All posts by James DelGenio

Individual, Family, and Couples Counselor with over forty years of experience as therapist, author, and continuing education provider.
Bipolar Mood Disorders

How to manage Bipolar Disorder and Denial?

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By: James E. DelGenio MS, LCPC
Senior Staff Therapist,
The Family Institute at Northwestern University


Denial is the biggest obstacle to management and recovery of Bipolar Mood Disorder.

People with bipolar disorders, in particular, seem to have the most issues with denial and are, therefore, the most difficult people to treat from a therapist stand point. Through self-deception, rationalization, justification, and excuse making, a person can deny that they have a problem when everyone around them sees that the problem is obvious. This seems to be most common with Bipolar Disorders.

Denial usual takes place around several key issues. They are: acceptance of the disorder, the use of medication in helping manage the disorder and the detrimental role of alcohol and substance use or abuse in achieving wellness.

When clinical depression is the disorder; it is biological. It is genetic in origin. One can usually trace it in family history. It may be a grandparent, parent, uncle or cousin, even if it was never formally diagnosed, the history is typically there. No matter how much one tries to pull themselves up by their bootstraps and try harder, they will not make a significant impact on managing their symptoms. Even a skilled CBT therapist, employing cognitive behavioral techniques will not make a significant difference in the management of the disorder.

This means that medication is indicated. Some women, generally more men will initially refuse medication. I often hear, “I won’t take medication.” I describe my view and experience in general terms. If that is not enough to convince them, I will agree to cognitive behavioral therapy for period of time. If there is still no impact on symptom management through clearly defined goals, I revisit the medication issue to encourage reconsideration. Ultimately, it’s your life; you can be a victim of your disorder or you can choose to manage it. It doesn’t happen often but I have discontinued treatment and offered some referrals to other therapists who are willing to treat the disorder without the help of medication. Personally, I just can’t do it at least not for very long.

This is also true around the use of alcohol and recreational drugs such a marijuana. Remember, alcohol is a depressant. When you are already depressed why make it worse. Initially it helps but then it slams you in the days that follow. That is why it is known as self-medicating.

Some clients, again mostly men will refuse to consider stopping the use of marijuana. Yet the reason they have initiated treatment is panic and anxiety. Duh! Though not addictive per se, marijuana is habit forming psychologically. Prolonged daily use may cause anxiety and panic for those with a mood disorder. Take medication or stop using. I encourage both.

Though denial can be an issue for both men and women, I have found that men especially do not want to admit that they have a problem. They are generally more resistant to seeking help, taking medication or facing dependence.

In my practice, I recognize that this is a trust issue. If I feel that this will be an issue, I will put the referral for a medication evaluation off for a time while building a therapeutic relationship. I also address this resistance as most therapists do by comparing mood disorders with other physical disabilities such as diabetes or epilepsy. All are physical issues with a genetic origin which affects thinking and behavior. If your doctor told you, “I’m sorry to inform you that you are diabetic like your father was”, you would not like it but would likely be willing to take insulin injections.

The same thought process regarding antidepressants or mood stabilizing medication should apply with a diagnosis of mood disorder. There really is very little difference! Until you can accept your issues and play the hand you were dealt by genetics, environment and personality traits, you will be unlikely to manage your life well.

This will affect your marriage, relationships, employment and your ability to cope with day to day life. There is no soft way to peddle this. A psychiatric evaluation will determine if medication is appropriate. Medication does the first 50% and is considered the foundation. Once on the right medication at the right dose, symptom management with a skilled therapist will likely be more successful. Once this is addressed, we are more likely to resolve relationship issues through individual, family or couples counseling.

Case Scenario
Case Scenario: Denial or Acceptance – Beth
Beth is a twenty something year old female who enjoys partying with friends. Her friends can drink, smoke pot and stay out until 4am without major negative impact on their life. Beth cannot. Her partying has made her medication ineffective.

She initially presented with severe anger issues. She reported that she would lose control, even become violent. She was already on an antidepressant but it wasn’t helping. The symptoms of clinical depression including her lack of motivation, poor sleep, poor concentration and tendency to withdraw and isolate have come to a head. She reported that her anger was out of control. In addition, she had no motivation and had difficulty getting out of bed. She was experiencing panic and anxiety and had thoughts of suicide.

Beth can’t do what her friends did almost every weekend. I encourage someone like this to track their alcohol and pot use in the days after to see if this can help her connect the dots. It’s tough when your friends can do it but you can’t. I always remind my clients that they do have a disability that they need to manage. This makes them different, not bad, just different. However, if she makes the connection then it becomes a choice. A choice to be a victim of her disorder or a choice to be well. You’re only to blame if you ignore it. Then you need to be held accountable.

Payment and Insurance:
Blue Cross and Blue Shield PPO insurance welcome. Cash, check, Visa, Master Card or American Express accepted.

Zoom

Now I can work via zoom with anyone, anywhere in the country and it may still be covered by BCBS Insurance.  Check with your BCBS representative for more information.

Call James E. DelGenio MS, LCPC, Senior Staff Therapist at The Family Institute at Northwestern University, 847-733-4300 Ext 638.

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication, if necessary, and supportive therapy.  Always share this material and your questions about this material with your doctor and therapist.

Alcohol Dependence, Couples, Premarital Issues, Relationships

What are the Benefits of Premarital Counseling?

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By: James E. DelGenio MS, LCPC
Senior Staff Therapist,
The Family Institute at Northwestern University

The Benefits of Premarital Counseling.

Premarital counseling can help ensure that you and your partner have a strong, healthy relationship. This will give you a better chance for a stable and satisfying marriage. Premarital counseling can also help you identify weaknesses that may become larger problems during marriage. Good marriages don’t happen by accident. Many issues can be resolved prior to marriage with the help of a therapist. Common issues addressed may include: mental health issues, work, finances, drug and alcohol use, lifestyle, spending habits, credit card balances, student loans, savings, retirement planning, roles and responsibilities, children, parenting, in-laws, and leisure and fun. Marriage requires an understanding of yourself, your future spouse, and the tools and skills you need to make it work.

Does your significant other have a Mood Disorder?
Some moodiness is a part of everyone’s life; sometimes we feel happy, other times we are sad; some days we have lots of energy, while at other times we may be fatigued and unmotivated. When mood changes interfere with your ability to function, work or go to school, when they harm your relationships significantly, when they cause you to miss sleep, abuse drugs, or behave in ways you later regret, or when they lead to risky behaviors, thoughts of suicide, or losing touch with reality, your mood requires professional attention.

If this sounds like you’re intended. All is not lost. The key factor in this decision is Denial. If your partner tends to deny issues now, do you really think it is going to get better later?

I find that most premarital couples are well aware of their intended’s mood and alcohol/substance issues. My main questions are as follows:
Is he/she:
• Willing to seek help?
• In need of psycho-education?
• Willing to take medication, if prescribed?
• Willing to honestly address alcohol and substance abuse issues?
• Willing to see a therapist for relationship issues and support?

Rules of Engagement
All couples need rules for fighting. The most important rule is civility and respect. This, of course, means no hitting or throwing ever. If there is physical violence, you must call the police. Beyond that essential rules are no screaming, swearing, or name calling ever. This is destructive and may lead to your undoing as a couple. Couples need to work on resolving conflicts in their relationship with civility and respect so that bitterness and resentments can not build. It is possible to argue, resolve conflicts, and agree to disagree. In order to do this, all couples need rules of engagement for conflict. Establish your rules!

Finances and Spending
One of the biggest causes of problems in relationships is differences in values and goals and habits when it comes to money, and especially communication about money issues. That old saying is true …. money can’t buy you love, but it sure can tear it apart.

This makes a discussion of finances necessary before marriage. Learn how to talk about money, and align your financial goals such as retirement, savings, spending, debt, and disposable income. If you can do those two things, you’ve done more than most couples, and you’ve done a lot to start your relationship off on solid ground.

I therefore, recommend meeting with a financial planner to discuss issues such as spending, use of credit cards and financial goals. Goals should include the following: savings, pension contributions, retirement planning, debt, discretionary spending, school loans and the use of credit cards. How will you handle school loans and debt brought into the marriage? How much money can be spent without consulting the other. I usually recommend $100 to $300.

Family Ties and In-laws
A family is made up of many unique individuals, each with a range of thoughts and opinions on almost every subject and situation. Add to the mix extended family with their countless beliefs and personal opinions and there is no wonder there are disagreements from time to time. Conflict is simply the natural and healthy progression of any relationship

Some questions to explore – What sort of relationship do you have with your extended family? Are they local? Do they like your fiancée? Are they affectionate? Are they over-involved or critical? Have there been any major conflictual issues?

I suggest that couples begin to see themselves as their own family unit. When addressing family of origin, always say that “we” will have to discuss the event or holiday and that he or she should respond to their own family unit. This is especially true once children enter the picture. Now consider, if you want to see us come over………  This way the kids don’t have to get up open presents and get in the car! Now your doing what is best for family.

Religious Beliefs
This potentially contentious issue should always be discussed in premarital counseling. The first step is to seek a better understanding of your future spouse’s religious and spiritual background.
Topics to look into are:
• How to reconcile differing ideologies and practices
• How to observe and celebrate each other’s holidays
• How to raise children so that they are exposed to both partners’ traditions without being overwhelmed and/or confused
• How to integrate both extended families, especially during the wedding/holidays

Case Study:

Mark is not religious; Eileen is and expects to go to Church every week. What if they did marry and had children; would Mark go to Church then?
What if Mark is Catholic and Eileen is Jewish? Will one of you convert? Does it matter at all? What will the respective families say? That is a big question especially in regard to child rearing.

“What do you mean; you are not going to raise the baby Catholic? Jewish?” For some, the consequences of that decision may be long lasting or a deal breaker. It is clearly better to decide before marriage and tell both families about your decision. In discussions with the extended families, always use the phrase “we” have decided.

Children and Parenting
Do you want children? How many and when? Are there already children from previous relationships? Have you discussed blended family issues? What do you expect from your spouse regarding parenting/step parenting roles? When a problem arises, how does my partner communicate? What are the responsibilities of each parent in raising a child?

I strongly recommend that you have two to four years together as a couple before you have children. This time is critical, it gives you the opportunity to get to know one another as a married couple.

Children don’t bring you closer together; they create stress and sometimes distance especially if you and your intended are not on the same page regarding roles and responsibilities. And even more stress when ex’s and step in-laws are in the picture.

Blended families have a lot to discuss: the ex, custody issues, the in-laws, parenting, finances, loans, debt, child support, etc.. They especially need premarital counseling. I am surprised at how often these have not been fully addressed.

I believe that the children don’t come first; your relationship comes first. Now I know that is not true but if you divorce, it will be children that suffer most. Of course, my point is don’t forget to make time for your relationship after you have children. Planning for alone time or date night is a key component in addressing this issue. Take turns planning so the wife isn’t doing it all. But above all – Parent as a team! Be consistent with consequences. Discuss issues prior to discussing them with the children. What to say and how to say it.

Work, Lifestyle, Leisure and Fun
What sort of lifestyle do you want? Will you both continue to work when children are born? Do you have the same idea of what is fun? Where will you want to live?

Today most couples are comprised of two working parents. Couples want to maintain or improve the lifestyle they had going into the marriage. This is difficult in today’s economy and job market. For the first time in history, couples may not meet or exceed their parents’ lifestyle. The common expectations of employment today are long hours and work from home in the evening and on the weekend. This reduces quality time together. These forces necessitate compromise and making the most of the time you have together. Planning mutually enjoyable activities and social events and balanced with appropriate alone time is a key component in maintaining a strong relationship.

Final Thought
You may not feel you NEED premarital counseling, but it is still wise choice to consider. You may be on cloud nine with the impending marriage but counseling may help bring up and resolve some difficult topics. Better to discuss issues before marriage then with a divorce attorney later.

Zoom!

Now I can work via zoom with anyone, anywhere in the country and it may still be covered by BCBS Insurance. Check with your BCBS representative for more information.

Call James E. DelGenio MS, LCPC, Senior Staff Therapist at The Family Institute at Northwestern University, 847-733-4300 Ext 638.

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication, if necessary, and supportive therapy. Always share this material with your doctor and therapist.

Bipolar Mood Disorders, Substance Dependence

Denial  is the biggest obstacle to being well when you have a mood disorder.

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By: James E. DelGenio MS, LCPC
Senior Staff Therapist,
The Family Institute at Northwestern University

What is the biggest obstacle to managing depression?

Denial is the biggest obstacle to management and recovery of a mood disorder or alcohol and substance dependence.  Through self-deception, rationalization, justification, and excuse making, a person can deny that they have a problem when everyone around them sees that the problem is obvious.

Denial usual takes place around several key issues. They are: acceptance of the disorder, the use of medication in helping manage the disorder and the detrimental role of alcohol and substances on achieving wellness.

When clinical depression is the disorder; it is biological. It is genetic in origin. One can usually trace it in family history. It may be a grandparent, parent, uncle or cousin, even if it was never formally diagnosed, the history is typically there. No matter how much one tries to pull themselves up by their bootstraps and try harder, they will not make a significant impact on managing their symptoms. Even a skilled Cognitive Behavioral Therapy (CBT) therapist, employing cognitive behavioral techniques will not make a significant difference in the management of the disorder.

This means that medication is indicated. Some women, generally more men will initially refuse medication. I often hear, “I won’t take medication.” I describe my view and experience in general terms. If that is not enough to convince them, I will agree to cognitive behavioral therapy for period of time. If there is still no impact on symptom management through clearly defined goals, I revisit the medication issue to encourage an appointment with a psychiatrist.

Ultimately, it’s your life!  You can be a victim of your disorder or you can choose to manage it. Lets not make life more difficult then it already is. Try the medication for six months and see if it helps.   At least go hear what the doctor has to say.

This is also true around the use of alcohol and recreational drugs such a marijuana. Remember, alcohol is a depressant. When you are already depressed why make it worse. Initially it helps but then it slams you in the days that follow. That is why it is known as self medicating.

Some clients, again mostly men will refuse to consider stopping the use of marijuana. Yet the reason they have initiated treatment is panic and anxiety. Duh! Though not addictive per se, marijuana is habit forming psychologically. Prolonged daily use may cause anxiety and panic for those with a mood disorder. Take medication or stop using. I encourage both.

Though denial can be an issue for both men and women, I have found that men especially do not want to admit that they have a problem. They are generally more resistant to seeking help, taking medication or facing dependence.

In my practice, I recognize that this is a trust issue. If I feel that this will be an issue, I will put the referral for a medication evaluation off for a time while building a therapeutic relationship. I also address this resistance as most therapists do by comparing mood disorders with other physical disabilities such as diabetes or epilepsy. All are physical issues with a genetic origin which affects thinking and behavior. If your doctor told you, “I’m sorry to inform you that you are diabetic like your father was”, you would not like it but would likely be willing to take insulin injections.

The same thought process regarding antidepressants or mood stabilizing medication should apply with a diagnosis of mood disorder. There really is very little difference! Until you can accept your issues and play the hand you were dealt by genetics, environment and personality traits, you will be unlikely to manage your life well.

This will affect your marriage, relationships, employment and your ability to cope with day to day life. There is no soft way to peddle this. A psychiatric evaluation will determine if medication is appropriate. Medication does the first 50% and is considered the foundation. Once on the right medication at the right dose, symptom management with a skilled therapist will likely be more successful. Once this is addressed, we are more likely to resolve relationship issues through individual, family or couples counseling.

Case Scenario
 Case Scenario: Denial or Acceptance – Mary
Mary is a twenty something year old female who enjoys partying with friends. Her friends can drink, smoke pot and stay out until 4 am without major negative impact on their life. Mary cannot. Her partying has also made her medication ineffective.

She initially presented with anger issues.  In addition, she had no motivation and had difficulty getting out of bed. She was experiencing panic and anxiety and had thoughts of suicide. The symptoms of clinical depression including her lack of motivation, poor sleep, poor concentration and tendency to withdraw and isolate have come to a head.

Mary can’t do what her friends did almost every weekend. I encourage someone like this to track their mood in the 3 days after to see if this can help her connect the dots. It’s tough when your friends can do it but you can’t. I always remind my clients that they do have a disability that they need to manage. This makes them different, not bad, just different. However, if she makes the connection then it becomes a choice, a choice to be a victim of her disorder or a choice to be well. You’re only to blame if you ignore it. Then you need to be held accountable.

Zoom!
Now for the first time, I can work zoom time with anyone, anywhere in the country and it may be covered by BCBS Insurance. Check with your BCBS carrier for details.  Call Jim at 847-733-4300 Ext 638.

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com
http://takenotelessons.com  Effective on line, one on one, SAT, ACT, GRE, standardized test preparation, via face time or skype.

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication, if necessary, and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.

Bipolar Mood Disorders, Glossary of terms

What are essential elements of managing depression?

1 Comment

By: James E. DelGenio MS, LCPC
Senior Staff Therapist,
The Family Institute at Northwestern University

Essential elements in managing your mood!
While a severe mood disorder and/or addiction may not be curable, their results need not be chronic dysfunction. You need not be a helpless victim of a debilitating illness. The frustrating pattern of wellness followed by relapse can be disrupted with proper psychiatric support, therapy and an array of supportive services which ultimately teaches the person about their disability and how to choose to be well.
The fundamental operating principle is that each person has the capacity and responsibility to maintain a state of recovery. Gladstone, DelGenio, Taussig, et al. (1984) have identified interrelated elements which will reduce relapse and bring the person to a higher level of functioning.
These components are:

Structure addresses the importance of your daily routine the management of symptoms including medication management and compliance and the use of free time, physical activity, exercise, social activity and hobbies. Planning your day/week is key to management.

Psychoeducation refers to the guided experiential learning that takes place in individual, couple or family therapy.

Ongoing treatment and support via the level of service necessary to maintain a state of wellness. This is a step-down approach which gradually reduces the frequency of individual therapy from weekly to as needed.
These are further defined below:

Structure
First, you must recognize the need for structure in combating your disorder. Initially, structure means securing an array of supports including an individual/family therapist and a psychiatrist. Add Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or Smart Recovery meetings and professionally led alcohol and addiction groups for dependence or dual diagnosis. Most service providers are willing to collaborate with one another once written permission is obtained from the client. The collaborative support of the treatment team will create a common treatment plan. This will aid all providers to work in the same direction with common goals.
Once the treatment team is in order, the client learns the skills to combat the lack of structure in their daily life. This includes their medication management, i.e., taking the medication at the same time each day which will help ensure compliance. It also includes management of the sleep issues that mood disorders create. This means maintaining consistent sleep/wake habits. It is important to get up and get to bed at the same time each day.
In addition, many people are overwhelmed with common daily tasks such as grocery shopping, chores and laundry. These too can be structured by the day of the week and can become routine. I recommend that you spread out these tasks by picking various days of the week for each task. If it is Tuesday for instance, and that is the day you have picked to clean the kitchen, the day of the week makes the decision for you. This will help to address the lack of motivation which is so common among various mood disorders. The structure provided by this approach will hopefully be the foundation for success, permitting the person to achieve his or her individual capacity for stability and consistency.

Psychoeducation aka Experiential Learning

In the early 1990s, my father-in-law had a heart attack. Fortunately, there was little damage to his heart. What was discovered, however, was that his blood sugar was elevated. He was diabetic. When he moved out of intensive care, they began to teach him how to cope with his newly discovered disability. He learned how to measure his blood sugar and how to give himself insulin injections. He was taught what he could eat and what he could not. He even learned what to do if he had a reaction to a particular food or his medication. When he was discharged from the hospital, a nurse visited him at home several times a week for several weeks just to make sure that what he had learned in the hospital, he continued at home. Through education and experiential learning, my father-in-law learned how to manage his diabetes. He learned to manage his disorder so well that eventually he was able to take oral medication and discontinue insulin injections.
In psychotherapy, psychoeducation refers to teaching the person how to be well. The therapist will explore relationship issues, provide education about the disorder, symptoms, medication, relapse warning signs, and teach the coping skills necessary to maintain healthy functioning. I say, “This is not as obvious as if you are sitting in a wheelchair, but you do have a disability. You will need to learn how to manage it.”
Clearly, you will need a licensed therapist to assess and identify your disorder. The therapist will guide you through the experience and teach you how to cope with your symptoms. The goal of psycho-education is to help you maintain consistency in the management of your disorder. Without consistency in management of your moods, life will be a rollercoaster and much harder than it needs to be.
You may also be referred to a psychiatrist to confirm your diagnosis and possibly prescribe medication for you. Medication education is very much a part of psychoeducation. Initially, if necessary, the doctor will discuss the reasons for and purpose of the use of medication. In the case of mild or situational depression, a psychiatrist may help you determine if medication may be appropriate for a limited time. Typically, the psychiatrist will give you the option of taking medication and encourage continued psychotherapy for daily management. Additional services and supports may be necessary if alcohol/substance abuse and dependence are related issues.

Ongoing treatment
Ongoing treatment refers to the lifelong nature of many mood disorders. Some call it recovery, but to me that implies cured. I prefer to call it maintenance and stability. It takes about a year, sometimes two to learn all that one needs to know and experience to master the symptoms of a mood disorder. As time goes on and stability is achieved, the focus of treatment becomes about consistency in managing the symptoms. Unfortunately, there are those who say, “I feel good; maybe I don’t need treatment or medication anymore.” As much as I try to warn against this, even predict that this day will come, there are those who have to see for themselves. I guess some people just have to learn the hard way. I hope you hear what I am saying and take the less difficult route.
If you do want to try discontinuing medication, please do it with your doctor’s guidance. Typically, you discontinue these medications the way you began them, i.e. gradually. Though antidepressants and mood stabilizers are not addictive medications, an abrupt discontinuation will create uncomfortable side effects and may even be dangerous. Many people refer to the symptoms of abrupt withdrawal from medication as flu like symptoms.
Major depression disorders and bipolar disorders have become more commonly accepted by society in general thanks in part to high profile actors and professional athletes who have disclosed their disorders to the public. Clinical depression and bipolar mood disorders are biological/genetic problems that you most likely inherited and are considered no different than the diagnosis of other medical conditions such as epilepsy. Other mood disorders may be just as debilitating if left untreated. Most will require psychoeducation, medication, and ongoing treatment. These disorders are usually manifested in the teens and as late as mid-30s. Real changes come from within. With structure, psychoeducation, and ongoing treatment, you can control your disorder.
The most effective way to achieve stability and consistency is through ongoing therapeutic support. Initially this means weekly visits to the therapist and monthly visits to the psychiatrist. As time goes on and the client gains mastery over his or her disorder, the time between visits is extended. You will know because there will be less to discuss. I have clients who I now see monthly or even quarterly. I have found the best long-term results are achieved with ongoing therapeutic support. Practically, this means that we gradually step down the frequency of therapy after you stabilize and begin to master your disorder. Sessions are gradually reduced from weekly to as needed. This is just to check in and remind people that because they don’t have active symptoms does not mean that they are cured. The goal is stability and consistency.
Recovery means management of an intermittent lifelong disorder with only minor interference in one’s life and relationships.

Zoom

Now I can work via zoom with anyone, anywhere in the country and it may still be covered by BCBS Insurance. Check with your BCBS representative. Call James E. DelGenio MS, LCPC, Senior Staff Therapist at The Family Institute at Northwestern University, 847-733-4300 Ext 638.

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication, if necessary, and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.