It’s fair to say that when I first sought treatment for my most recent bipolar episode back in May 2011, I wanted my psychiatrist to fix me. I’d heard so much about how “treatable” bipolar was, I was sure that if I was started on the correct drug I’d be sorted out and back at work within a few weeks. In my mind, nothing I did was responsible for my relapse; it had struck out of the blue after years of wellness. Perhaps, I thought, after so long in remission I had just run out of time.
As weeks stretched into months and I did battle with medication side effects as well as my original symptoms, I had to concede that it really wasn’t that simple. Even if my actions hadn’t precipitated my relapse, something I was doing had contributed to the severity of the relapse and was somehow sustaining the episode. And so I got hold of some self-help books for bipolar (Living with Bipolar Disorder: a guide for individuals and families by Michael W Otto, Noreen A Reilly-Harrington, Robert O Knauz, Aude Henin, Jane N Kogan and Gary S Sachs; and Overcoming Mood Swings by Jan Scott). I didn’t much like what I read; the exercises they suggested for monitoring moods, identifying methods of self care and managing symptoms seemed like hard work. Even when I underwent eight weeks of CBT, I resented the idea of having to manage myself. Why should I? Other people could do what they wanted! Why did I have to put in so much effort all the time just to feel OK?
It took me over a year and half of being unwell to admit this simple (but rather unpalatable) truth:
I don’t have to implement self-management strategies or a recovery plan if I don’t want to. But drugs can only do so much. If I don’t work on managing my moods myself, I am going to stay sicker, for longer. My choice.
And so I got serious about self-management. Having heard very good things about WRAPs (Wellness and Recovery Action Plans) I went onto WRAP founder Mary Ellen Copeland’s website and paid $10 USD to begin my plan. In some areas of the UK – and Scotland seems particularly good for this – you can access a WRAP facilitator who will guide you through the process in person; for those without access to a facilitator, the website makes a really good attempt at guiding you by offering suggestions, prompts and examples. The WRAP is part recovery plan, and part advance directive (an AD is a statement of what you would and would not wish to happen to you if you become too unwell to state your preferences). When you have completed the plan, you can email it to whomever you choose – clinicians, carers, relatives, friends.
The first thing that struck me was that a WRAP was going to be the exact opposite of a quick fix. It was going to take time, because it was so thorough. WRAP planning blew me away right at the start by getting me to list what I am like when am well. Here I was, right in the middle of a huge bipolar episode, and someone was less interested in my symptoms than how I really was as a person! As soon as I thought about the application of this to mental health treatment, I realised how vital it was. When faced with a psychiatrist, CPN or social worker you have never met before, the last thing you need is them mistaking your natural introversion for social withdrawal or labelling your habitual joking and punning as evidence of mania.
Next, the plan asks you to establish what your triggers might be. This is where I really began to look back over every episode I have ever had, right back to childhood. It was pretty easy to establish that stress has always been a trigger, and that working long hours is itself both a trigger and an indication that I am working too hard. For me, good sleep, as for many people with bipolar, is essential – both new motherhood and shift work have been disastrous for me in the past.
After identifying triggers, the plan then moves on to warning signals; how would you know when to be on guard for deterioration in your mental health? What would be your response? How would you discern when things were really breaking down? Again, how would you react? This, for me, is the heart of the self-management plan. What follows – signs of a crisis, what to do in a crisis, which clinicians you want involved in your care, which drugs and non-pharma treatments you have found both helpful and unhelpful in the past – is really AD territory. Where the work takes place for me as an individual is in the zone between perfectly well and crisis time, with the aim being to use my plan to prevent things from escalating to crisis point.
Because my experience of bipolar has so many facets, I have developed the plan to note signs of any of the many mood states I might experience: depression; panicky/anxious hypomania; elated hypomania; irritable hypomania; dysphoric mania. As a result, my full WRAP runs to 19 A4 pages. All of it is important, and that’s why my partner has a copy and another is attached to my Mental Health Trust electronic records. For use on a practical day to day level, however, I have distilled it down to how to deal with what is most likely happen to me – the appearance of hypomania in one of its forms, with a potential escalation to mania.
I’ve ended up with a four-step process. I tried to make an electronic version of my day-to-day plan but getting a table into WordPress proved beyond my abilities, so you’ll have to rely on the photo and text below. You’ll see that my plan consists of four steps graded from green to red, moving from the minute I wonder if I might be hypomanic, through to crisis time. My aim these days is to keep things between green and yellow, and last month I was able to make that happen for the first time, the proof positive that my plan can work.
I really should say that I believe I had to get towards stability with the help of meds before I was in any shape to implement my self-management plan. The plan has both come into its own as I have begun to get slowly well. I have moved from expecting my psychiatrist to fix things with a magic drug, to struggling to manage myself alongside my drug regimen and consultant care, to managing whatever fluctuations are left by myself with little medical input. In fact, having an operational self-management plan is probably the greatest factor in my Consultant’s suggestion that if all remains well by May, we should look at discharge planning.
So here it is. I would welcome feedback (I can’t have thought of everything!) and you are welcome to use anything you see that might be helpful for managing your own bipolar in the community.
1) GREEN: am I getting high?
(Indicators are detailed in the full WRAP include feeling very energetic and optimistic; wanting to exercise more, increased libido; noticing that I am talking more, and faster and louder; having loads of ideas for writing; dressing in brighter coloured clothes, wearing more make up and jewelry)
My response in this case is to increase vigilance
– Note concerning thoughts/feelings/behaviours
– Document amount of sleep
– As partner and friends if they’ve notices anything concerning
2) YELLOW: beginning to get high
(Indicators include making lots of plans to socialise; reduced amount of sleep but not feeling tired; excessively “goal directed” e.g. not wanting to stop writing, exercising, talking; becoming increasingly easy to irritate; beginning to lose perspective so partner and/or friends have to point aspects of my behaviour our to me; beginning to have a feeling of being “pushed” or “driven” from within and not being able to stop/relax even if I want to.)
Response in this case is to implement self-help measures.
What I have come to understand is that all my forms of hypomania are sustained by emotional arousal, so I tackle the hypo by reducing emotional arousal or any sort, whether fear/anxiety, excitement, happiness or irritation.
– Do ONE thing at time (i.e. do not watch TV and tweet,
do not cook and write a blog post)
– Avoid rushing around
– Cancel all unnecessary journeys or events
– Scale back on socialising
– Avoid caffeine or alcohol
– Avoid fast, repetitive music or exercise
– Listen to music without lyrics, beat or melody, e.g. “spa music” or nature sounds
– Do more yoga/meditation
– Use aromatherapy baths to aid sleep
– Tweet and write less
– Eat 3x healthy meals a day even if not hungry
– Read calming books (no thrillers!)
3) AMBER: Definitely high (significant number of indictors under yellow continue to be present for at least 4 days along with disrupted sleep and really beginning to feel out of control)
Response is to step up self-help measures and augment this with PRN (as and when) medications
– Seek emotional help from partner and friends
– Cancel any activity not 100% necessary
– Ask for help with practical tasks e.g. cooking, collecting the children
– Use additional quetiapine 25/50mg or diazepam 10mg to reduce agitation and aid sleep
– Get a professional massage
– Contact consultant’s secretary to bring appointment forward
– Spend time in dark, quiet bedroom
4) RED: Manic and/or suicidal
Response is to involve healthcare team
– Contact GP as emergency case
– Ring/present to Duty Team at CMHT
– Call partner home if he is at work
– Ask partner to remove any means of potential harm (e.g. drugs, knives)
– Implement rota of friends for 24/7 company/monitoring
– Ask a friend or relative to take the children so they don’t see me very ill.