What is a Bipolar Treatment Contract and why do you need one?
Treating bipolar disorder has a clear goal – to avoid a dangerous mood
swing into mania or depression. For me, my Treatment Contract has been critical to maintaining this stability.
Treatment Contracts are practical tools. They are easy to create but incredibly effective. In short, they work. In fact, anyone who makes a reasonable effort to create their own Treatment Contract can enjoy the certainty of knowing they have a safety net in place that will protect in the event of even the most extreme bipolar mood swing.
Do YOU need a Treatment Contract?
You make your Bipolar Treatment Contract when you are stable in order to protect yourself and your loved ones in the event your bipolar disorder causes you to become seriously manic or depressed any time in the future.
The contract is an agreement about what you and the important people in your life will do if you become unwell. As we have all learned the hard way, leaving treatment decisions until we are sick is way too late. During a serious bout of mania or depression we are unable to think clearly or make good decisions. Instead, we are likely to do things that harm us and the people we care about. To do things that we will later regret. By planning our treatment steps when we are our best and healthiest selves, we protect against disaster by having a concrete action plan in place ahead of time.
For me, having my Treatment Contract in place has paved the way to a wonderful marriage. My first marriage broke up when I was manic. I did some terrible things and felt sure I did not deserve to ever be happy again or that anyone could ever trust me – myself included!
My Bipolar Treatment Contract changed all that. My spouse and I both have confidence, optimism and peace of mind because we have a clear plan for dealing with even the mildest relapse.
In its simplest form, a Bipolar Treatment Contract could be a single sentence. For example:
“If I become manic or depressed, my wife in consultation with my psychiatrist is to make decisions in my best interests using the authority from my durable power of attorney and health power of attorney.”
The problem with this example is that it vague and subjective. What does “manic or depressed” really mean? How are “best interests” decided? When will the power of attorney lapse so that I can regain control of my own affairs?
In order to work properly, it is necessary to use concrete, objective,
specific and personalized details. (The example below illustrates this.) Also, it is important to “buy in”. A Bipolar Treatment Contract that you feel forced into is not a true contract. For any agreement to be meaningful there must be a “meeting of the minds” with genuine shared assent and consensus. It is YOUR treatment contract and it must contain YOUR instructions, YOUR plan and YOUR choices.
Suggested contents for Bipolar Treatment Contract
Your Bipolar Treatment Contract should contain the following:
Why? What is your purpose in creating the document?
Who? Usually this includes the patient, significant other and/or other family members, and medical professionals.
When? This is an opportunity to describe what your individual manifestations of bipolar mania and bipolar depression look like. When will the contract be activated? What signals will show the people around you that you need help and it is time to execute the plan?
What? There are many possible interventions, from adjusting medication to checking into a hospital treatment center for in-patient care. What specific steps are your authorizing in order to safeguard yourself and your loved ones?
Don’t worry if any of this seems unclear – the sample Bipolar Treatment Contract below shows exactly what to do.
Sample Treatment Contract (Bipolar Disorder)
As someone with Bipolar Disorder Type 1 who in the past has experienced episodes of mania and depression where my behavior has harmed myself and others, I am making this Treatment Contract in order to:
help all parties recognize the early warning signs that I am becoming manic or depressed
set forth in writing the steps I will take in response to these early warning signs
empower others to act in my best interests.
I, Rebecca West, make this Treatment Contract with my husband, Alex West. Alex and I agree that my Care Team may be involved as described below.
My care team includes:
My Psychiatrist, Dr Diane Preston, Telephone: (NNN) NNN-NNNN
My Therapist, Dr Jamie Wright, Telephone: (NNN) NNN-NNNN
My Doctor, Dr Ellen Ballard, Telephone: (NNN) NNN-NNNN
Spiritual Director, Frank Brennan, SJ Telephone: (NNN)
Attorney, Peter Crisp, Esq, Telephone: (NNN) NNN-NNNN
My signs of wellness
We agree that the following behaviors show that I am staying well and my moods are stable:
Getting up at the same time as Alex on weekdays and showering.
Billing at least 4 hours of work on weekdays.
Going to bed at night either at the same time as Alex or by 10:30 pm.
Maintaining a healthy weight between 130 – 140 lbs.
Honoring commitments, including attending my Book Group every
month, attending at least one of my registered Meetups.com each month, and honoring my monthly volunteering obligations at St. Vincent de Paul and the school library.
Following our Mint.com budget including savings and investment goals and sticking to the spending limits on clothing, books, entertainment and gifts.
Keeping all medical, therapy, hairdressing and business appointments.
Home atmosphere is harmonious with issues discussed calmly.
I do on a regular basis to help myself stay well include:
Taking my prescribed medication every day.
Exercising for 40 – 90 minutes each day or taking 10,000 steps.
Going to bed and getting up on a regular schedule.
Filling in my Mood Chart each day and sharing with Alex.
Journalling, scrap booking, or taking photos for 30 minutes daily.
Reading for pleasure at least every second day.
Skype, telephone or face to face with
someone other than Alex each day.
Take ALL of Sunday off and enjoy the day with Alex.
Always have at least one “girl’s weekend with Linda firmly scheduled.
Warning signs for my bipolar mania
Increased irritability such as saying “snappy” or “cutting” things.
Difficulty sleeping or not wanting any sleep.
Shopping, especially online for books, art supplies, and photographic equipment
at Amazon and at the mall for clothes, shoes and purses.
Heightened sex drive and hostile and objectifying towards Alex.
Internet surfing, including sites I would not “normally” visit.
Telephone and email flirting with male friends and colleagues.
Rude and impatient with people.
Restless and cannot focus on work, even neglecting critical tasks.
Irrational anger towards work colleagues.
Resentment towards Alex, thoughts or threats of moving out.
Sometimes buying cigarettes even though I don’t
smoke (except for half a cigarette when getting manic).
Feeling secretive and becoming very uncommunicative at home.
Impulsive financial decisions such as wanting to totally alter investment
strategy and spend savings on extravagant purchases such as new cars.
Agreed bipolar mania interventions
Seeing Dr Preston immediately and
getting medication to aid sleep.
Scheduling extra sessions therapy ASAP with Jamie.
Talking things over with Father Brennan.
Take time off work if possible rather than fall behind, miss deadlines or argue with colleagues.
Take a long walk with Alex and talk about what is happening and what we can do.
Avoid driving and other stimulation.
Choose a project to focus on but discuss it thoroughly with Alex and Care Team.
Ask Alex to talk to Dr Preston and make sure she has a full picture of what is
going on and that Alex knows what medication I should be taking.
Alex to confirm with Peter Crisp that durable power of attorney and health
power of attorney are in place and can be used if necessary.
Warning signs for my bipolar depression
Not dealing with mail each day by either shredding, filing, sending a payment by return mail or whatever else is needed.
Not showering/staying in pajamas during day.
Not running errands or doing the grocery shopping.
Not following up on household tasks, for example not emptying the dishwasher,
moving laundry from washer to dryer, or emptying dryer.
Neglecting appearance, for example not coloring hair on schedule or keeping up with pedicures, hairdressing appointments.
Overly casual dressing.
Not answering telephone, not returning emails, cutting off contact.
Not keeping up exercise routine.
Not keeping up with Mood Chart or other parts of daily routine.
Feeling alone and feeling that Alex does not care or understand.
Procrastinating with work or find work tasks more difficult than usual.
Anger towards work colleagues.
Isolating and avoiding commitments I usually enjoy such as Book Group, Meetup.com events, my volunteer work.
Agreed bipolar depression interventions
Talk to Dr Preston about possible
Schedule extra therapy sessions with Jamie ASAP.
Talk things over with Father Brennan.
Take a long walk with Alex go out for a healthy dinner with him and talk about
how I feel and what we can do.
If I am having trouble sleeping, take sleep aids for a maximum of 2 nights and “catch up” on sleep.
If I am sleeping too much, get out of the house and do my work on my laptop from a pleasant location like Borders or Starbucks.
Take a time out for a long bubble bath and read a good spy novel or thriller.
Arrange with Alex that we will eat all our meals together for at least two days and make these extra healthy and fresh.
Go to Mass.
Have my hair done.
Get a pedicure with paraffin and a foot massage.
Make some Kiva donations (agree amount with Alex).
Ask Alex to read favorite scripture with me such as Proverbs 31:10.
Stop all alcohol and sugar.
Get back into my exercise routine by asking Alex to encourage me to get started on the treadmill first thing in the morning before he leaves for work.
Do only gratitude journalling and/or gratitude scrap-booking for a week.
See Dr Ballard and get blood work done to check thyroid, iron, hormone levels, and so forth.
Emergency steps if moods get worse
Alex to monitor all of my computer
use through WebWatcher software.
Give Alex credit cards, check book, car keys, safe deposit box key – whatever he asks for, provided we both discuss it together first with Jamie or Dr Preston.
Alex to check bank accounts, brokerage accounts and Mint.com daily.
Alex to make decisions in my best interests using the authority from my Psychiatric Advance Directive and Health Care Power of Attorney.
As you can see, the Bipolar Treatment Contract between Rebecca and Alex requires a lot of self-knowledge and insight and a LOT of trust and honesty. Gather this information about the exact nature of your own bipolar disorder by mood charting and creating a detailed Wellness Plan.
Psychiatric Advance Directives (PADs) for Bipolar Disorder
If you want to place your Bipolar Treatment Contract on a full legal footing, you can use an advance directive or living will.
You can include your mental health care wishes in a standard advance directive or living will, or you can use a specific mental health document – the Psychiatric Advance Directive (PAD). You will need witnesses (not relatives or members of your health care team) and to have the document notarized.
Combine this with a Health Care Power of Attorney (HCPA), and you can be confident that any future episodes of bipolar mania or depression will dealt with promptly and in accordance with your wishes.