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

Copyright, 2011, All Rights Reserved.

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.

Table of Contents

Manage your Mood

Dedication

About This Book

Chapter 1. Introduction

Chapter 2. Questions and Answers

Chapter 3. About the Author

Chapter 4. Mood Disorder Defined

Chapter 5. Symptoms of Depression

Chapter 6. Situational Depression – Grief and Mourning – The Author’s Experience

Chapter 7. Symptoms of Bipolar Disorder

Chapter 8. Dual Diagnosis – Alcohol or Substance Dependence and Mood Disorder

Chapter 9. Denial or Acceptance of the Problem

Chapter 10. Homework in the Management of Mood Disorders

Chapter 11. Psychiatric Treatment – Help the Doctor Help You

Chapter 12. Essential Elements in Management of Mood and Relationship Disorders

Chapter 13. Goals and Objectives of Treatment

Chapter 14. The Role of Family in Treatment

Chapter 15. How to be well

Chapter 16. Common Relationship Issues

Chapter 17. The Use of Homework in Couples Counseling

Chapter 18. The Benefits of Premarital Counseling

Chapter 19. Brief Tips on maintaining your relationship

Appendix

Glossary of terms

Supporting comments

Weekly review of consistency

Present this information to your Doctor

Social support

Continuity of care

BIBLIOGRAPHY

Dedication

I dedicate this work to my family and my love, my wife of 40 plus years who has supported me throughout our marriage and to my children. I am very proud of you. I love you very much.

I would like to acknowledge Psychiatrist Lee Gladstone MD, my mentor. I worked with Lee for 28 years. Lee always led by example and his subtle message…. Be a lifelong learner. At 80 years old, he would bring in a psychiatric journal and say, “Jim, look at this article; this is just what we were talking about.” This man contributed a great deal to our profession. I still miss Lee.

I would also like to recognize David Taussig, LCSW and Nishad Nadkarni MD, my colleagues, and friends. Both have influenced and supported me and have given me feedback and suggestions regarding this work. Thank you for being my friends.

I would like to praise my staff over the years who provide quality mental health services to those in need.

I hope that this work begins the process of providing individuals, couples and families with the knowledge and tools necessary to manage their disorders and to offer a blueprint for excellent communication and improved relationships.

About this Book

The challenge in writing a book about understanding mood disorders and the impact on relationships for the public is that the best and most productive discussions are normally face-to-face. My goal then is to establish a rapport with you. It is just one reason I have woven some of my personal life experiences into this work. As you will see, my life has had its difficulties just like yours. We are all in this together.

Convention Used in this Book

I am not going to fill your head with medical jargon, so relax. In a straightforward way, we will explore together:

• Mood disorder, what is it and what causes it?
• Symptoms of mood disorders.
• Impact on relationships
• What you need to know.
• How to manage symptoms and improve coping skills.
• How to begin the journey to be well.
• The role of family in treatment of a loved one.

We will also look at common marital and relationship issues.

• Common marital issues.
• Tips for addressing conflict in any relationship.
• Rules for conflict and engagement.
• Benefits of premarital counseling.

For your convenience, there are also some easy-to-use forms which will help you track your progress.

• Doctor reporting form.
• Weekly review of consistency to help structure your week.
• Relaxation technique.

What you will learn. Manage your mood disorder or it will manage you!

• Psychoeducation, what you need to know.
• Coping skills and management.
• Common relationship issues and tips.
• Inspiration to find the right balance and enjoyment in your life.
• It is no one’s fault unless you do nothing.
• Practical guidance and goal setting.

This book does not replace treatment.

This book is designed to help you understand, control, and maintain good mental health when dealing with mood and relationship issues. You can use this book to gain deeper understanding, but it is NOT a replacement for therapy. Many mood disorders require a psychiatrist to access the need for medication and a skilled therapist to guide one through the process of learning how to be well. If medication is a part of the treatment regimen, it often provides a very necessary foundation for the experiential learning done with the therapist. In some instances, without medication, treatment with a therapist will be less effective or possibly ineffective.

With or without the need for medication, guided experiential learning with a skilled therapist is essential for management of symptoms and their impact on your daily life and relationships. The therapist holds the client accountable by encouraging the practice of the appropriate management and coping skills. Since there is no taking a day off from management, weekly discussion with a therapist will help the client learn to identify issues, set, and review goals and maintain stability. Only with weekly review of consistency with a skilled therapist will one learn true management of their disorder. As one gains mastery over their symptoms, frequency of treatment with the therapist may be stepped down. Eventually, treatment may be discontinued or simply reduced to as needed.

Note: Alcohol and substance dependence may require additional services and ongoing supports.

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.

Chapter 1.
Introduction

This book will not resolve all the issues associated with mood disorders without professional intervention. My goal here is to begin the process of identification and education. I want to help familiarize you with symptoms, terminology, facts, and related issues. I would also like to aid you in managing and coping with your disorder and to help you minimize the impact that it has on your daily life and relationships.

Historically, mood disorders have been prevalent in a large segment of the American population. The National Institute of Mental Health estimates that about one in seven people in the United States have a diagnosable mental disorder. So ultimately, if you have a mood disorder you are not alone. Surely, you or someone you know and love struggles with a mood disorder. Together, we will explore ways to bring your life back into balance.

In all, I have over 40 years of experience as a clinician, speaker, and continuing education provider. I have seen a lot of issues, counseled a lot of people, and helped people cope with some of the most severe mental health issues out there. I certainly have not seen it all, and I have learned enough after 40 years to know that I have not and never will. Each person’s uniqueness brings all kinds of flavors to different situations. What I have seen are mood disorders and marital conflicts of all kinds. And yes, there are ways to better manage your life and your marriage.

There are common symptoms and issues associated with a diagnosis of a mood disorder. Similarly, there are common marital issues that couples face. I will use these common themes and present examples of common case scenarios to represent issues related to various disorders and issues I have treated over the past 40 years. In some cases, real people have given permission to use their story as case studies. Even these cases are disguised to protect privacy and altered for demonstration purposes. Any other semblance to a real person is therefore purely coincidental to the common diagnostic issues of the subject matter.

Many symptoms of depression and other mood disorders are commonly associated with marital and family conflict, sleep issues, irritability, anxiety, panic, OCD, social dysfunction, and alcohol and substance abuse or dependence. These symptoms may vary from person to person as the specific diagnosis indicates but essentially the management issues are the same.

However, you have come to this book, whether you bought it, found it, or borrowed it, no doubt you are dealing with issues in your life for which you need help. We all experience issues in life that are difficult – that is a part of life’s journey. There is simply no way to avoid stress in society today. You will need to understand your disorder and its impacts on your life. Then you will need to learn the skills to manage it consistently. This will minimize the impact that a mood disorder has on your life and relationships, especially your marriage and family.

Perhaps this is one of the reasons why we are put here on this earth with millions of people around us, to help each other through good times and bad. It is my hope and wish that you will gain a better understanding of your disorder, learn some management skills, and begin the journey toward wellness because if you don’t manage it, it will manage you!

Chapter 2.
 Questions and Answers

The following is a list of commonly asked questions and answers. I believe this will give the reader an overview of mood disorders followed by case examples and common marital and premarital conflicts and issues. Please review them carefully; I also recommend that these questions be reviewed periodically.

1. What is a mood disorder?
2. Why shouldn’t you drink alcohol if you are not an alcoholic?
3. Why is a mood disorder and alcoholism often found in the same individual?
4. What is dual diagnosis?
5. What is addiction?
6. What are the symptoms of a mood disorder?
7. What are the symptoms of addiction?
8. How do these disorders interact with one another?
9. Can a mood disorder be compared to a physical illness?
10. How does a mood disorder affect thinking and behavior?
11. What should you report to your psychiatrist?
12. Will you have to be in treatment the rest of your life?
13. . Why is medication compliance so important?
14. How do you cope with the past?
15. Why are recreation, exercise, and socialization so important?
16. What if you do not feel motivated to do the things suggested here?
17. What are relapse warning signs aka positive symptoms?
18. What are the negative symptoms of a mood disorder?
19. What are the most common causes of relapse and regression to symptoms?
20. When should you call your doctor, 911 or go to the hospital?
21. What do you do if you cannot sleep?
22. What is the role of the family in treatment?
23. What can family members do to minimize the risk of relapse?
24. How can family members learn to cope?
25. Who is responsible for your happiness?
26. What are the goals of treatment?
27. What medications do you take?
28. Why is psychiatric medication useful in controlling symptoms of depression?
29. What if you are inconsistent in taking your medication?
30. What are the possible side effects of psychiatric medication?
31. What are the benefits and purpose of psychiatric medication?
32. What does one do if there is a medical emergency?
33. Should the client or family adjust medication dosage if symptoms reappear?
34. How does one learn to make healthy choices?
35. How to be well.

 What is a mood disorder?

A Mood disorder is a generic term for people experiencing mild to severe depressive disorders, bipolar disorders, situational depression, grief, loss, panic and anxiety disorders, phobias, personality disorders and other disorders which may include alcohol or drug abuse or dependence. (Brown, Wang and Safran, 2005)

Clinical depression and bipolar disorders have become more commonly accepted by society generally and thanks, in part, to high profile actors and professional athletes who have disclosed their disorders to the public. Clinical depression and bipolar disorders are biological/genetic problems that you most likely inherited and are considered no different than the diagnosis of other medical conditions such as diabetes or epilepsy. These require education, medication, and ongoing treatment.

 It is also important to note that not all mood disorders are lifelong or require medication.

For the purposes of definition here, I use two quite different definitions to describe severe mood disorders. The first reflects denial of a problem and the second reflects acceptance of what is. Which one will you choose? The first definition is as follows:

Various forms clinical depression and bipolar disorders are lifelong disabilities, episodic in nature that may cause chronic dysfunction, asocial behavior, and failed relationships.

Here is a breakdown of this definition:

• Lifelong means there is no cure to date, though new medications, if taken as prescribed, have made many people symptom free.
• Episodic means that sometimes the symptoms are worse than at other times for no apparent reason though stressful life events can also have an impact on symptoms.
• Chronic Dysfunction includes inability to manage day-to-day events, unemployment, and often failed relationships.
• Asocial Behavior is that behavior which is irrational, inappropriate showing poor judgment and a lack of insight into one’s own behavior. This can include poor self-care and appearance. It may also include behavior that is harmful to oneself or others.
• Failed Relationships include social dysfunction, isolation, withdrawal, marital and family conflict and divorce.

The second definition is as follows:

Clinical depression or bipolar disorder are lifelong disabilities, episodic in nature that the individual can learn to manage with medication, education, and a skilled therapist. Other mood disorders may require a skilled therapist for ongoing support but may or may not require medication.

In some instances, denial will create failed marriages and conflictual relationships. These two definitions are separated only by education, psychiatric treatment, and ongoing therapeutic support. The key here is management of a disability. You manage it or it will manage you! How do you want to live your life?

 Why shouldn’t you drink alcohol if you are not an alcoholic?

Where mood disorders are concerned, use may very well be the same as abuse! Alcohol impairs functioning and it affects thinking, behavior, and relationships. Alcohol and substances such as marijuana and cocaine also affect thinking and behavior. Do not do anything that would make you relapse to active symptoms. It is known fact that alcohol and substance abuse make the symptoms of a mood disorder worse and vice versa. Alcohol is a depressant; one drink at a family gathering may affect one’s mood for days.

Alcohol also “washes out” and therefore may negate the usefulness of the medication for 6 to 10 days. Remember, it takes four to six weeks to get the medication to a therapeutic level. When you drink heavily you affect that level. In addition, one should never use alcohol or substances when taking prescription medication. This can be fatal. It is understood that if you are an alcoholic, you cannot have any alcohol. If you are not an alcoholic, you still need to check with your doctor for approval of one or two drinks on special occasions. In the days after, monitor yourself to see if it has affected your mood or relationship. If it does, use is the same as abuse!

 Why is mood disorder and alcoholism often found in the same individual?

The answers here are not completely understood. Some doctors have told me that the sites in the brain that are affected by mood disorders are the same sites affected by addiction. Regardless of the chemistry, research has shown that just casual use of alcohol by a person with a mood disorder may eventually result in abuse or dependence. If you have a severe mood disorder, you should not have any! The consequences are just not worth it.

 What is dual diagnosis?

Dual Diagnosis means that two or more independent disorders exist in the same individual. Specifically, for our purposes, when I speak of dual diagnosis, I am referring to mood disorder and alcohol dependence or addiction. Each exists independently of one another and yet each makes the other worse. Both are biological and psychosocial disorders with similar symptoms. They are lifelong disorders, which cause the person to be prone to relapse. Both require integrated treatment that includes psychiatric treatment, medication, psychotherapy, education, symptom management and additional supportive treatment such as Intensive outpatient (IOP), group therapy and Alcoholics Anonymous.

 What is addiction?

An Addictive Disorder is the preoccupation with acquiring alcohol and/or drugs, compulsive use of alcohol and drugs despite adverse consequences and a pattern of relapse to alcohol and drug use despite the recurrence of adverse consequences (Miller, 1991).

 What are the symptoms of a mood disorder?

Clinical depression and bipolar disorders are biological disorders that can usually be traced through family history whether it was formally diagnosed or undiagnosed. Mark the symptoms under A and B with a check mark. If you have four or more related symptoms, discuss these symptoms with your psychiatrist or therapist.

1. Symptoms of depression, anxiety, panic, grief, loss

__ Lack of pleasure, loss of interest and energy.

__ Lack of goal directed behavior.

__ Lack of motivation, lethargy.

__ Inability to structure time, poor concentration.

__ Anger, hostility, irritability, resentment.

__ Strained relationships, marital issues, divorce, loss of friends.

__ Withdrawal, isolation, would rather be alone.

__ Difficulty in coping with the past or stuck in the past.

__ Sleeping too much or too little.

__ Anxiety, worry, sadness, low mood, tearful.

__ Paranoia or false beliefs, negative thinking, rumination.

__ Feeling guilty, stressed, or hopeless.

__ Poor self-care including hygiene and diet.

__ Aches, pains, dizziness, headaches, or stomach aches.

__ Unintentional weight loss, gain.

__ Crisis prone, police involvement.

__ Low sex drive.

__ Thoughts of suicide, homicide.

 What are the symptoms of a bipolar disorder?

Bipolar Disorder formerly known as manic depressive disorder is a mood disorder in which people may have mixed episodes of mania and depression. These symptoms may also include some of the above and in addition the following.

__ Rapid mood fluctuations.

__ Feeling high, euphoric, or having inflated self-esteem.

__ Irritability, hostility, anger.

__ Aggressive or risky behavior.

__ Pressured, fast speech, more talkative than usual.

__ Racing thoughts, skidding from subject to subject.

__ Delusions of grandeur, grandiose beliefs, or behavior.

__ Poor judgment, lack of insight, false beliefs.

__ Poor self-control.

__ Little or no need for sleep.

__ Increased activity, sexual drive and impulsivity including spending.

__ Easily distracted, poor concentration, short term memory issues.

__ Alcohol and substance abuse.

__ Bizarre dress and appearance.

__ Thoughts of suicide, homicide.

The above symptoms of depression and bipolar mood disorders are widely accepted. Since these disorders have a biological basis; a psychiatrist manages the medication while the therapist provides treatment and support. The therapist support often includes psychoeducation, symptom reduction and management, increased coping skills and management of other day to day stressors such as job loss, school failure and relationship issues. The psychiatrist, therapist, family, friends and of course, the patient must work together as a team to construct an effective approach to these disorders. The most important aspect of this is effective communication.

There are two types of bipolar disorders. They are Bipolar I and Bipolar II. Bipolar I is considered the more severe of the two disorders and has more extreme episodes of mania or depression. It may also have psychotic features such as delusions and paranoia. This generally includes being out of touch with reality. Bipolar II is characterized by milder swings of mania and depression and may have less serious effect on daily routine, relationships, or employment. Both bipolar I and bipolar II need ongoing treatment and medication to manage the symptoms well.

7. What are the symptoms of addiction?

Category of Drugs	Symptoms of Intoxication	Symptoms of Withdrawal	Symptoms of Prolonged Use
Depressants   Alcohol Barbiturates Tranquilizers Opiate derivatives Codeine Morphine Darvocet Demerol Vicodin Percocet OxyContin Fentanyl Heroin	Irritability   Drunkenness Depression Drowsiness Slurred Speech Psychosis Mood Changes Memory Loss Confusion Euphoria Constipation Itching, hives Skin flushing	Anxiety   Depression Restlessness Insomnia Panic Irritability Confusion Tremor Diarrhea Cold sweats Dilated pupils, tearing Nausea Vomiting	Hallucinations   Delusions, paranoia Thought disorders Depression
Stimulants   Cocaine Amphetamines Nicotine Caffeine	Depression   Mood Changes Violent Behavior Impulsive Behavior Antisocial Behavior Insomnia Paranoid Psychosis Racing Thoughts Delusions Euphoria	Depression   Irritability Insomnia Tremors Delirium Abdominal Cramps Lethargy Restlessness Panic Hallucinations	Hallucinations   Delusions, paranoia Thought disorders Depression
Hallucinogens   LSD Mescaline PCP DMT STP MDA	Mood Changes   Hallucinations Delusions Depression Paranoia Anxiety Panic	Paranoia   Visual Hallucinations	Hallucinations   Delusions, paranoia Anxiety Depression
Cannabis   Marijuana Hashish Hash Oil	Impulsivity   Panic, Fear Apathy Confusion Moodiness Suspiciousness	Cravings   Flashbacks Hallucinations	Hallucinations   Suspiciousness Anxiety Depression

8. How do these disorders interact with one another?

Mood disorders and alcohol and substance abuse do not interact well. In fact, each makes the other worse, especially when one is using and/or not taking medication as prescribed. One must manage both disorders simultaneously and treatment must be a collaborative effort with the level and the array of services necessary to maintain stability, sobriety, and consistency.

 Can a mood disorder be compared to a physical illness?

It is helpful to think of someone you know who is diabetic and what it means to be a diabetic. Mood disorders may not be as visible as sitting in a wheelchair, but you do have a disability. Mood Disorders, addiction and diabetes are comparable in many ways. Each is a lifelong, biological problem that requires daily attention, education, and support.

Medication, when taken as prescribed, stabilize each condition but knowledge and training play an especially significant role in healthy functioning. The comparisons demonstrate that mental illness, like other physical handicaps, can become manageable handicaps; not the global disability it is for some. It is a result of genetics, an imbalance in the chemistry of the brain. No one is at fault, and no one is to blame. Mental illness is a lifelong disability, episodic in nature that one can learn to manage, with hope and with dignity.

 How does a mood disorder affect thinking and behavior?

The symptoms of mood disorder and addiction are similar. In fact, the treatment is also similar. Once medically detoxified, a person with mood disorder may be prescribed the same medications as in the treatment of substance abuse. It often takes a year or more of sobriety to determine if the person is suffering the effects of addiction or mood disorder or both as in dual diagnosis. You may have heard of the term dry drunk. This refers to someone who is alcohol free but has not addressed the accompanying mood disorder. This includes irritability, hostility and relationship issues and conflict.

 What should you report to your psychiatrist?

The Doctor needs your honest input to best help you. If any of the following are problematic, report them to the doctor. Write things down. (See Doctor reporting form in the appendix)

Report on:

1. Medication compliance.
2. Changes in your symptoms including:
3. Sleep patterns
4. Low mood or manic behavior
5. Concentration, poor short-term memory
6. Disturbing thoughts, nightmares
7. Negative thoughts, rumination i.e., negative thoughts on repeat
8. Drug and alcohol use.
9. Medication side effects or allergic reactions.
10. Social activity or isolation.
11. Self-care.
12. Physical activities, hobbies, chores.
13. Poor money management.
14. Unusual behavior.
15. Thoughts of self-harm or threats to others.

 Will you have to be in treatment the rest of your life?

I would like to say no but many remain on medication their entire life. Therapeutic support may or may not be necessary after a time, depending on how well one learns to manage their disability. I have clients who see me a few times per year just to check in and reinforce their self-management. Some people with severe mood disorders may go in and out of the hospital their entire life if they remain in denial. This is usually a result of non-compliance with treatment and medication combined with alcohol and/or substance abuse. I try to point out that though you are not sitting in a wheelchair; it is not as visually obvious a disability but if you have a mood disorder you do have a disability. Mood disorders and addiction can be global disabilities or manageable handicaps. Medication and ongoing supportive treatment may be essential for maintaining healthy functioning.

 Why is medication compliance so important?

The number one cause of regression and recurrence of symptoms is not taking medication as prescribed. This is not like having a headache. When you have an ordinary headache, you take two aspirin and twenty minutes later your headache is gone. For antidepressant medications to work effectively, one must maintain a certain level in the body. When that level in not maintained, debilitating symptoms reappear. These medications take four to six weeks to reach their peak level of effectiveness. When you miss doses of medication you negatively affect that level.

How do you cope with the past?

Many people with mood disorders have difficulty coping with the past. Sometimes they appear to be living in the past, unable to get over some stressful life event. This needs to be explored with a doctor and therapist. This is a clear sign of depression and medication will most likely be necessary. When one dwells on the past, they often have difficulty coping with the present. I like the adage, yesterday is done; worry about today and tomorrow will take care of itself.

 Why are recreation, exercise, and socialization so important?

It is good to have fun. Have fun! People with mood disorders often become engrossed in the past, their illness, and problems. Recreation and exercise (especially walking) are good for depression and anxiety and are a great distraction when one is experiencing symptoms. Any physical activity is likely to be therapeutic. Distraction from symptoms is an important coping skill. The tendency to isolate and withdraw also need to be overcome. The Internet, video games, TV or reading generally do not qualify as distraction for most individuals.

 What if you don’t feel motivated to do the things suggested here?

Lack of motivation is often a direct result of a mood disorder. It is a symptom. If you wait to feel motivated, it may never happen. Walk 40 minutes per day at least 3-4 days per week with your doctor’s permission. Pick your days and let the day of the week make the decision for you. This will help to avoid, “I don’t feel like it today; I’ll do it tomorrow.” Unfortunately, tomorrow never comes. Do your chores and exercise on the days you have picked to do them. Try to have at least one social activity per week. Plan to have fun. Adding structure to your life addresses many common symptoms of a mood disorder but especially lack of motivation.

 What are relapse warning signs aka positive symptoms?

Relapse warning signs are also known as positive symptoms. They are positive because they are present, active, and uncontrolled by medication. These symptoms are typically a result of medication noncompliance or alcohol and drug use. Without intervention, these symptoms can have serious impact on thinking, judgment and behavior and may also include psychiatric hospitalization, danger of self-injury and harm to significant others or the community.

Relapse Warning Signs reflect symptoms that include:

1. Thoughts about hurting oneself or others.
2. Changes in one’s sleep/wake cycle, especially little or no sleep.
3. Inability to concentrate, rapid speech, skidding from subject to subject.
4. Rapid mood fluctuations, mania, or depression, especially negative rumination i.e., negative thoughts that repeat over and over again.
5. Hallucinations or delusions.

What are the negative symptoms of a mood disorder?

Negative symptoms are traits most often missing in the individual. They are characterized by the absence of:

1. Motivation or goal directed behavior.
2. Pleasure.
3. Insight.
4. Good judgment.
5. Self-care, hygiene.
6. Emotional expression.

These symptoms are only partially controlled by medications. They are often what are left when positive active symptoms are controlled. It is for this reason that a person with a mood disorder still needs guided experiential psychotherapy.

 What are the most common causes of relapse and regression to symptoms?

19. Medication noncompliance.
20. Alcohol and/or substance use or abuse.
21. Little or no sleep.
22. Social isolation.
23. Family conflict.

 When should you call your doctor, 911 or go to the hospital?

Call your doctor or pharmacist if you are experiencing medication side effects or an allergic reaction. When you are thinking of hurting yourself or someone else, call your doctor and therapist. If you are actively considering hurting yourself, call 911, go to the emergency room, or call the National Suicide Prevention Helpline, 1-800-SUICIDE (1-800-784-2433).

 What do you do if you cannot sleep at night?

Little or no sleep is a relapse warning sign. Mood disorders cause sleep/wake cycle problems. First stop drinking caffeinated beverages or eating food that contains caffeine. Do not nap during the day. Take your medication as prescribed. Maintain abstinence from alcohol and substance abuse. Maintain a consistent sleep-wake cycle. Always discuss your sleep issues with your doctor. Insomnia can be a precipitating event for relapse to active symptoms and possibly self-harm or harm to others. In this event, call 911 and/or your doctor.

 What is the role of the family in treatment?

The role of the family in treatment is simply to monitor and report. The family should observe the patient’s behavior and report anything that may be important to the stable functioning and health of the patient. The patient should not be interfered with directly unless, of course, s/he is a danger to themselves or others. The family’s role in treatment is a collaborative effort in communication. The family should think of themselves as team members. We are all on the same team! Keeping secrets from the doctor or therapist interferes with treatment and may ultimately have dire consequences. Families should call their doctor, therapist immediately or 911 if the patient has any of the following behaviors or symptoms, especially if they are new, worse, or worry you. Call when the patient is:

1. Not taking their medication as prescribed.
2. Abusing alcohol, substances or uses medications not prescribed by a doctor.
3. Severely depressed, irritable, threatens violence or expresses thoughts of suicide or dying.
4. Exhibits behavior which may result in injury or harm to the individual, family, or community.
5. Experience of any relapse warning signs, especially no sleep.
6. Experience of panic attacks, uncontrolled anxiety, or restlessness.
7. Acting on dangerous impulses.
8. Exhibits unusual behavior that is out-of-character for this individual.

In most cases I have treated over the years, I have seen the client get annoyed with friends and family when they say, “You seem crabby, did you take your medication today?” The typical response is “just because I’m angry or upset doesn’t mean I’ve skipped my meds.” The way I see it, if you have a history of noncompliance, you do not have the right to be angry when asked! Take the medication as prescribed so your family does not worry about compliance or need to be intrusive in your life. They should be relatively assured that you are compliant with medication and treatment. Regardless, it is the responsibility of the family to ask because the consequences of not taking it as prescribed can lead to regression to symptoms, self-injury, or harm to others.

 What can family members do to minimize the risk of relapse?

The following are frequent causes of family conflict and should be discussed with the doctor and therapist.

1. Monitor and report on medication compliance.
2. Monitor and report on the use of alcohol and drugs.
3. Avoid critical comments. Use “I feel” statements.
4. Avoid over involvement unless the person poses a danger to himself or others.
5. Avoid excessive pressure to achieve.
6. Avoid trying to help motivate compliance.

 How can family members learn to cope?

Mental illness is no one’s fault. It is a bio-psycho-social problem.

1. Avoid placing blame or guilt.
2. Don’t enable! You are not responsible for the patient’s wellness. S/he is!
3. Make regular opportunities to get away from each other. Have outside interests, hobbies, and social activities.
4. Get regular cardiovascular exercise. Join a health club or walk at least 40 minutes on regularly scheduled days each week. In the winter, use a treadmill or stationary bicycle.
5. Learn all you can about mood disorders but do not try to be a therapist.

 Who is responsible for your happiness?

Who owns the problem? Don’t blame others for your disorder or problems. We have to play the hand that was dealt us via genetics. That does not necessarily mean that relationship conflicts are not real or are just imagined but they can be exacerbated by the disorder and may need to be addressed in couples counseling or family therapy. Remember, a mood disorder is a biological problem like diabetes. If you don’t manage it, it will manage you.

 What are the goals of treatment?

The goals of treatment of mood disorders are typically as follows:

1. Be evaluated by a professional to identify if a disorder is present.
2. Have a psychiatrist identify the need for medication, if any
3. Learn about the disorder and to recognize active of symptoms of the disorder.
4. Learn symptom management.
5. Learn coping skills, especially distraction through structure. Structure is created by having regularly schedule of activities, hobbies, and social support.
6. Encourage regular socialization.
7. Encourage regular cardiovascular exercise at least 4 times per week. (Take a brisk walk at least 40 minutes.)
8. Encourage hobbies and attention to daily chores.
9. Be consistent in the use of coping skills.
10. Learn to identify regressive symptoms, i.e., relapse warning signs and triggers.
11. Learn how to make healthy choices.
12. Learn how to be well.

Generally, goals fall into five overlapping areas: See which ones may apply to you in addition to the ones described above:

3. Medical
4. Social activity and support
5. Coping skills
6. Daily living skills
7. Personal
8. Medical
9. Take medication as prescribed.
10. Report the presence of symptoms, suicidal or homicidal thoughts.
11. Maintain abstinence from alcohol and substance abuse.
12. Avoid caffeinated beverages, especially if sleep is poor.
13. Maintain a healthy diet and daily living skills.
14. Get medical and dental check-up annually.
15. Maintain psychiatric and therapeutic contact.
16. Have lab testing as directed by your doctor.
17. Report your sleep/wake cycle to your doctor.
18. Report medication side effects and allergic reactions to your doctor.
19. Social activity and support
20. Have at least one social activity per week.
21. Try to avoid napping during the day.
22. Join a club, call a friend, and take a class get a hobby.
23. Make plans for the weekend.
24. Coping Skills
25. Read goals daily, put a copy on the refrigerator at home.
26. Take a brisk walk 40 min at least 4 times per week.
27. See your doctor, especially when you are experiencing symptoms.
28. See your therapist regularly for support.
29. Check in with family and friends regularly and express your feeling appropriately. Try to avoid conflict.
30. Work on a hobby a half an hour every day or when you are experiencing symptoms as a distraction.

Note: Always consult with your doctor before starting any exercise regimen.

5. Daily Living Skills
6. Bathe daily.
7. Dress appropriately.
8. Do chores on selected days.
9. Do volunteer work on assigned days.
10. Go to work, be on time.
11. Manage your finances.
12. Personal
13. Always maintain civility and respect.
14. Make healthy choices.
15. Spend quality time with your family and friends.
16. Improve your self-esteem.

 What medications do you take?

You should always know the name of the medication, the amount of medication and the frequency of the dosage. For example: “I take 20mg of Escitalopram (Lexapro) in the morning”. This will help ensure that medications given by other physicians will not be contraindicated. In addition, you should always ask your pharmacist about drug interactions. Don’t forget to mention any supplements you may be taking. A list of medications and dosages should also be carried on one’s person in the event of an emergency.

 Why is psychiatric medication useful in controlling symptoms of depression?

Mood disorders are considered bio-psycho-social disorders. They affect thinking and behavior and frequently create relationship issues. Medication and medication management are typically essential in the management of the biology or the chemistry of the disorder. I consider this to be the foundation of treatment. It is difficult if not impossible to treat clinical depression without medication. You cannot build a house without a good foundation. Medication provides that solid foundation. To say it another way, medication does 50% while your management of the disorder does the other half.

Therapy addresses psychosocial treatment issues including identification and management of symptoms, daily living skills, coping skills and it can address the relationship issues which often accompany these disorders.

I do on occasion have clients who refuse medication. In the past, I have either chosen to discontinue treatment or say, “we will have ten sessions and see if we can make an impact on your symptoms.” If it does, that is great. If it does not, I will try to deal with the denial. In my experience, I have found that men have more difficulty with the notion of taking medication then do women. What if I told you that, “You are a diabetic and must be on insulin injections the rest of your life?” Of course, most people would not like it, but chances are they would do it. Why is this any different? I will also not hesitate to point out that alcohol is a drug, and you are self-medicating with a depressant. This may lead to alcoholism or substance abuse and addiction. At some point, I may give up and discontinue treatment. That does not happen very often because I can be very convincing, but it does happen.

 What if you are inconsistent in taking your medication?

The key word here is consistency. Medication is extremely important to maintaining mental health. It is the foundation of treatment. If you are not consistently taking the medication, you will have difficulty functioning effectively on a day-to-day basis. This is not a headache. You take two aspirins and twenty minutes later your headache is gone. These medications do not work that way. Remember, it takes four to six weeks to maximize the therapeutic effect of the medication. You must build up to a therapeutic level. When you miss medication, you affect that level. You may need to ask for assistance from family or friends. If you miss more than five pills a year, I consider you to be noncompliant with your medication. Always take the medication as prescribed. If you have concerns, side effects or allergic reactions contact your doctor or go to the ER or call 911.

 What are the possible side effects of psychiatric medication?

Know that all medications have side effects. Even aspirin can cause ringing in the ears if you take too much. The pharmacy must list all side effects but that does not mean you will experience them. Most of the common psychiatric medications for depression and mood disorder have very few if any side effects after the first few weeks. First, ask your doctor about allergic reactions and side effects and what to do in the event of a serious reaction. Always read the medication information given to you by the pharmacist. S/he is also a useful source for questions about medications.

The most common side effects are typically: nausea, diarrhea, blurred vision, sleepiness, insomnia, dizziness, or headache. These usually go away in the first few weeks. If these or any side effect becomes severe or you simply have concerns, contact your doctor, or go to the ER. Know the possible side effects and allergic reactions of your medications. You should always know the name of your medication, frequency, and the dosage in milligrams. Carry a card in your wallet which will tell emergency personnel exactly what you are taking. If you have questions or concerns, direct your questions to your doctor or pharmacist. Dial 911 or go to the Emergency Room for serious allergic reactions and side effects. The more you know the safer you will be. (Read the pharmacy materials)

 What are the benefits and purpose of psychiatric medication?

Mental Illness is a disease very much like diabetes. It takes insulin to manage diabetes; it takes psychiatric medication to manage depression and other mood disorders. Some say you just must be tough. “You just have to pull yourself up by your bootstraps and try harder.” This is false. The only way to successfully manage a mood disorder is with education, medication if necessary and ongoing treatment and support.

 What does one do if there is a medical emergency?

Call 911 immediately!

 Should the client or family adjust the medication if symptoms reappear?

Always contact the doctor when faced with positive (active) symptoms. Do not self-medicate. A doctor never operates on himself or his own family. Do not play doctor! Remember, the leading causes of relapse are medication non-compliance and drug or alcohol use. The doctor cannot medicate you properly if he does not know honestly what the patient is or is not taking including alcohol or substance use!

Rule of thumb: never lie or withhold information from your doctor or therapist.

 How does one learn to make healthy choices?

Sometimes people do not recognize the choices they make may not be healthy. This falls under the symptoms of lack of insight and poor judgment. Once stable and consistent, some clients simply need to check-in with me a few times per year. Others need ongoing supportive therapy every two to four weeks to remain consistent. The frequency will depend on the individual and how well one manages their disorder. Together with your doctor, therapist, and ancillary support if necessary for dual diagnosis, you can learn to manage your symptoms and cope with the day-to-day stress of a mood disorder. This is the reason that ongoing support from your doctor and therapist is essential for management.

 How to be well.

Coping with depression or mood disorders is no easy task! It takes professional support, medication, psychoeducation, and experience to manage debilitating symptoms. With the necessary supports and monitoring, persons with mood disorders can learn to:

1. Take your medication as prescribed. (Problems: contact your doctor or go to the ER)
2. Control symptoms with exercise, chores, and hobbies.
3. Remain stable by making healthy choices
4. Have a network of friends and supports
5. Maintain employment.

I have also found that it takes an average of 6 months to one year to reach these goals. In some cases, it may even take longer due to sensitivity to medication or allergic reactions. In still others it may be the first try at medication fails to control the symptoms and the doctor must switch to a different medication. Obviously, this will cause a delay in controlling symptoms. A company called GeneSight can do genetic testing when a person has difficulty finding the right medication at the right dose. They can tell you and your doctor which medications would work best for you.

In addition, many people will need some level of support on and off for their entire lives. The essential point is you cannot do it alone! You need a psychiatrist to manage your medication and a therapist to provide ongoing support. If things do not go well after a time, I would not hesitate to get a second opinion. (See Chapter 15 for more detail on how to be well)

Chapter 3.
About the Author

In 1974, I began working with people with severe and persistent mental illness as the co-founder and director of a community-based adult psychiatric day treatment program near Chicago. Throughout the years, I have provided direct services and developed numerous innovative outpatient programs. My work in community mental health has helped refine my cognitive behavioral approach in the treatment and support of individuals, couples, and families within the community. I have continued to champion psychoeducation and the role of medication in treatment and the management of mood disorders.

As a nationally recognized speaker and consultant, I have conducted hundreds of continuing education workshops to mental health professionals across the nation on services and treatment of mental illness and mood disorders and their impact on relationships. In addition, as Executive Director of the PHI Workshops, I published three handbooks: The Partial Hospital Handbook, The Comprehensive Community Support Handbook, and Cognitive Rehabilitation in the Treatment of Mood Disorders and Dual Diagnosis. After 35 years of Community Mental Health Services and achieving the role of Vice President, I retired from public service.

Today, I am a practicing therapist with The Family Institute at Northwestern University. I work via zoom and accept BCBS PPO. I employ a variety of clinical approaches, including Cognitive Behavioral Therapy (CBT) and Experiential Learning in the treatment of couples, families, and individuals.

Clinical Interests: Assessment and treatment of anxiety, stress, panic, grief, depression and other mood disorders, severe mental illness, support for alcoholism and addiction treatment, and common marital and family issues such as lack of civility and respect, poor communication, intimacy issues, infidelity, bickering, parenting conflict, financial stress, pre-marital and divorce issues.

Specialization: Treatment of individuals, couples, and families in which one or more persons has depression, mood disorder, or conflicts about alcohol and substance use.

Many therapists believe that you do not offer anything of yourself to the client. My training and experience say otherwise. Of course, this is a selective process based on who is sitting in front of me and what I choose to share.

As I have said, I am willing to share with the reader some of who I am by disclosing some of the life events that I have experienced. If that helps you see me as a person in the context of this work, then I am good with that. I know that trust is an essential ingredient of any relationship.

Life’s ups and down’s

I grew up in near west suburban Chicago. It was an Irish and Italian community, mostly Italian, though the O’Brian’s down the block had 14 children at last count. I am of Irish, Italian, and Polish descent. Mom was half Irish and half Polish. My father worked 5 jobs to pay the bills for a family with four children, 3 boys and the oldest a girl. Therefore, he was not around much and was emotionally unavailable.

There was another sister, but she died when she was two and that was long before I was born. I was told this was 1941, about a year before penicillin was developed in March of ‘42. She got measles which led to complications and encephalitis. She would have been the second oldest. After the death of my mom, dad, and my oldest sister, strangely enough, I also missed my sister Virginia. It is said that every loss we experience reminds us of every other loss we have ever had. As a clinician, I know that is true. I never knew her but sometimes I miss her and wonder who she might have been.

Mom and dad were married 49 years when my mom succumbed to cancer. That was the mid ‘80’s. I was almost 38; my son was almost five. At the time, I was working as a program director for the mental health center.

Mom said near the end that she would have liked to have seen who my son would become because he was a prodigy and he was her favorite grandchild at the end of her life, though she would never have admitted that to anyone else. So finally, after 6 years of marriage when this little boy came on the scene with his big personality and obvious intelligence, he won her over big time.

One positive by-product of this was that we had 6 years together before children. Children bring immense joy but also stress, especially in the first year. On a professional level, people are too quick to get pregnant these days and do not really give themselves a chance to get to know one another as a married couple. The running joke in the family was always who the favorite was among my siblings. From my point of view, it was always my sister because she was my favorite too, but that question was never really answered. That is how mom wanted it. All of us were favorites for distinct reasons.

 1967

I attended Benedictine University in Lisle, Illinois. The Psychology Department was very research oriented so when Dr. Alex Shukin, a visiting Professor came to teach Counseling Psychology, I gravitated to it. Before graduation in 1970, I applied to George Williams College in Downers Grove, where Dr. Shukin was the Dean of the Counseling Psychology Graduate Department, and I was accepted. It was a small private school, but it had a great Psychology Department with highly qualified faculty. It was largely one-on-one experiential learning.

I, of course, was not immune to life’s stressors, experienced situational depression, loss of a relationship just before I started graduate school. My girlfriend of over three years wanted to get married. I wanted and needed to get a master’s in psychology to be a licensed therapist. She was not willing to wait. It was a tough way to begin graduate school, but it was the right choice for me. As it turned out, she was married just seven months later. Fortunately, I had faculty and fellow graduate students all around me who helped me deal with my grief.

 1972

My first job was a part-time teaching position at Triton College one night per week. I was making $36.50 per week. It was just weeks after I graduated from graduate school in December of ’71. I had graduated five months early because I went straight through the summer having no summer job prospects that year.

I met my wife to be at a sandlot football game in January of 1972 just weeks after graduation from graduate school. About six months later, her mom died suddenly of a series of strokes. She called early Friday evening to cancel our date and said her mom was taken to the hospital as she had fainted. She said, “I’ll call you tomorrow.” When she called, she told me it did not look good for her mom. I paced around at home until my mom asked. I told her I really liked this woman and did not know what I should do. I decided to go to the hospital, and I got there just before her mom passed away. I supported her as best I could through the wake and funeral.

Later, she reminded me that in her very traditional Italian family, there could be no engagement or wedding plans for one year during their mourning period. I was fine with that as we needed more time just dating and I still was not ready to marry. We eventually married in the fall of ’74.

 1973

My first full-time job was as a Police Counselor in a Northern Illinois suburb. I was hired by the Chief of Police and the Mayor to work with the juvenile officer. I had secured an office in the high school as a place for kids to drop-in to talk about whatever. I was hired thanks to a grant from the Illinois Law Enforcement Commission (ILEC).

When the grant ran out, it was up to the Village to pick up my position and salary. It became a huge political battle. It was on the news and in the newspaper. This was the major’s final term before he intended to retire. He did little to help his Trustee’s to get re-elected so when it became time for the town to pick up my salary hundreds of people were attending the Village board meetings in my support; people were even picketing in front of the Village Hall to retain me in the position. It was heartwarming to know that I had made an impact. Though the story made the newspaper and TV but to no avail. Others stood up who were friends of the Trustees and said, “We need our potholes repaired.” In the end, they had the majority vote, and my position was eliminated.

A man from the Lake County Prosecutor’s office called and said. “Mr. Jim Thompson heard about your situation,” and asked if I was interested in working for the Illinois Department of Children and Family Services out of Waukegan, IL. Of course, Mr. Thompson went on to become the Governor of Illinois, one of the seemingly few governors in Illinois that has not gone to jail. I took the position.

It was not long after I started my new position that I knew this was not the job for me. I saw things that I never wanted to see. I took a baby with his mother to the hospital with cigarette burns by mom’s boyfriend and that was mild compared to some of my assignments. I spent half my week in court and half attending to crisis calls. I knew I could have little impact on the lives of these families and children. It made me physically ill to see all that I saw. I knew I could not stay.

 In 1974, I applied for a position as a program director for a new service in community mental health in Illinois. This was where I wanted to be. My understanding is that it was President Kennedy who helped form community mental health centers throughout the country. I was to develop and direct a day treatment program designed to reestablish people with serious mental illness back into the community from long term care hospitals. The introduction of new medications developed for the most part in the late 60’s that would help control their symptoms thus allowing persons with severe mental illness to return to the community. It would be considerably less expensive than housing patients in long term State Psychiatric Hospitals.

Our job was to develop a day treatment program that would reintegrate people back into the community and keep them out of State Hospitals. This was occurring all over the country. Six new staff all came together for the first time on May 6th, 1974. We had just three weeks to get to know one another and to develop and design a program to keep people out of the hospital.

We were young and enthusiastic, so this is exactly what we did. We did not have a budget for furniture, so we took 2×4’s and particle board and made benches for people to sit on. We got hand-me-downs from our own families like a kitchen sink, tables, a refrigerator, gas stove and a couch. Obviously, we were still underfunded and did not have much money to buy supplies or equipment. Leave it to the State of Illinois to mandate a service and then underfund it. Not much has changed in that respect.

It was rough in those early days. These new medications were crude at best with lots of uncomfortable side effects which made it difficult to maintain people on their medication. It very was difficult to keep people out of the hospital, but we did in large part, thanks to Lee Gladstone MD who was our psychiatric consultant for the program.

Dr. Gladstone worked in Scotland with Dr. Maxwell Jones who developed the concept of The Therapeutic Community. Dr. Gladstone would come twice a month to see patients and evaluate their medication. He also met with the staff to discuss issues and our approach to treatment. He always said, “Teach them about their disorder. Give them feedback about their attendance, participation, hygiene, social interactions both within the program on outside the program.” He also said, “Give them feedback about their appropriateness in the community.” In other words, could you tell by looking at them or by their behavior that they were seriously mentally ill?

I will add by the way, that this was the start of the vast majority of homeless people on the street that you see on a daily basis today. Many studies say that 70 to 90% of homeless men have mental health and substance abuse issues. In the early ‘70’s, State Hospitals reportedly drove patients into the city and released them with no support and very little income. When your disability check is less than $600 per month, you have a choice; you can eat or have a place to live, not both. In any case, the national average for relapse to the hospital among programs like ours was 44%. Our relapse rate was just under 7%. We published our findings in a ten-year study in the International Journal of Partial Hospitalization in 1986. This is the basis for what I refer to today as The Weekly Review of Consistency. (See Weekly Review in the appendix).

Each time Dr. Gladstone would come, his message was essentially the same, “Teach them and give them feedback” about their progress as I stated earlier. One day after he left, I took our only blackboard, and divided it into 8 sections across the top with a permanent marker. There was medication compliance, attendance in the program, personal hygiene, and participation in the program, socialization within the program, outside activity which meant socialization outside of the program, cooperation, and appropriate behavior. Down the left side, we had the first name of each of our clients in chalk. Each Monday, we would hold a group called Peer Review because the other clients were also encouraged to present information about the client we were reviewing for the previous week. The goal was to get all eight checks across the board consistently. This worked very well and was the foundation of our program and our success.

 1986

In 1986, I started doing Continuing Education workshops in over 60 cities throughout the country. I did 18 to 25 workshops per year for 14 years. The largest of the workshops was for a statewide conference in San Francisco. By the late 90’s, I was getting recognition as a speaker and consultant. After hearing my presentation earlier in the year in San Diego, a woman called and asked if I would be willing to be the only presenter on the first day of a major two-day conference. The second day presenter was a well published and highly respected Psychiatrist named Kenneth Minkoff MD. We were speaking on Dual Diagnosis, i.e., mood disorders and alcohol and substance abuse and dependence.

It was electrifying to stand in front of 300 plus professionals who were Psychiatrists, Psychologists, Clinical Social Workers, and Clinical Counselors and case managers listening to me for 5 hours! My presentation was well received with incredibly positive written reviews. People knew I was speaking from experience and not theory. On the second day, during the lunch break, many people approached me to tell me how much they enjoyed and learned from my presentation. Though they liked Dr. Minkoff, they felt that I was speaking as a person who had been in the trenches of treatment. It was very flattering to hear. Though I am sure they paid him double what they paid me but no matter. The recognition and exhilaration alone would have been enough to do it for nothing.

In the early spring of 2001, I flew into a snowstorm in NY. The airline lost my luggage, my workshop materials and I got into my cold hotel room at 3:00 am. I loved teaching but I needed a break from the travel aspect of it. So, I cancelled the rest of my workshops for that year. Then 9-11 happened and I said I am done with that part of my career. I have always enjoyed teaching, but the travel part got to be just too much.

 9-11-01

On 9-11-01, I was driving to work when I heard the first report of a plane hitting one of the twin Towers. My wife was a flight attendant at the time with United Air Lines and usually flew to the East coast and back on the same day. Flight attendants called these trips “mother trips” because they were usually flown by women with kids. She was always home when my children got home from school. After so many years, I only knew when she was coming home, not much about where she was flying. Then the second plane hit, and another hit the Pentagon and one went down in Pennsylvania. I started to think about what time she would arrive on the East coast and what time she would be flying back, and I began to panic. I called her cell repeatedly with no response. I keep watching the news to see if I could get any clues about where these flights originated. Still no call back.

When she finally called, I was so relieved to hear her voice that I began to cry and could not speak. She said, “Are the kids, OK?” When I could finally respond, I said, “They are worried about you,” My daughter was taken to the high school office to await any news about her mom. My son was at the University of Michigan, and he called and was relieved to hear she was OK. My wife connected with him and asked that he come home that weekend if he possibly could. He knew she needed to see him, and he did.

She told me when she called that she was in Denver and all air traffic was grounded until further notice. At that time, she had no idea how long the no-fly would be held. She did not know when or how she would get home. People were renting anything they could find, even U-Haul trucks to get home. She was standing in line hoping to rent a car with three other flight attendants from her crew. A man in front of her turned to them and said, “I have a car rented; all I have to do is pick up the keys. My colleague and I are going to Minneapolis if that would help.” They said, yes to this kind stranger.

It was a small compact car that really seated four, but they agreed that one of them would sit on the console between the two front seats and 3 would jam in the back and all would take turns on the console. They drove through the rest of the day and night. Along the way, the man said, “Forget it; we are going to take you to Chicago.” As they drove, they stopped for gas and food several times. Each time, people would ask who they were as all were watching their TV to see what was going to happen next. They responded that they were a flight crew with United. People could not do enough for them. One woman at an A&W restaurant in Nebraska said, “I’m sorry; I just cleaned and closed the grill down” but again they were asked, “Who are you people?” When she heard that they were a flight crew she said, “Order anything you want; it will just take a minute to reheat the grill.” She arrived early the next day exhausted and traumatized. We hugged and cried for a long time. To this day, she exchanges Christmas cards with that kind man who went well out of his way to help them get home.

All flights were grounded for five days. To deal with her fear, also known as Post Traumatic Stress Disorder (PTSD), she volunteered to take the first commercial flight into Washington, DC. There were only 8 passengers and I think three of them were armed Air Marshals. She felt safe as they approached the runway in DC. Two fighter jets came up on either side to accompany them right to the runway. She felt better until later when some idiot told her that they were not there to protect them; they were there to shoot them down if they diverted from the planned flight path. I am sure that was true but as I often say, always know who your audience is. Did she really need to hear that? She had to take a leave for 3 months with post-traumatic stress which is of course a depressive disorder.

 2009

The State of Illinois was in deep financial trouble. As a State funded community mental health center, I had not been able to fill vacant positions for several years and I had already lost several staff. The ultimate blow came in 2009 when the State owed about a million and a half dollars to the center, most of which helped fund my department, Adult Services. The result was that I had to lay off 15 people, nine in one day. Earlier in the year, there was a dinner to recognize my 35-year career along with others achieving multi-year milestones. I said to my wife on the way home that it felt like an ending rather than a celebration. Though I had anticipated staying another 3-4 more years, I knew that under the circumstances, it was time for me to go. I officially retired from the mental health center in mid-November. My thought was, now I can finish that fourth book that I had little time for previously.

At the time in ’09, I had been working part time for The Family Institute at Northwestern University in the LaGrange Park office. About a year later, the Institute offered me a full-time position. That brings me pretty much to date and that is enough about me. We all experience life’s ups and downs, even therapists. I hope that this disclosure about myself helps develop some trust in me and give you some insight into who I am and how I got to this point in my life.

Chapter 4.
Mood Disorder Defined

Mood disorder is a generic term for a variety of mental health disorders. This commonly includes people experiencing Situational Depression, mild to severe Clinical Depression, Bipolar Disorders, and borderline personality disorders to name a few. These disorders are often reflected by marital and family conflict and a general inability to function effectively on a daily basis. In many instances, alcohol and substance abuse are also symptoms associated with mood disorders. Even casual use of alcohol or substances may affect the management of symptoms commonly associated with mood disorders. In general, many adults drink casually and use marijuana without developing abuse or dependence but in contrast, very few patients with a mood disorder can sustain non-problematic use. If you have one of these disorders, I ask that you think about it this way.

This is not as recognizable as sitting in a wheelchair, but yes, you do have a disability. I strongly recommend that you recognize it, accept it, and get the help you need to manage it effectively.

The symptoms of clinical and situational depression and other mood disorders are commonly associated with marital and family conflict, irritability, disinterest, anxiety, panic, social dysfunction, and alcohol and substance abuse or dependence. Dr. Samuel J. Keith said, “marital and family conflict are present often enough that they are given symptom status.”  That is a significant statement. Symptoms may vary from person to person depending on the specific diagnosis, but essentially, the issues are the same.

Historically, mood disorders have been prevalent in a large segment of the American population. The National Institute of Mental health estimates that about 57.7 million people – or 26.2% of the American population of adults aged 18 or older – had a diagnosable mental disorder. One in six will experience a mood disorder and one in sixteen will experience a severe mental health issue. So ultimately, if you have a mental disorder, you are not alone. And yes, it is manageable.

In most instances, denial of these disorders will result in a person spending his or her life struggling with mood, employment, and relationship issues. Severe cases may result in frequent hospitalizations and possibly harm to oneself or others.

For our purposes, I use two vastly different definitions to describe these disorders. The first reflects denial of a problem, and the second reflects acceptance of what is. Which one will you choose?

The first definition reflects denial:

Clinical depression and bipolar disorders are lifelong disabilities, episodic in nature that may cause chronic dysfunction, asocial behavior, and failed relationships.

A breakdown of this definition is as follows:

Lifelong means there is no cure to date, though new medications, if taken as prescribed, have made many people almost symptom free.

 Episodic means that sometimes the symptoms are worse than other times, for no apparent reason, although stressful life events can also have an impact on symptoms.

 Chronic dysfunction includes inability to manage day-to-day events, employment, and often, relationships issues.

 Asocial behavior is that behavior which is irrational and inappropriate, which is reflected by poor judgment and lack of insight into one’s own behavior. This can include poor self-esteem, negative thinking, and neglect of personal care and appearance. It may also include behavior that is harmful to oneself or others. Failed relationships include social dysfunction, isolation, withdrawal, marital conflict, and divorce.

The second definition reflects acceptance of what is:

Mood disorders and bipolar disorders are lifelong disabilities, episodic in nature that the client can learn to manage with hope and with dignity.

The consequence of ignoring mood disorders or relationship issues may have a serious impact on your life. The more you know, the easier it is to control and the less it will interfere in your day-to-day life and relationships. The essential point is: “How do you want to live your life?”

No one is to blame as these are genetic issues. Situational depression caused by stressful life events may not be lifelong but may also have a serious impact on your life and relationships. Together we will lay down the foundation for success, but it is you who is responsible for your own success. This is your disorder, and these are the symptoms associated with your disorder. This is what you need to do to manage it; “How to be well.”

Chapter 5.
Symptoms of Depression

If left untreated, symptoms of depression may worsen and severely disrupt one’s life. It can cause untold suffering and possibly lead to hospitalization, strained relationships, divorce or even suicide. Recognizing the symptoms of depression is often the biggest hurdle to the diagnosis and treatment of depression. I will list the symptoms; see how many apply to you. Typically, if you recognize more than three or four from the checklist below you should consider getting some help. I will discuss symptoms further in relation to the case scenarios I present.

Symptoms of depression checklist: Note the symptoms that apply to you.

__ Lack of pleasure, loss of interest and energy

__ Lack of goal-directed behavior, lack of motivation, lethargy

__ Lack of insight into one’s own behavior

__ Inability to structure time, poor concentration

__ Anger, hostility, irritability

__ Strained relationships, marital conflict, loss of friends

__ Withdrawal, isolation, would rather be alone.

__ Difficulty in getting along with people.

__ Sleeping too much or too little.

__ Anxiety, worry, sadness, low mood.

__ False beliefs, negative thinking, rumination

__ Feeling guilty, stressed, or hopeless.

__ Poor self-care including hygiene and diet

__ Aches, pains, dizziness, headaches, or stomach aches

__ Unintentional weight loss or gain

__ Crisis prone, police involvement

__ Low sex drive

__ Thoughts of suicide, homicide

Case Study – Major depression triggered by losses – Mary

Mary is a truly kind, intelligent women. She reported that she had the world by the tail. She had a loving husband and a supportive family. She had a well-paid, high-profile job that she quit abruptly due to conflict with her new boss. She could no longer tolerate situations that she perceived to be unfair. Her anger would spin out of control, and she felt to be at the mercy of her emotions. Her job loss was a major issue even though she quit.

Her concentration and memory were off; she was not motivated; she was not sleeping well and was overcome with her anxiety and anger. Even her loving husband would “catch hell” for no good reason as she reported. The best part was she knew what she was doing but could not help or stop herself.

She also talked of her mother and the relationship she had wished they had but never did. Mom passed away almost two years prior. As we discussed her family, her grief and anger with mom spilled out. She never felt loved, but she sought her approval. Mom never seemed to appreciate her efforts and gave her attention to other siblings. In the end, when mom passed away, they were not speaking, and nothing was ever resolved. There was the regret and anger that so often accompanied losses.

Her losses had triggered a major depressive episode. I referred her for a medication evaluation, and she was prescribed an antidepressant. Now we could begin work on processing her losses. We worked on “I feel” statements. This allowed her to express her emotions in a civilized way. We processed her losses while working on a new way to manage her emotions. This was a yearlong process. Today she is back on her feet enjoying her life, her husband and family.

Anger is a normal emotion and not in and of itself a problem. In fact, all emotions are normal; it is what we do with them and how we manage them that is the key. Remember, anger and depression can be the flip side of the same coin. Uncontrolled anger may come from depression or other mood disorders. Your psychiatrist will help determine the diagnosis and prescribe the appropriate medication to control the accompanying symptoms.

Case Study – Major Depressive Disorder, Recurrent and Severe – Joe

In 1987, I began working with a man with a long history of hospitalizations. He had a major depressive disorder. This means that there does not need to be a reason in his life for depression. This is from within; this is a genetic issue that he inherited from a parent or grandparent. Joe had been hospitalized over 50 times previously. He had been struggling with his disorder long before he was formally diagnosed at age 20; he was forty-six when I met him.

We first began our journey with education. He learned about the mood disorder he inherited from his grandmother. It was clearly a genetic issue – clinical depression. He began to recognize and understand his symptoms and their effect on his decisions and outlook. He gained some insight into his own behavior. He learned to understand the role of medication in keeping him stable. He had never consistently taken the medication as prescribed. There was no stability in his life and his parents had come to enable him in remaining in a sick role. They had come to that place as a way to survive the situation. They simply wanted peace and gave in to his demands to avoid the conflict and chaos created when he did not get his way. It was perfectly understandable and quite a common scenario but now it was time for some changes.

My role was to ensure compliance with the medication and to curb mom and dad’s enabling behavior along with Joe’s threats. This took weekly individual and family therapy to ensure progress toward the goals of independence and stability. A major step in the recovery for Joe was to move him out into an independent living situation. It took months of family meetings to convince mom and dad that Joe needed to learn to be independent. But first I needed to convince Joe that there was a better way to live his life. That in and of itself was no easy task. In addition, there were risks! Of course, there were risks. Joe could follow through with his threats to kill himself. This was the emotional blackmail he held over mom and dad. I made it perfectly clear that he could in fact follow through with his threats, but it was clearly time to make some changes. He needed to be held accountable for his behavior and the choice to continue to be a victim of his disorder. He had never taken responsibility for his disorder; he blamed everyone else for his unhappiness.

So, I made it clear that even if he chose to go back to the hospital when he was discharged, he would return to his apartment not mom and dad’s house. Regardless, he would never live with them again. I told Joe, “Don’t bother trying to sabotage the plan.” I explained that if he did not gain independence while mom and dad were living, he probably never would. After mom and dad had passed, he would likely spend the rest of his life in a supervised living arrangement or nursing home. He clearly did not like that idea.

Mom and dad were onboard and that made an enormous difference. They knew they could not continue to live with the conflict and chaos. Joe agreed reluctantly because he really had no choice. He never knew any other way so it took a lot of trust building to get him to see that there could be another way to live his life. He needed to be independent and to develop his own social network of friends and support. We had to remove him from his family home, stop his threats and minimize contact with mom and dad. It was a process; we started with two nights per week in the apartment and gradually moved toward seven. It was a struggle that took over a year to accomplish.

Joe was highly intelligent. Once he overcame his resistance to change, he took guidance well. He learned about his disorder and how to manage his symptoms. He learned that there was another way, a better way to live his life. He was stable and enjoying life. He was having fun. He had developed good coping skills and a social network of friends. He felt more fulfilled than at any other time in his life.

Then in 2005, his brother passed away and his dad died seven months later. He was experiencing situational depression and grief in addition to the major depressive disorder he was managing well for over ten years. He came to me and asked,

“Will I have to go back into the hospital?”

Jim, “Let me ask you some questions. Are you taking your meds as prescribed?”

Joe: “You know I do.”

Jim: “Are you using alcohol or drugs?”

Joe replied, “You know I don’t.”

Jim: “Are you being social?”

Joe: “You know that I am.”

Jim: “Do you utilize your hobby to manage free time?”

Joe replied: “You know I do all those things I’m supposed to do in order to be well.”

Jim: “Then you won’t need to go into the hospital.”

Joe “But it feels the same as when my depression was out of control.”

Jim: “Yes but the symptoms of your mood disorder and the symptoms of grief feel the same, but they are not. Grief is normal and depression is not.” It still feels the same.

I cannot stress this enough: when you have a mood disorder, it is difficult to tell the difference between depressive symptoms and grief symptoms. They appear and feel identical. Knowing the difference and seeking help is the key to management.

Joe never did go back to the hospital. He had learned about his disorder and how to recognize relapse warning signs. He knew the importance of medication compliance. He followed his homework plan and used distraction, exercise, hobbies, and socialization to manage his symptoms. Joe was in control; he had learned how to be well. Joe has made his mood disorder a manageable handicap rather than the global disability it was before we met in treatment.

Case Scenario: (OCD) obsessive compulsive disorder – Mary

Mary is 22 years old, highly intelligent from a well to do and loving family. She reported that her obsessions were interfering with her ability to function. She was afraid of germs, constantly washing her hands, checking door locks numerous times before leaving the house, constantly counting the number of times she had to do things before she could let go and move on. There was also a family history of depression. I referred her to a psychiatrist for a medication evaluation. She was prescribed an antidepressant which of course helped but she still needed to learn symptom management and explore issues related to her personality.

Her symptoms were in large part a defense against anxiety and guilt. If she did these compulsions, this behavior would keep bad things from happening. Initially, she could not identify what the terrible things were. The strategy was to identify and explore what was really making her anxious.

She came from a solid family with strong moral values. She was a virgin and denied her sexual feelings. Her guilt over her sexual feelings was the basis for her compulsions. It is important to note that the depressive gene was present, and this is how her personality manifested her depression. Once she was able to disclose her guilt, we were able to normalize her feelings. This took about six months.

Case Study – Post Traumatic Stress Disorder (PTSD) – Mary

Post-traumatic stress is commonly associated with returning war veterans. PTSD is more common than one might think. War veterans, police and firefighter are frequent victims of PTSD. They see horrific things almost daily.

This case scenario, however, is about an accident on the highway. It was a horrific accident, involving just one person. Mary witnessed a man riding a motorcycle go down in an area where there was construction. The man hit some gravel on the pavement; Mary was behind the man and witnessed the entire event. When he hit the pavement, his clothes were ripped from his body. His shoes flew up and hit her blood splattered windshield. Fortunately, she was able to stop safely. The man was badly hurt and dying. She got out of her car and went to him and held his hand and watched as he eventually stopped breathing before paramedics could arrive. She said she did not want him to die alone. She rose to the occasion but within days afterward she found herself angry and depressed. She had difficulty just getting out of bed. Her memory was off, and she had difficulty concentrating. Medication is frequently used along with therapy in which the victim is recalling the catastrophic event. Mary was able to recover and put the traumatic event in perspective. It was about a year and a half before she could discontinue the medication.

Seasonal Affective Disorder

SAD as many know it, is a type of depression related to the dark gloom of fall and winter with shorter days and less sunlight. SAD is exacerbated by a decrease in activity level that is generally created in the cold winter months. The symptoms are largely the same as for other depressive disorders including poor sleep and fatigue, crying spells, irritability, poor concentration, weight gain and loss of sex drive. In some severe cases, seasonal affective disorder can also be associated with thoughts of suicide.

Though symptoms usually improve in the summer, many people have found relief from the use of full spectrum lighting in their homes. These lights come in a variety of shapes and sizes and can be found on the internet. Probably the least expensive of these is the 27-watt full spectrum CFL bulb which can be placed strategically in fixtures and lamps throughout one’s residence. These are effective when used daily. Sometimes, however, these lights are simply not enough. In these cases, many of my clients have found relief by taking an antidepressant for a period of time and by increasing the level of physical exercise, especially cardio work.

Chapter 6:
Situational Depression – Grief and Mourning – the Author’s Experience

Grief, job stress or loss and divorce are good examples of situational depression. We will all face situational depression one day.

I had a horrific experience in 1991. At the time, my dad was a retired accountant, but his true love was playing the trombone for weddings, banquets and even concerts in the park. He would never retire from his music. Even now in his mid-seventies he always looked forward to any chance to play music with his cronies. It was a Wednesday in July, and he had band practice that evening. He called that afternoon to tell me he was going to play a concert in the park with his friend Louie and the band. He asked if the family could make it tomorrow night. I said, “We will be there.”

About 10:30 PM Wednesday evening as I was just getting into bed, the phone rang. It was my nephew. He was calling to tell me that after band practice, dad was driving home and was in a bad car accident. He said, I needed to get to the hospital right away. I said, “Is he alive?” There was an awful pause and he said, “Just get here now.”

Upon arriving at the hospital, I heard the words that I feared, “He is gone.”  Dad had severed his aorta on the steering wheel; I was told he died within 4 minutes.

The intersection where the accident occurred is a large one; normally cars turning left can turn on the green arrow only. But the intersection was under construction so that sign was covered. The other driver was a twenty-something year old coming home from work. Fortunately, he was not injured, and he was not high or drunk. As accidents happen, he assumed that Dad would stop on the yellow, so he turned left in front of him. Dad T-boned him.

Ironically, as I left the hospital that night, the kid from the accident was getting into the passenger side of his mother’s car as I was getting in my car on the driver’s side. There we were shoulder to shoulder. He knew who I was and I, of course, knew who he was. Neither of us said anything as we made eye contact almost nose to nose. I certainly understand the anger associated with grief but don’t think it did not cross my mind to start swinging but I controlled myself. I was taught to do the right thing regardless of what other people may have done. I felt better for using restraint.

My mother had passed about 7 years earlier, and when I compared my mom’s passing from cancer over the course of an exceedingly long year to the instant reality of my father dying in a car accident, I do not know which was worse. It was tough to watch my mom wither away, but I do not think it can compare to the impact of my dad being taken in an instant. After losing both mom and dad, it took a year or more in each case to just lessen the sting. You must go through all the holidays, birthdays, and anniversaries at least once; that is not easy. I do suggest that one remembers a birthday rather than a death day. An acknowledgement by giving a toast to mom or dad at dinner also takes the elephant out of the room. Sure, some will cry but all will feel better for having addressed it. For several years after dad’s accident, I made sure I was on vacation for a couple of weeks in July so I would lose track of the calendar. It made it a little easier. There simply is no good way to lose a loved one.

Generally, people do not really understand the grieving process. People expect to be sad, but what they often do not expect are the other issues associated with grief. For example, there is almost always regret. Regret that you did not say I love you. Regret that the relationship was not better. Whatever your regret may be, expect it. It will be there in some form. This, of course, is best addressed in therapy. The therapist will explore those feelings and work through the issues associated until resolved or accepted.

It is also important to recognize the anger associated with the loss. People become irritable, even hostile to those closest to them. Wherever there was prior tension between the remaining parents, siblings and others, those feelings will become intensified. This is often the reason that after the death of a parent, many families have difficulty recovering. Conflicts may be about money, assets, memorabilia, or even who the favorite child was. Though these issues may be real, it is really about their grief.

In addition, after a long-protracted illness, there is often the feeling that I am glad their suffering is over. That feeling may last for a few weeks or months before an individual either begins to feel guilty that they are glad it is over, or the feeling of missing the person begins. This is typically when symptoms appear such as irritability, loss of interest, anxiety, poor concentration, poor sleep or excessive use of alcohol or marijuana to name a few.

When a loss triggers negative feelings about a parent such as, “Why did I never feel loved?” or issues of verbal and physical abuse, I encourage the client to see the parent as a person rather than as a mom or a dad. Take a good look at who they were and how they were raised. Hopefully, this will help you understand and see them as a person with flaws rather than mom or dad. This may also help explain some reasons why they did what they did. Looking at your parents as human beings with flaws may not always bring forgiveness but hopefully their shortcomings will not haunt you the rest of your life.

It has been my experience that looking at pictures with my clients, going to the cemetery and “talking” to the parent or writing a letter to him/her will help bring out unresolved issues or other feelings stuffed deep inside. Sometimes a loss can be a trigger for mild depression to surface.

In these instances, it is helpful for the person to see a psychiatrist; medication could be useful. If it is, typically medication is used for a period of six to eighteen months. When it is time to discontinue the medication, it must be with the doctor’s supervision. Abrupt withdrawal from antidepressants can have negative side effects known as flu-like symptoms. Communication with your psychiatrist is important. There is a doctor reporting form in the appendix that is helpful to ensure you communicate what is necessary for the doctor to do his/her best for you.

Case scenario – The Family Pet

When assessing a client with a history of psychiatric hospitalization, I always ask why a person was hospitalized, how many times and what are the common characteristics precipitating the hospitalization. Usually there is a pattern. This is valuable information as we move through therapy and develop a plan to prevent further hospitalization.

This day when I asked these questions the answer was, “My cat died.” Now I know full well that it is hard to lose a pet. I have had pets my whole adult life. I also remember Tweety our parakeet growing up. My aunt Rose won him at a carnival on the ring toss game and gave him to me.

I was fifteen; he was about 9 years old when he died. I found him in the bottom of the cage. It was difficult and I cried. So, when this woman told me why she was hospitalized, I thought ok, I do understand that pets become a part of the family. Upon further assessment, the real cause was that she had stopped taking her medication about 3 months earlier. This was another case of medication non-compliance, not really about the loss of a pet. Medication non-compliance is by far the most common reason for relapse to active symptoms or in severe cases re-hospitalization.

I have had three pets as a married adult. All those pets were dogs. The first one was Satie. He was part Black Lab and part Husky. He was fifteen when I found him lying in his own pee. My daughter learned to walk holding on to him. She would pull herself up on his fur and they would walk around the house together. He was very patient and did not mind at all. So, it was hard on all of us when we had to have him put down. Everyone was crying including me; I said, “Never again; I do not want to go through that…. ever again.”

It was about a year later, when we found Bailey, a little 7lb Yorkie. He was a sweet little guy. He died eleven years later on the way to the vet in my wife’s arms. That too was tough. Again, I said, “Never ever again.”

On Christmas Eve, later that year, I had to work a half day. When I got home, I got ambushed. I walked into the house about noon, my wife, son, and daughter were there standing in the kitchen looking at me. I said, “What’s going on?” They said in unison, “We want another dog!” How could I say no; it was Christmas Eve, and I really wanted another one too. Again, we found Casey. Casey was also a Yorkie but a Yorkie on Steroids. He was a big Yorkie, almost 15 pounds, but nevertheless they said that he was a full breed with papers, but it seemed doubtful. It did not matter; we brought him home.

By this time, my kids were young adults, but it was ok. My wife and I knew they were going to be moving out and he would be ours. He was sweet but not so little. He was sturdy and strong unlike some Yorkie’s that have lots of health issues. When he went into the yard he would sprint from the patio to the grass like a long jumper. He would sort of catch air; it was extremely cute. On one occasion, there was a rabbit in the yard. I don’t know if the rabbit knew it, but Casey just wanted to play. He chased the rabbit around and around. After a time, the rabbit stopped; Casey stopped beside him just a few feet away. They took a breath for probably a minute and then the chase was on again, round, and round they went, always about the same distance apart. Finally, the rabbit ducked under the fence and the chase was over.

Casey’s favorite toy was a ball. He was all about the ball. If you have a dog, I know you probably have seen it. It is about the size of a baseball, but it was designed to look like a basketball. Of course, it is soft and has a squeaker inside. He would drive us crazy in the evening playing with the ball squeezing it, rolling it around in his food bowl or making us throw it for him. He would put it down at my wife’s feet and just sit there and wait for her to pick it up and throw it. When it rolled under the couch he would bark until someone got it for him.

That Thanksgiving, we took a family vacation. We left Casey with our close friends of forty years. They have two labradoodles but welcomed Casey whenever we went out of town. All three got along well and played together all day long. Though Casey was a fourth their size he still would try to hump these dogs. When they had enough, they would bark at him to be left alone as if to say …enough buddy!

That spring, however, Casey was diagnosed with an enlarged heart. He was ten. The vet told me he had about six months which landed around Thanksgiving and coincidentally during our family vacation. Our friends knew what could happen and welcomed him anyway. We thought ok it was only going to be 10 days and I had just taken him to the vet and had his medications adjusted. The vet said he was doing well. We thought he would be fine. Unfortunately, that wasn’t the case. Our friends were up most of the night with him just a day before we would return home. At 7:30am his heart stopped, and he died.

We got off the plane and called minutes after we arrived home. I said, “How’s the beast” as I lovingly called him and was shocked to hear that he had passed away. We sat silently in disbelief. Now we had to tell the kids because we knew they were waiting for a Casey update. We wanted them to have a few hours before hearing the news. My daughter knew when she did not hear from us that something was wrong. She called and we told her. She wailed. A sound a parent does not ever want to hear from their child no matter how old they are. We let her cry for several minutes until she could speak. Her boyfriend was sitting next to her in anticipation of sad news when we did not call. My son and daughter-in-law would not be home until later, we walked around the house not quite knowing what to do with ourselves dreading yet another phone call ahead of us.

My son and daughter-in-law also took the news extremely hard except my son consoled us. He, however, had the same feelings we all did. We never should have left him. We felt guilty that we were not there for him in the end. At the same time, we were glad we did not have to see it and felt guilty for feeling that way and we were angry at him for leaving us. Our wonderful friends were traumatized but said it was ok and they were honored that they had the role of holding him, petting, and talking to him until he stopped breathing.

All these reactions that I know as a mental health professional are common to mourning were present…. denial, regret, guilt, and anger. It is always interesting to know the process and experience it as if observing someone else. As a mental health professional, I realize that knowing about grief does not make it any easier. So now when asked if we will get another dog, I say, “Never ever again……until next time.”

Chapter 7.
Symptoms of Bipolar Disorder

Bipolar disorder, formerly known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Episodes of bipolar disorder can last for days, weeks, or months. The severity and frequency of these symptoms are classified into distinct types of bipolar disorder.

The cause of bipolar disorder is not known, but it is believed to be a combination of genetic, biological, and environmental factors. Bipolar disorder symptoms can result in damaged relationships, poor job, or school performance, and even suicide or homicide. But bipolar disorder can be treated effectively and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person’s late teens or early adult years. At least half of all cases start before age 25. Some people have their first symptoms during childhood, while others may develop symptoms later in life.

The Bipolar Symptom checklist below may include some of the symptoms of depression. Note the symptoms that apply to you.

__ Rapid mood fluctuations

__ Feeling high, euphoric, or having inflated self-esteem

__ Irritability, hostility, aggressive or risky behavior

__ Pressured, fast speech, more talkative than usual

__ Racing thoughts, skidding from subject to subject

__ Delusions of grandeur, grandiose beliefs, or behavior

__ Poor judgment, lack of insight, false beliefs

__ Poor self-control

__ Little or no need for sleep

__ Increased activity, sexual drive, and impulsivity, including spending

__ Easily distracted, poor concentration

__ Alcohol and substance abuse

__ Bizarre dress and appearance

__ Thoughts of suicide, homicide

The symptoms of depression and bipolar mood disorders are widely accepted. Since these disorders have a biological basis, a psychiatrist manages the medication while a therapist provides treatment and support.

The therapist support includes psychoeducation (guided experiential learning) and development of coping skills for management of day-to-day symptoms not addressed by medication. The therapist may also address marital and family conflict or refer the couple to a marital therapist if either party feels it may be a conflict of interest for the therapist to see the husband individually and the couple together.

The medication does 50% while the client with the help of the therapist addresses the other half. These symptoms are discussed weekly to explore how they were managed and what you will do next time in a comparable situation. Keep in mind that the medication reduces the overt symptoms known as positive symptoms while the therapy addresses the negative symptoms. The psychiatrist’s role is to continue to evaluate the mediation to see if it effectively manages the overt (positive) symptoms. (See appendix for glossary of terms.) Some medications today help both the positive and negative symptoms, but a therapist is still necessary for guidance.

There are two types of bipolar disorders:

Bipolar I is considered the more severe of the two disorders and has more extreme episodes of mania or depression. It may also have psychotic features such as hallucinations and delusions.

Bipolar II is characterized by milder swings of mania and depression and may have a less serious effect on daily routines, relationships, and employment. Both forms need treatment and medication to manage the symptoms effectively.

Let me point out that depression or mood disorders in general and alcohol/substance abuse do not interact well. In fact, each makes the other worse, especially when medication is not being taken as prescribed. For any mood disorder that includes alcohol and substance abuse, treatment of both issues must be done simultaneously and as a collaborative effort with the level of support and the array of services necessary to maintain stability, sobriety, and consistency. It is an arduous task, but it is manageable when support is utilized effectively. Alcohol and substance use plus psychiatric medication can cause serious medical risks, even death. To safely prescribe for you, the doctor must be aware of your alcohol and drug use.

Chapter 8.
Dual Diagnosis – Alcohol or Substance Dependence and Mood Disorder

An addictive disorder is the preoccupation with acquiring alcohol and/or drugs, compulsive use of alcohol and drugs (despite adverse consequences), and a pattern of relapse to alcohol and drug use despite the recurrence of adverse consequences (Miller, 1991).

Mood disorders and addiction are biological disorders that can usually be traced through family history, whether it was formally diagnosed or undiagnosed. When both dependence and a mood disorder are present in the same individual, this is known as dual diagnosis.

Dual diagnosis is defined as two or more independent disorders that exist in the same individual while each makes the other worse. Specifically, for our purposes, when I speak of dual diagnosis, I am referring to mood disorder coupled with alcohol substance abuse and dependence. Each exists independently of one another, and yet, each makes the other worse. Both are biological and psychosocial disorders with similar symptoms. They are lifelong disorders, which cause the person to be prone to relapse. Both require integrated treatment that includes psychiatric treatment, medication, psychotherapy, education, symptom management, and additional supportive treatment such as Alcoholics Anonymous or Narcotics Anonymous. Mood disorders and alcoholism are often found in the same individual.

Where mood disorders are concerned, the use of alcohol is often the same as abuse! The answers here are not completely understood. Some doctors have told me that the sites in the brain that are affected by mood disorders are the same sites affected by addiction. Regardless of the chemistry, even casual use of alcohol by a person with a mood disorder may eventually result in abuse or dependence. These substances impair functioning and affect thinking, behavior, and relationships. Don’t do anything that would make you relapse to active symptoms.

I am sure you have heard this incredibly old joke. A man goes to the doctor and says, “Doctor it hurts when I curl my arm up and down.” The doctor replies, “Then don’t do that.” It is a known fact that alcohol and substance abuse make the symptoms of a mood disorder worse and vice versa. If it hurts, don’t do it. Alcohol is a depressant; two or three drinks at a family gathering may affect one’s mood for days.

Alcohol also “washes out” and may, therefore, negate the usefulness of the medication. Remember, it takes four to six weeks to get the medication to a therapeutic level. When you drink heavily, you affect that level. It may even precipitate a psychiatric hospitalization. In addition, one should always consult with the doctor about the dangers of alcohol and drug use in conjunction with psychiatric medication.

It is understood that, if you are an alcoholic, you cannot have any alcohol. If you are not an alcoholic, check with your doctor for approval of one or two drinks on special occasions, especially if you are taking medication. In the days after, monitor yourself to see if it has affected your mood. If it does, this will determine if you can have one, two or none. In this scenario use is the same as abuse.

Case Study – Dual Diagnosis – Bipolar Mood Disorder with substance abuse – Joe

Back in the day, our Day Treatment Program had a reputation as one of the best programs in the Country. After a few publications about our services, there was a demand for presentations of the program. This was the start of my continuing education practice which I did for 14 years. The center had developed a reputation for managing difficult clients. In any case, one day I received a call from the Department of Mental Health and Human Services.

The caller said, “We have this hard to manage person with a long history of over eighty hospitalizations in a ten-year period, and we would like you to treat him.”

He had spent more days in the hospital than he did outside the hospital for ten years. He also had 23 minor arrests. When the president came to town, the Secret Service wanted to know where he was. Apparently, he had made a threat to the President at the time. The caller said, “His name is Joe.”

I said, “I know Joe. Everybody knows Joe.” He was infamous in the State system. “What do you expect me to do?”

He replied, “Keep him out of the hospital. You are the guy who can do it.” The caller was flattering me, and I knew it.

I said, “Ok, but I will need some special funding.” He gave it to me gladly and said the state was initiating a program for hard to manage persons. The funding was $16,000 per year, per person if they met the criteria, a mere drop in the bucket compared to cost of 300 days (about 10 months) per year of inpatient hospitalization for ten years. I estimate the cost for this one individual was about a million dollars.

I met Joe for the first time in 1990. His diagnosis was bipolar mood disorder with cocaine and marijuana abuse issues.

Joe and I wrangled a bit in the early days. I was direct and confronted him frequently. I offered him an incentive: a place to live with paid utilities in exchange for his cooperation with treatment. Now he had something to lose. So initially, when I tried to have him, drug tested, he would refuse, saying he just could not pee. My response was, “Then you are dirty,” of course, meaning he had been using cocaine or pot. “If you want to keep all these things, I have given you than I am going to expect you to be drug free and take your medication as prescribed.” Previously, upon discharge from the hospital, he would toss the meds in the bushes as he walked out the door.

Each Christmas at the Center, I would dress up as Santa and meet with each client in front of the entire group and ask, “Do you have any special wishes?” and, “How is your treatment going or how are you getting along with Jim and the staff. Jim is up on the roof tending to the reindeer.” The responses were usually, “Health and happiness for everyone.”

I would also say that “The staff reports that you are or are not cooperating with treatment. How about trying harder?” or “Good job.” “Regardless, Santa will be watching.” It was genuine fun and very therapeutic. All enjoyed Santa’s visits just after our Christmas dinner.

For many of our clients, this was their only Christmas and only gifts. Their families, as sad as it is, would frequently disown them due to the conflict that is common with the severity of their disorders. This helped the remaining family maintain some sense of sanity for themselves. I understood it but it did not make the Holidays any easier for our clients.

That year, when Joe came up to sit next to Santa, I gave him a bag of charcoal briquettes along with the gifts that had been donated by a wonderful family who also donated our Christmas tree and turkeys for dinner with all the trimmings, plus a bag of hygiene products, gloves, and hats for each person. Kudos to that family for their generous hearts!

Joe laughed but it made an impact on him. He began to cooperate with his treatment. He also was able to call other people out when they were not cooperative.

One day Joe called me and said, “The suits have me. I am at the local police department.” I knew he meant the Secret Service. I said, “Put the agent on the phone.” The agent asked me about Joe’s progress in treatment and I replied, “He doesn’t pose a danger to anyone, let alone the president. He takes his medication as prescribed, and he is compliant with his treatment. The agent said, “That is what I needed to hear. Have a good day.”

I taught Joe about his disorders and how to manage his symptoms, especially his anger. I also taught him the importance of taking his medication as prescribed as the foundation of his treatment. Psychoeducation and medication compliance helped Joe learn to manage the debilitating effects of a severe mood disorder.

People frequently do not understand that anger and hostility are very much a part of the symptoms of a mood disorder. In addition, they frequently resist taking medication, especially psychiatric medication. I say, “Try it for six months and see if it doesn’t help.” I think this is where knowledge and trust and the desire to get better come into play.

I still see Joe casually on occasion today, though I retired from the community mental health in 2009. To my knowledge, he still has those briquettes. He keeps them as a reminder to take his medications as prescribed. Joe tells me that I turned his life around after we met. But in truth, I was only his guide. Joe did his homework, followed his program, and learned to manage his disorder and substance abuse. Overall, it took about two years for him to understand and be consistent in managing his disorder. Today, he is proud of who he has become. He is concerned with the welfare of all people. Today, Joe has his own apartment, job, girlfriend, and two cars. He proudly says, “I’m a citizen now” meaning a productive member of society. To date, he has never been hospitalized again.

Chapter 9.
Denial or Acceptance of the Problem

Denial is the biggest obstacle to management and recovery of a mood disorder and the associated issues. 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 usually 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. I am also sure that some professionals would beg to differ with me on this but that has been my experience.

This means that medication is indicated. Some women, generally more men will initially refuse medication. I often hear, “I won’t take medication.”  I will describe my view and experience in general terms. If that is not enough to convince them, I will agree to cognitive behavioral therapy for a 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 cannot do it, at least not for long.

This is also true around the use of alcohol and recreational drugs such a marijuana. 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 on drugs or alcohol.

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 of them 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 little difference! Until you can accept your issues and play the hand genetics, environment and personality traits dealt you, you will be unlikely to manage your life well.

This will affect your marriage, relationships, employment, and your day-to-day ability to cope with life. There is no soft way to peddle this. A psychiatric evaluation will determine if medication is appropriate. Once this is addressed, we are more likely to resolve relationship issues through family and couples counseling.

Case Scenario: Denial or Acceptance – Mary

Mary is a twenty something year old female who enjoyed partying with friends on the weekend. Her friends drank, smoked pot and stay out until 4am without major negative impact on their life. Mary could not; her partying had 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 was not 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 was not motivated and had difficulty getting out of bed. She was experiencing panic and anxiety and had thoughts of suicide.

Mary cannot do what her friends did almost every weekend. I encourage someone like this to track their alcohol and pot use to see if this can help her connect the dots. It is tough when your friends can do it, but you cannot. I always remind my clients that they do have a disability that they need to manage. This makes them different, not bad, simply 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 are only to blame if you ignore it. Then you need to be held accountable.

Case Scenario: Alcohol Abuse, Marital Conflict, and Mood Disorder – Joe

Joe is a thirty something year old, married, unemployed male with a family history of alcoholism. His wife Mary called and asked for couples counseling. She reports that Joe got a DUI recently. He drinks one to two glasses of wine per night. When he goes out with friends, however, he becomes obliterated. He also becomes generally angry and verbally abusive. Alcohol affects his mood and their relationship for days. It has also affected their level of intimacy and created a disconnect between them. Joe came into counseling reluctantly because Mary is running out of patience and is threatening to leave. The good thing is that Joe is very committed to the marriage.

Joe has a family history of depression. The depression in his mom was never formally diagnosed but he admits she was often depressed and at times she could not get out of bed. After gathering family history and hearing the current issues, we explored the problem. Joe has a mood disorder, and he may very well be dependent on alcohol. These are not easy things to hear but I try to soften the blow by educating the couple about the disorders. He has come to these issues through no fault of his own. These are genetic issues. He has masked his depression with his alcohol use. Now he may be dependent. Alcohol gives one a lift initially but then slams them with depression. It is a depressant. He is asked to greatly reduce his use of alcohol. This will permit us to see if he is dependent.

Joe’s symptoms include his lack of motivation to look for work. He spends his time playing video games or on the internet. He drinks with his friends but now it is interfering in his marriage. He denies being an alcoholic or even depressed. He does admit to being angry. He rationalizes with, “there is no work out there and she is always on me. Yes, I get angry, but she is the cause.” I also hear, “I like wine; I like trying distinct kinds. I don’t drink that much during the week; only when I am out with friends.” My response to this denial is typically the following: If you are not an alcoholic then stop drinking for one week. Show Mary that you are not an alcoholic. “Prove it.”

Joe became defensive and said that he did not need to prove anything, but Mary and I agreed to disagree. I did not want to be too tough on him for fear that he would quit coming. I also did not want him to feel that I was taking sides. I was not I am on the side of repairing the relationship. Breaking down his denial would take time and patience to keep him engaged in the process. The key here is that his disorders are interfering in the marriage, and he did not want to lose Mary. I chided him some and said, “If not in this marriage, you will have to deal with it in the next relationship.”

I do not like the concept of harm reduction over abstinence unless it is a step toward abstinence. I will bend a little and say, “Let’s see if you can cut down to reduce the conflict and the level of anger in your household.” as a step in the right direction. The goal was 2 beers twice per week but never back-to-back days. However, by definition, an addiction is the preoccupation with acquiring alcohol and drugs, compulsive use of alcohol and drugs despite adverse consequences, and a pattern of relapse to alcohol and drug use despite the recurrence of adverse consequences (Miller, 1991). In simple words, “When alcohol or drug abuse cause problems in your marriage and you continue to abuse them anyway, there is a problem.” When alcohol is causing marital and family conflict; that is a problem.

As far as his mood is concerned, he not only needs to stop drinking but he also needed to be evaluated for medication. I encouraged him to hear what a psychiatrist had to say.

The therapist works through issues around their emotional connection and sets both personal goals for each and marital goals. I always explain that the homework in and of itself will not solve their issues, but it will help. The real work will be in session.

We will explore resentments and set goals: Initial Goals for this couple were:

1. Civility and respect. This means no screaming or yelling, no name calling and no swearing. Sarcasm is also disrespectful. Obviously, there should be no hitting or destruction of property. Call time out if the discussion is starting to escalate out of control. Time out means the discussion is over for today. Hopefully, you can try it again tomorrow. If it goes bad again, hold it until the next therapy appointment.
2. Meet and greet. When one comes home, it does not matter which one, you should find one another and give each other a hug and a kiss.
3. Have a date night at least twice per month. Date night is not a time to discuss issues or problems. It is a time to work on their relationship and be a couple. If they report that that they do not know what to talk about on a date night, then I suggest they should plan their next date.
4. Be affectionate. Guys, this does not mean groping!

Couples may also have individual goals that will help with issues.

Goal for Mary:

1. She is encouraged to attend Al Anon meetings.

Goals for Joe:

1. Reduce alcohol use (moving toward abstinence)
2. See what the psychiatrist has to say about his mood issues and his alcohol abuse.
3. Consider medication, if recommended by the doctor.

Giving homework to a couple is a way to make their relationship a priority. If they are going to improve their connection, they must give it the attention it takes to keep it strong. By assigning homework, I can often see the resentments that emerge, their level of disconnect and their commitment to one another. Airing those past unresolved issues with a skilled therapist will pave the way toward improved communication, a repair of their emotional connection and eventually, their level of intimacy.

Chapter 10.
Homework in the Management of Mood Disorders

Management of a mood disorder requires education, experience, and skills training. Most coping skills are a way to distract you from low mood, negative thinking, and rumination. These include:

1. Exercise.

You do not have to join a gym; all you need to do is take a brisk walk. You don’t have to run but you do have to hustle a little bit. Studies going back thirty years or more say that cardiovascular exercise lifts one’s mood and reduces anxiety. The more recent studies show that those old studies are true, but the walk needs to be at least 40 minutes to get the full benefit. Walk at least 4 times per week. I also recommend that you pick your days, otherwise you will say, “I don’t feel like it today; I’ll do it tomorrow.” Tomorrow comes and the same thing happens. If you pick your days, say, Monday, Wednesday, Friday and Sunday, the day of the week makes the decision for you. “Oh darn, today is Monday, I have to walk.” Remember, depression affects one’s motivation; if you wait to feel like doing it, it may never happen.

2. Plan to have fun (structure)

If you have a mood disorder, you need to take time to plan to have fun. Join a bowling league; take a pottery or cooking class; take ballroom dancing; take a photography class at the Park District. Adult Education Classes at your local community college or park district are inexpensive and fun. Don’t do it for a grade; do it because you are interested in it. Do it to help manage your symptoms and free time. Make time to nurture your relationship. Line up sitters so you can have time alone. This may feel awkward at first but keep it up anyway. Gentlemen don’t let the wife be responsible for all the social and vacation planning. Do your share. Plan a date night. When you go to dinner, discuss your next date night event, or do vacation planning. Do not use the date night to discuss difficult issues. This is supposed to be a fun time.

3. Be social.

A common symptom of a mood disorder is social dysfunction or social isolation. Human beings are by nature social creatures, but a common symptom of depression includes social isolation or withdrawal. Call a friend and make a lunch date. Have people over to play cards or watch a sporting event.

4. Get a hobby.

Pick a hobby and stick to it. Do it several times per week or when you are feeling low, negative, or worrisome. Crafts, needle point, woodworking, art, sports, music lessons, karate, adult education courses, and dance to name a few. What will you pick?

5. Do chores.

Most physical activity is a good distraction from your negative rumination and your disorder. When you have depression the thought of cleaning the entire house can be overwhelming. Chores are a terrific way to distract yourself and give you a clean environment which will also make you feel better. Break your chores up into one or two chores each day. For example: Monday is vacuuming. Tuesday is bathroom cleaning. Wednesday is washing the floors. Thursday is clean the kitchen. Friday is changing the sheets and towels day. Saturday is laundry day. Sunday is cut the lawn.

6. Use a Relaxation Technique or Yoga

Most people with mood disorder experience anxiety. Knowing how to relax can help relieve tension and a number of other stress-related symptoms. This technique may not be for everyone, but it can help. It does take practice to master but if it is done consistently, it may help reduce anxiety. People who can master it often feel refreshed when they are done. Listed below is a simple relaxation technique for reducing tension and stress.

Position: Find a comfortable chair, preferably a recliner or chair with an ottoman and a headrest where you will not be disturbed for at least ten minutes. Loosen any tight clothing you may be wearing. Assume a comfortable position; let your hands rest comfortably at your sides. Open your mouth slightly, let your lower jaw hang loose, drop your shoulders, let your chest collapse and your stomach stick out. Breathe slowly and smoothly. Close your eyes; do not fall asleep; do not cross your arms or legs.

Breathing: Inhale through your nose, exhale through your mouth. Become aware of your breathing. Allow your exhalation to be slow and easy. As you breathe out, say the word “one” to yourself. Repeat this for several minutes, thinking “one” each time you exhale. Imagine that with each slow exhale the tension is leaving your body. When you finish, sit quietly for a few minutes at first with your eyes closed before you get up.

Imagery: When you close your eyes, clear your mind. Go to a pleasant peaceful place in your mind where you feel relaxed, safe, and free of worries and concerns. Stay there about ten minutes and savor the experience. You can imagine this place to be a restful retreat whenever you feel tense or anxious. It is your private tranquilizer.

Install relaxation into your daily routine. Make your daily relaxation a ritual by selecting two regular times each day for about ten minutes at a time and stick to your plan. Note: Using any relaxation technique takes practice; the more you practice the better you will get at this natural form of reducing tension. It is a safe, effective, drugless way to relax. Try it!

Chapter 11.
Psychiatric Treatment – Help the Doctor Help You

The Psychiatrist is an integral part of the treatment team. S/he needs your honest input to best help you. If any of the following are problematic, report them to the doctor. Write things down.

Report any changes in your symptoms to your doctor including:

1. Sleep patterns.
2. Changes in Mood
3. Poor concentration, poor short-term memory
4. Disturbing thoughts of self-harm or harm to others
5. Drug and alcohol use.
6. Medication side effects or allergic reactions
7. Social activity or isolation
8. Poor self-care
9. Physical activities, hobbies, chores
10. Poor money management
11. Unusual behavior

Psychiatric Medication

Psychiatric medication is useful in controlling symptoms of mood disorders. Mood disorders are considered bio-psycho-social disorders. They affect thinking and behavior and often create relationship issues. Medication and medication management are essential in the management of biology or the chemistry of the disorder. I consider this to be the foundation of treatment. It is difficult, if not impossible, to treat a severe mood disorder without medication. You cannot build a solid house without a good foundation. Medication provides that solid foundation.

Therapy addresses psychosocial treatment issues including identification and management of symptoms, daily living skills, coping skills, and the relationship issues which often accompany these disorders.

Refusal to take medication is a common issue. I do on occasion have clients who refuse medication. In the past, I have said, “I will work with you to see if we can make an impact on your symptoms.” If we do, that is great. If not, I will try to deal with the denial and the refusal of medication.

What if I told you that you are a diabetic and must be on insulin injections the rest of your life? Of course, most people would not like it, but chances are they would take their medication. Why is medication for a mood disorder any different?

Let me remind you that alcohol is a drug and if you are drinking, you are self-medicating with a depressant. This may lead to alcoholism or substance abuse and addiction. Wouldn’t it be wiser, safer, and more productive to let a doctor prescribe the correct medication to help you get on the path to recovery?

Medication and Support

Many people remain on medication their entire lives. Some people with mild depression or situational depression can use medication intermittently for periods of stress that cause their depression to re-emerge. Others do not want those periods of regression in their life, so they choose to just stay on the meds. I encourage clients to consult with their doctor for recommendations.

Therapeutic support may also be intermittent or as needed after a time. Depending on the severity of the disorder and how well a person learns to manage, I recommend that my clients check-in at least three or four times per year. This is especially common for couples whose disorders affect their marriage.

Unfortunately, some people with severe mood disorders may go in and out of the hospital their entire lives if they remain in denial. This is usually a result of non-compliance with treatment and medication, combined with alcohol and/or substance abuse. Mood disorders and addiction can be global disabilities or manageable handicaps. Which one will you choose?

The number one cause of regression and recurrence of symptoms is not taking medication as prescribed. This is not like having a headache. When you have an ordinary headache, you take two aspirins and twenty minutes later your headache is gone. For antidepressants or mood stabilizers to work effectively, the drug must maintain a certain level in the body. When that level is not maintained, debilitating symptoms reappear. These medications take four to six weeks to reach their peak level of effectiveness. When you miss doses of medication, drink or use drugs, you negatively affect that level.

Medication Side Effects and Allergic Reactions

All medications have side effects. Even aspirin can cause ringing in the ears if you take too much. The pharmacy must list all side effects, but that does not mean you will experience any or all of them. Most of the common psychiatric medications for depression and mood disorders have very few, if any, side effects after the first week or so. First, ask your doctor about allergic reactions and possible side effects and what to do in the event of a serious reaction. Severe allergic reactions typically include but are not limited to rash, hives, and swelling (of the face or tongue). Always read the medication information given to you by the pharmacist. He or she is also a reliable source of information on medications.

The most common and less serious side effects are typically nausea, diarrhea, blurred vision, sleepiness, insomnia, dizziness, or headache. These usually go away in the first week or two. If any side effect becomes severe or you simply have concerns, contact your doctor, or go to the ER. Know the possible side effects and allergic reactions of your medications. You should always know the name of your medication, frequency, and the dosage in milligrams. Carry a card in your wallet that will tell emergency personnel exactly what you are taking. If you have questions or concerns, direct your questions to your doctor or pharmacist. Dial 911 or go to the emergency room for serious allergic reactions and side effects. Ultimately, the more you know, the safer you will be.

Mental Illness is a disease very much like diabetes. It takes insulin to manage diabetes; it takes psychiatric medication to manage severe depression and other mood disorders. Some say you just have to be tough. “You just have to pull yourself up by your bootstraps and try harder.” This is false and it won’t work. The only way to successfully manage a mood disorder is with education, medication, if necessary, structure, ongoing treatment, and support.

Always contact the doctor when faced with positive (active) symptoms. Do not self-medicate. A doctor never operates on himself or his own family. Don’t play doctor! Remember, the leading causes of relapse are medication non-compliance and drug and alcohol use. The doctor cannot possibly medicate you properly if he does not know honestly what the patient is or is not taking including alcohol or substance use! Rule of thumb: never lie or withhold information from your doctor or therapist.

It is extremely important to learn to make healthy choices. Sometimes people do not recognize that the choices they make may not be healthy. Once stable and consistent, some people simply need to check-in with their therapist a few times per year. Others need ongoing supportive therapy every two to four weeks to remain stable. The frequency will depend on the individual and how well one manages their disorder. Together with your doctor, therapist, and ancillary supports, if necessary for dual diagnosis, you can learn to manage your symptoms and cope with the day-to-day stress of depression, mood disorder, or dual diagnosis. This is the reason that ongoing support from your doctor and therapist is essential for management.

You should call your doctor, 911 or go to the hospital if you are experiencing medication side effects or an allergic reaction. If you have thoughts of hurting yourself or someone else call your doctor and therapist immediately. If you are actively considering hurting yourself, call 911, go to the emergency room, or call the National Suicide Prevention Helpline, 1-800-SUICIDE (1-800-784-2433).

The Leading Causes of Relapse

The causes of relapse to active symptoms of a mental disorder have been well documented over the years. It is no surprise that these reflect the relapse warning signs listed below.

They are:

• Medication non-compliance (Not taking the medication as prescribed).
• Alcohol and substance use and abuse.
• Little or no sleep.
• Lack of social support.

Non-compliance with medication and alcohol or substance abuse are by far the leading causes of relapse to symptoms. These are self-explanatory. However, little or no sleep and lack of social support also need to be addressed.

Sleep is a critical issue for most with mood disorders. People with Bipolar disorders usually report that they do not need much sleep. They tend to play with their sleep/wake cycle. They like the euphoric hypomanic feeling that lack of sleep creates. It is very much like moths and flames. There is an attraction to the high that one gets when they are sleep deprived. Unfortunately, you can take anyone in the world and keep them awake for two, three or four days, they will become actively psychotic. For people with a mood disorder, sleep is a mental health issue.

Social support is also very much a part of maintaining good mental health. Even if one is compliant with medication and not using or abusing alcohol and drugs, social isolation can create considerable stress and ultimately cause a relapse to symptoms. It is imperative that people with mental disorders have an avenue to combat their tendency to isolate and withdraw from people. I encourage my clients to maintain regular social contact. This contact creates reality testing. We do not think of socialization as reality testing, but it is. For example: You have an argument with your spouse; you call a friend and say here is what happened. What do you think? You get feedback on your situation and behavior. That is reality testing. Lack of social support may result in an inability to test the accuracy of what one is feeling or experiencing. Just because you feel something, does not make it accurate or true. This is obviously a very important component of maintaining good mental health.

Relapse Warning Signs

Be aware of relapse warning signs and symptoms. When one is taking medication as prescribed by the doctor, symptoms are largely under control and the client is stable. The reappearance of certain symptoms is an indication that the medication may need to be adjusted, reevaluated, or changed. These symptoms may also be an indication that the medication is no longer being taken as prescribed or alcohol and substance use is interfering with the effectiveness of the medication.

These symptoms include:

• Thoughts about hurting oneself or others.
• Changes in one’s sleep/wake cycle, especially little or no sleep.
• Inability to concentrate, rapid speech, skidding from subject to subject.
• Rapid mood fluctuations, mania, or depression
• Poor judgment, risky behavior, or lack of insight into one’s own behavior.

These symptoms are reflected by poor daily functioning, lack of motivation, loss of interest and conflict. These are active symptoms and usually are caused by non-compliance with medication and use of alcohol or drugs. In many instances, the medication may need to be changed or the dosage adjusted by the doctor. This may also reflect the need for family members to monitor medication compliance and alcohol/drug usage. Relapse warning signs should be reported to the doctor and therapist immediately. Don’t wait!

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.

Chapter 12.
Essential Elements in Management of Mood and Relationship Disorders

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 teach 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:

1. 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.
2. Psychoeducation refers to the guided experiential learning that takes place in individual, couple, or family therapy.
3. 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:

1. Structure

First, you must recognize the need for structure in combating your disorder. Initially, structure means securing an array of support 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. (See appendix for form Weekly review of consistency)

2. Psychoeducation aka Experiential Learning

In the early 1990s, my father-in-law had a heart attack. Fortunately, there was minor 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 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 could 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 psychoeducation 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 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 medication use. 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 support may be necessary if alcohol/substance abuse and dependence are related issues.

3. 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 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 must see for themselves. Some people just must 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 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 it 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.

Chapter 13.
Goals and Objectives of Treatment

As a therapist, my goal is to:

1. Gather history and make an accurate assessment of needs.
2. Present and explain the diagnosis.
3. Offer referrals for psychiatric evaluation for medication when necessary and explore the need for ancillary services for additional support, if needed.
4. Establish concrete and measurable goals.
5. Provide psychoeducation and support.
6. Encourage symptom recognition and management.
7. Teach coping skills.
8. Teach How to be Well.
9. Provide information, education and support to the client and family.
10. Help coordinate services for a unified and consistent treatment plan.

The objectives of treatment are as follows:

1. To provide the opportunity for the appropriate expression of feelings.
2. To promote the opportunity for people to learn to communicate effectively in order to develop satisfactory interpersonal relationships.
3. To educate the person and their family about mood disorders and the relationship issues associated with these disorders.
4. To teach relapse warning signs and triggers.
5. To teach symptom management and methods of problem solving.
6. To enhance the individual’s sense of self-esteem through understanding the symptoms of their disorder.
7. To provide emotional support for the person and family during their growth.
8. To introduce and encourage the incorporation of a broad spectrum of community activities to address the social dysfunction, isolation and withdrawal often associated with mood disorders.
9. To help people develop an appreciation of work and leisure and their interdependence.
10. To provide a setting to support the family.
11. To provide external controls, when necessary, for behavior which would result in harm to oneself or others.
12. To expect the person to learn to be well by developing a sense of awareness and responsibility for one’s choices.
13. To offer people a road map for effective communication for life.

Chapter 14.
The Role of the Family in Treatment

Marital conflict is common when a mood disorder is present. A review of the family history of symptoms of depression or bipolar disorder suggests that multiple family members have mood disorders. For example, a cousin committed suicide two years prior.

Common marital problems often become the focus of frustration and conflict. Family meetings are a collaborative effort on the part of the therapist, interested family members or significant others and the patient. The purpose of involving family in treatment is to teach the family all that we teach the patient. Family education and support are essential ingredients of treatment.

Case Scenario – Joe and Mary

Consider the case of Joe and Mary. Joe and Mary are both 35. They have two children six and eight years old. Joe helps the children get off to school but then goes home and goes back to bed until noon. He is unmotivated to look for work and has been unemployed for almost a year. Mary complains that he does not seem to be looking extremely hard. Though he is home all day, he does not help with chores or laundry. He sleeps a lot during the day and is up all-night playing video games or surfing the internet. There is no intimacy in their relationship. They bicker a lot. Joe drinks daily or binge drinks on the weekend. He becomes nasty and disrespectful; it has become clear to Mary that their relationship is in trouble.

I encourage and support the need for structure in the management mood disorders. Having a structured week helps manage symptoms. For instance, walk 40 minutes at least four times per week. These addresses symptoms of anxiety and low mood. While planning social activity on a regular basis addresses the tendency to withdraw and isolate. Chores assigned to specific days of the week also help with the lack of motivation and the feeling of being overwhelmed with facing the task of cleaning the whole house in one day. Working on a hobby or taking an adult education class addresses both distraction from negative thinking and social dysfunction. The patient is also encouraged to develop a budget when overspending is problematic as is customary with people with bipolar disorder.

Family meetings offer an opportunity to vent frustrations while giving a progress update. Understanding the symptoms and how they affect the individual reduces the family conflict commonly associated with living with someone with these disorders. Much of the time spent in family treatment is in reality family education and methods of coping with the identified patient. It is apparent that family and friends need information and support. Families are encouraged to seek support as needed. The goal of this is to provide the same information, education, emotional and social support. There is the recognition that family members have their own needs. These sessions may be conducted without the identified patient present; however, their involvement is usually encouraged.

Family Support Questions

In addition to Psychoeducation, family support groups are available to answer the most pressing questions families have, including:

1. What is wrong with my loved one?
2. What causes the bizarre behavior?
3. What can be done about it?
4. What can we do to help?
5. What can we expect of her/him?
6. What does the medication do or not do?
7. What did we do wrong to cause this?
8. What is the philosophy of treatment?
9. What are the consequences of relapse to symptoms or substance and alcohol use?

I pay particular attention to accepting the family’s frustration and hostile feelings. The aim is to reduce feelings of guilt, dependency and anger through communication, respect, and concern. Never make threats if you are not prepared to follow through with the consequences. Involvement in support groups such as the National Alliance for the Mentally Ill (NAMI) and other mood and addiction disorder support groups are encouraged as needed. Concern for family members to take care of themselves is especially supported. Attention to family concerns and their questions help reduce tension and conflict within the family.

What is discussed in treatment can be continued at home. The philosophy, expectations, and coping skills are taught to the family. The family, in turn, provides the staff with information which can help with treatment planning.

The overall goal with the family is to win their support and patience. It typically takes the patient about a year to learn the intricacies of how to be well. One can hear and be educated but experience, often by trial and error, takes time. It is a process. No one is to blame for the person’s disorder. There is no emphasis on guilty cause or scapegoating. The patient is responsible for his/her wellness. The person will learn how to manage their disorder and the family can help. Everyone can be better educated about the disorder and what is required on a day-to-day basis.

The skills learned in treatment — both daily living and social — are to be practiced at home. The family should not become over involved in teaching or applying consequences; this will be addressed in treatment. The increased participation in social and recreational activities helps manage the symptoms of the disorder. Should the patient experience too high a level of Expressed Emotion (EE) within the family, more activity can be encouraged outside of the home. Such an expectation works both ways: not only is the patient becoming more involved with age-appropriate peers, but the family is also encouraged to expand their networks beyond the patient. Periodically, the family is gathered without the person and given the chance to explore issues, commiserate, and vent their frustrations.

The family learns to change their own attitudes and the negative effect, if any, they have on their family members. The patient learns about their disorder and the importance of medication compliance. Social networks are established for everyone concerned. The family is encouraged to join others in support groups with whom they can reach out for support. Patients learn how to function more usefully and appropriately within their social environment. The therapist helps manage family conflict, greatly reducing the tension and stress in the home.

The dually diagnosed persons require a wide range of services based upon a systematic and unified treatment approach (Carpenter, 1986). Research has shown that a broad-based treatment approach utilizing combinations of family therapy, pharmacotherapy, networking, skills training, and psychoeducation has decidedly proven results (Strachan, 1986). In time, the increased self-reliance which treatment offers increases the potential for stability and family harmony. By expanding the treatment expectations and philosophy to the family, both the patient and family develop a more productive, cooperative relationship.

Simply Monitor and Report

The role of the family in treatment is simply to monitor and report. The family should observe the patient’s behavior and report anything that may be important to the stable functioning and health of the patient. Families often get into trouble because they try harder than the patient. Families must let the person stand on their own two feet. You cannot do it for them.

The patient should not be interfered with directly unless, of course, s/he is a danger to themselves or others. The family’s role in treatment is a collaborative effort in communication. The family should think of themselves as team members. We are all on the same team! Keeping secrets from the doctor or therapist interferes with treatment and may ultimately have grave consequences. Families should call a healthcare professional or the police immediately if you or a family member has any of the following symptoms, especially if they are new, worse, or worry you. The person is:

1. Not taking their medication as prescribed.
2. Abusing alcohol or substances.
3. Depressed, irritable, or has expressed thoughts of suicide or dying.
4. Exhibiting behavior which may result in injury or harm to the individual, family, or the community.
5. The presence of any relapse warning signs, especially no sleep.
6. Panic attacks, uncontrolled anxiety, or restlessness.
7. Feeling incredibly angry, agitated, or violent behavior.
8. Acting on dangerous impulses.
9. Unusual behavior that is out-of-character for this individual.

In most cases I have treated over the years, I have seen the person get annoyed with friends and family when they say, “You seem crabby, did you take your medication today?” The typical response is “Just because I’m angry or upset doesn’t mean I’ve skipped my meds.” The way I see it, if you have a history of noncompliance, you don’t have the right to be angry when asked! Take the medication as prescribed so your family doesn’t have to worry about compliance or need to be intrusive in your life. They should be relatively assured that you are compliant with medication and treatment. Regardless, it is the responsibility of the family to ask because the consequences of not taking medication as prescribed can lead to self-injury and possibly suicide.

Family members can help to minimize the risk of relapse. Mental Illness is no One’s Fault.

These are frequent causes of family conflict and should be discussed with the doctor and therapist. Families should avoid the following:

• Avoid critical comments. Use “I feel” statements.
• Avoid over involvement unless there is alcohol and substance abuse, medication noncompliance or danger of self-injury or injury to others.
• Avoid excessive pressure to achieve.
• Avoid trying to help motivate.

Family members learn to cope by learning all that the patient learns about their disorder. Mental illness is no one’s fault. It is a bio-psycho-social problem.

• Avoid placing blame or guilt.
• Don’t enable! You are not responsible for the patient’s wellness. S/he is! That means the patient should be scheduling their own appointments, filling their own prescriptions, setting reminders on the calendar, and if necessary, attending substance treatment and AA meetings as often as is necessary to maintain sobriety.
• Make regular opportunities to get away from each other. Have outside interests, hobbies, and social activities.
• Get regular exercise. Join a health club or walk at least 40 minutes on regularly scheduled days each week. In the winter, use a treadmill or stationary bicycle.
• Learn all you can about mood disorders but do not try to be a therapist.
• The patient is responsible for his own happiness. Who owns the problem? Don’t blame others for your disorder or problems.

Note: a mood disorder is a biological problem like diabetes. If you don’t manage it, it will manage you.

Chapter 15.
 How to be Well

Coping with a mood disorder is no easy task! It takes professional support, medication, psychoeducation, and experience to manage debilitating symptoms. With the necessary support and monitoring, persons with mood disorders can learn to have long-term stability and consistency.

I have also found that it takes an average of about one year to reach those goals. In addition, many people will need some level of support on and off for their entire lives. The bottom line is you cannot do it alone. You need a psychiatrist to manage your medication and a therapist to provide ongoing support.

 Ten Steps to Wellness

1. Take the medication as prescribed by your doctor.

• “I don’t miss often; maybe once per week.”

The number one cause of relapse to symptoms is medication non-compliance. This is a tough one. For psychiatric medication to be effective, it must be taken daily as prescribed. I consider compliance to be missing no more than 5 pills per year! Many people do not like to take medication, especially if it means daily life. Let’s take one step at a time and see what it is like to function to your capacity for a year or two before you make decisions about the rest of your life.

But remember, clinical depression is a lifelong illness and it is all about a chemical imbalance. It is a biological problem first. It is like being a diabetic: you must take the medication as prescribed in order to be well.

2. No caffeine, substance use/abuse, or alcohol.

• “It’s not the caffeine. I like coffee. It doesn’t affect me. I have always drunk coffee.”

Whether it is coffee, power drink, soda or tea, caffeine can interfere with sleep and create anxiety. It is the most obvious reason for poor sleep. With your doctor’s supervision to avoid anxiety and headaches, gradually reduce your daily caffeine use. Eventually, when you are caffeine free, I believe, you will feel and sleep better.

I would certainly recommend gradually reducing caffeine use before asking the doctor for a sleep aid. Caffeine may interfere with your sleep/wake cycle. As far as your mental health, I recommend keeping caffeine to a minimum and before noon.

I also do not recommend working the night shift i.e., midnight to 8 AM. It is difficult for your body to adjust. For a person with a mood disorder, this is not recommended. The back and forth between day and night shifts and the social isolation are risky to one’s mental health. It also wreaks night havoc with the sleep/wake cycle. Lack of sleep for a client with a bipolar disorder may bring about rapid mood fluctuations and jeopardize stability. Tell your doctor or your therapist if you are not sleeping. Wouldn’t it be better to reduce the caffeine rather than take a habit-forming sleeping pill?

• “What? I can’t have a glass of wine with dinner. I don’t do it often. It’s just one glass. It is not like I am an alcoholic.”

The second leading cause of relapse to symptoms is alcohol and substance use. Some doctors and even therapists say that it is all right to have one or two drinks if you have no alcohol abuse or dependence issues. I still question this because alcohol and pot are depressants. Why would you take a depressant when you are depressed or taking an antidepressant under any circumstance?

Alcohol may affect your mood for days, even weeks. At least track your mood on the calendar after you have been drinking to see if it has made your symptoms worse. As far as alcohol and substance use, it is as simple as it is hard. If it interferes with your life, your daily functioning, or your relationships, don’t do it!

There is a negative correlation between the use of alcohol or drugs and a mood disorder. The increased chance of dependence and risk of relapse to the symptoms of your mood disorder are just not worth it. Connect the dots! The essential point is that for many people USE IS THE SAME AS ABUSE!

I recommend you discuss this with your doctor. If you already know you have a problem, get into Rehab. It is never too late to turn your life around. Get professional help and go to your Alcohol or Narcotics Anonymous meetings as often as it is necessary to maintain sobriety. Even if you are not dependent, alcohol or pot may not be a healthy choice for you. Do not deny the obvious. So, remember, the healthy use of alcohol for one person may not be healthy for you. Make healthy choices!

3. Take care of your physical health.

Be sure to have annual dental and physical exams. Some medications require regular blood testing. Some physical ailments can cause depression. See your doctor regularly.

4. Exercise

People with mood disorders tend to be sedentary. They need to walk and get exercise as much or more than any of us. You do not have to join a gym; all you need to do is take a brisk walk. You do not have to run but you do have to hustle a little bit. Studies going back thirty years or more say that cardiovascular exercise lifts one’s mood and reduces anxiety. The more recent studies show that those old studies are true, but the walk needs to be at least 40 minutes to get the full benefit toward lifting your mood and reducing anxiety.

Walk at least 4 times per week. I also recommend that you pick your days, otherwise you will say, “I don’t feel like it today; I’ll do it tomorrow.” Tomorrow comes and the same thing happens. If you make a schedule and stick to it (say, Monday, Wednesday, Friday, and Sunday), the day of the week makes the decision for you. “Oh darn, today is Monday. I must walk.” Remember, depression affects one’s motivation; if you wait until you want to do it, it may never happen.

Note: Always consult with your doctor before starting any exercise program.

5. Plan to have fun.

It is good to have fun; have fun! When my son was about four years old, I remember distinctly, it was a beautiful summer day. Our front door was open, and he stood there and saw children outside playing. He said, “Dad, there are kids out there! Can I go out and play?”

My point is that when you are a child, all it takes is something as simple as finding other kids and the party is on! As an adult, it takes planning, especially if you have a mood disorder. You need to take time to plan to have fun. Join a bowling league, take a pottery class or cooking class, take ballroom dancing, or take a photography class at the local park district. Take an adult education class at your local community college or park district. It is not about the grade so you can also skip the tests and homework. These are inexpensive and fun and a terrific way to meet your socialization goals!

• Do it to be more social.
• Do not do it for a grade.
• Do it because you are interested in it.
• Do it to help manage your symptoms and to structure your free time.

6. Make time to nurture your relationship.

Line up sitters so you can have time alone with your spouse or significant other. This may feel awkward at first but keep it up anyway. Gentlemen don’t let the wife be responsible for all the social and vacation planning. Do your share. Plan a date night. When you go to dinner, discuss your next date night, event, or do vacation planning. Do not use the date night to discuss difficult issues. This should be a fun time and a way to nurture your relationship. If you are going to have fun, you are going to have to plan ahead!

7. Be social.

A common symptom of a mood disorder is social dysfunction or social isolation. Human beings are by nature social creatures, but unfortunately, a common symptom of mood disorders includes social isolation and/or withdrawal. Call a friend and make a lunch date. Have people over to play cards or watch a sporting event. If you don’t have a large social network, use the park district or local community college to meet people. Taking a class or joining the volleyball league at least gives you an opportunity to be with people and make friends. While meeting strangers may seem intimidating, think of it this way: if you do not know them to begin with, then you really have nothing to lose if things do not work out. On the other hand, you never know when a stranger can turn into your new best friend, business partner, or love interest!

8. Hobbies

Try woodworking, paint by number, sewing, knitting, crossword puzzles, gardening, toy trains, arts and crafts, archery, or whatever you choose! Go to a hobby shop and look around but pick something and stick to it. Work on your hobby several times per week or when you are feeling low, negative, or worrisome. It is quite possible you will enjoy the activity so much that you will forget about your symptoms for a while. Hobbies are a terrific way to distract yourself from troubling thoughts when one else is around.

9. Chores

Most physical activity is a good distraction from your negative ruminating thoughts and symptoms. Chores are another way to distract yourself and give you a clean environment. When you have depression, the idea of cleaning the entire house or apartment can be overwhelming. Break your chores down into one or two chores each day. For example:

• Monday is vacuuming.
• Tuesday is bathroom cleaning.
• Wednesday is washing the floor.
• Thursday is cleaning the kitchen.
• Friday is changing the sheets and towels day.
• Saturday is laundry day.
• Sunday is a free day. It is your reward for doing your chores all week long.

Chores are a fantastic way to distract yourself from your symptoms. Most physical activity will help. Make a schedule and stick to it. Try to produce your own list of distraction activities. The more things you try, the less likely you will be a victim of your disorder.

10. Make healthy choices.

This is my generic one. This one may very well be different from person to person. A healthy choice for one person may not be healthy for you. If you have a mood disorder, poor sleep, too much caffeine, alcohol or drug use, and social isolation are mental health issues. Remember! You manage it or it will manage you!

Chapter 16.
Common Relationship Issues

For a vast majority of individuals, families and couples there are common conflict themes. These include mood disorders, lack of civility and respect, resentment, poor communication, lack of intimacy, infidelity, alcohol and substance abuse, financial and parenting issues to name a few. One thing is certain, there is no guarantee of “happily ever after” especially today when so many things can get in the way of your relationship. Relationships take work and attention to ensure a good marriage. Life has a way of interfering in our relationships. Couples can get lost in the day-to-day grind of life. We must make time for one another to keep our connection strong. Many of the common issues listed here are addressed in the following case studies.

Case Scenario- Depression – Joe and Mary

Joe and Mary have been married for 10 years. They dated for three years prior to marriage. They have two children. Joe’s mother has a history of mood disorder though it was never formally diagnosed. She lives in the past having never gotten over the infidelity of her husband, their subsequent divorce, and his marriage to another women. His Dad is a recovering alcoholic. Dad has been sober for many years but he is difficult to get along with as his second marriage is also an unhappy one.

Joe is currently unemployed because he cannot get along with co-workers. He has no friends; all have abandoned him because of his temper. Joe tends to hold grudges and he writes people off if he perceives that they have wronged him. He has few interests and spends his time surfing the internet or playing video games. Joe lacks motivation and drive and his concentration is poor. He stays up until four or five in the morning. Mary is scared because he is unmotivated to look for work and they are now in financial trouble. They bicker over his alcohol use and his inability to share his feelings.

My assessment indicates that Joe has many of the classic signs for clinical depression, his symptoms include lack of motivation and no friends. He isolates himself and his sleep wake cycle is reversed. He is up most of the night and sleeps most of the day, which is a way of avoiding people and responsibility. He has been drinking more than usual. Mary made the appointment and Joe was reluctant to join her, but he did. I asked Mary to come in even if Joe said that he would not come. Invariably the husband will ask about the appointment. I suggest when asked, “If you want to know you’ll come with me next time.”

I gave Joe the list of depressive symptoms and asked him to put a check next to those that applied to him. He checked 8 of the symptoms listed. I encouraged him to have a psychiatric evaluation for medication to address his depression and use of alcohol to self-medicate. The doctor put him on the appropriate medication. I worked closely with the doctor to ensure a unified treatment approach. Goals were set for him and for them as a couple.

The first part of his education was learning about his depression. I pointed out that it was not his fault. More than likely, he inherited this from either one of his parents. To start him on his path to recovery, I encouraged him to have more structure in his day. That meant getting up at 8pm and going to bed no later than eleven. He was also to take a walk at least 4 times per week for forty minutes since they could not afford a gym membership at that time. Part of creating his plan was to pick the days that he was to walk each week. He was also encouraged to reconnect with his friends and to avoid the use of alcohol. After a few weeks on the medication, he began to feel better. In the meantime, I continued to educate both he and Mary about his depression. Once Joe was feeling better, we began to address the marital issues created by his depression. He was encouraged to make “I feel statements”. These types of statements help address emotional withdrawal by allowing the partner to understand what their loved one is thinking and feeling, helping them feel more connected. Saying “I feel,” is also a signal to alert Mary that Joe is trying to communicate effectively. Hopefully, this signal will help both Joe and Mary to be less defensive in their communication.

I also encouraged a date night at least twice per month and advised that these dates do not have to cost a lot of money. Just going out together, walking or going for coffee or ice cream was fine. The idea is to spend some quality one-on-one time.

Mood disorders are a chemical imbalance in the brain but also include environmental issues and personality traits. About one in seven individuals will at some point in a marriage experience it. Situational depression is created by marital conflict, job loss, grief, and ongoing health issues. These will surely affect your relationship.

Many disconnects in a relationship begin with mood disorder, alcohol or substance abuse and situational depression. If these issues are not addressed, it is unlikely that progress will be made in couples counseling.

Many studies show that there is usually a history of mood disorder or alcoholism on one or both sides of the family. It is imperative that the therapist be direct with their clients about the assessment and encourage a psychiatric evaluation to determine if medication is appropriate. Once this is addressed, it is very possible to resolve many of the couple’s issues.

Case Scenario – Civility and Respect – Joe and Mary

Joe and Mary have been married almost three years. They have one child. Joe’s parents divorced when he was 5 and Mary’s parents are still married but have never had a good relationship. Joe and Mary dated for almost three years before marriage, but they never learned how to resolve conflict. Both are determined to win the argument. When this happens, no one wins. The baby has not helped the situation because he has colic. The resentment is building because of unresolved issues which are now affecting their level of intimacy. Arguments turn into history lessons in which the conflict is never resolved and never focuses on the issues at hand. They recognize their marriage is in trouble. Joe and Mary want to find their joy again and address issues before they end up divorced.

All couples need rules of engagement for conflict. When a couple loses civility and respect, their relationship is in serious trouble. They feel distant, disconnected and as a result, bickering occurs.

After getting the necessary preliminary information, I acknowledge the stress that they are experiencing and try to reestablish civility and respect when in conflict. No couple can withstand loss of respect. I point out that it will take some time to change their communication habits. When one or the other fails at respect, I encourage them to immediately say “I’m sorry; I should not have said that” as a step in the right direction of not having lost respect in the first place. Time out is the signal that this conflict is going nowhere but the rule of time out is that you must get back to the issue within twenty-four hours. Hopefully, with a day to reflect on the discussion, it will be more productive. If that fails, then they are instructed to save the discussion for our next appointment. I also look at how long it has been since the baby was born that they have had a night out together. In most instances, they have had no time out together because they have no babysitter that they trust. I encourage them to take the time to find a babysitter; bring in the sitter and let them get to know one another under the parent’s supervision. Their goals also include a date night at least twice a month if possible. It may take three or four sessions to see some changes, but they will often start seeing better communication and less conflict.

Poor Communication

Many marital problems are rooted in poor communication. As seen above, effective communication between partners can be learned and developed. When communication is poor and feelings go unsaid or unaddressed, the couple feels disconnected. Over time, this leaves them feeling distant, even resentful. Resentment creates a further distance which in turn creates a lack of civility and respect and a lack of intimacy. Effective communication is often oversimplified as just being romantic. It is not. Effective communication involves the sharing of ideas and feelings. Effective communication is made possible by means of trust, confidence, and mutual understanding. Try to convey to your spouse the importance of expressing feelings, even though they may think it is silly. Explain how important it is to you and how it makes you feel. Explain to them how never knowing how they feel about this or that confuses you and makes it more difficult for you to feel connected. I encourage both men and women to use “I feel” statements. This allows the couple to say things that have in the past created conflict when sentences are started with: “You always” or “You never.” Never say never or always. This is known as skidding into other issues or a history lesson into the past and therefore a minor conflict is never resolved and may even be magnified.

Active Listening

If you want to resolve an issue, stick to the topic at hand. Each spouse should show that they are listening by mirroring what was said or to say it another way, repeating back what was heard with emphasis on the feeling being projected. This shows the other you are listening to and helps clarify the issue. This also helps prevent bickering over nonsense that really is not relevant to a couples disconnect. The most obvious example of that was almost 40 years ago. The couple I was seeing had a major argument over where they squeeze the toothpaste tube. She squeezed it on the end; he squeezed it in the middle. Obviously, the disconnect was not about the toothpaste. Sometimes all one wants is to be heard. Men often make the mistake of trying to solve the problem when all the wife wants is for him to listen. In this case, the wife needs to say it clearly, “I just need you to listen; please don’t try to solve the problem.”

Lack of Intimacy

Lack of intimacy can certainly create marital tension. Most of the relationship issues listed here as common marital issues can lead to resentment and ultimately a lack of intimacy. Therefore, I view lack of intimacy as a symptom.

The lack of intimacy is typically a result of resentment about some unresolved issue. I find that most couples cannot explore resentments without a skilled therapist in the room. Though these are typically difficult meetings, just the experience of airing resentments in a safe and neutral environment often resolves these issues and allows couples to move on with repairing their relationship. In the process, couples learn to address issues that may arise in the future without creating resentment. Bringing romance back into the relationship through the little things you do and say can make all the difference. For most women, it is the communication all week long that leads to intimacy in the bedroom. I say men are “R” rated while women are “PG.” Men don’t need that connection to get it on the way women do. A lot of guys just do not get it. The essential point is …listen more, be civil and respectful, affectionate, take time to plan and nurture your relationship and you will be rewarded in the bedroom. Put your date night plans on the calendar.

Parenting Issues

Every day, parents are faced with decisions about how to raise their children. Some decisions are minor, and some are major. There are literally thousands of books and articles that discuss good parenting. To me, it is simple. Here are five keys to good parenting.

• Make your expectations clear.
• Parent as a team, support and back one another.
• Never parent when you are angry or out of control.
• Never argue with your spouse (about parenting issues) in front of the children.
• Be consistent especially when applying consequences.

Sometimes parents agree on these matters, and other times they do not. I feel the most important of these are consistency and parenting as a team. A common example of inconsistency is:

“I want a popsicle.”

“No, it’s too close to dinner.”

“I want a Popsicle.”

“No. “

“I want a popsicle.”

“No.”

“I want a popsicle.”

“Oh, go get one.”

What has the child learned? If I badger mom long enough, she will give in. Do not get caught undermining each other’s authority. Many couples are not on the same page with parenting and do not parent as a team. In some cases, when a couple feels disconnected, they undermine their spouse’s authority with the children. Obviously, children learn very quickly who will give them what they want. Children should receive the same message from both parents. Never argue in front of the children.

 Blended Families

One of the trickiest situations for a couple is when they have a blended family. The preverbal yours, mine and ours creates stress and conflict among most couples. The ex-wife or husband is commonly an issue. Perceived or real allegiance to my child over your child is also common, as well as my family over your family. When one has a blended family, I believe that therapy is needed to address the resentment that is often present but was never considered before marriage.

The single most tricky thing to carry out after a divorce is keeping in mind what is best for the children. Hopefully, the following will keep you on track.

 Co-parenting after the Divorce

1. Try to parent as a team. Co-parenting can be difficult at best however I have seen some couples who still attend family functions together and make a point of going out to dinner as a family once a month. It is understood that they will swap visitation dates when their schedules dictate. It can be done if you really are interested in doing what is best for the children.
2. Communicate with civility and respect. Remember the walls have ears. A 10-year-old once told me that he could listen to his parents argue through the heating vents in the floor. No badmouthing your ex. No matter how angry you are, you still need to do what is in the best interest of the children.
3. There are several apps that help couples collaborate on their schedules and calendars. These apps give parents the ability to coordinate their schedules to stay on the same page. This can be particularly useful when there is still tension with your ex.
4. If your ex-grounds a child, you should honor that decision and continue it even if it is your weekend. I do recommend that there be parameters put on such consequences.
5. Do not bring a new love interest around the children. Some people ask me for a time when it is ok to bring someone around. I think it depends on the children and how they are adjusting to divorce. If I am forced to give a time, I say one year. Parents really need to examine their own feelings and keep those emotions separate from what is in the best interest of the children.

Morning and Bedtime Routine

Frequently the morning and bedtime routine can create chaos, screaming and conflict within a family. The morning and bedtime routine needs to be discussed at a time when everyone is calm. Expectations need to be made clear, including the consequences of not adhering to the guidelines. One couple decided to serve breakfast last before leaving the house. If a child dawdles, then they get a breakfast bar in the car on the way to school. They reported that their child only let that happen once. It has not been an issue since. I encourage a weekly family meeting to discuss Stars, News, Issues, and Feedback. These meetings can address multiple family issues and behavior. (See family meetings below.)

Homework

Set a specific time for homework. Who will check what assignments are due and if the assignments are complete?

Consequences

Some parents, for example, apply consequences when they are angry: “You are grounded for a month.” The weekend rolls around and lo and behold, “I can’t let her miss the big dance.” So, the consequence is voided. I recommend that you hold off on the punishment and say, “I am very angry right now; I will let you know what the consequence for your behavior is after I have cooled off and I have discussed it with you father.” The essential point is “Never parent when you are angry.” The key to good parenting is consistency.

Family Meetings

Once upon a time, families ate dinner together. There was no eating in front of the TV; no texting or answering the phone and no internet. This was a time when families discussed what was going on in the household i.e., news, upcoming events, behavior issues and general discussions. Dinner used to be the natural time for families to discuss their lives, upcoming events, and issues of importance.

Today, families rarely eat together, missing the opportunity for family discussion. Child activities including little league, football, soccer, music lessons, dance lessons, and all kinds of after-school activities have come to interfere in this essential family event. Families have become ships in the night passing one another as they head out the door. The idea of after-school activity is potentially a good one: keep the kids busy and you will keep them out of trouble. However, what has been lost is the sense of family and the opportunity for effective communication.

When I was a child, dinner time was always between 5 and 5:30pm. I had a lot of freedom, but I also knew what was expected of me. In this case, it was being home by 5pm for dinner.

We would hear stories, news and discuss family issues. Today parents have become dependent on dual incomes in order to maintain the lifestyle they want to give their family. Now that the world economy has become more difficult and we have high unemployment and home foreclosures are rampant, parents are working two jobs just to make ends meet. They work late or have different schedules and their relationship suffers. They too, are ships passing in the night. Many couples today report they feel disconnected, their communication has suffered and, in turn, so has the level of intimacy they share. This will ultimately lead to bickering, conflict, infidelity and possibly divorce. How sad that an important family event has disappeared without realizing the major negative impact on the family. Even when couples do realize the problem, there is little that can be done since they are trying to stay afloat financially.

One way to reclaim some of that lost family communication time is family meetings, though some of my couples prefer to call them team meetings. I encourage families to gather at least once per week to discuss four areas. Ideally, this should be done on the same day and time each week in order to maintain consistency in meetings.

The general topics to discuss are Stars, News, Issues and Feedback. Here are some examples:

1. Stars: Search for things your child is doing well, no matter how small and acknowledge it. It will increase their sense of confidence and self-esteem. Show that you are excited and proud of them. “You did a nice job getting ready for school on time.”
2. News: This is a chance to keep everyone up to date with all the family events coming up. The more informed everyone is, the more opportunities to share the scheduled load and the less stress for last minute- must do projects. “We are going to grandma’s house next weekend or Joey has a science project due and he will need craft paper”
3. Issues: We live in an increasingly complex world that challenges us every day with a wide range of disturbing issues. By initiating conversations with your children, you will create an open environment which will allow you to address the tougher topics i.e., homework, curfew issues, chaotic morning or bedtime routine, alcohol, and drug abuse.
4. Feedback: Listen to your children and allow them the chance to express their concerns, complaints and express their feelings. You will learn more about your child if you open your ears and close your mouth.

I have found that both parents and children love this opportunity. The only concern is that as much as everyone in the house likes this, parents themselves have a tough time being consistent. They often report that they were consistent initially, but the process has not been repeated in weeks. Be consistent! Family meetings are just one way to address the potentially poor communication within the family.

The Holidays

In general, holidays have long been known to create stress and conflict in marriage and relationships. I hear often, “I hate the Holidays because of the stress created by family pressure and guilt.”

 Thanksgiving

Mary wants to be with her family while Joe wants to be with his. I have often tried to encourage couples to rotate Holidays. I certainly remember when I was dating, trying to satisfy both families and not eat too much so we could go to the others for Thanksgiving Two. It never worked for various reasons including eating too much at one house and then not eating at the other. Then you heard the statement, “I made all this food, and you are not eating.” Of course, then there is Thanksgiving in Chicago which could always throw in a snowstorm for good measure. So, a forty-five-minute trip could easily turn into an hour and a half one way. So, families spend the day in the car risking life and limb to try to make everyone happy including each other. This is often complicated by family saying, “This is how we have always done it.”

Even more complicated is dealing with aging parents and their health issues. Now we have the fear that this may be the last holiday together. The result, of course, is strained relationships. So, when mom calls months ahead to ask about holiday plans and says, “Can we count on seeing you on Thanksgiving? The correct answer is, “I’ll get back to you when we have figured out what we are doing.” Do not throw your spouse under the bus by saying, Mary wants to go with her family, or I must check with Mary. The correct answer is, “We have to decide what we are doing; we will get back to you.” Mom will forgive you, but your partner will be an outlaw forever. I recommend, in the case of Thanksgiving, for instance, one year with your side and the next year with hers. Another solution is having Thanksgiving dinner on Thursday and again on the weekend. Ultimately, the real goal here is the ability to work through emotionally charged differences of opinion with civility and respect, discussion, and compromise.

 Christmas

Christmas is also complicated. I hear, “Both our families always got together on Christmas eve and Christmas day.” So, rotate! One year have Christmas Eve with his parents and Christmas day with her family. Now, what if one or both sides live out of town? Someone is likely to be unhappy, even resentful. Let Joe tell his mother and Mary tell her mom what “we” have decided. Now add children to the mix. The kids do not want to get up, open presents from Santa and then leave immediately for grandma’s house.

Your family unit consists of you, your spouse, and your children. You are now your own family unit; you want to begin to have your own family traditions. One way that has worked for many is to host Christmas. If your family does not come until the afternoon, this will give the children a chance to open gifts and play for a few hours before the extended family arrives. In-laws on both sides need to recognize that now as a new family entity, things have changed for you. Even if they do not get it, hopefully they will accept it. Addressing the Holidays in a civil and respectful manner is a good avenue to addressing other conflicts that frequently have no real resolution other than compromise. The only answer is listening and understanding your partner’s feelings and vice versa. Be willing to work on a solution with a win-win attitude in an atmosphere of civility and respect. This will go a long way in addressing other conflicts in which you simply do not agree.

Infidelity

When cheating is an issue, the relationship is in serious trouble. A one-night stand may be viewed as evidence that “we have lost our connection.” A long-term affair is evidence that the marriage is likely seriously damaged and in trouble. Cheating occurs in about 18% of all marriages. Spouses consider an emotional affair to be no different than a physical one. The phrase, “She is just a friend” is devastating. She typically feels resentful that she should be the best friend. The cheater wants nothing more than to move on and put it all in the past. But the trust issues created by cheating are long lasting. Getting past infidelity will take months, possibly even a year and that includes a therapist to help guide the couple through the hurt, anger, and resentment.

Infidelity does not have to mean an end to the relationship. A few things that a person should keep in mind to heal yourself after infidelity are:

• Have an open honest talk.
• Stop asking the same questions repeatedly. You will never really get the answers you are looking for.
• Forgiveness is a key but know that it will take time. Be patient!
• Share your feelings.
• Sexual intimacy will return in time; don’t rush it.

Getting over infidelity is hard, painful and takes time. Seek help!

In therapy, sometimes I ask each partner for three things that the other can do to make the other feel closer, more connected. Then I ask each to guess what one will say about the other’s needs. This will give me a good indication of just how disconnected they are. Do not wait until it is too late to seek help. Also, do not hesitate to change therapists, if you do not get a good feeling about the connection with the therapist. Sometimes the therapist is just not a good fit for one or both of you. It does not mean you should give up on therapy.

Children Sleeping in Mom and Dad’s Bed

When one parent permits a child to sleep in their bed, this usually reflects an intimacy problem. Often when a couple does not meet each other’s emotional needs, they seek fulfillment by becoming excessively attentive and emotionally over-involved with their children. If mom feels like co-sleeping is fine and cozy and dad is spending more time on the couch, resentment is sure to set in. This can be the beginning of an end to the marriage. Couples cannot permit children in their bed for the night. After about ten minutes of snuggling mom should say, “Ok it’s time to go in your own bed.” Dad confirms by saying, “you heard your mom; it’s time.”

Anger

• Anger and depression are often the other side of the same coin.
• Anger is one of the major sources of marital and family stress.
• Anger is a less obvious sign of a mood disorder, but it can certainly have the same devastating effect on your relationship.
• Anger is also common when alcoholism has reached a more advanced stage.

If you find you are constantly angry, yelling, screaming obscenities at your spouse or children, you may have a mood disorder. Regardless, this kind of behavior has a long-lasting negative effect on your relationship. Long after you have forgotten what the conflict was about, you will remember the emotional impact of angry words. This creates resentment and this in turn creates distance. Monitor yourself, mark it on the calendar and see how often you get angry or lose control. Your marriage is at stake. I set civility and respect as a goal. Achieving civility and respect is a process. Changing habits takes time. If the angry spouse cannot get themselves under control with the help of a therapist, I recommend a psychiatric evaluation for medication.

Lack of Emotional Expression

The inability to express feelings can be a major issue in many relationships. Many times, people who cannot express their emotions are assumed to have limited vocabulary or be shy, but often there are much deeper reasons. Emotional intimacy is founded on each person’s emotional security and confidence, and the ability to communicate their feelings with their partner. Emotional insecurity derives from many factors, including depression, low self-esteem, past rejections, and failed relationships.

I find that many men have difficulty expressing their feelings at all let alone appropriately. This lack of expression of feelings is one of the major causes of marital disconnect. Women, especially it seems, need to know what their man is feeling in order to feel connected and consequently warm and fuzzy in the bedroom. Good communication is key; work on it. Men tend to be more R rated; they don’t have to talk. Gentlemen, you need to remember that good communication is needed for marital success. Good communication is reflected by “I feel” statements and good listening skills. If a topic is a source of tension in the relationship, it will be much less so if you start sentences with “I feel” rather than with “you always or you are never.” And please, never say never and always. One helpful thing to remember, if you have something difficult to say– be nose to nose, with your arms around your spouse. Physical intimacy combined with a difficult topic, is perceived much differently than things said across the room. Journaling has long been used to help people get in touch with their feelings. Simply writing a diary of sorts about your feelings is extremely useful and very therapeutic. This is one of those things that is preferred by women over men but may be extremely beneficial to both sexes.

Alcohol, Substance Use, and Dependence

Remember, when there is a family history of alcoholism, there is a 70% likelihood that there is also a mood disorder. If one or both issues are not addressed and under control, it is unlikely that the marriage will survive. Get help in a timely manner.

Resentment

One of the most destructive forces in a marriage is resentment. Unresolved issues are its cornerstone. Even if a couple calls time-out to stop the conflict, they normally don’t have a follow-up conversation and the issue remains.

Case Scenario – Joe and Mary

Joe is a binge drinker and denies he has a problem. Mary clearly sees this as an issue but does not know how to address it without a fight. If it does not get resolved, it will eventually create distance or a disconnect in the relationship. I recommend that Mary attend Al-Anon meetings and see a therapist individually. If Joe wants to know what was said, Mary should say join me in my next session and find out. It is human nature to avoid difficult issues rather than risk intense conflict. But avoidance, also known as enabling may be the undoing of the relationship.

Finances

Even wealthy couples argue about finances, spending habits, use of credit cards, student loans, savings, and retirement goals. I recommend that you:

1. Outline your savings and retirement goals.
2. Establish a budget. What is discretionary spending and what are essentials?
3. Decide on major purchases together.
4. Outline what constitutes a major purchase. Set a dollar amount.
5. Pay off credit card balances each month. A good rule to follow is if you cannot pay the bill when it comes, do not make the purchase.
6. Decide if you will combine your income.
7. Delegate who will pay the bills monthly. I recommend that you do the bills together at least occasionally so that each is aware of your financial state.
8. Do not purchase a house and become house poor. You will need to have some disposable income for fun and a date night to nurture the relationship.
9. Be sure your budget includes disposable income and retirement savings.

Chapter 17.
The Use of Homework in Couples Counseling

As a cognitive behavioral therapist, I assign homework between sessions to the couples’ I counsel. Homework will not solve conflict, communication, or resentment issues. Those issues need to be addressed in session. Homework will, however, help and typically addresses the following:

Civility and Respect

This one is a must. Civility and respect are the foundation of your relationship. When a couple loses civility and respect, their relationship is in serious trouble. They feel distant and thus intimacy suffers. There is never a good reason to scream, swear, name call, or act out like mooning your spouse. If you have gotten into these habits, you may need professional help to get it under control. It will take some time; it is a process – but if you work at it and strive for consistency you can regain civility and respect. As in any process, owning your errors is important. Do not hesitate to acknowledge it if you say something that is not civil or respectful. Say, “I am sorry I should not have said that.” and mean it. All couples need rules of engagement for conflict. You can never allow yourself to lose control. It is the foundation of your relationship. You cannot build a house without a good foundation. Couples cannot permit yelling, screaming, swearing and name calling to undermine their relationship.

Call Time Out

When conflict becomes too intense and one or both of you are in danger of losing civility and respect, call a time out. The words time out will become a signal for both of you to settle down. Never follow your spouse when they are trying to retreat from the conflict. Standing outside the bathroom door and continuing the discussion is out of bounds. If you decide to go for a walk or to a movie, say so your spouse knows when you are coming back. It is cruel to just walk out without regard for the other feelings. The rule of time out is you must get back to the discussion within 24 hours. Far too often couples will just let the issue go unresolved, swept under the rug. This creates resentment and distance. Hopefully, after a day of reflection, you will be able to discuss the issue calmly. If not, hold the issue for the next therapy session.

Reduce Alcohol/Drug Use

Many fights occur when too much alcohol has been consumed. Alcohol reduces inhibitions making it easier to allow yourself to lose control. If you drink daily, you may have a problem. Denial is a huge part of alcoholism. I typically say, can you stop drinking for a week or two and two months (for binge alcoholics). If you make excuses and refuse the challenge, you have an alcohol problem. There is no good reason one should be drinking daily.

Date Night

A night out alone is a common suggestion among both therapists and self-help books. As I have said, couples lose their way because of all that life throws at them. Don’t forget to nurture the relationship by spending time together alone. This does not have to be a big money issue. Many people with financial stress will simply go out for coffee or ice cream. I find it a statement of the current economic times and somewhat sad that couples will go out after therapy because they cannot afford a babysitter twice in one week.

Meet and Greet

Meet and greet is another way to address the lack of affection that many spouses feel. Touch is particularly important. This is not sexual touching. This is simply affection. Offer a hug and kiss when you leave and when you return. The responsibility is on both of you to find one another and do this when one of you walks in the door or leaves for work. Reaching out and holding hands when walking or just watching TV is also a way to address a lack of affection.

Parent as a Team

Children learn quickly who to go to get what they want. Sometimes tension between parents is noticed by the children and they will take sides. As I say, “the walls have ears.” Even when you do not think they hear your arguments more than likely they do. I have had children tell me, “I listen to their arguments through the heating vent in my room.” A daughter will often side with mom. The result is when dad tells the daughter to get ready for bed, she ignores him. He gets upset and mom steps in often creating even more conflict between mom and dad. Mom needs to back dad and of course vice versa. “Do what your father says.” When mom is angry at dad anyway due to unresolved marital issues, mom unconsciously gets satisfaction from the child’s disrespect toward dad. This will continue for a while until marital issues are addressed and parents recognize how they undermine the other’s authority, and the child sees that they are consistently parenting as a team. Parents need to support one another in family meetings to address disrespect to the other parent. This is a common issue addressed under family meetings below.

“I feel” Statements

Inability to express feelings is a major issue in many relationships. One of the hardest things for many men to do is to get in touch with feelings. I find that many men have difficulty expressing their feelings at all let alone civilly and respectfully. Yet, lack of expression of feelings is a major cause of marital discontent. Opening up is critical for a good relationship. In addition, expressing feelings aloud appropriately helps dissipate negative feelings. Women, especially it seems, need to know what their man is feeling in order to feel connected and consequently warm and fuzzy in the bedroom. Men are more R rated; they generally don’t like to talk about feelings. Women say about 6,000 words per day; men only 2,000. I believe that effective communication leads to romance and that communication is needed for marital success. For most women and many men, it is that expression which makes a couple feel connected. I encourage “I feel” statements…. It may at times still be a confrontational statement but much less so than when you begin statements with “you always “. First, never say never and always. When you have something difficult to say be nose to nose with your arms around the person. Say, “I feel” and it will more likely be perceived less defensively than things are said from across the room or behind a closed door.

No History Lessons, No Skidding

Stay on the present issue. “I need you to pick up after yourself.”  Response, “you don’t take out the garbage.”  Many couples allow their conflicts to skid into the past. When this happens, there is rarely a resolution to the current issue. This can create hostility and resentment. When you find yourself fighting about where you squeeze the toothpaste tube (he squeezes in the middle you squeeze on the end) obviously you are not addressing the real issues.

Family Meetings or Team Meetings

Family meetings are just one way to address the disconnect in a couple or within the family. Obviously, some issues should not include the children. When family meetings to include the children, it will address 4 major areas on a weekly basis:

• Stars: Celebrate positive events; give compliments. Applaud good grades, a promotion at work, doing better on a calm morning and nightly bedtime routine.
• News: Discuss upcoming events and plans both short term and long term.
• Issues: Discuss negative events, behavior, issues such as the bedtime routine or morning chaos getting everyone off work or school.
• Feedback: Give the children a voice; this is their opportunity to be heard about what their concerns are. At the next family meeting, discuss the behavior issues from the previous week to see if they have improved and to give props to reinforce that improvement. It may take several weeks for noticeable improvement; don’t give up on it if it does not go well.

Note on Consistency: I often hear about how well this works but somehow people just stop conducting these meetings. Make it a part of your weekly routine; try to be consistent.

Chapter 18.
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 do not happen by accident. Many issues can be resolved prior to marriage with the help of a therapist. Common issues addressed may include work, finances, 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 aware of their intended mood and alcohol/substance issues. My main questions are as follows:

Is he/she:

• Willing to seek help?
• In need of psychoeducation?
• 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?

It is not going to get better if your intended is in denial. Get out while you still can!

Civility and Respect

Work on resolving conflicts in a civil and respectful way. Lack of civility and respect will eventually be the undoing of any relationship. It is possible to argue, resolve conflicts, and agree to disagree in a respectful manner. To do this, all couples need rules of engagement for conflict. It is important that couples express how they feel, but this needs to be done in a very caring and respectful manner. This means there should be civility and respect when conflict occurs. That means no hitting (of course), no yelling, no swearing, no screaming, or name calling. I encourage you to look at yourself and your relationship with your intended. Are you holding onto resentments? If so, you will need a therapist to help resolve this and teach you how to fight with civility and respect.

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. As it is often said, 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. If you can do those two things, you have done more than most couples, and you have done a lot to start your relationship off on solid ground. 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? I recommend meeting with a financial planner to discuss issues such as spending, use of credit cards and financial goals.

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” must discuss the event or holiday and that he or she should respond to their own family unit.

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 consider 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

Joe is not religious; Mary is and expects to go to Church every week. What if they did marry and have children; would Joe go to Church then? What if Joe is Catholic and Mary is Jewish? Will one of you convert? Does it matter at all? What will the respective families say? That is a big question especially regarding 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.

 How to Parent the Children

Do you want children? How many and when? Are there already children from previous relationships? 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 do not bring you closer together; they create stress and sometimes distance especially if you and your spouse are not on the same page regarding roles and responsibilities. There is even more stress when ex’s and step in-laws are in the picture. I believe that children do not come first; your relationship comes first. Now I have already stated that I have two children, so I know on one level that statement is just not true. On the other hand, if you divorce it will be children that suffer most. Of course, my point is do not 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. But above all – Parent as a team!

Work, Lifestyle, Leisure, and Fun

What sort of lifestyle do you want? Will you both continue to work once you have children? 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 expectation of employers today is long hours and work from home in the evening and on the weekend. This reduces quality time together. These forces necessitate compromise to make the most of the time you have together. Planning mutually enjoyable activities and social events, balanced with appropriate alone time is a key component in maintaining a strong relationship. There needs to be me time, family time and couple time. When those are out of balance, conflict will occur.

Final Thought

You may not feel you NEED premarital counseling, but it is still a 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 than with a divorce attorney later.

Chapter 19:
Brief Tips for Maintaining your Relationship

All couples fight. The key is to have rules for fighting so as not to create resentment over time. Resentment is very destructive to a relationship. Always be civil and respectful. There are no winners when couples lose control. The best-case scenario is that you both feel understood even if you do not agree. Always be willing to compromise. When all is said and done, you should both feel understood even if the issue is unresolved. Agree to discuss the conflict in therapy if an issue remains unresolved.

• Always be civil and respectful. This is the foundation of your relationship. When civility and respect break down, the relationship is in trouble. Resentment is created and this has long term detrimental effects including lack of intimacy and bickering over trivial things.
• Relationships are like a car. They need maintenance to run well. Don’t take your relationship for granted. This is a very hectic world we live in. Sometimes couples get lost in the day-to-day grind of life, especially when there are children and tons of after-school activities. Make time for one another. This fosters good communication and a feeling of connection.
• Effective communication means everyone walks away feeling good about the interaction. Find a way to compromise or at least agree to disagree civilly.
• Offer greetings, a hug, and a kiss when you leave in the morning and when you return. The duty of meet and greet, as I call it, is for both of you to find one another and give a hug and kiss. When you kiss remember you are not kissing your mother. It’s OK to laugh. I think you will find that this turns into a family hug once the children notice. Even the dog will want in.
• Look at one another when you talk. Make eye contact. It is better to be nose to nose, possibly with your arms around each other for difficult conversations. The intention is that this is about effective communication and never about winning an argument.
• Be affectionate. Take walks together; hold hands while sitting on the couch.
• Make a love call during the day.
• Have a date night regularly for just the two of you. Do not discuss issues; plan your next date or vacation.
• Take time to talk for a few minutes when you get home. Talk about your respective day. Share your feelings. Men typically try to offer solutions. Gentlemen, you need to listen, you do not have to offer solutions. Men tend to try to fix it; just listen and acknowledge what you have heard by saying back what you heard with emphasis on the feeling you heard. This will help avoid, “you’re not listening.”
• Have family meetings weekly and include the children. Discuss the meeting together before it occurs so you are on the same page.

1. Offer Stars (compliments).
2. Offer news (We are going to grandma’s house this weekend).
3. Discuss the children’s current issues and behavior and give kudos next time when appropriate for improvement in various issues.
4. Allow the children to give feedback and have a voice.
5. Listen to what they have to say.

Almost all my clients who have had family meetings as suggested report that they like it as well as the children. With children under five years old, keep the meetings to about five to ten minutes. After that you will lose them. Do this consistently and you will easily see the benefits.

Rules of Conflict:

1. No hitting; no throwing, no jumping up and down. The latter is my generic for acting out.
2. No swearing, no cursing, no name calling. Long after you have forgotten what the fight was about you will remember the ugly name you were called.
3. Keep your voice down; talking louder does not help the person hear you better.
4. One argument at a time. No skidding; stick to the topic at hand. No history lessons— a review of the past is not helpful; stick to the issue at hand.
5. Do not start sentences with “you”. This immediately puts the other person on the defensive. Start with “I feel…. because…” This has a much better impact. It may still be confrontational, but it does not create as much defensiveness.
6. Try to understand what the person is feeling. The best way to do this is by reflecting or mirroring what you have heard, especially the feeling behind what was said. This is simply good listening, but it is especially important to effective communication.
7. Do not talk over one another. If you are both talking, that means no one is listening.
8. Do not argue from different rooms or behind a closed door. When she goes into the bathroom to get away, give her some space. Do not stand outside the door and continue to try to talk. Do not just walk out either; your partner does not know how to interpret that. At least say, “I need a time out. I am going for a walk; I will be back in an hour.”
9. Do not allow yourself to lose control…ever. Call “time out” if the conflict is getting heated. “Time out” is your mutual signal that we must stop now. Agree to discuss it further within 24 hours or when you have cooled off.
10. Never threaten divorce or separation. This is very destructive, and it can create resentment and trust issues.
11. No sarcasm, ever.
12. Seek help from a therapist when needed.

Zoom!
Now I can work via Zoom with anyone, anywhere in the country and it is currently 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

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.