Clinical vignette

Doreen is a 34-year-old, single mother of four, with a history of two prior hospitalizations for suicide attempts during mixed states. Doreen entered IPSRT during a mixed-state episode following the birth of her fourth child. She had stopped her mood stabilizers during the pregnancy and had not yet resumed them, despite instructions from her psychiatrist to restart them immediately after delivery (Doreen did not plan to breast-feed). The initial phase of treatment emphasized psychoeducation, including the importance of following the psychiatrist's recommendations in order to prevent another hospitalization (the patient was not currently suicidal). It was immediately apparent that Doreen's erratic sleep schedule, driven by the needs of her newborn infant, contributed substantially to her symptoms. Thus, the therapist moved rapidly to help Doreen enlist assistance from her extended family. Doreen's mother and several sisters each agreed to stay with Doreen one night per week in order to provide her with some relief from nighttime feedings as well as assistance with other household responsibilities. Doreen restarted lithium and olanzapine, and immediately began to feel better.

As Doreen's mood began to stabilize, it became clear that the interpersonal problem area most salient to Doreen's current mood episode was a role dispute with Roger, her boyfriend of 2 years. Roger, the father of Doreen's two youngest children, was unemployed and had a history of drug use. He denied current drug use, but Doreen said, "I'm not so sure." Roger was very suspicious of doctors and medication, routinely disparaging Doreen's efforts to enter treatment and actively discouraging her from taking medication. In fact, he routinely took her medications from the cabinet, perhaps selling them on the street, claiming, "You don't need these." He did not contribute financially to the household, and instead often demanded money from Doreen. The intermediate phase of treatment focused on helping Doreen set some limits with Roger. She had no wish to end the relationship; however, she admitted that she had trouble getting her needs met in it. Therefore, her therapist began to help Doreen's identify and articulate what she wanted from Roger.

The therapist suggested that they first work on the conflict over Doreen's seeking treatment for bipolar disorder. Doreen asked for some educational materials to give Roger in the hope that he would eventually "come around", but also decided to hide her medications in a new, secure location so that he would be unable to take them from her.

Because Roger often showed up unannounced in the middle of the night, contributing to Doreen's erratic SRM, they also worked toward helping Roger understand that he was only welcome to "show up" before 10 p.m. Initially, Roger was enraged by these limits and disappeared for 2 weeks. When he returned, however, he was conciliatory, and Doreen felt empowered by her capacity to "stand firm" with him. She then decided that she would refuse to give any more money to Roger unless he did some things around the house to help her (fix a broken door, etc.), a decision which helped her feel more competent in the management of both her household and her relationship.

Doreen's mood stabilized after 4 months of treatment, and she graduated to the maintenance phase, which focused on helping her tolerate medication side effects, develop more effective ways to manage her hectic schedule at home, and manage disputes with Roger. Given her multiple psychosocial problems and history of stopping medications precipitously, the therapist felt it important that Doreen continue psychotherapy indefinitely.

Understanding And Treating Bipolar Disorders

Understanding And Treating Bipolar Disorders

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