Category: LGBTQQ

this episode was pre-recorded
as part of a live continuing   education webinar on-demand, CEUs are
still available for this presentation   through all CEUs register at all
CEUs comm slash counselor toolbox I’d like to welcome everybody to today’s
presentation on a strengths-based biopsychosocial   approach to recovery from bipolar disorder
so we’re going to talk a little bit about   what bipolar is what causes it and how to
mitigate it by helping people understand their   own bipolar because what triggers it for John
may not trigger it for James help them identify   their warning signs because bipolar episodes
just like depressive episodes and manic episodes   often don’t come from completely out of the
blue if we look backward we can see where the   person was beginning to resume some unhealthy
lifestyle habits that were making them   more vulnerable well look at the symptoms
of depression and mania and real quickly   review bipolar one versus two and look at some
co-occurring disorders and interventions another   thing I added to this presentation was a little
a short piece on differential diagnosis because   I often see people who are diagnosed either only
with bipolar when there’s also attention deficit   disorder present or they’re diagnosed with anxiety
when it’s bipolar disorder so we’re going   to talk about how people might mistakenly diagnose
one for the other and how to kind of try to ferret   that out a little bit one way is using the online
assessment measures there’s another measure   we’re going to talk about in here too so we care
because uncontrolled bipolar puts people at risk   for suicide addiction and addiction relapse you
know even if somebody doesn’t have an addiction   when they are in a manic episode they can be more
likely to engage in potentially self-injurious   behaviors, not for self-injury but
just because they’re looking for even more of a   rush and when they’re in a depressive episode
they can also be at risk for addictions because   they’re looking to feel better in some sort
of the way so a lot of it we’re talking about well   with we’re talking about self-medication with
mania we’re just talking about what they perceive   as something exciting and people are often in manic
episodes engage in extreme risk-taking behavior   we don’t want our clients to go down any of these
paths so we want to be aware of what might trigger   it and I don’t think I talk about it anywhere
else in the presentation, it’s important to be   aware that for suicide when somebody is coming
out of a depressive episode who somebody who’s   bipolar well or unipolar depression but when
they’re coming out of the depressive episode   and they start having more energy is actually
when they’re at greater risk of suicide than   when they’re at their absolute bottom not saying
they’re safe at their absolute bottom but we don’t   want to get complacent when somebody starts
feeling better and assume that they’re out   of the woods with poorly controlled bipolar disorder
can leave people feeling hopeless and helpless   if they have bipolar one and they have at least
a full-blown manic episode but maybe more they   may not mind that they may because it disrupts
their life the depressive episodes tend to be   when patients usually present when they’ve got
bipolar disorder so we want to look at what’s   going on with them and help them see how the
bipolar disorder disrupts their life because   that can go a fair way to encouraging medication
and treatment compliance well controlled bipolar   like well-controlled addiction helps a person feel
happy optimistic motivated and energized the key   is helping them manage their vulnerabilities you
now take care of their body so they have   enough energy to do things but also make sure
that they get their medications right some of   the mood stabilizers can be flattened and make
people feel more exhausted and it’s important   it’s vital that they openly communicate with their
psychiatrist or physician about the medications if   they are if the side effects are so significant
is impairing their quality of life which means   they’re likely to be medication non-compliance so
we want to make sure that if they’re feeling too   flat that they talk it over with their medication
provider bipolar disorder is a brain disorder you   know sometimes with like depression we can look
for situational causes for anxiety we can look   for some situational causes we can look for some
cognitive stuff we know in bipolar disorder something is going on in the brain that causes
unusual shifts in mood energy activity levels   and the ability to carry out day-to-day tasks many
very successful let me go back to that so just to   be clear and generalized anxiety panic disorder
depression they also can have a brain organic   component to them but not always sometimes you
can have those from a situational cause whereas in bipolar disorder we know that there’s something
that’s not quite right with the balance of the   neurotransmitters for most people with bipolar
okay so who has bipolar lots of people you’d be   surprised Mel Gibson demi Lovato Axl Rose, Britney
Spears Jean-Claude Van Damme Marc Vonnegut and   Amy Winehouse to name just a few that I came
across you know doing some internet research   Lee Lee Thompson young and Robin Williams were
also, both are quite successful and revered in their   fields despite if you want to call it losing
their battle with bipolar so why do I bring   that up because a lot of times people when they
are given a diagnosis of bipolar disorder feel   very isolated feel very unique and I want them to
realize that there are a lot of really successful   awesome people who have bipolar disorder you
know it once it’s managed then people can   live a stereotypical life I work hard to
avoid the word normal because what’s normal for   one person may not be for another but we want
to look at they can have a very high-quality active   life bipolar disorder is caused by imbalances and
neurochemicals especially dopamine serotonin and   norepinephrine the imbalances could be genetic or
triggered by sex hormone changes or stress hormone   changes so they may be at you know steady state
but when there’s a particular stressor some sort   of change or you know other thing and it depends
on the person, it can throw those neurotransmitters   out of balance enough that it causes either a
manic episode hypomanic episode or a depressive   episode more than one in 50 adults are classified
as having bipolar disorder in any 12 months so I encourage people when they’re walking around
the store when they’re walking around the grocery   store when they’re at church when they are sitting
in a meeting at work with you know 50 other people   at least one person in that group has bipolar
disorder and or will be diagnosed with it in   the year I want them to recognize how common
it is I want them to start looking around and   thinking when they’re driving down the road on
rush-hour traffic you know every 50th car they   pass somebody in those 50 cars probably had
bipolar disorder to help them realize again   it’s not us weird diagnosis is pretty
doggone common among patients seen in primary   care settings for depressive and/or anxiety
symptoms twenty to thirty percent are estimated   to have bipolar disorder a lot of times primary
care physicians misdiagnosed bipolar disorder as   either generalized anxiety or unipolar depression
so it’s you know eighty percent of the time   seventy eighty percent of the time they’re right
but the other twenty to thirty percent you’ve got   this person who is going to continue to struggle
and get frustrated because the treatments   for generalized anxiety and depression are
generally, SSRIs and SSRIs can trigger mania so it can make the mood lability worse bipolar
the disorder is still under-recognized primarily   due to misdiagnosis as unipolar depression and
that’s not just in primary care that’s also in   you know our field because if we see somebody who
has unipolar depression you know they may not have   had a manic episode yet likely they have but they
may not have had a manic episode yet or they may   not report it or if it’s a hypomanic episode they
may not note that as something problematic and yes diagnosis of mental health conditions
is out of the scope for a lot of GPS and a lot   of them will tell you that a lot of them will say
If you’ve been diagnosed before I can help you   continue your medication but there are so many
nuances to psychological diagnosis I want   you to get an evaluation from a psychiatrist in
order to better make sure that we’re getting you   started on the right path because nothing is
more frustrating to somebody who is struggling   and again generally they present in a depressive
episode nobody is nothing is more troubling for   somebody who’s presenting and struggling then
getting on medication and not feeling like it’s   working is one of the things they see and I’m jumping
ahead of me is when somebody who has bipolar   disorder is started on an SSRI one effect could be
to set off a manic episode another effect could be   to have rapid improvement and you know it
takes four to six weeks for the SSRIs to get in there but they tend to have rapid
improvement in days unfortunately that improvement   doesn’t last and then  they tend to go back into
a depressive episode and they start to feel even   more defeated I want clients to understand us
if they start talking about that pattern where   they’ve been on antidepressants and it works
for a little while but then it doesn’t anymore   you know that may just be the wrong medication
for them, their case is not hopeless so we know   the symptoms of depression apathy feeling down
empty hopeless low energy decreased activity   sleep changes worrying difficulty concentrating
forgetting things a lot of changes in eating habits   and feeling tired or slowed down how is this
different than Low Energy I’ve had clients ask   me this before and what I try to the way I try to
differentiate is energy is your desire to get up   and do things and feel like you can when people
are feeling tired or slowed down it almost feels   like they’ve got a 50-pound rucksack on their back
or their arms and legs feel like they’re just lead   and it is exhausting to even get up and walk
across the room go to the kitchen go outside so   there’s a difference there’s energy to do things
and then there’s just feeling like you’re filled   with cement mania people feel very up high or
elated now after people come out of a depressive   episode even unipolar depression there’s a period
of mild very very mild euphoria and we don’t want   to mistake that for hypomania or mania they’re
just feeling good they’re like oh my gosh I see   the Sun again I see colors how awesome is this and
then you know it kind of levels out but you don’t   have a crash it’s just kind of a good and
then a-ok contentment people in a manic episode   have a lot of energy and increased activity levels
they often feel jumpy or wired you know like they   can’t settle down they want to sometimes but they
can’t they’re wide awake and they’re just looking   for something to do they have trouble sleeping
may talk fast about a lot of different   things so they’re jumping around and when we talk
about ADHD in a minute, we’re going to talk more   about these symptoms they may agitate irritably
or touchy not everybody who’s manic is in a good   mood so they can be manic but agitated
they feel like their thoughts are going fast and think they can do a lot of things at
once people especially in a hypomanic episode   often find themselves taking on three four five
six projects and not being able to complete them   you know when they come out of their hypomanic
In the episode, they’re like oh my gosh what did I get   myself into but there’s no sense of time in a
manic or hypomanic episode and they can especially   in a manic episode engage in risky and reckless
behavior so mixed bipolar includes symptoms of   both manic and depressive symptoms at the same
time which can be confusing to clients   they’re up they feel like they’re wired but they
have no their flat they have apathy and just   that lack of pleasure and anything they may feel
very sad empty and hopeless and energized bipolar   one now that big difference is bipolar one has at
At least one full-blown manic episode if there hasn’t   been one full-blown manic episode then we’re going
to look for bipolar 2 where you have hypomania and   major depressive disorder bipolar one can have
either major depressive disorder or persistent   depressive disorder so the big difference is if
there’s a manic episode there they’re number one   bipolar one patients experienced depressive
symptoms more than three times as frequently   as manic or hypomanic symptoms so yeah when they
hit a manic or hypomanic period it’s not a wonder   they feel pretty good and they don’t want it to
go away if they experienced it three times more   often bipolar 2 patients experience depressive
symptoms approximately hold your horses   39 that’s not a mistake 39 times more often than
hypomanic symptoms so people with bipolar 2 can   have 39 depressives before a manic episode now
unfortunately, the body is not that consistent   where we can go okay 38 39 you’re due for a manic
episode but we do know that both types of bipolar   depression are experienced a lot more frequently
than mania or hypomania so a common misdiagnosis is generalized anxiety disorder how do you
differentiate because some people when they get   anxious get revved up and they feel
like they’re wired and they can’t sleep the   goal-directed activity and generalized anxiety
the disorder is often related to an anxiety theme   like if they think that there’s a problem with
their finances or if they’re you know whatever   they’re worried about their activities and their
thoughts generally race in that direction they’re   not all over the place they’re pretty directed in
more or less and their mood is often irritable and   energetic versus elated now again just because
somebody is irritable doesn’t mean it’s the anxiety   we want to look specifically at what is causing
the sleep disruption and what are the themes of   the thoughts that the person is having the racing
thoughts because if you know something’s going bad   at work you hear there’s going to be layoffs
somebody can get anxious and go well if   I get laid off then I’m going to lose my job if
If I lose my job then I’m not going to be able to   pay the house payment and I’m dead a debt a debt
it and go in this rapid cycle of catastrophe and   get themselves all worked up and then not sleep
then they start trying to figure out okay what I need to do to make sure I can pay
the house payment what do I need to do to make   sure I can do this so anxiety disorder pretty
focused ADHD approximately 60 to 70 percent of   people with bipolar disorder also have ADHD and
20% of people with ADHD have bipolar disorder   so you can draw your own Venn diagram if you
want the take-home message is we don’t want to   assume that they’re mutually exclusive because if
you’ve got somebody with bipolar disorder you can   get that controlled but they’ve still got the ADHD
symptoms going on over here they’re going to feel   often feel frustrated now what’s the difference
people with ADHD often have a hyper focus that’s   one of the hallmarks this may happen on a deadline
pressure or when wrapped up in a compelling book   project or video game and so you can you can
see where there’s a trigger for it hyper focus may   cause a decreased need for sleep and look like
increased goal-directed activity   but is often short-lived in people with ADHD who
feel exhausted when the hyper-focus fades so we   want to look for number one was there something
that triggered this hyper-focus could be a video   game could be an awesome book or even
a Netflix marathon whatever it is and once   that hyper-focus faded did they feel exhausted
if so we’re probably looking more towards ADHD   than bipolar a manic episode is independent of
external circumstances you know it’s not where   somebody gets a project and it sends them into
In a manic episode, there’s a lot less control and   predictability in people with bipolar disorder
and people with bipolar often want to go to sleep   or relax but describe the feeling as if they can’t
wind down which can go on for a week or more so   we’re looking at duration we’re looking at what
triggers it if they report let’s go back to here   sometimes having manic episodes that there was
no trigger and they lasted a long time but they   also report manic goal-directed activity under
deadline pressure or you know they can have all   these symptoms which means you’re looking at ADHD
and mania or bipolar disorder together potentially   in ADHD people often interrupt or talk too much
without noticing because they miss social cues   or because they lose focus on the threads of
a conversation because their minds going six   ways till Sunday I had a friend of mine one time
who had ADHD she was in graduate school with me   and she gave a presentation on it one time and we
were talking and she was presenting and as she was   presenting somebody started flicking the lights on
and off and all of us were looking around at each   other going this is annoying and then a little
while later you know 30 seconds or a minute later   somebody turned on the radio not loud but
low in the background and we’re all looking at   each other and then she started doing something
else after that oh she turned on a fan so the fan   was oscillating and blowing in our faces and and
finally, she’s like is this annoying and we were   like yeah that’s annoying it’s hard
to concentrate and she said this is what life   is like for somebody with ADHD many times because
we have difficulty filtering out what’s important   to pay attention to and what’s not so we’re paying
attention to everything so that made it a lot more   understandable to me which was helpful later when
my son was diagnosed with ADHD because you know   it helped me tailor his learning environment
so people with ADHD kind of get lost and they’re paying attention so much that they
can miss the social cues people experiencing manic   bipolar episodes are often very aware that they’re
changing topics quickly and sometimes randomly but   they feel powerless to stop or understand they’re
quickly moving thoughts so they’re just trying   to keep you in the loop in everything and they
may notice that you’re getting uncomfortable or   irritated or impatient but they don’t feel like
they can stop racing thoughts you know all these   kind of go together but kind of not people with
ADHD report racing thoughts that they can grasp   and appreciate but can’t necessarily express
or record quickly enough think about the time you   got excited about something and you just
had all these ideas whenever we get a new grant   that comes in I’m in charge of or I used to be in
charge of writing the grant so I get the grant and   I’d read through and I start identifying all the
different things that we could do to you   know get this grant and it would be hard for me to
keep my pencil going fast enough to keep up with   my ideas and you know I don’t have an and you
know that was perfectly normal but I was excited   and so my mind was racing people with ADHD can do
this a lot you know not just because of a grant   coming in people with mania the racing thoughts
flash by like a flock of birds overtaking them   so fast that their color and type are impossible to
discern I loved this explanation because it’s just like you have this whole massive bird coming
in and then going out and you didn’t have a chance   to even notice what they were people with with
mania often feels that way they don’t can’t grab   any of those thoughts and hook on to them they’re
just in and out so helping people differentiate to make sure that if they’ve got anxiety and bipolar
if they’ve got anxiety and ADHD and bipolar bless   their hearts that were attending to all of their
presenting symptoms and issues so what do they do   to treat bipolar well we’re going to get down into
that in a minute sorry got ahead of myself things   that can trigger a bipolar episode medications
antidepressants as I said can propel a patient   into mania captopril which is an ACE inhibitor
something that’s used for high blood pressure can   also trigger a bipolar episode corticosteroids
certain immunosuppressant medications levodopa   which increases dopamine you may see patients
with schizophrenia or Parkinson’s taking web   dopa and methylphenidate or dexmethylphenidate
which are ADHD medications all of these different   categories of medications can potentially trigger
a bipolar so do they trigger it in every single   person no so that makes it even more difficult
but it is important to be aware if somebody has   bipolar when they start taking medications
that they need to be conscious and cognizant of   their symptoms so they can you know identify
early onset of a depressive or a manic episode   circadian rhythm desynchronization can trigger
or look like bipolar disorder hyperthyroidism can   look like a manic episode that means too much
thyroid you know a lot of times we talk about   hypothyroidism and depression hyperthyroidism
gets people to revved in children mania can be   misdiagnosed or look like oppositional defiant
disorder and substance use both intoxication and   withdrawal but more specifically intoxication can
also, look like mania or depression depending on   whether they’re taking stimulants or depressants
so it’s important to make sure that the person   when they’re being assessed is substance-free
Do you know what medications they’re on they’ve   had a physical to rule out any hormone causes
the thyroid is a hormone and looks at their circadian   rhythms if they happen to be visually impaired
that can cause problems in circadian rhythm if   they are shift workers that can cause problems
with circadian rhythm so let’s make sure we don’t   label something as bipolar and start treating
as such before we’ve ruled out everything else bipolar distinguishing factors and let’s see
let me see if I can get that open for me right   now well anyway spontaneous hypomania premorbid
affective temperament particularly hyper thymic   or cyclothymic so before somebody had an episode
that they presented with do they have a history   of remembering dysthymic is feeling blue
low unhappy hyper thymic is more elated and   cyclothymic is rapidly switching Moodle ability
increased mental or physical energy even during   depressions family you know you know
we talked about the mixed episode if there’s a   family history of bipolar disorder or a good
response to lithium for unipolar depression   or bipolar that’s a risk factor or a hallmark
that you might be dealing with bipolar in this   client if they have treatment-emergent hypomania
mania or mixed States so as soon as they start   medication treatment generally SSRIs they have
an uncharacteristically rapid response followed   by a crash again and or they have more than two
failures on antidepressants now we want to look at what that means because antidepressants work
differently for different people, somebody can be   on and I’m going to use the trade names here just
because I don’t have all of the generics memorized   I’m not promoting any particular trade name but
people could be on Lexapro or Paxil and feel like   they can’t wake up people can be on Prozac and
feel like they’ve got more energy some people are   on Zoloft and don’t feel any energy change some
people feel lousy but with antidepressants, we want   to look at what failure means did it fail to
improve the mood or were the side effects so bad   that the person had to switch if this if it was
the side effects that are not classified   as a failure because the person wasn’t able to
stay on it long enough for that antidepressant   to get in their system now I do want
you to see the mood disorders questionnaire, haha and that’s in this article here but there
are three all of these questions that you can   have people just complete at assessment and
it helps you identify if they’ve had a manic   or hypomanic episode so have there ever been
a period of time when you are not your usual   self and you felt so good or hyper that people
thought you are not the normal self you were so   irritable that you shouted at people or started
fights you felt much more self-confident than   usual you got less sleep than usual and found
you didn’t miss it you were much more   interested in sex than usual spending money got
you or your family in trouble you know you can   go through all the rest of the questions and they
identify yes or no to each of these once they do   that if they did check yes to more than one of the
above have they ever happened during the same period if yes then again we’re probably looking
at one of the bipolar and finally how much of a   problem did any of these cause for you and if it’s
a minor problem then we may want to look for other   things this does not diagnose bipolar but it is an
excellent screening instrument to give you an idea   about whether you need to look in that direction
have clients keep a life chart ideally for three   to six months where they chart their sleep their
dietary habits their exercise their life stressors   hormones for women and any bipolar symptoms that
they’re having now when I have clients chart this   much I create a really simple fill in the blank
a chart like for sleep number of hours did you   feel rested yes or no dietary habits I have them
keep on their mobile device for exercise did you   exercise yes or no if so how much for how long you
know really simple things so they can complete the   chart in under five minutes otherwise, they’re
not going to do it for the bipolar symptoms I   have check blocks you know did you feel depressed
did you have difficulty sleeping yada-yada so   it’s easy it’s very very simple for them to fill
out and it’s also simple for me to evaluate when   I go through it encourages people to understand
their bipolar because everybody’s presentation   is going to be a little bit different have them
identify you know their cognitive patterns and negative thinking patterns that contribute to
their depression and if so how do they handle   those in the past when they felt depressed how did
they change their thinking or what they do to   help themself be a little bit more optimistic and
also looking cognitively what if they got going   for them are they intelligent are they creative
are they you know build on those if somebody is   creative you know I’m not so I it’s wonderful
to see creative people but for somebody who’s creating one of the greatest things they can do
to work with their depression is art therapy you   know it’s very therapeutic for a lot of people
so find their strengths and use those to help   them resolve their current presenting symptoms
physically encourage them to get adequate sleep to avoid opiate and sedative medications alcohol and
any sort of over-the-counter herbs including Jen   Singh Sant Sami 5htp without talking to their
the doctor first encourages them to eat a good diet   they may already be doing some of this so how much
they change at one time it is gonna vary between   the person and what they’re motivated to change
remind them not to change too much at once let’s   just do one or two things right now and then you
can work on two more things once you have those   under underway situationally have them do
a coping skills inventory to figure out how they cope when things get stressful and have them
identify triggers for their bipolar that what   types of situations make you feel depressed what
types of situations have you noticed might seem   to trigger a manic episode some people when they
get stressed about something there’s that   anxiety it can the stress of that and having the
HPA axis activated can trigger a manic episode for   them so encourage them to you know in their chart
they’re going to be keeping track of what might be   contributing to triggering and mitigating bipolar
symptoms so if they’re getting good sleep and eating   a decent diet their life stressors are pretty
low and they’re not having any symptoms well we   know what they can do interpersonally have them
identify supportive friends to help them learn about   interpersonal behaviors that trigger them and ways
to deal with those interpersonal behaviors so if   when somebody tends to be in a manic episode or
even in a depressive episode if they tend to be   irritable think about having them look at what
behaviors trigger their irritability trigger   their anger and figure out a plan to deal with
it to minimize the impact that being on   one end of the spectrum or the other mood wise
might have on their relationships angers normal   irritability is normal don’t get me wrong but when
somebody is in a depressive episode or a manic   episode that irritability can be intensified
tenfold and people may be taken aback by it   environmentally encourage clients to look around
their environments and look at what they can do to   make their environment cheerful calm and safe you
know what that looks like for that particular   person those are things that they can do because
it’s you know when you felt calm and safe before   what was different or what was the same what helps
you feel cheerful we just recently had the inside   of the house repainted because it was time but
I’ve always felt more cheerful, especially during   the winter and when there’s less sunlight when I
have like a light yellow color on the walls like   straw not bright yellow and that helps me feel
a little bit more cheerful which is in contrast to   all the black that I put in there but whatever it
works for me and that’s how I feel comfortable in   my environment to encourage clients especially
you know when they’re feeling like they’re   heading toward a depressive or manic episode
to eliminate negativity from social media and television media you know if it stresses them out
to watch the news do they have to watch the news   you know what will happen if they go for a month
without watching the news and in their real-life environment encourage them to try to eliminate
as much negativity as possible and that can   be altering how they deal with interpersonal
relationships that can be looking around and   finding things that stress them out and addressing
there are a lot of different things but we   want to look at it as biopsychosocial II Romania
we still want to build on strengths and encourage   them to become aware of any medications they’re
taking and how those medications affect them this   can include stimulants thyroid medications, Sammy
and 5htp encourage them to avoid stimulants when   possible and don’t combine them with caffeine
if they put ephedra for example in combination   with caffeine that used to be a common
combination in pre-workout supplements that can get somebody revved up and so we want
to make sure that they’re aware of the effect   not only on their body but the likelihood
that could also trigger a mood episode have them identify warning signs and
interventions sometimes like I said   that for people with bipolar disorder the
depression and/or manic episode may seem   like it comes out of the blue and sometimes
it may but 99% of the time when I’ve traced it   back with clients they weren’t taking good
care of themselves they were either taking   on too much at work or they weren’t getting
enough sleep or they weren’t eating well or   you know there had been something that had
changed from when they were doing well and   they felt good too when they started feeling
like they were heading down towards an episode some patients may try to identify triggers for
manic episodes to increase those we   want to encourage them not to do that because
that’s like driving your car with the RPMs up   at five indefinitely that’s not good for your
the car eventually something Bad’s gonna happen   so we don’t want them to read themselves up that
much we need to help them find that happy medium   where they’re content there are three or four
on a scale of 1 to 5 and they’re feeling good   for some clients when they start feeling depressed
they notice thinking changes and have difficulty   concentrating this is a warning sign you know they
may not feel completely depressed yet but they may   be waking up in the morning going yeah not so sure
I want to get out of it they may have low energy   changes in sleeping or eating irritability
sadness negativity resentment withdrawal and   environmentally they may notice that they’re in
the area becomes more disorganized or they may just   not be caring as much about personal hygiene as these
are all things that they can identify early on and   say huh you know it looks like maybe I need to
take a little bit better care of myself and it’s   hard for clients it’s hard for a lot of us to
listen to our body and go okay I wanted   to do XYZ but my body is telling me that maybe I
need to rest for mania warning signs can include   racing thoughts heightened creativity that’s
one that for people to be aware of especially   if you’re dealing with somebody who’s naturally
creative they may thrive during this period of   heightened creativity and get upset when
you start suggesting that they may need to temper   that to stabilize their mood they’re
gonna have to cut the top off the highs and raise   the bottom on the lows physically they may have
difficulty sleeping or sitting still maybe may   feel elated excited irritable or thrill-seeking
you may have some anger outbursts frustration   with others and environmentally what I’ve seen
with patients especially with full-blown mania, it varies on what they do sometimes they are
cleaning like crazy and other times it looks like   a whirlwind absolutely hit the room but so it’s
usually extreme so treatment compliance we want   to encourage clients to do a decisional balance
back exercise and I broke it down so it’s shorter   what are the benefits of eliminating depressive
episodes if the person was no longer depressed how   would they feel emotionally mentally physically
and how would it impact their family and friends   a lot of times that this one’s easy to fill out
the drawbacks to eliminating depression are this can   be harder to fill out because they’re like well
I’ll see any drawbacks okay we can leave that   for now sometimes patients come to the awareness
that if they’re no longer depressed they may not   get as much attention and people may expect more
of them which is anxiety provoking but this   area usually doesn’t have a whole bunch of stuff
in it and then we want to ask them what are the   benefits of eliminating the mania emotionally
mentally physically and socially this one’s a   little harder not as hard as the drawbacks to
eliminating depression a lot of times clients   can see the benefits of eliminating the manic
episodes because they don’t have the periods I   mean they have the highs and those are awesome
but they don’t have the periods where they have   the lows and they don’t feel like they can do as
much they don’t have the loss of time they don’t   kind of come out of it and realize that they’re
completely overwhelmed because when they were in   the manic episode they took on 17 things so there
are a lot of things that clients may identify as   benefits to eliminating the mania but we also
want to talk about the drawbacks to eliminating   it because like I said for some people that’s
when they’re their most creative and if they’re   a writer or an artist or a musician this may be
the time when they are feeling like they’re uber   selves so they don’t want to get rid of it and
it’s terrifying to them to think that they might   not be able to tap into what we can talk about
ways to tap into their creativity when they’re   not manic and you know there are techniques that
they can use it to get that focus that they   so desire but it depends on the person exactly
what you’re going to use if we don’t address   all of these concerns about eliminating their
mania treatment compliance is going to be lower   because people will just they’ll miss it they’ll
miss it a lot and they’ll want to feel that high again so general techniques in clot ask
clients how do you deal with it up until now when   you felt depressed what have you done this helped
you feel better even for 10 minutes or an hour or   half a day you know maybe it didn’t work the whole
time but or it helped you feel instead of feeling   just devastated you felt sad you know it helps
you feel a little bit less intensely depressed   build on that ask them what they’re willing to do
some clients are gonna look at you and go no I’m   not gonna do that keep your
journal no not gonna do that okay so what are you   willing to do I tell my clients a lot of times I’m
gonna suggest things that you may not think fit   for you or work for you or you’re not going to do
well I’d rather you tell me number one that you’re   not going to do it and what I’m more
concerned about is what you’re gonna do instead if   you don’t want to keep the journal okay how are
we going to be able to notice changes and find   connections between your eating your sleeping your
stress levels and your mood episodes you know   help me let’s figure out a way that we can we can
do this and they may come up with something you   know I state what it is that I want to
do or accomplish and why it’s important and I   say is there another way we can accomplish this
when I work with clients and recovery sometimes   they don’t want to go to 12-step meetings okay
if you’re not going to go then what are you gonna   do instead because you need to have some social
support you need to have something to do besides sitting alone in your apartment from the time you get
off work until the time you go to work the next   day because that’s a dangerous period encourage
clients emotionally to practice mindfulness   because it does prevent episodes from sneaking up
if they start feeling run down or tired or off you   know sometimes I hear that word I just feel off
okay that’s when you need to stop and check in   with yourself and go what’s going on how do I feel
what do I need and mindfulness also encourages   behaviors that prevent vulnerabilities when people
check in with themselves they may say you know   what I’m really tired today I need to rest and
that’s a good thing because it keeps them from   becoming vulnerable and potentially triggering
an episode of stress reduction encourages clients   to identify and eliminate or mitigate stressors
so what stressors do you have and they can write   them down on the list they can a lot of times if
I’m doing an individual I’ll have somebody write   down on our big whiteboard all of their stressors
and then we go through on one by one and say okay   can this one be eliminated if so how and the
the client will start making a plan for how they’re   going to start eliminating stressors if there’s a
a stressor that can’t be eliminated maybe they don’t   get along with their in-laws and periodically
the in-laws come to visit or whatever okay well   you can’t eliminate that so how are you going
to mitigate that stressor before your in-laws   come what can you do or may it be less stressful
if you go to their house instead of them coming   to yours so we talk about different things we talk
about time management because in those manic and   hypomanic episodes people can take on too much and
then they feel a little overwhelmed when they’re   steady-state and they feel overwhelmed
if they’re in a depressive episode I do want to   point out and I think most of us know this person
don’t usually cycle from a manic to a depressive   to a manic like that they can have a depressive
episode and then be asymptomatic for anything for   months and then have another depressive episode
or a manic episode so it’s important to recognize   that most people who are bipolar don’t rapidly
cycle and there are periods of remission or symptomatology in between cognitive processing
therapy can also help people mitigate stressors   when they start feeling overwhelmed encouraging
them to identify what thoughts they’re having   that are contributing to them feeling stressed
or overwhelmed and then looking for the facts   for and against that thought if they’re feeling
like they’ve got too much to do what are the   facts for it what are the facts against it if
they do have too much to do then they need to   figure out how to address it but this helps keep
people from getting stuck in emotional reasoning   where every time they feel stressed or they feel
depressed or they feel anxious they think there’s   something to be dysphoric about encourage people
to identify their anger management triggers they   differ for everyone they need to develop a plan
for de-escalation and begin addressing their anger   triggers to maintain control of their energy
they need to identify if driving in heavy traffic   stresses you out and makes you irritable and angry
well ok how can you address those triggers maybe   driving a different way or maybe putting on your
favorite music loud in the car or whatever   it is that you can do to mitigate that anger anger
takes a lot of energy everybody everybody’s energy   is precious but people with bipolar disorder
stress and excess energy drain can potentially   trigger an episode so we want to help them
conserve their energy so yeah they’re gonna   get angry about some stuff but help them identify
what’s worth getting angry about and using their   anger energy for and how to deal with the
rest of it so they have more energy to enjoy the life   we’ve been talking about the negatives but let’s
look at the positive they need to infuse happiness   have them make a list of what makes them happy and
do more of it or be around it more encourage them   to schedule a belly laugh every day and there are
Reddit forums there are YouTube videos there are   places they can go to get a good old belly laugh
but it helps release endorphins and release some   of the calming neurotransmitters that have them keep
a good things silver lining or gratitude journal   and it doesn’t have to be prose you can have them
identify at the end of the day three things three   good things that happen that day or three things
they’re grateful for or when things go bad they   say I got demoted at my job today alright well
what’s the silver lining to that you didn’t get   fired and maybe have less responsibility now I
don’t know but there are different ways you can   approach it but encouraging people to be cognizant
and try to embrace the dialectics there’s going to   be bad in life but help them focus on the good to
reduce dysphoria mentally address cognitive errors   all Arnon thinking focusing on only the positive
or negative using feelings as facts and focusing   only on a small piece when something happens maybe
you turned in a group project and your boss sent   it back and said uh no try again some people will
take it very personally and focus only on the fact   that the boss sent it back with feedback instead
okay it wasn’t just me participating in this   project so you know all of us need to contribute
to it again and you know yes it was given back to   us but we get a second opportunity so it’s looking
at a bigger piece of the puzzle encourage clients   to develop their self-esteem and view failures
as lessons applaud courage and creativity   and nurture their inner child I have an inner
the child my inner child comes out a lot more than   some people would like to admit or really
like to see but that’s okay you know on Saturday   morning it is not uncommon for me to be watching
cartoons in the living room my kids are teenagers   I can’t say I’m watching it with them anymore I
like Yogi Bear I’m sorry I’m weird that way but   you know sometimes at the end of a long week of
being serious and everything I just kind of need   to regress for you know half an hour two hours no
encourage people to nurture their inner child and   don’t be afraid to be silly don’t be afraid to
laugh or do something goofy physically increase   clients to exercise class to increase exercise
it increases serotonin levels reduces stress   helps balance hormones and neurochemicals and
may combat some medication side effects exercise   is anything that moves the body gardening cleaning
going to the gym of course walking the dog playing   soccer with the kid anything like that so what
is it that they like to do or at least they’re   willing to do nutrition provides the building
blocks for the neurochemicals so people need   to have quality proteins and a nutritionist
A friend of mine suggested always try to have   three colors on your plate at every meal and use
a salad plate that is smaller instead of a dinner   plate because it tricks your brain into thinking
that you’re getting more food as Americans we tend   to eat way more than we need and try
to avoid mindless or comfort eating when people   start comfort eating a lot of times they’re not
being mindful they’re eating to deal with stress   instead of acknowledging the stress and dealing
with it so yeah they’re infusing themselves with   carbohydrates and fats and getting the serotonin
and dopamine flowing but when all that goes away   whatever was causing the stress is probably
still there so they’re either gonna have to   stress eat again or deal with it so encouraging
people to be mindful of their eating sleep   helps the body repair and rebalance and sleep
deprivation is known to trigger both manic and   depressive episodes too much sleep or sleeping
at the wrong times can also mess up circadian   rhythms so keeping naps to a minimum of 45 minutes
one time a day, if the person has to take a nap, is   important so they don’t get into that deep
sleep and preferably try to avoid naps for most of a 15-minute power nap where you’re
closing your eyes and you don’t ever completely   drift off has been shown to increase focus in
the afternoon but naps where you’re laying down   and getting under the covers tend to mess
up circadian rhythms, if people are on medication   for their bipolar which they probably will be
have them work with their doctor to adjust the   dosages and dosage times to fit their schedule so
if they have a medication that makes them feel sleepy maybe they take it right before
dinner so it’s worn off completely by the time   they get up in the morning and it’ll be up to the
person to work with their doctor I had one client   who took Seroquel and she ended up having to take
it at 2:00 in the afternoon for it to be   out of her system enough where she felt alert
when she woke up at 6 o’clock the next morning   so it’s gonna differ for different clients again
encourage them to discuss any negative medication   side effects with their doctor and not to expect
a pill to do everything you know the pill can help   stabilize the moods but if you’re taking this pill
but then you’re still you know pulling the rug out   from under it by not sleeping and using cocaine or
or whatever it’s likely the pill is just not going   to be able to do it all interpersonally support
groups are really helpful to chat rooms if the person   is either in a rural area working shift work can’t
get to an appropriate support group not all   communities have support groups that are embracing
of all different types of people so it’s important   to recognize that even though there may be a support
group the person that you’re working with may not   feel comfortable with the people that are in that
the particular group so chat rooms can be helpful in   the know family and friends and I say in the know
these are people who have to understand or have to   know that the person has bipolar disorder and be
aware of their warning signs trigger their   symptoms which helps so they can be supportive
and facilitative environmental clients can   explore things that improve their environment
different pictures a temperature can also be   a big thing if you’re too cold or too hot it can
make people irritable certain essential oils can   help increase energy such as peppermint rosemary
or lemon calming essential oils if somebody tends   to have some anxiety going on lavender chamomile
valerian Valerians kind of they say woody some   people think it stinks to high heaven some people
love it catnip is the same way yes stuff you use   for your cats you can get it in essential oil
and it’s a sedative type essential oil   for humans bergamot it’s a pretty mild smell
rose is helpful rose geranium is a little bit   less expensive and frankincense is all supposed
to help with calming so he’s hypomanic having   difficulty winding down anxious whatever some of
these may help memory triggering include ginger   cloves cinnamon orange and jasmine which works for
one person is not necessarily going to work for   another I mean there are studies out there that
show certain essential oils have effectiveness at   anxiety reduction and depression improvement but
it’s going to be up to that person and I   found that when a person smells something if it
smells noxious to them then it’s probably not   something that they need if they smell valerian
and they’re like oh my gosh that stinks okay   that’s not triggering what their brain needs their
the brain knows what it needs I do the same thing with   my rescue animals you know I let them take a
a good whiff of it and if they like it they’ll   stick around and they’ll sniff it some more if
it’s not what they need then they’ll go somewhere   else I tried fur for our donkeys when we first
got them into rescue I tried lavender because I   thought you know that’ll help them calm down they
hated it they liked valerian so I learned that for   them they preferred that particular
essential oil for whatever way it works in the   brain and encourage clients to visit a store that
sells essential oils because they have testers and   they can sniff them to see which ones work for
they and essential oils also smell different   from different manufacturers so it’s important
again for them to figure out places that they can   get their essential oils and try to stick with
the same company once they find one that works organization can help another thing that’s
important for people with Bipolar is to   manage impulse items when they go into a manic or
hypomanic episode especially and they’re prone to   engage in risk-taking behavior or less restrained
behavior car keys need to be somewhere where maybe   they can’t access them if they’re known to go out
and drag race or you know drive 100 miles an hour   just to see how it feels credit cards that’s a
big one credit cards need to be somewhere some   of my clients will freeze their credit cards in
a block of ice so they can’t get to them and they   can’t see the numbers to read them and
put them in on the phone this can help prevent unrestrained spending, especially at 2:00 a.m.
or something when the infomercials are on porn   sites if the client happens to have an attraction
to porn sites having those blocked because it’s   really easy to get sucked into that same thing
with video games and alcohol and other drugs   alcohol a lot of people have in their house so
if this is a dangerous impulse item for somebody make sure they have it locked up somewhere so if
they do and have a hypomanic or manic episode they   can’t drink the same thing with certain medications
especially the benzos and the opiates if you can   keep it locked up somewhere all the better and
during the day keep it light and bright try not   to be in an office where it’s dark
some people can’t help it I mean if you’re a nurse   and you’re working in the neonatal intensive
care unit it’s going to be dark most of the   time and there’s nothing you can do about that
but if you can help it keep the lights on if you   don’t like fluorescent lights get lots of stand up
lights that you can put around to keep it bright   so your brain knows that it’s time to be awake
co-occurring disorders depression can co-occur   with bipolar I mean you can have part
of bipolar is depression so when somebody is in depressive episode suicidality high-risk and
addictive behaviors and self-medication we want   to shout for it just like we would for unipolar
depression with mania we want to help the person   become aware and look out for explosive anger
which can get them into legal trouble relationship   issues etc heightened libido which also can get
them into legal trouble and relationship issues   etc and any other risk-taking that they do because
when they’re in a manic episode is like they’re   this is a bad idea filter is completely turned off
or it’s switched on the other way and as the let’s   try this filter so helping them understand that
when they’re in that manic state it’s important to   have safeguards so that when they come out of it they
haven’t done something that they’re going to end   up regretting or have to undo so bipolar is caused
by neurochemical imbalances especially among   serotonin dopamine and norepinephrine the symptoms
and presentation varies widely depending on the   person it’s more important to address each symptom
then to address bipolar as a whole you know we   want to look at what symptoms this person
presenting with and how can we help them manage   those the medication provider is going to be
managing kind of the bipolar as a whole and trying   to stabilize the mood but we want to help them
start addressing their symptoms so they   can feel as healthy happy healthy and productive as
possible help them address each symptom identify   warning signs and eliminate or mitigate
triggers and vulnerabilities remember that   treatment compliance is a huge issue because the mood
stabilizers tend to flatten those highs and people   miss the most dangerous times for suicidal
ideation and people with bipolar disorder are   when they’re coming out of a depressive episode
or and I didn’t mention this before or during a   mixed episode remember mixed they can be depressed
and have high energy both at the same time ensure   people with bipolar disorder have a crisis plan
and people who interact with them daily who are   aware of their warning signs and symptoms because
sometimes they’re not being mindful and most of   us are guilty of not being mindful all the time
sometimes these symptoms can creep up so if they   have people they interact with daily
who are in the know and can say you know John   it seems like you’re starting to destabilize a
little bit then John can take a look at it people   with co-occurring addictions also need to be aware
that a bipolar episode can trigger an addiction   relapse and vice versa so they need to be aware
and have an extra-special relapse addiction   relapse prevention plan for when their mood
symptoms arise if you haven’t already signed up   please remember that addiction and mental health
counseling and Social Work continuing education   credits are available for this presentation and
are accepted in most US states Canadian provinces   Great Britain Australia and South Africa go to all
CEUs com counselor toolbox and click on the link counselor toolbox CEU spreadsheet to easily
locate the course based on this presentation okay are there any questions now remember we’re not having class
tomorrow but we’re having class on   Thursday and that is just chock-full of
stuff that I’ve never actually presented   before so there is no repeat possible there
oh and then next Tuesday we’re going to be   talking about enhancing social justice
and why that’s important for recovery you

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