by Dr Dimosthenis Tsapekos, Postdoctoral Researcher at King's College London
My CIRCuiTS™ for Bipolar Disorder
The first time I encountered Cognitive Remediation (CR) and CIRCuiTS™ was almost 10 years ago. After graduating, I worked on a study assessing the feasibility and benefit of CIRCuiTS™ for people with bipolar disorder (BD) as a therapist. Some BD clients experienced substantial cognitive difficulties and struggled with daily functioning and this study showed that CR can benefit them not only with their cognition but also their daily life functioning and personal goals .
My role evolved into a PhD exploring treatment response following CIRCuiTS™ and potential mechanisms of cognitive remediation in BD. We found that age and education level, and their clinical characteristics, such as duration or severity of symptoms were not barriers to the benefits of CIRCuiTS. Those with more cognitive difficulties are likely to improve the most in their cognition and daily life functioning. However, CIRCuiTS™ can support even those without objective cognitive difficulties to reach their goals . We also found that these benefits are more widespread, suggesting that CR can target cognition not only to enhance cognitive skills, but also to improve how well people do in their jobs, their relationships, and other areas of their lives . These findings demonstrate that CIRCuiTS™ can tackle cognitive and functional difficulties and bring hope to patients and their families for better clinical outcomes and management of BD in the future.
CIRCuiTS™ for people with BD
For those with BD, pharmacological treatments and psychosocial interventions help patients recover from acute mood episodes, maintain euthymia, and avoid relapses. However, support to achieve functional recovery and attaining personal goals or outcomes is often missing. Outcomes that matter might include starting or returning to work or education, living independently, managing finances, having fulfilling relationships, and enjoying leisure activities.
Persistent cognitive difficulties, after clinical symptoms have improved, can be at the core of functional challenges. Many struggle with metacognition, and are not aware of their cognitive strengths or shortcomings and do not have strategies to help them with cognitively demanding tasks. People with BD tend to jump into action, seeking immediate reward or gratification before considering the potential consequences, leading to avoidable mistakes. CIRCuiTS™ provides a structured context with tools to detect the effect of impulsivity and can support people to regain cognitive control. As a therapist, I felt the most important component of my role when working with a client was translating the work we did together into real-life applications, such as supporting scheduling their work tasks or commute.
Challenges as a CIRCuiTS™ therapist
Beyond our research, working with people with BD and helping them achieve their recovery goals has been the most meaningful aspect of my involvement with CR. Witnessing people’s commitment to CIRCuiTS™, completing an intensive therapy course, often incorporating sessions into busy schedules, including work, school, or caregiving. While some embraced therapy and its requirements from the beginning, others struggled with motivation and relied on my support. The flexibility of CIRCuiTS™, in terms of tailoring the therapy to each person’s needs is a significant component of successful therapies. The adaptable CIRCuiTS™ framework allows therapists to be flexible, engage clients and facilitate their needs.
Motivating people to adopt “the CIRCuiTS™ way of thinking”, was also challenging at times. For many people, progress was not an easy or linear process, steps forward were often followed by setbacks, as it meant breaking and re-constructing established thinking and behavioural patterns. Many had to accept and face their difficulties before being able to work on them and realise improvements, which can initially hinder confidence and self-esteem. It is the therapist’s responsibility to keep clients engaged and support them to persevere as achieving meaningful change takes courage and effort.
A final thought
When finishing my PhD, I looked through participants feedback so I could include a meaningful quote in my thesis. I discovered the following which I wanted to share: “I felt empowered. Now I have the tools, let’s start digging.” For me this quote encapsulates the impact CIRCuiTS™ can have. Above and beyond any improvements achieved in therapy, clients can develop tools applicable across different areas of their life long after therapy has finished so they can keep on moving forward, setting and achieving new goals and ultimately flourishing.
1. Strawbridge, R., Tsapekos, D., Hodsoll, J., Mantingh, T., Yalin, N., McCrone, P., ... & Young, A. H. (2021). Cognitive remediation therapy for patients with bipolar disorder: a randomised proof‐of‐concept trial. Bipolar Disorders, 23(2), 196-208.
2. Tsapekos, D., Strawbridge, R., Cella, M., Wykes, T., & Young, A. H. (2022). Towards personalizing cognitive remediation therapy: Examining moderators of response for euthymic people with bipolar disorder. Behaviour Research and Therapy, 151, 104054.
3. Tsapekos, D., Strawbridge, R., Cella, M., Young, A. H., & Wykes, T. (2023). Does cognitive improvement translate into functional changes? Exploring the transfer mechanisms of cognitive remediation therapy for euthymic people with bipolar disorder. Psychological Medicine, 53(3), 936-944.