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Mental Health Counseling in Bipolar Disorder

Bipolar disorder

The incidence of bipolar disorder is fairly high: more than 2 million people in America above 18 years have this illness (Bipolar disorder, 2007). It can be present at adolescence or later and may have a triggering event in the life of the patient. The one advantage of this illness is that treatment can allow a patient to lead as normal a life as possible. Before an adequate diagnosis, the patient’s life would be a mess as symptoms may not be interpreted correctly by the family or friends or at the workplace. Damaged relationships and poor performances at school are significant features.

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Cognitive behavior therapy (CBT)

The cognitive model of the illness is based upon the patient’s phenomenological experiences while in his depressive or manic phases. The model of depression has more research support (Leahy, 2004). Cognitive schemas are exhibited in the bipolar disorder patient’s automatic thoughts and maladaptive assumptions. Anxiety may be expressed as a threat and danger. Anger may be interpreted as humiliation and domination. Deprivation may produce a feeling of loss and deprivation. Mania will be exhibited as increased competence and opportunity. The automatic thoughts occur spontaneously and are associated with dysfunction. The genetic predisposition is triggered by cognitive schemas (Leahy, 2004). Management of a bipolar disorder patient involves flexibility and efficient strategic planning. The patient must be able to handle crises by himself. The episodes of depression with the suicidal tendency and mania with the risk-taking tendency need to be managed differently. Other co-morbidities must be simultaneously treated. Substance abuse, conflict within the family, and nonadherence could be incidental issues that also need attention in the management (Leahy, 2004). People with this disorder have the features of self-denial, guilt hostility towards others, and self. Self-blame is another behavior. These are expressions of solutions to their problems. Ongoing mental health counseling is the only method of prevention of the odd behaviors. This can help to identify the warning signals of the illness early so that appropriate management is instituted.

The automatic thoughts, assumptions, schemas, compensatory and augmentation strategies are studied for further management. The information obtained is selectively filtered and evaluated. Personal causation is understood. Thoughts that are reactive to emotions are selected. Inferences are made. Mislabeling and generalization are a tendency. The reasoning may be bizarre. Problem-solving skills are bad and recall is defective (Johnson, 2004).

Pressing concerns like suicidal risk, controlling aggressive behavior, or nonadherence to medication is initially treated. The patients are best provided CBT when they are not in one of the moods or when mood stabilization has been achieved through medication. Mania proves more difficult to treat than depression. The plan of treatment consists of a preliminary evaluation. The family and significant people in the patient’s life would be consulted for details of the illness. The patient is socialized to the therapy (Johnson, 2004). He is taught to self-monitor himself by learning about the various features of the illness and how he is to keep track of his behavior changes. The orientation procedure would include explaining the features of the illness. He is informed about the continuous treatment necessary for his condition and the necessity of adherence to the regime which includes medications and psychotherapy. The biological basis for the illness is detailed. Many factors influence the onset of symptoms like the environmental, psychological, and psychosocial factors which contribute to the timing of episodes (Frank, 2005). The patient must be informed about the genetic transmission that can go on for several generations. Familial history of any mental illness is sufficient to indicate a risk of bipolar disorder. Efforts are made to develop the patient’s realistic decision processes. The patient’s evaluation of his mood would help him modify his actions. Regret and self-criticism can be led to self-correction. The patient may realize that he can control his illness. The urge to spend profusely is a habit in mania. It can be spoken out of. The self-reward system can be used here. Family interventions also help. Maintenance of therapy would require the patient to continue using his mood checks, self-instructions, rational responding, and problem-solving skills (Johnson, 2004).

Interpersonal and Social Rhythm Therapy (IPSRT)

The model of physiological instability as the central cause of illness is the basis of interpersonal and social rhythm therapy (Frank, 2004). Lifestyle changes or modifications form the main part of the therapy. Goodwin and Jameson postulated that “the instability model is the fundamental dysfunction in manic-depressive illness” (Frank, 2004). This instability model also accounts for the sleep abnormalities of both depression and mania. Psychosocial stressors and changes in biological rhythm are modified. Major and minor life events may act as the precipitants for the illness. Social support, coping, gender, and temperament may influence life events so that social prompts, social rhythms, biological rhythms, and somatic symptoms are changed. Interpersonal psychotherapy is concerned with improving the quality of interpersonal relationships and providing comfort to the patient. Daily and weekly social interaction and activity are encouraged (Frank, 2004).

IPSRT has three interventions: psycho-education, social rhythm therapy, and interpersonal therapy. This therapy regularizes the daily social life of patients, prevents episodes and symptom fluctuation within episodes. It is administered in four phases: initial, intermediate, maintenance, and termination. All 3 strategies would be used in all the phases. History taking, education of the patient, completing the inventory on interpersonal relationships, and identifying the problem area are performed in the initiation. Case formulation is completed here. Psychoeducation, cognitive behavior therapy, and interpersonal and social rhythm therapies are included in mental health counseling. The patient is taught to recognize triggers and behavioral changes in himself. These should be interpreted as incidents that could lead to mood swings. Maintenance of a mood diary helps the patient to record events and incidents or behaviors. These could then be related to the resulting mood changes. Soon there is a realization on the part of the patient in that he discerns the behavior changes as triggers for the consequent moods and finds coping strategies. Taking the diary to the psychotherapist or showing his counselor would help them to interpret matters for him. The patient learns to discover his behavior changes and uses strategies to abort or delay an episode.

Emotions are labeled and thoughts identified so that the patient can rationalize his actions. With time, the patient himself understands when he needs to refer back to the counselor. Advice sought at this point prevents untoward incidents and keeps the patient’s spirits high. The counselor uses the sessions to help him overcome his behaviors to remain within the healthy status: progress to full-fledged illness is prevented. Through prevention of overt illness, the patient is saved from a repetition of the breakdown of family or losing his job, or a disruption of his social relationships. The patient learns to handle his self-esteem issues too (Mortensen, 2006).

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The intermediate phase involves the regulation of the social rhythms and the solving of the interpersonal problem and ensuring euthymic mood for the patients. (Johnson, 2004). The problem area could be in the unresolved grief, interpersonal problems, role transition, or interpersonal deficits. Grief for the lost healthy self is an added component. The last phase is the termination phase which is opted for when it is felt appropriate. Unresolved grief is caused by the death of a close relative. Patients are guided to investigate the limitations placed on them by the “illness, lost hopes and missed opportunities” (Frank, 2004). The patient is then assisted to recognize his strengths to help him recover and set new goals. Role transitions are seen in the first employment, marriage, getting a child, or divorce. Bipolar disorder patients are especially prone to problems in role transitions. Role dispute is seen when expectations do not see an intimate relationship materializing. The intermediate phase is handled by therapeutic strategies like role play, exploration of realistic opinions, and analysis of communication. The interpersonal deficits are investigated only when other problem areas do not apply (Frank, 2004). The social rhythm therapy is done during the intermediate and maintenance phases.

The Family-Focused Therapy (FFT)

A combined effort is taken by the family and friends for the sake of a bipolar disorder patient. Many people do not know what bipolar disorder is and what is done to allow the patient to lead a normal life. Psycho-education for this group is essential and the care plan is simultaneously planned. Occasionally praising the patient helps her feel wanted and providing support helps to reduce the symptoms (Linton et al, 2000). The patient must also be vigilant enough to set his own goals and go about achieving them. The patient needs to exhibit a social relationship. This therapy lasts 9 months and 21 sessions. The family is assessed, education about bipolar disorder is provided, communication-enhancement training is done, enhancing the education and problem-solving skills (Micklowitz, 2004). The FFT serves the purpose of enhancing mood stabilization by medication, using communication skills in the patients and family members.

Supporting collaborative management

A collaborative method has been mentioned in the literature. The Mental Health Care Team provides the best holistic approach (Hall et al, 2008). The team comprises the psychiatrist, the nurse, the therapists involved, or the counselors. Assessment and evaluations would be ongoing and change made from time to time.

The Life Goals program is a group-based program that imparts psycho-education informing the patients of the methods to become good collaborators in the illness management of their illness. This intervention has its roots in the optimization of the medical-model treatment. (Baeur, 2004). Individual practitioners can use this in their clinics. This organization of care helps to build disease management skills, Provider capability, or availability are supported. Patients are helped to make decisions regarding their illnesses. The revised version of this schedule has six sections depending on the feedback of the patient and therapist. Phase 1 and 2 see the patient acting in his self-interest. Phase 1 involves the use of agendas while phase 2 uses goals. Phase 2 helps the patients identify self-defined goals that they had not been able to achieve when they were ill. Fixing these goals in understandable language is also done. The behavioral approach is modified to help in the achievement of these goals. The group interacts to define the goals of each member with the help of the therapist. Sub-goals are then composed and these would be focused upon (Baeur, 2004). Behavioral, cognitive, and supporting techniques would be used. Members would discuss and share their experiences. The therapist ensures that the goals are selected by the member for whom these are important to his quality of life concept. The goals are to be measurable. The individual himself must aim at achievements by breaking them down into achievable steps. Cognitive and interpersonal techniques help to resolve issues of life problems including demoralization, stigmatization, and lack of opportunity to learn from peer figures. Mental health counseling forms a major treatment option in bipolar disorder.

References

Baeur M.S. (2004). Supporting collaborative practice management in Psychological Treatment of bipolar disorder (Eds.) Sheri L. Johnson & Robert L. Leahy. Guilford Press.

Bipolar disorder, (2007). National Institute of Mental Health, US.

Frank , E. & Swhwartz, H.A. (2004). Interpersonal and Social Rhythm in Psychological Treatment of bipolar disorder (Eds.) Sheri L. Johnson & Robert L. Leahy. Guilford Press.

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Hall, A, Wren, M & Kirby, S (2008), Care Planning in Mental Health: Promoting Recovery, Blackwell Publishing, Victoria Australia.

Johnson, S.L. (2004) Psychological Treatment of bipolar disorder, Guilford press.

Leahy, R. L. (2004). Cognitive therapy in Psychological Treatment of bipolar disorder, (Eds.) Sheri L. Johnson &Robert L. Leahy. Guilford Press.

Linton, A, D, Matteson, M, A & Maebius, N, K (2000), Introductory Nursing Care of Adults, 2nd Edition, W.B. Saunders Company, Pennsylvania USA.

Micklowitz, D.J. (2004). Family Therapy in Psychological Treatment of bipolar disorder, (Eds.) Sheri L. Johnson &Robert L. Leahy. Guilford Press.

Mortensen, P.B., Pedersen, C.B., Melbye. M., Mors. O. and Ewald, H. (2003). “Individual and Familial Risk Factors for Bipolar Affective Disorders in Denmark Arch Gen Psychiatry. 60:1209-1215

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