Healthcare Training Institute - Quality Education since 1979
Psychologist, Social Worker, Counselor, & MFT!!

Section 15
An Integrated Treatment Approach for Clients with Bipolar Disorder

Question 15 found at the bottom of this page
Answer Booklet | Table of Contents
Get PRINTABLE format of this page

It is clear that the problems posed by those with MD are multi-factorial and span biological, environmental, social and psychological aspects. A vulnerability model would facilitate the adoption of an overall framework with which to view the treatment of MD. The encouraging results demonstrated by various psychosocial interventions, applied to specific problem areas in MD, offer the opportunity to optimize their strengths by pulling them together into an integrated treatment approach and operated through a service designed to address the multi-faceted needs of the individual with MD. Informed by psychosocial developments in schizophrenia and the findings from psychosocial work undertaken in MD, the integrated treatment model we developed was influenced by the work of McGorry, who outlined a number of key principles in the concept of recovery and secondary prevention in psychotic disorders (McGorry, 1992). Although there are many differences in the needs of these two distinct patient groups, some of the principles applied to recovery in non-affective psychotic disorders can equally and usefully be applied to MD. Those selected are outlined below. First, the role of the patient should be active. Patients have a number of possible roles that range from passive compliance to active collaborator (Strauss et al., 1987). The importance of involving the patient as an active collaborator is essential if they are to develop a sense of responsibility and establish some control over the disorder. Indeed Strauss et al. (1987) notes that of prime concern is the interaction between patient and the disorder over time. Second is the importance of establishing a therapeutic relationship whose continuity is assured. This is essential to enable the person to cope with and survive the experience of the disorder and its sequelae. Finally, a positive focus on the strengths, attributes and coping skills that people possess should be encouraged.

Key Elements
1. Engagement and psycho-education.A rationale for the integrated treatment approach includes an introduction to the stress--vulnerability model, such as that proposed by Greenberg & Padesky (1995). This would enable the client to consider the biological as well as psychological aspects of the condition and provide the intellectual basis upon which ‘control’ can be fostered. Psycho-education about the disorder should be provided to the client and their family. It should encompass all aspects of the condition and may be offered in a group or on an individual basis. Psycho-education must emphasize the role of responsibility and strive to empower the client to initiate self management and access to services.

2. A focus on relapse prevention. Included in the psycho-education program should be the identification of ‘early signs’ of relapse. Precise information about the nature, duration and timing of an individual’s prodrome or ‘relapse signature’ can be obtained through careful interviewing of the client and, if possible, other close associates. This can be facilitated by the use of prompt symptoms such as those documented by Birchwood et al. (1989) and Smith & Tarrier (1992). We have adopted a ‘card sort’ procedure in which the client chooses, from those listed, the experiences which conform most closely to their prodromes. This also provides the first opportunity to discuss with the client the relationship between changes in thinking, feeling and behavior and their prevailing mood. This process enhances the client’s awareness of their ability to gain control over this vital period of prodromal change.Regular contact through systematic monitoring of those at ‘high risk’ is used to correlate such changes with ongoing events/activities undertaken, and any necessary adjustment or changes to lifestyle can be implemented to develop a more stable and balanced mood. Procedures for responding to I early signs’ are rehearsed in the context of a ‘relapse drill’, and contact protocols with professionals are worked out in advance to ensure a prompt response optimised for any potential relapse. Strategies to deal with ‘early signs’ are recorded on prompt sheets to facilitate the self-management philosophy and copies are distributed to other professionals to ensure a consistent approach is adhered to.

Identification of those factors/events known to trigger a relapse are identified and the relationship between these and the changing mood state are used to inform the client about the role of stress in manic depression. Consideration of existing stress management strategies can then be enhanced by helping the client develop a thorough knowledge and understanding of, for example, relaxation, stimulation control, problem solving, activity scheduling and time management techniques so that mastery over worrying changes in arousal can be dealt with appropriately. Problem-solving skills are used to deal with ongoing life events, offering further opportunity to explore clients’ coping repertoire and to enhance and develop any additional coping strategies. Using examples from previous life events or situations that have led to a manic episode provides the opportunity to discuss the relationship between increased stimulation and heightened arousal, thus facilitating a discussion of the role of ‘risky behaviors’.

3.  Cognitive therapy and personal vulnerability. The cognitive focus provides the client with an understanding of the role of cognitions, in particular how they mediate appraisal of threat and offers the opportunity to address these in relation to changes in behavior and emotion. Throughout, the client is be encouraged to understand the connection between their thoughts, mood state and subsequent behavior. Using the ‘Socratic method’ enables the client to challenge his cognitions and utilize the appropriate mood desired thought, extending the repertoire of coping and encouraging a more active role in the management of the condition. ‘Thought chaining’ is used to identify those cognitions that are associated with perceived threat, for example, becoming unwell. In addition the client should be encouraged to explore other situations where a change in cognitions has led to a change in mood. This can then form the basis upon which ‘mood induction’ techniques can be introduced and discussed. It is important to discuss these in the light of both polarities, so that clients understand the relevance of each procedure used. The utilization of ‘mood associated cognitions can then, together with other ‘mood induction’ techniques, be incorporated into the client’s self-management repertoire.

4.  Group support and solidarity. Support offered in the context of a group promotes a shared understanding of experiences in an accepting and non-threatening setting. Properly led, it is a forum where clients can develop or rebuild lost confidence and self-esteem, accomplished by encouraging members to take an active role in the organisation of the group and its activities. Such a group provides the means by which self-management strategies can be reinforced and new ones developed. The structure of the group lends itself to group presentations, for example, from within the service or from invited outside speakers in those areas where information or advice is required, e.g. benefits, pharmacotherapy, etc., or where new areas of interest may be inspired, e.g. music, computing, etc. The group provides a readily available network of contacts to members who can, if they wish, use in times of crisis. Furthermore, the availability of social activities for those who have become isolated fosters self-worth and encourages contact with others.

Service implications
Implementing such an integrated treatment approach for manic depression poses a major challenge to both professionals and to mental health services as a whole. The very nature of the intervention depends on a close working alliance between professionals and their clients. It demands the harnessing of multi-disciplinary skills, and that professional groups and service users be incorporated into the treatment model. Collaboration is therefore paramount in the development of the treatment rationale and requires that a shared understanding is a prerequisite. Rigid roles and practice will therefore need to be more flexible if the approach is adopted. Developments in future training programs must address these issues if the philosophy of self-management is to succeed. We firmly believe that a unimodal treatment response, e.g. pharmacotherapy or cognitive therapy, will alone, be insufficient to properly engage clients and provide the necessary potency to achieve genuine change across a range of outcomes. Experience with unimodal intervention in schizophrenia -- for example, family intervention -- is that they are difficult to implement without a change in the value base of the organization. Implementing our treatment model faces the same challenge and is why we have adopted a service wide approach to training, dissemination and fidelity to treatment protocols.
- George, Sandra; Towards an Integrated Treatment Approach for Manic Depression; Journal of  Mental Health; Apr98, Vol. 7 Issue 2, p145.

=================================
Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about an integrated treatment approach for people with bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
According to George, what are the four key elements in an integrated treatment approach for people with bipolar disorder? Record the letter of the correct answer the Answer Booklet.