It is often necessary to find professional help to get out of Crisis or Managed Stage. A trained professional can also play an important role in helping us to move through Freedom and Stability Stages on the way to Self-Mastery. While it is most likely not necessary to have every professional on the team, it is nice to know what is available.

The following outlines were created by experts in the various fields. While not a complete list of what is available, it should give you a good feel for your options.

Psychiatry

by Peter Forster, MD

Point Of View

As physicians, psychiatrists begin with a perspective that has been called "the medical model." There are many definitions of this term; mine is "the predominant Western approach to illness, the body being a complex mechanism, with illness understood in terms of causation and remediation, in contrast to holistic and social models." One key aspect of the model is the notion of diagnosis. The psychiatrist identifies conditions, known as disorders, that are felt to underlie difficulties that the patient is experiencing in daily life.

The disease model represented a significant advance in the approach to people with depression and bipolar as contrasted to models that were common in the late 19th century. The close connection between a disease model, which is often associated with biological explanations, and reductions in stigma has been noted by many. In fact, advocates for those with bipolar and depression generally favor a disease model as contrasted with other models which, for instance, might result with having people who are manic incarcerated as opposed to treated.

Modern imaging techniques have pointed to changes in both structure and function of the brain. It is now clear that similar kinds of brain changes take place when people are treated with medications, or with psychotherapy. Most psychiatrists don't view psychiatric disorders as either biological or psychological, but instead tend to view these conditions as having psychological, biological, social, and spiritual dimensions.

"Does it work" is the question psychiatrists focus on. This pragmatic approach can be frustrating in that it may make people feel as if they're simply undergoing a series of experiments. At best, it reflects a willingness to try a varied approach as outlined in this book. At the same time, it demonstrates a willingness to change what is done based on new clinical research.

Goal Setting

Psychiatrists tend to focus on the reduction of symptoms. One prominent psychiatrist, Dr. Gary Sachs, has proposed that, "The ultimate goal of bipolar management should be complete and sustained remission (meaning the absence of significant symptoms), whenever possible..." Dr. Sachs goes on to say, though, that for most people this goal may not be achievable.1 I would argue that the question of whether this is even a good goal or not needs to be raised, as this book does.

Dr. Sachs points out later in the same article, "Over aggressive management might entail pushing medication doses to intolerable levels...." I suspect a better goal is to medicate in a way that helps reduce mood changes to a point where they are manageable and don't interfere with a successful life.

Treatment

Psychiatrists tend to be interested in using many different approaches to treatment. These treatments may include medications, psychotherapy, behavioral therapy, health interventions, referrals for appropriate non-psychiatric medical assessments, and advising patients on healthy living habits. Even such treatments as Transcranial Magnetic Stimulation (TMS) or Vagal Nerve Stimulation (VNS) could be included. Depending on the nature of the disorder, the severity of symptoms, and level of impairment, a treatment can take place in a number of settings. Options include out-patient treatment, the more intensive partial hospitalization program, or even residential treatment options.

Psychiatrists vary in the extent to which they practice all of these different modalities. Most psychiatrists are comfortable using and monitoring medications, and will usually refer people for psychotherapy. Other types of psychiatric treatment may require consultation with another psychiatrist (such as with TMS).

Psychotherapy

by Rochelle I. Frank, PhD

Point Of View

Most clinicians who treat people with bipolar conditions embrace a theoretical model that includes biological, psychological, and social variables. Though often necessary, medication alone usually is not enough. Successful treatments typically target negative symptom reduction and include interventions that will maximize as well as sustain individuals' progress over time. Psychotherapy plays a critical role in educating patients about their condition and the many factors influencing its course. It also teaches skills that can help people overcome disruptions in functioning and improve their overall quality of living.

Goal Setting

Meaningful outcomes derive from specific needs, though the task of developing treatment goals may be confusing and overwhelming. Breaking this task down into short- and long-term targets, developing a "wish list" for change, and thinking about how one's life would be different if problems miraculously disappeared, can be stepping stones toward goal setting.

Common goals might include a reduction in depressive, (hypo)manic, and other symptoms, as well as qualitative improvements in daily functioning. For example, the plan might focus on helping someone resume academics or work, increasing contact with others, and establishing healthy relationships. Health and wellness goals might reflect gaining/losing weight, improving nutrition, and developing an exercise plan. Increasing self-esteem and diminishing the shame that often accompanies mental health problems also are important, though determining one's progress on these dimensions can be difficult. All goals should include identification of clear and measurable outcomes in order to assess progress.

Treatment

In selecting a therapist that is the "best fit" it is important to consider rapport, ability to collaborate, experience, and expertise in treating bipolar conditions. The most positive outcomes seem to be achieved by clinicians who are trained in empirically supported treatments (ESTs).

A longstanding EST is cognitive-behavioral therapy (CBT), which helps people change underlying beliefs and maladaptive behaviors to facilitate reduction of negative depressive and manic symptoms. CBT also is effective with anxiety and obsessive-compulsive symptoms, which often accompany bipolar conditions. Interpersonal social rhythm therapy (IPSRT) facilitates functional and mood stability by examining and restructuring individuals' current activities, sleep-wake cycles, relationships, and situational stressors. Dialectical behavior therapy (DBT) was developed to treat borderline personality disorder, but recent applications also have proven effective in treating bipolar conditions in adults and adolescents. Family-focused treatment was developed for pediatric bipolar disorder, though adult interventions often incorporate family supports to help individuals recognize early warning signs and prevent relapse. Many therapists integrate components of different ESTs to address specific patient needs. Regardless of which therapist or type of treatment you choose, it is important to ask how your progress will be regularly assessed and monitored, since ongoing monitoring has been shown to facilitate the best outcomes.

Relationship Counseling

by Maureen Duffy, PhD

Point Of View

Relationships are a central focus area of the Advantage Program and as such putting them "in order" is an important goal. We work with all participants who have direct experience of bipolar to help them face up to any difficulties they might be having in their relationships. We also work with family members and friends to do the same. When relationships are "in order," they can be a source of ongoing support and nurturance for those wanting to live richer, fuller lives. Conversely, relationships that are in "disorder" hold people back from living the lives they want to live.

We help those with direct experience and family members and friends to be accountable for their own actions and reactions in relationships. We help participants imagine the kinds of positive relationships they would like to have with family members and friends and then we help them do the difficult and exciting work of creating those relationships.

Goal Setting

The relationship improvement plan is the outcome of the process of relationship life planning. Difficulties in any of the relationship dimensions listed above are suggestive of breaks or ruptures in important relationships. Such disruptions are normal and inevitable in all relationships.

The key is learning how to identify and repair those relationship ruptures as quickly as possible. The relationship therapist will work with you to develop relationship goals that are of particular importance to you and your family.

Everyone's relationships are unique so the relationship plan for you and your family members will be individually tailored. Your relationship therapist will assist you in setting goals that are realistic and manageable. Those goals will include a focus on areas in which you experience the most frequent and intense difficulties and ruptures.

Your therapist will help you identify benchmarks by which you can measure progress towards reaching your relationship goals. Your therapist will also help you and your family members assume shared responsibility for achieving these relationship goals. Through goal setting, you and your family will have an understanding of the steps all of you need to take to have better relationships.

Treatment

Relationships can be improved and relationship ruptures can be repaired. People with direct experience of bipolar are not doomed to have diminished relationships and neither are their family members. Participants will learn evidence-based skills shown to improve the quality of relationships between people with direct experience of bipolar and their family members.

General skills that participants will learn include the following:

Increasing the frequency of positive interactions with each other.
Decreasing criticism, fault-finding, blaming, and expressions of exasperation.
Learning how to handle anxiety better through practices of personal self-regulation--staying calm and reacting to situations as thoughtfully and tranquilly as possible.
Increasing problem-solving behaviors and decreasing panic and intense emotional reactions.
Setting realistic expectations for one another.

Individualized relationship education and therapy is designed to meet the unique needs of each person with direct experience of bipolar and their circle of family and friends.

Mind Skills Coaching

by Brian Weller

Point Of View

Mind Skills training is an adventure! It offers fresh and time honored techniques to unlock our power to be fully alive. The mind is extremely powerful. It is so powerful and intimate to us that we forget that it requires great skill to use it effectively. This is especially true for those with a bipolar condition.

Some of the greatest minds in history have displayed bipolar traits. When we reflect on the lives and contributions of people like Ludwig van Beethoven, Buzz Aldrin, Ernest Hemingway, Winston Churchill, and Florence Nightingale, what singles them out for greatness is that they lived their "bipolar condition" as an advantage. This creative attitude or point of view is what made the difference in their own lives, but more importantly, made a difference to us all. We can learn from them. The secret is to know your purpose and get organized to achieve it by managing your mind.

Exercising the mind and developing skills is as important as developing the body, if not more so. Our mental abilities are central to our ability to get Bipolar In Order. Without a well developed mind, we do not have the strength to control our minds when put under duress. Just as a weak body breaks down when it needs to do heavy lifting, an undeveloped mind breaks down when under stress. Depression, mania, hallucinations, and delusions are the greatest mental stressors known to man. It takes a well developed mind to overcome them.

Treatment

Turning good intentions into real and lasting change builds the confidence essential for putting Bipolar In Order. Coaching is essentially a facilitation process for people to integrate and establish skills. These skills include Mind Mapping, memory strategies for short and long term recall, mindset and attitude coaching, creativity processes, personal change work, and mental rehearsal techniques.

Coaching is done both one-to-one and in groups. It can be done in person, over the phone, or via the internet. It is usually done in forty five minute to one hour sessions and can be as frequent as weekly, but should be at least once a month if the skills are going to be reinforced enough to hold.

Daily practice, and some times multiple times a day, are necessary for the mind to create the habits needed for success. Mental exercises seem very simple on the surface, but we know the mind's tendency to avoid change easily rivals the body's. It takes discipline to keep up the practice.

Adherence can be greatly helped by working with friends and family or in support group settings. It can also make a huge difference to have one-to-one sessions with a coach.

Mind Skills coaching includes:

Check-in to reaffirm purpose, goals and actions - "What am I creating in my daily life and why?"
Exploration - "How am I doing?" Clients explore their issues, questions, and concerns that have arisen during the week. The coach clarifies them so that clients can reset their goals. In group sessions, these issues are explored with the group and invariably others share similar or related issues.
Tune up - Tuning up the Mind Skills routines so that they fit more successfully into a clients' work, leisure, and home life.
Development - The coach gives hands-on training to build skills to new levels of competence and effectiveness.
Support - Individual and group support to help clients to stay on the path.

Spiritual Counseling

by Scott Sullender, PhD

Point Of View

Depression and bipolar are multi dimensional conditions. It affects one's emotions, one's thoughts, one's physical health, one's relationships, one's will power and, of course, one's spiritual life. You might say that depression is a whole person disorder or condition.

We call depression an affective disorder, which means that it is primarily a condition that damages one's mood or emotions. Yet, those who struggle with depression know full well that it is much more than that and depression must be and is best addressed on multiple levels.

Depression, or its cousin mania, affects our spirituality. Depression becomes like a filter on our glasses that prevents or colors how we experience our spiritual life. In times of depression or since becoming depressed, we may come to feel that God is now far away or silent or angry. It may be harder to pray or meditate when the depression is intense. It may be difficult to feel at peace, to forgive others, to see any hope in the future, to feel any sense of genuine gratitude, or to find a sense of purpose in life. Depression or bipolar condition can damage or alter our spiritual life, even as it influences every other part of life.

Yet, it is also true that periods of depression may also be times when we have a rich opportunity to strengthen our spiritual life in new ways. The very depression that seemingly prevents us from seeing God may actually force us to see God in a new way, and to discover a deeper, more profound spirituality. This is the message of many of the mystics and saints from both western and eastern religious traditions. Sometimes it is precisely through these periods of what St. John of the Cross, called the "Dark Night of the Soul" that God can be experienced in renewed and powerful ways.

Spiritual practices are not a substitute for psychotherapy, medication or other related services if needed. Spiritual counseling can, however, be a supplemental resource that will help strengthen the spiritual arm of our battle with depression. It can be one component, sometimes even a very significant component in a total person approach to depression.

Goal Setting

The goal is simple enough: to revitalize your spiritual life and use that revitalization to strengthen your battle with depression and mania. In particular spiritual counseling aims to increase the following:

A sense of purpose or meaningfulness of life
An ability to forgive self and others
An ability to feel and sustain gratitude
A sense of connectedness to a spiritual community
A sense of personal worth and significance
An awareness of the presence of God
A sense of hope regarding the future
A sense of inner peace or serenity in the face of addictions
The use of prayer, meditation and other spiritual practices

Treatment

Our treatment regimen normally includes a series of conversations with a qualified spiritual counselor. Our definition of "qualified" is a professional with both academic and clinical training in both psychology/counseling and theology/spirituality. It also includes a person who does not work in isolation, but is accountable to and consultative with a team of interdisciplinary professionals. We respect the training and program of the American Association of Pastoral Counselors.1 We also respect spiritual directors who are members of Spiritual Directors International.2

During our treatment, the spiritual counselor will discuss the various components of spirituality, noted above in the assessment phase. The counselor will then explore the blocks that prevent the client from realizing a fuller spirituality. We will help the client tap into the various, perhaps hidden spiritual resources within his or her life that can be useful in this enterprise. Spiritual counselors normally assign homework, usually in the form of various spiritual practices and actively coach clients through the successful use of these practices.

Spiritual counselors will also help clients self-assess on a regular basis to make sure the client is achieving the results he or she desires.

Addictions Counseling

by Michael R. Edelstein, PhD

Point Of View

REBT offers an alternative to the conventional view of addictions. No one is powerless over their drug/alcohol abuse, no matter what their past or current circumstances happen to be.

Rather, the immediate cause of addictions lies with the thoughts, beliefs, ideas in your head--what you tell yourself--immediately before you drink, overeat, smoke, or shoot up. Unrealistic thinking is the essential cause of addiction, and such thinking takes the form of "must's," "awful's," and "can't-stand-it's." By changing the thinking process, addictive behavior can be overcome. "I MUST get high! It's AWFUL to be deprived! I CAN'T STAND discomfort!" is the refrain of those addicted. Such "musty" notions lead to escape into drugs.

Individuals addict themselves to pleasurable experiences to escape discomfort, enhance good feelings, or both. Improving performance, fitting in with peers, and differentiating oneself from other groups (especially parents) are specific instances of these larger goals.

When you feel depressed, for example, you may drink excessively to drown these feelings. The next morning you may get depressed about your previous night's self-destructive behavior. This pattern illustrates how individuals with emotional and addiction problems often use addictions to escape their emotional difficulties. Emotional problems may also be created in response to addictions. This vicious circle has been labeled "dual diagnosis."

The addiction may be addressed separately from the emotional problem or in conjunction with it, depending on the circumstances of the client, the problem, or the therapeutic interaction.

Using addictions to escape disturbed emotions has also been labeled "self-medication." In other words, the individual drank in response to the initial depression as a way to "medicate" it away or escape from it. Prescription drugs may be used for this purpose, as well.

Goal Setting

Clients tend to have a variety of long-, medium-, and short-term goals in the process of overcoming an addiction. The most common long-term goal involves either quitting for good or moderation. Variations on this involve a middle-term goal of abstaining for a predetermined period followed by long-term moderation. Others begin with the long-term goal of moderation, and should this fail, abstinence as the default.

When a client is unsure about whether moderating or abstaining from drinking is reasonable, a look at history often provides the answer. Many compulsive drinkers have a history of attempting moderation and failing multiple times. This points to abstinence as probably the best solution.

"Do I reach my final goal by abstaining or tapering?," involves a common issue, especially for smokers. Since there is no perfect way of determining the answer in advance, I recommend taking a best guess at which is likely to be successful, then experimenting with it.

A final factor involved with overcoming addictions involves time frames for each step in the process. This is an individual choice based on history, including past failures and successes, and the consequences the addicted individual faces by continuing the self-defeating behavior. Some individuals quit overnight. Others take months or years of patience, persistence, learning from mistakes, relapses, and refusing to give up, before they ultimately succeed.

Treatment

REBT addiction counseling generally is conducted in-person or by phone. The average course of treatment involves 8-10 sessions, beginning with sessions weekly. As the client masters the REBT concepts and tools, and gets in control of the addictive behavior, sessions tend to get spread out over a few weeks, then monthly.

REBT follows an educational teacher-student, rather than a medical doctor-patient, model with sessions resembling a tutorial. After the initial assessment process described above, the therapist teaches the client concepts and strategies immediately applicable to the client's problem. Each session concludes with specific collaboratively-devised exercises for the client to practice daily between sessions. The following session begins by reviewing the homework, with modifications added based on the client's successes and failures with it during the week. If the client has immediate questions or concerns, addressing these would take precedence over the usual structure, with the homework reviewed after this.

The bulk of each session consists of reviewing tools and strategies the client may use in overcoming the addiction. These include: vividly reading a disadvantages list, refuting rationalizations, Three Minute Exercises, setting goals with rewards and penalties, and bibliotherapy. The client is encouraged to experiment with a variety of these to discover which ones prove most effective.

Career Management Counseling

by Maria Chang-Calderon, PhD(c), MSHR

Point Of View

Employment, well-being, and quality of life are closely tied for several reasons. Gainful employment contributes to financial freedom, the ability to pay for wants and needs, and the enjoyment of physical, mental, emotional, and spiritual well-being. Predictors of success at work include employment history, psychiatric diagnosis, and the ability to manage one's condition. An Advantage Program career management counselor is not looking to spell out limitations; they are there to help create the life you want.

Career management counseling does not include job placement services; however, it addresses how to stay competitively employed. This entails assessing one's strengths, weaknesses, and workplace conditions. Career coaching is based on identifying immediate problems and successes in the workplace and finding the indicators that will help an individual maintain or improve his/her performance.

If there are issues due to stigma that need to be dealt with in the workplace, the career management counselor can help clients identify what resources are available to them to ensure their rights are protected. The counselor encourages clients to make use of the Integrated Team, managing their condition with the help of trusted therapists, friends, family, and health care providers.

Goal Setting

Career goals must be aligned with one's values, preferences, knowledge, skills, and abilities in order to develop a career maintenance and/or development plan that will result in goals being met. Once an individual's inventory of strengths and weaknesses has been discussed, it is necessary to discuss short- and long-term goals and how they can be met by taking steps to build on what is already working. The goal setting process should include a discussion with trusted advisors, friends and/or relatives to ensure the goals are SMART (Specific, Measurable, Achievable, Realistic and Time-framed). Discussing your goals with trusted individuals within your support network can lead to obtaining valuable feedback that will help further refine your career goals to ensure success.

Treatment

Career management counseling services are individualized sessions requiring meeting with the advisor at least once a week in the beginning and less frequent once the plan has been fully implemented. Sessions are conducted by phone or in person. E-mail sessions are discouraged because having a flow of dialogue is important to understand the context of the problem and to consult appropriately. In addition, participating in an employment support group that addresses common employment issues can be beneficial.

Financial Coaching

by Denise K. Hughes, M.A.

Point Of View

Money touches every aspect of our lives. Our bank account influences our choice of the car we drive, the size of our house, the neighborhood we live in, schools our children attend, grocery stores we frequent, the healthcare insurance we choose, and much more.

Control, competence, and confidence in our money management creates well being. Benefits of practicing financially mature behaviors include peace of mind, a sense of security, freedom for greater choices, increased life energy, and a good night's rest, free of worry.

The reverse is certainly true, as well. When our financial affairs are not "in order," we are left feeling inadequate, confused, and out of control. The result is even greater stress, which includes the pressure to earn more, conflicts within our relationships, and a deep sense of lack. Eventually, this chronic level of financial strain brings us to our knees and places us in survival mode on Maslow's hierarchy of needs. Over time, this type of continuous assault will break us down physically, mentally, emotionally, and spiritually.

Many of us come from family and educational systems that have not prepared us for even the most basic functions of money management. Money remains one of our society's most taboo topics of conversation. We talk more easily about sex.

Couple depression or mania with a lack of understanding of money handling and even more problems will arise. Using money as a device to feel better, elevate one's mood, or express an expansive mood are all ways that can drain one's bank account and assets.

To support you in discovering your personal recipe for financial success, I want to share with you, secrets of financially successful people:

Financially successful people control their day to day finances in order to afford things that bring them satisfaction and enjoyment. In practical terms, this means creating a cash flow plan to help set priorities and stay within boundaries in order to get more of what they want in life. More freedom, more fun, and more joy are all outcomes of mindful spending.
Financially successful people are in the "know" when it comes to their finances. They know their credit score, the interest rates on their mortgages, debt balances, and how to protect themselves from fraud and scams. They initiate taking steps toward financial literacy.
Financially successful people create the habit of saving and investing money. They realize that small steps each month add up to big dollars down the road. They understand the concept of dollar cost averaging and laddering.
Financially successful people protect their assets in order to prevent financial disasters caused by catastrophic illness or personal tragedies. They insure themselves with adequate coverage and take balanced risks.
Financially successful people embrace certain mind-sets. They live in the space of possibility and gratitude. They are able to delay gratification and hold both short- and long-term visions for what they want in life. Their dollars nourish their highest values.

Treatment

Treatment plans are client specific and based on the agreed upon goals for the course of session work. Generally speaking, a treatment plan may consist of the following processes and concepts:

Move out of the money fog - Gaining clarity is the first step in the process. Insight allows one to operate from a perspective based on reality. In regards to money, one needs to be cognizant about the entire financial picture. This includes cash flow, savings, investments, debts, all property loans, income, etc.
Take action - The goal is to bring the behaviors of respect, mindfulness, and stewardship to one's finances.
Create healthy money habits - The desired outcome is to be in a place of control, ease, and peace when it comes to money.

Generally speaking, money coaching sessions consist of bi-monthly appointments. Session appointments are focused on both process and outcome. Homework assignments, requiring about one hour per week are also required.

Physical Rehabilitation Therapy

by Justin Liu, MD

Point Of View

In today's world of immediate gratification, individuals with physical or emotional ailments often seek medical attention with the expectation that a doctor will be able to provide them with a magical pill or medical procedure that will miraculously alleviate all their symptoms instantly. To approach medical treatment with this mentality is usually not realistic or fruitful. As advanced as modern medicine has become, successful treatment of more complicated functionally-impairing conditions requires careful planning and effort by both the physician and the patient.

Regardless of whether an individual has sustained a loss of function due to deconditioning from inactivity or a physical injury from an accident, any loss of function that disrupts a person's ability to participate in the usual daily activities is highly traumatic to the body and mind. Because of this, it is vital to acknowledge the global effect mental illness and physical injury can have on a person's overall well-being. Prolonged physical debility can lead directly to negatively affecting a person's self-image and mood. Conversely, poor mental health can severely impact a person's ability to properly heal and regain lost function.

With the close tie between a person's physical and mental health, it quickly becomes evident that physicians must not make the mistake of treating the mind and body as two separate entities. A successful approach to an individual's global well-being requires that a plan of care be developed with the deeper understanding that the treatment plan's objective is to ultimately promote physical and mental health simultaneously.

Goal Setting

Once an accurate assessment of an individual's current physical condition has been done, the PM&R Physician can help design an activity program specific to the patient's strengths and weaknesses. The idea is to design a therapeutic exercise regimen that is neither too easy nor too difficult for the patient. The program must also provide an appropriate challenge to the patient from both a physical and cognitive standpoint. Another vital factor is to create a routine that is dynamic and entertaining for the individual. No one likes performing activities that are repetitive or dull. Various therapy modalities should therefore be used to help keep things from becoming monotonous. Unless it is medically contraindicated, I feel it is beneficial to have patients participate in a variety of activities: from isometric weight-training activities to isodynamic aerobic-type activities to more alternative use of interactive gaming technologies like the Nintendo Wii. The key is to be creative while never losing sight of the primary objective of assisting the patient to regain a sense of physical and mental well-being through a structured program of progressively increasing physical activity.

When designing the exercise regimen, it is important to check in at regular intervals with the patient and his or her Rehab Therapist or Fitness Coach to see how a patient is doing in reaching a specific goal. It is crucial that the goals set for an individual are realistic and actually attainable. Functional goals should not be rigid. Depending on progress, new goals can always be set. It is paramount to always remember that goals, like the individuals themselves, need to always evolve and not remain static.

Treatment

As the individual continues on his regimen of therapeutic exercises, the PM&R Physician will need to constantly maintain lines of communication with the patient. Feedback on how the patient feels physically and emotionally should be assessed at regular intervals. To ensure that the patient does not develop a physical barrier to hinder his or her progress with the program, it is critical that the PM&R Physician assess the patient's overall pain levels and provide appropriate treatment in an efficient manner. In an effective therapy program, there are often noticeable physiologic and emotional changes that occur. Blood pressure and blood sugars often improve with weight loss and improved overall fitness. Patients who struggle with insomnia start to have improved sleep-wake cycles with a structured exercise routine. Individuals who are on psychotropic medications for depression and mania begin to notice improvement of their overall mood, self-image, and energy levels. As the PM&R Physician who is checking in and monitoring all of these positive changes, appropriate medical management must concurrently be provided. Necessary coordination and discussion with the patient's Primary Care Physician, Psychiatrist, and other treating specialist physicians must be done to ensure that the patient's various medications are appropriately lowered or tapered off based on the noted physical and emotional changes.

Nutrition Counseling

by Ruth Leyse-Wallace, PhD, RD

Point Of View

The mind and brain, as well as the body, need adequate nutritional intake for wellness and optimum functioning. Even though nutrition is only one factor in mental and physical health, it is highly influential for both mind and body. It is also quite easily improved and should be included in any effort to sustain mental health. A complete and sufficient array of nutrients are needed for:

an energy supply
transporting and transforming food into the energy form usable by the physical body and brain
creating enzymes, hormones, bone, muscle, neurotransmitters, and immune system
facilitating the expression of DNA
coping with stress

Memory, cognition, attention span, aggression, irritability, feelings of well being, and mental energy may be affected by nutritional status. Consuming too few of the necessary nutrients affects so many bodily systems it is not surprising that poor nutrition decreases the quality of life in both obvious and subtle ways. Nutrients include:

carbohydrates
essential fatty acids
amino acids
folic acid and other B vitamins
vitamin C
minerals such as chromium, zinc, and iron

Bipolar disorder and depression may influence whether an individual consumes an adequate supply of foods and the nutrients they supply. The manic state can lead to distraction in which less attention is given to the preparation of adequate foods. Increased activity during this phase requires additional nutritional needs that are not always met. Depression can lead to a lack of energy and motivation for eating adequately, leading to weight gain or loss and associated health issues.

Medications may interact with nutrient intake or metabolism and affect the body's use of nutrients. Toxicity may result from excess intake of some nutrients, which in turn can affect mental function.

Often, the scientific evidence linking nutrition to mental health is correlational in nature. Cause and effect links are scientifically difficult in both nutrition and mental health research. However, scientists around the world publish new research results monthly that contribute to knowledge in these areas.

Goal Setting

Goals are statements of behavior; actions to be undertaken with commitment for obtaining a nutritional intake that will support the desired mental and physical health. Individualized goals in relation to nutrition will be based on the nutritional assessment as well as each client's personal interests and life situation.

Goals may be short- or long-term. Goals that are stated simply with a single focus are preferable to complex goals. The best goals are those that can be clearly evaluated. "Eating better" isn't as easily evaluated as "eat three times per day instead of one meal per day."

An individual may have a few or several goals. Certain goals may be addressed one at a time and achieved relatively quickly. Other goals entail changing lifelong habits and will require longer periods of time because readiness to change is influenced by many factors. Goals that involve lifestyle may require several interim goals. Simplistically put, if the desired life style goal is to lose 25 pounds, the first interim goal could be to limit sugar intake. To that end, a second interim goal could be to stop buying a candy bar from the vending machine everyday at break.

Treatment

A treatment regimen will reflect an individual's goals and plans for how best achieve them. It will be developed by the treatment team and the client. The nutrition treatment regimen may include a food plan, supplements, self-monitoring, and education. Treatment may also include assistance from family and friends. Decisions regarding activities that involve food may have to be addressed. Consideration regarding activities that don't involve food may also need to be taken into account.

Monitoring an individual's progress in reaching his/her goals and whether they are having the desired effect is important. Regularly spaced appointments with the nutritionist will be important until the treatment regime is going smoothly. During these appointments, acknowledgment of successes is motivating. They also provide an opportunity to make any necessary changes. Over time, the treatment regimen will most likely change as goals are met, new factors emerge, insight and knowledge acquired, and new goals are set. It is hoped that treatment will evolve to where it is no longer treatment but is in fact a new way of life.

Fitness Coaching

by Mark Jenkins

Point Of View

As a trainer who has worked with a slew of performing artists, I realize how much of an anchor proper exercise and diet can be. I have clients who won't even record unless they are training, much to the record company's dismay! To someone who is dealing with bipolar or depression, the need for such an anchor is even greater.

Having your body fall apart will only make it harder to handle bipolar or depression. It is hard enough to battle your mind. Neglecting your body will only make the battle more difficult to win. Keeping good physical habits will give you an edge. Being in great shape can be the difference between a depression that puts you out of action and one that only slows you down. A recent study1 suggests that exercising three times a week may be just as effective in relieving the symptoms of major depression as the standard treatment of anti-depressant medications. A conditioned body might help you with the challenges of excess energy and inability to focus that often accompanies mania.

There are four main areas to consider in taking care of your body in addition to good nutrition. Optimal physical fitness is only achieved by combining all four types of exercise with a diet that supports you well. The four types are strength, endurance, flexibility, and body awareness. Strength is best developed with resistive weight training. Endurance is increased via aerobic exercise. Flexibility comes through stretching. Body awareness is achieved through dance, yoga, tai chi, or the many activities that have you focused during movement.

Goal Setting

The expertise of the fitness coach is critical in goal setting. While setting goals that are unreasonable can discourage the client from continuing with the program, goals that are too easy can result in boredom and disillusionment with the idea that making progress is based on effort. This disillusionment can spill over into the other aspects of the integrated program. A good coach knows from experience what goals to set and how hard the client is going to push to achieve them. The coach can also guide the client in adjusting the goals according to current mental conditions that affect motivation.

The advantage of fitness goals is that they are very specific and measurable. You either ran five miles or not; there is no ambiguity about it. The clarity of goals combined with achieving them gives the client self-esteem and faith that the less measurable mental goals can also be accomplished.

Treatment

The best fitness program is one that the client will do. The program needs to be adapted to each individual so as to keep up motivation. This is accomplished by finding the right mix of exercises that address the strength, endurance, flexibility, and body awareness needs while matching the interests of the client.

A unique blend of skill and creativity is what sets the great trainer apart from others. Anyone can change their body type if they can stick with a program, often consisting of an innovative fusion of pilates, calisthenics, sports drills, weight training, and high intensity cardio. The trainer needs to keep the custom-fit workout sessions fresh by incorporating a wide range of sweat-inducing activities, such as boxing, bungee cords, and kettlebells. I never give the same workout session twice. Staying away from routine keeps the muscles and mind constantly stimulated.

Primary Care Physician

by Will Meecham, MD

Point Of View

Our brains and bodies are one. The brain directs the activities of the body, while the body provides the environment the brain needs to work properly. Neither can function without the other. As a result, the health of our bodies must not be ignored when we work to improve our mental wellness. There are many ways in which emotional wellness or distress influence somatic health, and vice versa.

For instance, an occasional case of what looks like psychiatric illness is discovered to be due to thyroid dysfunction. The early stages of dementia sometimes manifest as behavioral disturbances. It is important to detect such conditions in order to ensure proper diagnosis and avoid inappropriate treatments.

Chronic pain can exacerbate depression, as well as be worsened by it. Similarly, it is well known that emotional stress and heart disease are interrelated. Immune competence appears to be influenced by emotional states. These bidirectional influences between bodily and mental health are probably the rule rather than the exception, though the strength of the associations vary widely.

At the same time, the qualities of nutrition, rest, and conditioning all influence mental well-being. Although frequently overstated, the "sugar rush" and subsequent "crash" are widely known results of a particular kind of improper nutrition. Alterations in the sleep-wake cycle occur commonly when moods fluctuate in bipolar conditions, while shift work and jet lag have been observed to set off mood crises.

Finally, medications for psychiatric disorders may have substantial medical consequences. Weight gain, neurologic symptoms, and sexual dysfunction are common side effects. At the same time, some drugs for medical conditions alter moods, cause anxiety, disrupt the sleep-wake cycle, etc.

Success in the Bipolar Advantage program therefore requires the participation of medical practitioners. Depending on the client's situation and preference, medical workup and management may be the responsibility of his or her existing primary care provider. Alternatively, members of the Advantage medical staff can take on this role.

Goal Setting

Medical goals in the Advantage Program are similar to those for the general public. However, people with mental illness often have increased sensitivity to bodily imbalances. Therefore, it is of paramount importance that the Advantage client works toward a healthful regimen of nutrition, exercise, and sleep hygiene. Although other team members usually direct the client as lifestyle goals are formulated, the medical provider oversees the plan. He or she also follows the client over time to be sure the lifestyle changes are well tolerated by the body.

The client's medical history at intake and any newly discovered physical disorders dictate whether the medical provider suggests specific additional goals. Whenever possible, attempts are made to bring the body into a state of optimal health with a minimum of medical intervention. For this reason, and in order to further the client's mental wellness, a healthy lifestyle is one of the pillars of the Advantage Program.

Treatment

Other team members help the client achieve the desired changes to diet, exercise, substance use, sleep, and so on. However, the medical provider maintains oversight in order to ensure safety and optimal results with regards to bodily health. Where necessary, the provider prescribes medications and other treatments for physical conditions, whether ongoing or newly discovered in the course of the Advantage medical workup.

Specific behavioral improvements are frequently advised. Smoking cessation aids will be prescribed as needed. Medical assistance with substance abuse recovery is provided when necessary. Dietary changes may be indicated to reduce weight, improve cholesterol profiles, decrease fasting glucose levels, or lower blood pressure. Hopefully, such changes will forestall the need for medication to manage hypercholesterolemia, hypertension, or diabetes.

When needed, the patient may be referred for outside management of complex medical conditions. However, conservative measures are preferred when possible, and the medical provider works with the rest of the team to help optimize the client's bodily health, comfort, and longevity. The medical perspective ensures that Results Worth Striving For include improvement in bodily health as well as mental well-being.

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