to me, I get a sense of hope of effective intervention from the strategies you describe. I have noticed that in sessions, you have included the caution that not everything works all the time, but still some things may work/help. And your website and you seem to involve your hearts in your work; you seem to care for those with whom you work. I appreciate that.”

The current series runs through March 28th, 2016. We meet on Mondays, 6 – 7:30 pm, in room E214 of the Muenzinger Psychology Building on campus at CU-Boulder. The next series will be offered in the fall.

You can purchase an audio version of the entire series through BipolarResources.org

On a rainy June afternoon, RDSF Board Secretary, Rachel Cruz, sat down with one of Sutherland Center’s most dedicated psychiatrists, Dr. Gregg Olsen, who has been doing pro bono work as a Board Member and with the Center’s clients for over a decade.

 

Rachel: How did you get involved with the Sutherland Center?

Gregg: I got involved through Will Van Derveer. Will is a longstanding friend and colleague of mine, and he knew Bob Sutherland. He told me of the Sutherland Center and the work that they were doing. I’m fully supportive of any organization that’s promoting mental health. What I loved about it is the fact that all the funding goes directly towards clinical care. That’s what was most appealing to me. And Bob, once you meet Bob… he’s such a kind man. It’s easy to want to support him and partner with him with his mission.

R: Yes, I feel very fortunate in that, working with him; he’s great to work with. So how long ago was that?

G: That was 2004. When I got involved, I got on the Board fairly quickly. I was on the Board from 2004 to 2008.

R: Were you working tangentially to service patients, as well?

G: No, that was just work-work. There was a big bottleneck for psychiatrists. There were a lot of psychological evaluations coming through the Sutherland Center.  Essentially there was a bottleneck of being able to get consistent psychiatrists to take on those patients. There were a few psychiatrists that were getting paid by the Sutherland Center to provide consultation and services. But then, they left and there was really nobody to fill their roles. And then there was concern among the people at the Sutherland Center about having physician psychiatrists who were good at treating bipolar disorder. They didn’t want to refer patients to just anybody in the community. So I recommended trying to get people to do pro bono evaluations for the Sutherland Center, even if it was just consultation and then referring them to someone in the community. But then again, there was a lot of protection because the Sutherland Center had seen a lot of people, I think, who were mismanaged by particular psychiatrists in the community. That was one of the things they really wanted to make sure, and David Miklowitz was in this as well, they really wanted to be assured that there were people who would be familiar with and adept at working with bipolar disorder.

R: Was it David Miklowitz who chose the doctors?

G: I don’t know who actually chose and how we ended up getting chosen over time. Sutherland Center staff said, if you’re willing to see a pro bono person we would love that. And Will Van Derveer was the same thing. Then Gila Steinbock came on; I don’t know how they became familiar with her work, but they decided to invite her as well. And I’m not even sure who are pro bono providers for psychiatric services now.

R: But you’re doing pro bono work, right? It’s all pro bono, what you do for the Center?

G: Yes, I’ve never gotten paid by anybody. But I only usually take one person at a time. That’s usually all because I do pro bono work for other organizations, too. I have to make a living! I’m really big at giving back to the community, being a part of the community.

 

And I love treating bipolar. It’s really become an area of my biggest interest. When I started out, it was mostly mood disorders in general anyway, certain psychotic disorders, but not in a private practice kind of setting. They usually ended up in a mental health center setting if they have a more severe illness, and they need to have a system around them. So I’d been seeing mostly mood and anxiety disorders, and the majority of mood disorders we were seeing were bipolar-type mood disorders because primary care doctors are not at all treating bipolar disorder. Primary care doctors were very comfortable treating major depression or anxiety. But once patients become unresponsive to medication or aren’t responding in typical ways, they refer to us, and a lot of times there’s a suspicion of a bipolar disorder. So we kind of just end up with those.

 

Anyway, I find them the most challenging. I think there are so many aspects of working with bipolar clients. They tend to be very articulate, have a wider range of emotion, which makes them very interesting. I see a lot of high intellect in people with bipolar disorder, interestingly enough. People have been very successful before they’re ever diagnosed. Many people have been running companies, starting companies, chains of restaurants, all sorts of things before they were even adequately treated.

 

And we’ve fortunately had more medications come out over time, but we’ve been sort of limited in the amount of medications we have to treat bipolar disorder to some respect. But for me, it comes to challenge, and I like a good challenge and handling medication management.  There’s nothing better than seeing somebody get stabilized, and how appreciative they can be once they had a period of mood stability (for a year!) that they can start trusting that they’re not going to have another mood episode.

 

They also tend to be a really creative population of people, musicians and artists, with their creative powers, and they’ve created meaningful work for themselves, successful work.

 

R: How do you think the family unit contributes to their lives? Do they help in healing them, managing them? Is family a really big part of the treatment?

G: Yeah, well, David Miklowitz and his book speak volumes about that, and it can go either way. It can be a family who is incredibly supportive, and is making sure the person is getting the right services they need and is trying to provide the right support that the person needs just on a day to day basis. On the other hand, when you have an identified patient in the family, then sometimes if there’s any sort of discord or problem he gets blamed, that the person is unstable in some way. At the same time, I think families are crucial because what they always say is, people come in complaining of depression, but nobody comes in complaining of mania. Patients like the euphoric feeling, they like the creativity, and they think nobody gets it, that only they get it, the grandiose quality that can come along with it. So it’s often times not until I get a call from a family member saying they’re manic do we really know that they’re in that phase of an illness, so family and collateral information is really helpful.

 

I also treat adolescents as well, so there’s that tricky dynamic between adolescents and their parents, and the parents are trying to control and dispense the medication. And I’m trying to get the adolescent to take responsibility for the illness, manage their own medication, and then learn how to manage their illness as they turn into young adults.

 

R: Are you finding that patients are being diagnosed even earlier on with bipolar disorder?

G: I think so. There’s been a lot of controversy around that. There’s the question, are we just getting better at screening for it at this point? Are there environmental factors that are contributing that are increasing the incidents of that, many other factors that can play a role environmentally as well? But we’re definitely better at screening. There was also a lot of controversy about there being a spectrum of bipolar disorder that there was just a Type 1 and just a Type 2, and that they were classic types. And if they didn’t meet the criteria for 1 or 2 they didn’t have bipolar disorder. And yet they responded best to mood stabilizers and got worse on anti-depressants.

 

R: What do you see are the challenges that patients face today?

G: I think the biggest challenge is getting an accurate diagnosis because the earliest identification and the earliest treatment have been shown to improve the overall course of the illness. So the sooner somebody can be identified and treated, I think the better their outcome over time. The average is 7 years until a bipolar disorder diagnosis from their first presenting symptom. There might be a number of different medication trials, and that’s a lot of exposure to a lot of medications that have a lot of side effects. Getting an accurate diagnosis as early as possible is challenging.

 

R: Why does it take so long?

G: Because people don’t always present with classic criteria. And many people present with depression as being their first mood episode. If they present with mania it’s very easy and very clear. But if they present with depression, it’s hard to know what direction they take, especially with adolescence and late adolescence; it’s almost always a depressive episode.  And the hypomania doesn’t really develop until a bit later in a number of people, so it makes diagnosis a bit more difficult.  Their challenge is also finding medications that are tolerable and coming to terms with having an illness that’s likely a lifelong illness, and they may need medications for the rest of their life. And there’s also the label that’s almost become slang in modern society about “oh, they’re acting so biploar…” It’s hard for people to feel comfortable coming out saying, “I have bipolar disorder.” Like many other psychiatric illnesses, the stigma is not just confined to bipolar disorder.

R: … especially if they’re so young…

G: Yes. And while they’re taking medications that have side effects, I think one of the other challenges is that they get dulled to a certain degree. It’s finding that line between are they going to have the richness of experience of emotions but not tip over the end one direction or the other? They want a little creativity, but we have to keep them out of the manic creativity. They want to be able to cry at a sad movie, but they don’t want to end up in a major depression. So it’s really the finessing of the physician/patient relationship– let’s work to find that sweet spot for you.

 

And there’s the challenge in finding psychiatrists in general. I get calls from people in Boulder, certainly, but I also get calls all the time from all over the country looking for psychiatrists. There’s a shortage of psychiatrists, and many are relegated to medication management only. When I trained, I trained to do medications and therapy, and I find that useful because then you’re relying on a psychologist or a master’s level therapist who has the most contact with the person to identify symptoms early. We’re just seeing them once in a while; we’re going through our little checklist and we don’t really get a bigger sense of what’s happening.

 

R: Does meditation play a role in some treatments? Self-awareness…?

G: Absolutely. It’s very popular now, mindfulness-based stress reduction therapies and programs. There are physician trainings dedicated to mindfulness-based stress reduction, and it’s even made it into our APA (American Psychiatric Association) Guidelines as a recommendation for anxiety disorders. I think over time we’re discovering more and more that anything we can do to help self-regulate and cultivate an internal skill is more helpful versus rely on an outside resource, whether it be a therapist or a medication or turning to alcohol or other substances. I think that’s one of the other challenges that people face with bipolar disorder.  There’s such a high co-morbidity with substance abuse and with anxiety disorder. So trying to tease that all out and help somebody get off substances to help clarify their diagnosis can be very tricky if you’ve been self-medicating for a long time.

R: But the more that they can learn that skill of self-soothing, self-regulating, self-awareness it empowers them.

G: Exactly. It gives them a tool, a very useful tool. So, I’m a meditation practitioner, and a yoga practitioner. I’ve always encouraged that for clients as a way to quiet a busy mind, which is one of the things, one of the biggest complaints I hear from people.

 

And exercise as well. That’s another thing that somebody can do to help them regulate their illness by getting enough exercise. Because sleeping well, I think, is one of the key components of maintaining stability in bipolar disorder. If someone’s getting adequate sleep, then I think they do much better than someone who has an irregular sleep schedule, works a night shift, is waking frequently throughout the night, or has an altered sleep cycle where they’re up until 3am then sleeping until 10 or 11am. Those are the college kids and adolescents I see; they do that. So just regulating somebody’s sleep cycle is very helpful.

 

And that’s one of the things I also talk to people about as a warning sign, that they’re moving into a mood episode when their sleep starts changing and they need less sleep or more sleep. If they’re not feeling consistently rested, or they’re waking up with racing thoughts, or they can’t get to sleep because of those racing thoughts, those are early warning signs, and things can topple very quickly with poor or very little sleep.

 

R: And how about diet? Does diet play a role?

G: I know less about diet and the role that it might play. There is a lot of study going on now about nutrition and the potential factors. What we do know is that we have serotonin receptors all throughout our gastrointestinal system, so we have receptors throughout the body. And there is a lot now on the concept of psycho-neuro immunology where all of this is tied together. I’ll see people with IBS (irritable bowel syndrome) who have bipolar disorder, and when their mood is stabilized their irritable bowel will stabilize. It’s the same thing with migraines. I think there can be an interplay in both directions. We can’t separate the mind from the body. That would be ridiculous for us to try and do so.

 

And sugar. I think we’re going to find that sugar is one of the biggest problems in our culture at this point and the role it can play in people’s rising moods and energy levels and other aspects that get confused with psychiatric symptoms.

 

Will Van Derveer is very big on the nutritional aspects, so he would be a great resource for you to talk to if you wanted to know more about that. Dr. David Perlmutter has a new book. He’s doing a lot of work to look at the nutritional aspect, and it’s just broadened from there.

 

But not a lot of people can afford a good doctor, a good therapist, mindfulness-based training because it’s very hard to ask somebody to do that on their own. People give up meditation very quickly because they don’t see an immediate benefit, so being able to work with someone on a consistent basis like that is good. Also, not everyone can afford to eat well. They either don’t have access or they just can’t afford good quality food, so there are a lot of things that make it difficult. And there are various reasons why people can’t or aren’t getting enough exercise; it might be a medical issue, so I think these things become a barrier of somebody being able to cultivate a tool.

 

And access to medications, that’s another big issue for some people. It depends on one’s level of healthcare coverage, and what the insurance is willing to authorize and what they’re not willing to authorize. If it’s a newer, better medication, oftentimes insurance still won’t cover it unless they failed a number of the other ones. They’re working harder and harder to create medications with less and less side effects and improve compliance, but if people are still experiencing side effects that’s one of the most common reasons for people to discontinue their medications, and understandably so.

 

R: What are the hopeful scenarios that patients can look for when they receive treatment through the Sutherland Center?

G: I think what the Sutherland Center does so well is education, such comprehensive education. Psychiatrists can do education during the course of an appointment, but a six week Seminar Series, it’s invaluable for many clients to help them understand their illness and understand how to treat it, to help them come to terms that they have the illness. When they look at the criteria and compare themselves to other people in the room, they begin to recognize that this is something that they have and that treatment can be very successful. What I always encourage people is that I’ve never seen anybody that we’ve not been able to successfully treat. The more difficult thing is to successfully maintain somebody. But even then, once they’re on a good treatment regimen, they stick with that consistently. The Sutherland Center, its big strength is on education, and I think psycho-education is so important.

 

R: So whether it’s education for the patient, or their family, or their friends…?

G: Absolutely. And that’s a lot of calls that I’ll get are from family members, “how do we best support them? What is it that we can do?”

R: And you end up telling them, “Go to the Seminar!”

G: Yeah. Or whatever education there is. But we don’t have the time. If I could spend six to eight weeks, two hours a week, so 16 hours…? I barely get 15 minutes to educate a patient in one appointment. And again that’s based on their financial resources. And I think that another nice thing about the Sutherland Center is that it makes it more accessible to more people. And probably people who need the most education, again because they have the limited resources.

 

R: So one of the ideas that I’ve had is to record those seminars and make them available online.

G: Yeah, that would be fantastic.

R: We would make them available and then the Foundation could get a little bit of a kickback from people who want to download the Seminars so we can raise some money for patient care.

G: Yeah, I think that’d be fantastic. And physicians! I think there’s a way to provide continuing medical education credits for physicians that would encourage physicians. Because I see bipolar stuff coming up all the time in continuing medical education, but oftentimes it’s on the pharmacological aspect of it. Many physicians aren’t comfortable treating it, because they don’t know enough about it. They don’t have enough expertise in treating it.

 

R: Well, thank you so much for meeting with me today, Gregg. And thank you for all the work you’ve done for the Foundation and for all the clients you’ve helped at the Center. We greatly appreciate you!

G: Thank you. I hope this was helpful.

R: Yes, I’m sure everyone who reads this article will glean a lot of information. Thank you so much!