TCPR: How did you get interested in psychotherapy for bipolar disorder (BD)?
Dr. Malliaris: It was part of my PhD training at the Institute of Psychiatry, at King’s College in London, and I’ve spent the past 15 years building a specialist CBT practice for patients with bipolar disorder in Greece. I also grew up with a father who suffered from a severe bipolar illness.

TCPR: What is most important in this work?
Dr. Malliaris: Establishing rapport. We look after our relationship with each patient. BD is very threatening to patients, from the experience of symptoms to the diagnosis and treatment. We need to help them feel safe so they understand the treatments.

TCPR: Do they find medications threatening?
Dr. Malliaris: Yes, especially in countries that don’t have direct-to-consumer advertising, but even in the US with generics like lithium. Patients come in with all kinds of misconceptions about the risks. They fear they won’t be able to live a normal life. The medications can be burdensome, especially during a crisis, but we can reduce those side effect burdens during the preventative phase. We have to hold up hope that they can have a great life and a full recovery.

TCPR: Does the “bipolar” word trigger fear?
Dr. Malliaris: Many have learned about bipolar from news reports or streaming shows like Maid and The Pitt. They associate it with violent behavior, drugs, family breakdown, and a chronic, untreatable course. This is where group therapy is useful. It helps them see the positive side of recovery.

TCPR: How do you educate a client that they have BD?
Dr. Malliaris: There are many types of bipolar and many types of people with bipolar, so I customize the message. I avoid being aggressive with psychoeducation, especially if they have a comorbid personality disorder or they are traumatized or cognitively impaired.

TCPR: How do you personalize it?
Dr. Malliaris: I often introduce it as a mood disorder to normalize their experience: “We all have mood swings, and these ups and downs go to bigger extremes in BD. There is a biology behind it, and the brain learns under certain conditions to respond with more extreme crises.” Then I will introduce their particular symptoms. I don’t start with, “You have this disorder.” I use a similar approach with personality disorders, where I will talk about how they developed responses that helped them cope with traumatic childhood experiences. Though once useful, those responses get in their way today. We lead up to the diagnosis. If we start with the diagnosis, it becomes stigmatizing.

TCPR: You describe bipolar as a “crisis.”
Dr. Malliaris: That captures the extreme ups and downs they go through, and patients often identify with that word. Another tip is to use guided discovery. Learn from the patient as they describe their experience. While you listen, guide them with questions. For example, you might learn that their episodes come on after seasonal changes, travel, stress, or childbirth. Those events affect the neurohormones that set the biological clock, which regulates energy, sleep, appetite, concentration, and drive. Disruptions of that clock drive bipolar episodes. It is like an extreme version of jet lag. Their experience is an understandable reaction to those circadian disruptions. Another part of the therapy is to help them recognize their early signs of relapse so we can intervene sooner. Once their experiences are normalized and set within a behavioral framework that makes sense to them, treatment makes more sense and feels less threatening.

TCPR: How do you ask about a patient’s signs of relapse?
Dr. Malliaris: “What was happening to you before the hospitalization? Did you notice any changes? What changes did your family or friends notice?” You can ask about specific symptoms, but you’ll learn about more personal signs if you leave it open-ended. Before a manic episode, clients have noticed they write long texts, clean more, buy expensive groceries, or feel a buzzing in their head. One woman would break into spontaneous singing at night. Another one would go shopping to a very expensive supermarket and so forth. The key is to pick up the personal signs.

TCPR: You’re personalizing rather than categorizing. Learning rather than labeling.
Dr. Malliaris: Yes. We do progress to mood charting and symptom monitoring, but first we need their personal contact with the experience. We need them to trust us. Humor helps. During a manic episode, a woman believed she was designing missiles for Elon Musk. Later, she laughed at the grandiosity. You laugh with them, but not at them.

TCPR: What do you advise them to do when they have early signs of relapse?
Dr. Malliaris: First, I explore how they’ve handled episodes before, listening for what worked and what didn’t work. They might say, “I stopped my meds because I didn’t need them, and that didn’t go well.” Another time, things went better. Maybe they took care of their sleep, stepped away from arguments and overstimulation, or called their psychiatrist to increase their mood stabilizer. Once you have uncovered the effective and the ineffective coping strategies, you can gently guide them and make plans about using the more effective ones. Again it’s important to guide and to avoid being didactic. With the right support, patients are smart enough to figure it out themselves.

TCPR: How do patients respond to self-monitoring?
Dr. Malliaris: There are two sides to that. During mania, self-monitoring helps. Self-awareness goes down during mania, and we counter that by engaging them to reflect and notice their moods. It provides feedback that regulates the high. But during depression, too much self-monitoring can make people feel worse. They ruminate, dwelling on their inner pain and negative thoughts. This is something I saw in my PhD research. The effect is not big enough to worry about, but it can get in the way of mood charting (Wright LA et al, J Med Internet Res 2025;27:e71525). Self-monitoring is an intervention by itself, so it needs to be cultivated and shaped during therapy.

“During mania, self-monitoring helps. But during depression, too much self-monitoring can make people feel worse. They ruminate, dwelling on their inner pain and negative thoughts.” - Yanni Malliaris, BSc, PhD

TCPR: Do some clients struggle more with mood charting?
Dr. Malliaris: Some clients obsessively monitor their mood, while others—especially those with personality disorders like narcissism—avoid it. They may fear it’s too simplistic, or don’t want to be exposed. We personalize it. The goal is to keep it consistent and useful without spending more than five minutes a day on monitoring. They may rate more often during mania and less often, sometimes once a week, when stable. Paper or electronic charting are fine—whichever works. I’ll have them rate basic things like mood, energy, sleep, medication intake, and life events to create a life chart, which is a useful guide for treatment. If they cannot do it or for some reason they avoid it, we can always dedicate 5–10 minutes during our session to do it together for their entire week.

TCPR: What other behavioral strategies help mania?
Dr. Malliaris: Sleep problems often trigger mania and depression, and most clients are motivated to work on sleep. We always cultivate sleep hygiene. Sleep hygiene materials present the ideal, but we have to personalize it, starting with changes they are motivated to make, like getting up at a regular time, staying out of bed during the day, avoiding electronic screens before bed, or wearing blue-light filtering glasses at night. Sleeping in a pitch-dark room, often a cold room, works best. Many patients are focused on sleep medications, but this is not good practice, and we don’t have evidence that sleep meds prevent or treat mania (Kishi T et al, Neuropsychiatr Dis Treat 2019;15:1479–1486). We also use mindfulness at night to improve sleep.

TCPR: Do you use any devices to help with sleep?
Dr. Malliaris: Blue-light blocking glasses can improve mania and sleep. The blue wavelength regulates the biological clock. Melatonin rises when blue-light is blocked, just as it does in a dark room. Hospitalized patients were tested in a randomized trial of mania. The patients either wore blue-light blockers—creating virtual darkness—or stayed in a pitch-dark room throughout the evening, from 6:00 pm to 8:00 am. After a week, their mania decreased significantly (Henriksen TE et al, Bipolar Disord 2016;18(3):221–232). For milder mania or insomnia, we have them put the glasses on later, like one to two hours before bed.

TCPR: Do they sleep with the glasses on?
Dr. Malliaris: No. They sleep in total darkness or wear a sleep mask. Companies like Therabody make “smart goggles” that my clients have found useful. The product is a mask that blocks out light and can be worn while asleep. It has several modes that help patients relax at night, providing mild heat, massage, or vibration. It can also play meditative music or guided mindfulness exercises through an app (therabody.com). The sensations help patients stay grounded in the mindfulness exercise. Other clients use regular sleep masks, earplugs, white noise, or nature sounds to ease sleep.

TCPR: How do you work with patients who sleep all day?
Dr. Malliaris: That’s tough. Many patients with BD are night owls and will sleep all day if they have no reason to get up. We work on waking up 30 minutes earlier each day and establishing a daily structure. We may use a dawn simulator. When patients wake up to a gradual increase in light, they are more alert and have an easier time getting started in the morning. Often their meds need adjustment, so we work with our psychiatrists to help them make the necessary changes. Luckily, we now have many options to choose from, and not all mood stabilizers are sleep inducing.

TCPR: What other strategies do you use during active mania?
Dr. Malliaris: Mindfulness is difficult during mania, but we may use simple grounding techniques. We teach them to focus on their surroundings or senses, like touching a cold object or looking at colors in the room. We want them to avoid stimulating activity, especially at night, and focus on what they find calming, like a hot bath, a candlelit room, puzzles, aromatherapy, or relaxing music. I may ask them to delay making decisions during mania, but in a way that is validating: “I see you could start a business now. You could also start it in a month. What do you think about waiting and doing it later with your family’s support?” With all these tools, the key thing is that they are in charge of when they use them. It’s easier to implement during hypomania. In mania, patients lose insight, and you can’t force reality on them.

TCPR: How do you distinguish hypomania from mania?
Dr. Malliaris: Mania gets people into serious trouble—stuff that is hard to reverse, take back, or repair. Hypomania causes milder conflicts, but it can also improve their performance. It’s just hard to maintain. Hypomania can also cause depression and life problems, and it often goes unnoticed, so we pay particular attention to it at my practice.

TCPR: How do you work with severe mania?
Dr. Malliaris: I may need to involve the family. I may have to ask the patient to blindly trust their treatment team to help them stay out of the hospital. That can work if you have a secure therapeutic relationship. They may also be motivated to prevent depression. I may say, “Yes, I’m happy you feel so well and don’t have any more social anxiety. I hope it stays this way, but anxiety is part of everyday life, and if this isn’t stable we may see depression coming up afterward.” If they don’t accept that concern, they are not going to accept treatment for it. The fear of forthcoming depression (or unfortunate hospitalization) may act as a negative reinforcer to increase treatment engagement, even in mania. But you do need the secure and trusting relationship. Otherwise, you will not go very far. It’s difficult to guide a blind person across the road if they don’t trust you.

TCPR: How do you involve family?
Dr. Malliaris: I try to involve family members from the start. I gather collateral information to help make the diagnosis and hold one or two family sessions to discuss treatment. The family is often anxious or even traumatized by the episodes, and this anxiety can be overbearing to the patient. Both need to heal. I also use humor to connect with the family. I tell them we are all a little bipolar, and they understand that. When I share that my father had bipolar, they are less likely to see me as an outsider. It’s important to respect their privacy, but it’s helpful to have as many people on board as possible. I reframe it as a team problem. They are leading the fight, but both our treatment team and their family are with them.

TCPR: Are you a buffer between the patient and family?
Dr. Malliaris: Yes. This reduces tension, and most patients are happy for me to take that role. It also works within the treatment team. If they are fearful of the psychiatrist, I may act as a buffer, creating a safety net that prevents dropout. We trained an AI companion (Flippy) at our practice to help. Flippy is a supportive buffer for all of us providing psychoeducation without being too invasive.

TCPR: How do the families need to change?
Dr. Malliaris: High levels of expressed emotion predict relapse. That means being overly critical, invalidating, or not giving them space. We help them express their concerns in a more validating and constructive way. We also explain that functional recovery takes longer than symptomatic recovery. Otherwise, their expectations will be too high. They need to learn how BD affects their relative and how it’s best handled and treated. They need to become helpful treatment team members.

TCPR: Thank you for your time, Dr. Malliaris.