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for Medication Evaluation (21)The client was referred for a medication evaluation to consider psychotropic medication to control the manic state.The client has followed through with the medication evaluation and pharmacotherapy has begun.The client has been resistive to cooperating with a medication evaluation and was encouraged to follow through on this recommendation.

      22 Refer to Outpatient Systematic Care Team (22)The client was referred to an outpatient systematic care team to help manage medications and provide support services.The client has followed through with the referral to an outpatient systematic care team and support services have begun.The client has not engaged with the outpatient systematic care team and was redirected to follow through on this recommendation.

      23 Monitor Medication Reaction (23)The client's reaction to the medication in terms of side effects and effectiveness was monitored.The client reported that the medication has been effective at reducing energy levels, flight of ideas, and the decreased need for sleep; the client was urged to continue this medication regimen.The client has been reluctant to take the prescribed medication for their manic state but was urged to follow through on the prescription.As the client has taken medication, which has been successful in reducing the intensity of the mania, they have begun to feel that it is no longer necessary and indicated a desire to stop taking it; the client was urged to continue the medication as prescribed.

      24 Maintain Reviews of Psychotropic Medication (24)The client's adherence with the psychotropic medication prescription was reviewed.The client indicated a desire to terminate medication because the client “doesn't feel normal”; the client was encouraged to continue to use the medication, in consultation with the prescribing clinician.The client was monitored regarding compliance with the psychotropic medication in regard to their belief that they no longer need the medication because the client has stabilized.The client was reinforced for maintaining medication use in accordance with the prescribing clinician's expectations.The client was confronted for nonadherence with the psychotropic medication regimen.

      25 Monitor Ability to Participate in Group Psychotherapy (25)The client's pattern of symptom improvement was monitored, with a focus on how stable the client is in regard to participation in group psychotherapy.The client was judged to be significantly improved and capable of participating in group psychotherapy.The client was judged to still be too manic to allow helpful participation in group psychotherapy.

      26 Educate About Mood Episodes (26)A variety of modalities were used to teach the family about signs and symptoms of the client's mood episodes.The phasic relapsing nature of the client's mood episodes was emphasized.The client's mood episode concerns were normalized.The client's mood episodes were destigmatized.

      27 Teach Stress Diathesis Model (27)The client was taught a stress diathesis model of bipolar disorder.The biological predisposition to mood episodes was emphasized.The client was taught about how stress can make them more vulnerable to mood episodes.The manageability of mood episodes was emphasized.The client was reinforced for their clear understanding of the stress diathesis model of bipolar disorder.The client struggled to display a clear understanding of the stress diathesis model of bipolar disorder and was provided with additional remedial information in this area.

      28 Provide Rationale for Treatment (28)The client was provided with the rationale for treatment involving ongoing medication and psychosocial treatment.The focus of treatment was emphasized, including recognizing, managing, and reducing biological and psychological vulnerabilities that could precipitate relapse.A discussion was held about the rationale for treatment.The client was reinforced for understanding of the appropriate rationale for treatment.The client was redirected when displaying a poor understanding of the rationale for treatment.

      29 Enhance Motivation for Medication Adherence (29)Motivational interviewing techniques were used to help the client identify and increase motivation for medication adherence.The client was asked about satisfaction with the current level of medication adherence and mood stability.The client was assisted in identifying the benefits of changing their approach to the medication.The client was assisted in assessing optimism for making changes in the medication adherence pattern.The client was assisted in developing specific tactics for medication adherence.

      30 Educate About Medication Adherence (30)The client was educated about the importance of medication adherence.The client was taught about the risk for relapse that occurs when medication is discontinued.The client was asked to make a commitment to prescription adherence.The client was reinforced for understanding and commitment to prescription adherence.The client was redirected when displaying poor understanding or commitment to prescription adherence.

      31 Assess Prescription Nonadherence Factors (31)Factors that have precipitated the client's prescription nonadherence were assessed.The client was checked for specific thoughts, feelings, and stressors that might contribute to prescription nonadherence.The client was assigned “Why I Dislike Taking My Medication” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).A plan was developed for recognizing and addressing the factors that have precipitated the client's prescription nonadherence.

      32 Coordinate Group Psychoeducational Program (32)The client was admitted to a group psychoeducational program that teaches clients the psychological, biological, and social influences in the development of bipolar disorder.The client's involvement in the group psychoeducational program focused on the biological and psychological treatment of the disorder.The client has followed through on involvement in a group psychoeducational program and key topics were reviewed.The client has not followed through on involvement in a group psychoeducational program and was redirected to do so.

      33 Teach Illness Management Skills (33)The client was taught about illness management skills.The client was taught about identifying early warning signs, common triggers, and coping strategies.The client was taught about problem-solving regarding life goals and development of a personal care plan.

      34 Use Cognitive Therapy Techniques (34)Cognitive therapy techniques were used to identify, challenge, and change cognitive appraisals that make the client vulnerable to manic or depressive episodes.The client was reinforced for greater insight into their cognitive appraisals.

      35 Assign Homework (28)The client was assigned homework exercises in which they do behavioral experiments to test biased versus alternative predictions.The client was assigned “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in reviewing their insight regarding biased versus alternative predictions and successes were reinforced.The client was provided with corrective feedback toward improvement of understanding of biased or alternative predictions.

      36 Teach Coping and Relapse Prevention Skills (36)The client was taught coping and relapse prevention skills via cognitive-behavioral techniques.The client was taught about delaying impulsive actions, structuring and scheduling daily activities, keeping a regular sleep routine, avoiding unrealistic goals striving, and using relaxation procedures.The client was taught about identifying and avoiding episode triggers.The client was assigned “Keeping a Daily Rhythm” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced for understanding of taught skills.The client did not understand the provided skills and additional information was provided.

      37 Conduct Family-Focused Treatment (37)The client and significant others were included in the treatment model.Family-focused treatment was used with the client and significant others as indicated in Bipolar Disorder: A Family-Focused Treatment Approach (Miklowitz & Goldstein).As family members were not available to participate in therapy, the family-focused treatment model was adapted to individual therapy.

      38 Assess Family Communication (38)Objective instruments were used to assess the family communication.The level of expressed emotions within the family was specifically assessed.The family was educated about the role of aversive communication (e.g., highly expressed emotion), how it increases risk of relapse, and how change in communication style can reduce that risk.The family displayed a clear understanding of the effects of aversive communication and this was reinforced.The family was provided with feedback about their style of communication.The family has not been involved in the assessment of communication style, and the focus of treatment was diverted to this resistance.

      39 Teach Communication Skills (39)Behavioral

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