Adult Treatment Planner

Objectives and Interventions

• Describe mood state, energy level, amount of control over thoughts, and sleeping pattern.
  • Assess the client for classic signs of mania: pressured speech, impulsive behavior, euphoric mood, flight of ideas, reduced need for sleep, inflated self-esteem, and high energy.
  • Assess the client's stage of elation: hypomanic, manic, or psychotic.
• Differentiate between real and imagined losses, rejections, and abandonments.
  • Pledge to be there consistently to help, listen to, and support the client.
  • Explore the client's fears of abandonment by sources of love and nurturance.
  • Help the client differentiate between real and imagined, actual and exaggerated losses.
• Verbalize grief, fear, and anger regarding real or imagined losses in life.
  • Probe real or perceived losses in the client's life.
  • Review ways for the client to replace the losses and put them in perspective.
• Acknowledge the low self-esteem and fear of rejection that underlie the braggadocio.
  • Probe the causes for the client's low self-esteem and abandonment fears in the family-of-origin history.
  • Confront the client's grandiosity and demandingness gradually but firmly; emphasize his/her good qualities (or assign "What Are My Good Qualities" or "Acknowledging My Strengths" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Cooperate with psychiatric evaluation as to the need for medication and/or hospitalization to stabilize mood and energy.
  • Arrange for or continue hospitalization if the client is judged to be potentially harmful to self or others, or unable to care for his/her own basic needs.
  • Arrange for a psychiatric evaluation of the client for pharmacotherapy (e.g., Lithium Carbonate, Depakote, Lamictil).
• Take psychotropic medications as directed.
  • Monitor the client's reaction to the psychotropic medication prescription (e.g., compliance, side effects, and effectiveness).
  • Continually evaluate the client's compliance with the psychotropic medication prescription.
• Achieve a level of symptom stability that allows for meaningful participation in psychotherapy.
  • Monitor the client's symptom improvement toward stabilization sufficient to allow participation in psychotherapy.
  • Conduct Family-Focused Treatment with the client and significant others, or adapt the model to individual therapy if family therapy is not possible (see Bipolar Disorder: A Family-Focused Approach by Miklowitz and Goldstein).
• Complete psychological testing to assess communication patterns within the family.
  • Arrange for the administration of an objective assessment instrument for evaluating family communication patterns, particularly expressed emotion (e.g., Perceived Criticism Scale by Hooley and Teasdale); evaluate results and process feedback with the client and family.
• Verbalize an understanding of the causes for, symptoms of, and treatment of manic, hypomanic, mixed, and/or depressive episodes.
  • Teach the client and family, using all modalities necessary, about the signs, symptoms, and phasic relapsing nature of the client's mood episodes; destigmatize and normalize.
  • Teach the client a stress diathesis model of Bipolar Disorder that emphasizes the strong role of a biological predisposition to mood episodes that is vulnerable to stresses that are manageable.
  • Provide the client with a rationale for treatment involving ongoing medication and psychosocial treatment to recognize, manage, and reduce biological and psychological vulnerabilities that could precipitate relapse.
• Identify sources of stress that increase the risk of relapse.
  • Identify the client's sources of stress/triggers of potential relapse that will become the target of treatment (e.g., aversive communication, poor sleep hygiene, medication noncompliance).
• Verbalize acceptance of the need to take psychotropic medication and commit to prescription compliance with blood level monitoring.
  • Educate the client about the importance of medication compliance; teach him/her the risk for relapse when medication is discontinued and work toward a commitment to prescription adherence.
  • Assess factors (e.g., thoughts, feelings, stressors) that have precipitated the client's prescription noncompliance; develop a plan for recognizing and addressing them (or assign "Why I Dislike Taking My Medication" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
  • Educate and encourage the client to stay compliant with necessary labs involved in regulating his/her medication levels.
• Implement good sleep hygiene.
  • Teach the client about the importance of good sleep hygiene (or assign "Sleep Pattern Record" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); assess and intervene accordingly (see Sleep Disturbance chapter in this Planner).
• Develop a "relapse drill" in which roles, responsibilities, and a course of action is agreed upon in the event that signs of relapse emerge.
  • Educate the client and family about the client's signs and symptoms of pending relapse.
  • Help the client and family draw up a "relapse drill" detailing roles and responsibilities (e.g., who will call a meeting of the family to problem-solve potential relapse; who will call physician, schedule a serum level to be taken, or contact emergency services, if needed); problem-solve obstacles and work toward a commitment to adherence with the plan.
• Client and family commit to replacing aversive communication with positive, honest, and respectful communication.
  • Assess and educate the client and family about the role of aversive communication (e.g., high expressed emotion) in family distress and risk for the client's manic relapse.
  • Use behavioral techniques (education, modeling, role-playing, corrective feedback, and positive reinforcement) to teach communication skills, including offering positive feedback, active listening, making positive requests of others for behavior change, and giving negative feedback in an honest and respectful manner.
  • Assign the client and family homework exercises to use and record use of newly learned communication skills; process results in session.
• Client and family implement a problem-solving approach to addressing current conflicts.
  • Assist the client and family in identifying conflicts that can be addressed with problem-solving techniques.
  • Use behavioral techniques (education, modeling, role-playing, corrective feedback, and positive reinforcement) to teach the client and family problem-solving skills, including defining the problem constructively and specifically, brainstorming options, evaluating options, choosing options and implementing a plan, evaluating the results, and reevaluating the plan.
  • Assign the client and family homework exercises to use and record use of newly learned problem-solving skills (or assign "Plan Before Acting" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); process results in session.
• Terminate self-destructive behaviors, such as promiscuity, substance abuse, and the expression of overt hostility or aggression.
  • Repeatedly focus on the negative consequences of the client's behavior to reduce his/her thoughtless impulsivity (or assign "Recognizing the Negative Consequences of Impulsive Behavior" or "Impulsive Behavior Journal" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
  • Facilitate the client's impulse control by using role-playing, behavioral rehearsal, and role reversal to increase his/her sensitivity to consequences of his/her behavior.
  • Calmly listen to the client's expressions of hostility while setting limits on his/her aggressive or impulsive behavior.
  • Set limits on the client's manipulation or acting out by making clear rules and establishing clear consequences for breaking rules.
• Speak more slowly and be more subject-focused.
  • Provide structure and focus for the client's thoughts and actions by regulating the direction of conversation and establishing plans for behavior.
  • Verbally reinforce the client's slower speech and more deliberate thought process.
• Be less agitated and distracted - that is, able to sit quietly and calmly for 30 minutes.
  • Reinforce increased control over hyperactivity and help the client set goals and limits on agitation; model and role-play increased behavioral control.
• Report more control over impulses and thoughts, and a slower thinking process.
  • Monitor the client's energy level and reinforce increased control over behavior, pressured speech, and expression of ideas.
  • Reinforce the client's reports of behavior that is more focused on goal attainment and less distractible.
• Participate in periodic "maintenance" sessions.
  • Hold periodic "maintenance" sessions within the first few months after therapy to facilitate the client's positive changes; problem-solve obstacles to improvement.
• Increase understanding of bipolar illness by reading a book on the disorder.
  • Ask the client to read a book on Bipolar Disorder (e.g., The Bipolar Disorder Survival Guide by Miklowitz).