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By Robert Bouws, LMSW, ACSW
"What can we do to help? How can we prevent
this from happening again? What is the best way to talk to them when
we think something is
wrong?"
These common concerns are shared by families and friends of the person
with bipolar disorder when they too are impacted by the illness. Even
the most concerned and well-intended have found themselves exhausted
and frustrated when trying to engage and support their loved one during
and after an episode of mania or depression. It is not uncommon for families
and friends to distance themselves because of traumatic experiences they
have endured. Some have made the decision that they can no longer be
involved and have chosen to limit or discontinue their contact. The degree
of involvement one chooses to accept is a decision that must be respected.
For those who choose to be involved, adopting a hopeful yet realistic
attitude is helpful. A commitment to learning more about the illness
provides the foundation for helping people with bipolar disorder during
their journey.
RECOGNIZING THE SYMPTOMS
People with bipolar illness are generally high functioning, intelligent,
interesting and enjoyable to be around when the illness is under control.
They are able to hold down jobs, be good parents and friends, and contribute
to their communities. But when personality and mood changes are observed
and the person is unable to function in their normal role responsibilities,
families and friends need to pay attention. Recognizing the symptoms
of relapse, especially changes in a person’s mood, thinking and
behavior, is critical. Early detection and intervention can help control
the duration and severity of the episode.
In depressed states, the person’s mood will be sad and they will
feel hopeless, helpless and apathetic toward life. Prolonged periods
of tearfulness and anxiety are usually evident. Eating and sleeping disturbances
occur for prolonged periods of time. Their ability to care for themselves,
for others, and to function in their role at home, work or in their community
is impaired. The content of their thinking is negative and may regress
into thoughts of suicide. They may even talk of a plan on how they would
hurt themselves. This is considered to be a critical point of intervention
as the depression may worsen to self abusive behaviors and even suicidal
gestures. Giving away of personal possessions or an abrupt mood change
to a relaxed even euphoric state of mind are warning signs that need
to be taken seriously.
In the manic phase of bipolar disorder, the picture is almost the opposite
in that the person’s mood will be very elevated and even euphoric
with an inflated sense of self worth and feelings of invincibility. Reports
of decreased need for sleep, feeling highly energized and creative, and
having unrealistic or grandiose plans are common for people in the manic
phase of the illness. Speech is usually loud and pressured, and it is
difficult to stop them from talking. Thoughts race through their minds,
and their thinking and behavior is usually disorganized. Irritability,
arguing and even aggressive behavior are common symptoms. Judgment and
decision making are impaired and decisions to quit a stable job, start
a new business, cash in retirement plans or increased credit card spending
are not uncommon. Socially, there is generally an increase in activity.
This can include the need for more social stimulation and episodes of
indiscriminate sexual behavior can occur. Grandiose delusions that can
include statements that they are Jesus or have special powers occur in
the more advanced stages of mania and should signal that it is time for
an intervention. Behaviors that could intentionally or unintentionally
harm themselves or others require immediate intervention and are the
basis for hospitalization.
Co-occurring substance abuse and bipolar illness has become more evident
with the estimates being about 50% or more of people with mental illness
using substances. Clients frequently report that having a drink or smoking
marijuana helps calm them down. Likewise, use of stimulants like coffee,
caffeinated drinks, and over-thecounter weight loss products are very
common with persons experiencing mania, to boost energy levels. Herbal
remedies are also being used more often and can seriously interfere with
mood stability. Increased use of pain medication is a new challenge and
likewise can interfere with maintaining a stable lifestyle. Control and
tolerance are key components of substance abuse. The evidence is clear
that when in the depressed or manic phase of their illnesses, people
do not exercise good judgment or make good decisions and this includes
their use of substances. Substance use of any kind is strongly discouraged
for people with bipolar illness. It not only exaggerates the symptoms
of depression or mania but also interferes with the effectiveness of
the medications. Increased or indiscriminate use of substances is a warning
sign of trouble ahead.
ENGAGING A PERSON WITH BIPOLAR DISORDER
Respecting the person yet realizing they are suffering from an illness
is an important principle when interacting with a person with bipolar
disorder. People who are in a state of distress and are struggling with
depression or mania have an illness. They need a compassionate yet firm
approach to help provide a healthy boundary they can use to regain their
stability. From my experience, it is very clear that how you treat a
person, especially when they are struggling, will always be remembered.
Respect, compassion and patience are the cornerstones for sustaining
a trusting and therapeutic relationship.
When interacting with a person with bipolar disorder, it is important
to understand that verbal intervention is often ineffective. Trying to
cheer someone out of a severe depression or reasoning with a person in
a manic state has minimal impact. With depressed individuals, it is most
helpful to validate emotions they are experiencing. Just being present
with the person and near them is comforting to most depressed people.
Expecting too much or placing too many demands on them can fuel feelings
of inadequacy and poor self worth. By encouraging and reinforcing even
small attempts at self care or achievement, they may gain some confidence.
Sharing your assessment of their self care or home situation may be necessary
to assure their safety and well being as neglecting basic needs is very
common with the depressed person. Realistic expectations and a common
sense approach to safety and basic needs are essential for the depressed
patient. Patience, presence and concern about keeping open lines of communication
will help develop trust and assist the person in feeling connected to
the outside world.
Dealing with the person in a manic state requires a different approach.
Maintaining a calm exterior and speaking in a slow, relaxed tone of voice
provides a necessary contrast to the loud, excited and exhilarated presence
of the manic. Avoid trying to argue or reason with them. Rather, try
to provide clear, simple and repeated messages to ensure your observations
and input are being heard. The tendency to try to match the emotional
level of the manic is an easy trap to fall into and may only lead to
an escalation of emotions and even more conflict. Their view of reality
is distorted and their beliefs in what is true and real are difficult
to challenge or re-direct.
Distracting the person by changing the topic or re-directing their attention
to an activity or topic that is less stimulating is a helpful tool. Again,
respecting the intelligence and dignity of the person and realizing we
are dealing with an illness is important. When a person is in their normal
state, they will not act or think in this manner. It becomes a matter
of weathering the storm of emotions, including the verbal abuse that
is common in mania. Showing a sense of humor and sharing common experiences
can also be a helpful way of engaging the manic person.
Providing solid boundaries is the most important intervention that needs
to occur. Communicating what is appropriate and tolerable and what is
not needs to occur as the manic has little restraint and often ignores
their own safety or the safety or needs of others. Again, safety is essential
and paying close attention to basic needs is as important for the manic
as it is for the depressed person. Manic people often engage in exhausting
activities such as walking long distances, exercising, or staying up
all night cleaning or re-arranging furniture. They do not feel the need
to eat, drink fluids, get enough sleep, or stay out of the hot sun. Obviously
a balance of sleep and activity, good nutrition and drinking enough water
is very important. Medications like Lithium require that the person drink
enough water and stay nourished. Mental exhaustion can also occur when
people stay on the computer for long periods of time, try to plan a new
business idea, or drive long distances. Behaviors such as uncontrolled
spending, indiscriminate sexual behavior, or getting into physical altercations
with others are unfortunately quite common with manic people and can
have devastating results. Early intervention is important as families
and loved ones are usually the ones who must assist in rebuilding and
repairing the losses that occur.
ASSISTING IN RECOVERY
For the person with bipolar illness, having a family member or friend
involved in their recovery increases compliance with the treatment plan
and helps in the recovery process. Knowing they have a supportive and
concerned person to help them through difficult times is reassuring and
helps build confidence and self esteem. There are several helpful concepts
when working or living with a person with bipolar disorder.
Understanding the disease concept
Simply stated, bipolar disorder is a disease of the brain that affects
one’s mood, thinking, and behavior. It is not caused by a moral
failure. It is not caused by something the person has done or something
caused by someone else. Like any disease that is not treated properly,
bipolar illness can lead to more serious problems, even death. Therefore
it is important for the person with bipolar illness to accept the reality
that they have an illness and are responsible for getting treatment.
Acceptance of any illness means acknowledging a loss and trying to cope
with the emotions that accompany a loss. Giving up the euphoria, creativity,
and energy is a major loss for the manic person. Experiencing the shame
and low self esteem that often occurs during depression is a hurdle that
needs to be overcome. Rebuilding damaged relationships and repairing
financial problems caused by bad decisions made during a bipolar episode
becomes their responsibility. The person with bipolar disorder must accept
that medications need to be a part of their life to help control the
symptoms of the disease, just like people who suffer from diabetes or
hypertension. They must also accept that medications are only part of
the treatment and recovery. Outpatient counseling and medication reviews,
case management services, family therapy, and support groups are all
part of the safety net of services needed to support and educate the
person with bipolar disorder. Acknowledging the use of substances and
the negative impact they may have on a successful recovery is also important.
The treatment of these co-occurring disorders is a critical intervention
that needs to be incorporated into the recovery process.
Learn how to establish and maintain healthy boundaries
As mentioned previously, the degree of involvement that a family member
or friend is willing to commit to is a personal decision that needs to
be respected. Choosing to be involved is commendable and, in most cases,
very helpful for the person with bipolar disorder. It also can be exhausting
and frustrating in some cases. Therefore it is critical for you to take
care of yourself first and foremost. Paying attention to your own physical
and mental health is essential. Don’t compromise your own stability
or the stability of your existing family system while trying to address
all the needs of the person with bipolar disorder. Maintaining yourself
in your existing role as a parent, an employee, or friend to others provides
the stability you will need to be an effective partner for the person
with bipolar disorder. Balance your activities to include time for yourself
and your family. Carrying the burden alone can lead to burnout. Knowing
when to delegate responsibilities and share the burden is a key to keeping
a positive attitude.
A person with bipolar disorder needs to be accountable and responsible
in their treatment and their behaviors. If you observe behaviors you
feel are unsafe, irresponsible, or not consistent with their treatment
plan, communicating your concerns to them is necessary. They need your
feedback and sometimes your intervention in getting them back in touch
with the mental health professionals who have the resources and the expertise
to address their needs.
Becoming a partner in the recovery process
Trying to establish a relationship with a person with bipolar disorder
that is based on mutual respect and a sense of trust will help in establishing
open lines of communication. Being able to communicate openly with each
other provides the avenue for a more successful recovery.
Educating yourself in the symptoms of relapse and encouraging the person
with bipolar disorder to adhere to their treatment plan are important
ways to enhance the chances of a successful recovery. Ask to become part
of their treatment program and to attend meetings where treatment is
being discussed. Providing input to the primary care doctors, psychiatrists,
counselors, and case managers who work with the person with bipolar disorder
gives a more accurate and reliable picture of how things are going for
them in the real world. People with bipolar disorder have a tendency
to mask symptoms or to minimize the problems they may be experiencing.
Having the report from the family or a friend is helpful in effective
treatment.
Another way families and friends can help support recovery is in helping
the person with bipolar disorder establish an environment that will support
recovery. Helping with housing problems, providing transportation, assisting
in getting bills paid, or giving a helping hand with things around their
home are just a few examples of ways to support them in the community.
Helping them establish daily goals that encourage balanced nutrition
and sleep, a sense of independence, a feeling of support, and a commitment
to constructive activity will provide the physical and emotional structure
needed in their recovery. Encouraging the person with bipolar disorder
to take advantage of the opportunities in their community that provide
education and support is essential. The National Alliance for the Mentally
Ill (NAMI) has educational material and support groups in the community
that provide services for clients, families, and friends. They also have
a web site that can be accessed for current information related to mental
disorders and resources in your community. There is now a national publication,
BP magazine, that is “dedicated to bringing hope, dignity, and
support by providing inspiration and information about mental health
issues.” Local support groups for individuals and their families
provide a safe setting for sharing concerns and addressing the diverse
needs of those affected by mental illness. Finally, being an advocate
in your community for the mentally ill and their needs is probably the
most important way families and friends can be involved. Battling the
stigma and the misunderstandings about mental illness are the responsibility
of every member of our society. Our communities have the responsibility
to provide an environment of acceptance and understanding for the mentally
ill. Being an informed and involved member of one’s community is
the only way necessary change can occur.
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