How important is it to know when you are getting manic? One study indicated that there were two predictors of rehospitalization in bipolar disorder: not taking medications, and failing to recognize the early signs of relapse (Joyce, 1985). On a more hopeful note, people with bipolar disorder who receive educational interventions, such as learning to identify early warning signs of mania and then seeking mental health services, are less likely to have full recurrences of mania and have better social and work functioning over 18 months than those who do not receive this kind of education (Perry et ah, 1999). As Robert said, once he and Jessie had begun to implement a successful relapse prevention plan, "I used to think I was in the driver's seat when I was manic, but that was just the illness talking. Now I think I'm in the driver's seat when 1 can stop myself from getting manic."
In this chapter, you'll learn a three-step strategy for getting off the train before mania takes you for a harrowing ride. The method, called a "relapse drill," was developed by Alan Marlatt and Judith Gordon (1983) for the treatment of alcoholism relapses. The relapse drill was used successfully in our studies of family-focused treatment for people with bipolar disorder (Miklowitz & Goldstein, 1997; Rea et al., 2001; see Chapter 6). A relapse prevention method is also a central part of the "collaborative care" program for patients in NIMH's Systematic Treatment Enhancement Program for Bipolar Disorder (Sachs, 1998; Otto et al., 1999).
A relapse drill is like the fire drills you took part in back in school. Like fire drills, relapse drills are formulated when everything is safe and going well so that you know exactly what to do should a disaster occur. Like fire drills, the relapse drill involves a series of steps to take to try to prevent the damage done by an anticipated event:
• Identify your prodromal symptoms
• List preventative measures
• Create a written plan or contract detailing prevention procedures
In the first step, identifying your prodromal symptoms, you make a list (usually with the help of others) of early warning signs that signal the beginning of a manic period. Identifying warning signs may also involve identifying the circumstances that elicit these symptoms (for example, drinking heavily, missing medication dosages, missing your therapy or physician appointments, encountering stressful work situations).
In the second step, listing preventative measures, you brainstorm with your relatives about what actions to take if one or more prodromal signs appear (for example, call your psychiatrist, go in for an emergency medical appointment, arrange for others to take care of your children). These actions involve you, your doctor, and members of your core circle (see also the examples in the sections that follow).
In the third phase you, your significant others, and your doctors put the first and second steps together and develop a written plan, which is a kind of contract, for what to do when you feel a manic episode coming on. It's important that all key players have ready access to the contract so that they can help you put it into action when you are beginning to cycle—since that is when you're least likely to seek help.
This chapter focuses only on the prevention of manic episodes. This material is also relevant to preventing hypomanic episodes, which often have a similar set of warning signs and can be derailed with some of the same preventative strategies. The next two chapters discuss ways to prevent or minimize the downward spiral of depression. But before 1 get into the actual mechanics of developing a contract, let me say something about a sensitive issue that may have already occurred to you: the discomfort of relying on others when you are becoming ill.
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