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.It is sometimes helpful during hypomanic and depressed episodes to remind patientscognitively what normal is like, compared with current manic or depressed thoughtsand behavior.This can sometimes be accomplished by reviewing past logs, charts, andquestionnaires with the patient.With patients who are not agitated or angry, visits andreports from trusted friends or religious leaders or teachers sometimes helps the person toreconstitute and more willingly accept treatment requirements such as constant Treating bipolar disorders 133supervision or hospitalization.The therapist focuses on making a realistic plan thataddresses the severity level and immediate needs of the patient and family.If medicationsare not working and the illness escalates, focused psychotherapy methods will not behelpful.Patients in the midst of a severe depression or mania often need in-patienthospitalization.Additionally, severe depression or mania may spiral into psychosis.During psychotic periods, psychotherapy provides concrete support and casemanagementservices to the patient and family.However, between episodes, this module may also beused for addressing personal, family, and developmental issues that are not specificallyrelated to illness.Cognitive restructuring and clarification module An important part of psychotherapyis helping people to understand and know how to cope positively with their symptoms,medication side-effects, and routine problems.It can be extremely helpful, as an example,for patients to be able to identify the difference between their natural highs and lowsfrom the behaviors and moods that signal the onset of depression and mania.Furthermore, cognitive restructuring allows patients to reframe their strengths intomeaningful and useful structures and schemata.Behavior awareness, reinforcement, and modification module Standard rewardsystems can shape behaviors that increase the patient s social skills and decrease actionsthat limit their successes and quality of life.While positive reinforcement takes longer tochange behaviors, the change will outlast changes achieved by punishment.Familiessometimes find this difficult to put into practice, but with guidance they most often meetwith success.Personal insight and understanding module When symptoms are in remission,patients have the opportunity to explore themselves as unique individuals.Many arelooking for help and guidance for exploring question such as Who am I , Why do I actthis way , or How do my personality, temperament, past experiences, and learningsupport interact with both my strengths and symptoms? This can be hazardous if clientsare allowed to develop false logic or incorrectly link past developmental and socialevents for explaining their illness.The focus needs to be firmly anchored in the present.Existential psychotherapy module Patients and families need to understand that withbipolar disorder a person may have more limited life choices, but nonetheless they oftendo have choices.As an example, one cannot make a choice to stop being depressed, andeven the choice to enter or remain out of the hospital may have disappeared.In situationsof this type, the therapist s job is to help the patient discover the choices that remainwithin the restricted circumstances.It is important to keep in mind, however, that bothdepression and mania can rob a person even of the choice of attitude.This is whysometimes decisions must be made for the patient.While it is important not to promotehelplessness, it is nonetheless also crucial for people with an illness to accept and livewithin their limitations.Furthermore, it is sometimes therapeutic for patients for a shortperiod of time to stop trying to fight their way out of depression.Existentially, patientsmay make progress by accepting that they do have depressive episodes, exploring theboundaries of the illness, and learning to live more productively within the boundaries.That is, the patient does not have a choice not to become depressed, but, with help, somepatients can find positive choices within the walls of their illness.Additionally, duringperiods of symptom remission, clients can work on learning to accept having bipolarillness, and explore the question, Why me? Perhaps, however, the most important Atlas of bipolar disorders 134purpose of this module is helping patients and families to learn to make sense of andderive meaning from their difficult situation.It can be helpful for patients and families todiscover how the illness has not only given them heartache, but also taught themimportant unique lessons, forcing them to become perhaps kinder, stronger, smarter, ormore understanding.The purpose is not to downplay the negatives of chronic illness, butrather to help patients and families to examine the flip-side of the hardships.Termination module Psychotherapy ends for many reasons.Patients move, grow tiredof sessions, or currently no longer need the support and cognitive interventions thatpsychotherapy provides.More than simply saying goodbye, the termination module isused to examine what has and has not been accomplished and make plans for how futureepisodes and crises can be managed.An important termination task is ensuring that thepatient and family know the signs signaling the need for emergency medical help orpsychotherapy support.Booster sessions module Many patients find it helpful to return every 4 months or sofor 1 3 psychotherapy sessions.Keeping in mind that bipolar disorders are not cured,booster sessions allow the patient and family to maintain a relationship with the therapist,and share how they are changing.When the patient is not having any specific problems,the booster session offers an opportunity for the patient and therapist to explore anddeepen their relationship and knowledge of each other.That is, the session is used forproviding general support to the patient and sharing appropriate information that buildsempathy and respect between the therapist and patient.Every booster session assesses thepatient s progress, medication compliance, symptoms, and strengths.The sessions alsoprovide time to clarify issues and ensure that the patient recalls how to know whetheremergency medical help or psychotherapy assistance is needed
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