Engaging Through the Elation: Forming an Early Therapeutic Rapport With a Patient With Bipolar Disorder

Bipolar disorder, a severe and chronic psychiatric disorder affecting an estimated 1%–4% of the population (2, 3), is characterized by recurring mood episodes (manic, depressive, and hypomanic). Mania is the defining characteristic of bipolar I disorder and is indicated by abnormally elevated, expansive, or irritable mood; persistently increased activity; and a decreased need for sleep. Having a first-degree relative with bipolar disorder increases the risk of diagnosis (4). The functional disability that individuals experience from this disorder varies widely. During manic episodes, individuals often have little insight into their disability and vehemently resist efforts to be treated. Suicide risk is elevated among individuals with bipolar disorder, with some studies estimating rates of suicide 20 times higher than in the general population (5).

Age at onset of bipolar disorder is important in the course and outcome of the disorder. Bipolar disorder may arise throughout the life cycle. Studies have suggested a strong birth cohort effect for bipolar disorder, with higher overall rates of the disorder and earlier ages of onset over successive generations (6). Meta-analytic results suggest that an early (compared with late) age at onset of bipolar disorder is associated with a longer delay to treatment, greater severity of depression, higher levels of comorbid anxiety and substance abuse, and a greater likelihood of having attempted suicide. Rapid cycling (four or more episodes of mania or depression in 1 year) may also be more common in the younger cohort (7). In a large international study, age at onset of DSM-IV bipolar I disorder was estimated to occur among 5% of patients during childhood (ages<12) and 28% during adolescence (ages 12–18), with a peak of 53% for those ages 15–25. Younger age at onset of bipolar disorder, especially childhood onset, was associated with a poorer functional outcome and a stronger family history of the disorder (8). A recent systematic review by Bolton and colleagues (9) reported a trimodal bipolar disorder age-at-onset distribution, segregating patients into early-, mid-, and late-onset subgroups, which was proposed to help delineate more homogenous presentations.

Environmental factors affect clinical outcomes of bipolar disorder. Childhood maltreatment (neglect, family conflict, or physical, sexual, or emotional abuse) among patients with bipolar disorder is associated with a heightened risk of more severe symptoms; risk of comorbid posttraumatic stress disorder, anxiety, and substance or alcohol misuse disorders; early age at bipolar disorder onset; risk of rapid cycling; number of manic and depressive episodes; and risk of suicide attempt (10). Treatment nonadherence is another negative prognostic factor among patients with bipolar disorder. It is estimated that about half of individuals diagnosed as having bipolar disorder are nonadherent to their prescribed medication regimen (11). Medication nonadherence is associated with significantly increased risks of relapse, recurrence, hospitalization, and suicide attempts and a decreased likelihood of achieving remission and recovery, with subsequently higher overall treatment costs (12).

Jamison and Akiskal (13) distinguished between four groups of factors responsible for nonadherence and the consequent reduction in treatment effectiveness: factors specific to the disorder (type and phase of bipolar disorder), to therapy (therapeutic regime, adverse medication symptoms), to the patient (demographic characteristics, patient’s beliefs and attitudes toward the disorder and the treatment), and to the physician (beliefs concerning the disorder and the treatment, connection with and influence on the patient). A poor doctor-patient therapeutic alliance is an important, remediable variable associated with poor patient treatment adherence. A lack of congruence between the physician and patient concerning the most important aspects of treatment success may lead to poor treatment adherence. A study by Maczka and colleagues (14) found that patients believe that doctors consider improvement to patients’ quality of life much less important than alleviating symptom severity. Patients identified adverse effects of the medication as the reason for poor adherence, whereas physicians considered compliance the crucial problem. Discrepancies in beliefs were also observed regarding the perceived importance of different psychoeducation topics: coping abilities and quality of life improvement were the most important issues for patients but were given low priority among doctors (14).

Early diagnosis, initiation of effective treatment, and treatment adherence are essential factors in optimizing positive outcomes for individuals diagnosed as having bipolar disorder. Children of parents with bipolar disorder merit particularly close monitoring. Reluctance to engage in treatment is common with many teens, and engagement may be even more difficult with individuals experiencing mania or hypomania, because they may not perceive a need for intervention. The initial therapeutic engagement with younger individuals experiencing symptoms of bipolar disorder is crucial. Enhancing attention to the factors that improve treatment adherence from the first encounter onward can improve a patient’s lifetime prognosis.

Clinical Vignette

Marcus is a 17-year-old 11th-grade student in the local high school. He was a motivated and accomplished student through ninth grade but has subsequently demonstrated a decline in his grades and behavior, which was attributed to his initiation of marijuana use. He began to show other concerning behaviors as well. He left home at night, began having sexual experiences with multiple girls from school, was truant from school or missed classes, and began to snap at his parents and teachers over minor frustrations. Marcus and his father began having loud arguments. Marcus broke a lamp during one such argument, and his father slapped him hard enough to leave a mark. This incident prompted the school counselor, who heard about the bruise and talked to Marcus, to call child protective services. She was concerned about Marcus’s presentation. He was talking too quickly, initially minimizing the severity of the argument with his father. Moments later, he threatened that he might hurt his father or himself if he went home. Marcus was sent by ambulance to the emergency department to receive a psychiatric evaluation for safety and altered mental status.

In the emergency department, a drug screen returned positive for cannabinoids but no other substances. Marcus was fidgety and hypermotoric but not combative or threatening. When he was medically cleared, a psychiatry consult was called.

Dr. Jackson, the psychiatrist on call to the emergency department, obtained relevant history from Marcus’s mother. She described Marcus as having always been a “very active” child and recalled a prior concern about attention-deficit hyperactivity disorder. However, Marcus did well in school and participated in sports, so medication was not deemed necessary. Despite his hyperactivity and intermittent impulsivity, Marcus was described as a “good kid” with respectful behavior, good grades, and nice friends when he was younger. His mother identified ninth grade as a crucial turning point. He began to hang out with friends who smoked marijuana, and Marcus joined them in this habit. He was more oppositional and irritable at home. Little things seemed to get on his nerves. He sometimes was withdrawn, isolating himself in his room, and at other times was talkative and gregarious. He was described by his friends as “the life of the party,” and he was invited to them all. His grades began to fall, he was suspended from school multiple times for disrespecting teachers or smoking in the bathroom, and he began to sneak out at night. His parents became concerned. His pediatrician referred him to a therapist, but he refused to go, noting, “I don’t need a shrink.”

Marcus and his father had been fighting more, and the disputes had become physical a few times. Marcus’s mother noted that his father was particularly sensitive to disrespect, because Marcus’s paternal grandfather had been an alcoholic and moody. The grandfather had been hospitalized once and diagnosed as having bipolar disorder, but he did not take the prescribed medication. He died of liver disease at age 60. Marcus’s mother reported that Marcus’s father had a temper and used to spank Marcus with a belt when he misbehaved as a young child. More recently, Marcus had started to “fight back,” including by yelling, cursing, threatening, and breaking things, although he never hit his father. She said that the recent slap by his father had been the first time his father had hit Marcus in years. She felt that Marcus’s threats to hurt his father and himself were due to his drug (marijuana) use.

Dr. Jackson entered Marcus’s room and excused his monitoring sitter. Marcus was lying in bed watching television and glanced up when she entered.

“So, are you going to send me to the crazy house?” Marcus inquired.

“Crazy house?” Dr. Jackson queried.

“Yeah, where the crazy people like me go,” Marcus replied.

“Do you think you are crazy?” Dr. Jackson asked kindly.

“They say I am—I mean the school and my dad and all.” Marcus got up and began to walk around the room, inspecting the equipment as he went.

“How can I be helpful, Marcus?” Dr. Jackson asked.

Marcus stared at her with suspicion. “What do you mean?”

“Well, it seems that things in your life have been getting out of control. Perhaps I can be helpful.”

“Just get me out of here so that I can go party with my friends tonight,” Marcus replied.

“Your mother told me that you like to party. Can I hear that from you? Exactly what does ‘partying’ mean for you?” Marcus fidgeted with objects as he moved around the room and did not answer. “I assume there is alcohol, a few substances, perhaps cute girls and guys.”

“Hey, I’m straight!” Marcus snapped.

“OK, cute girls then. Do you find yourself doing things your parents wouldn’t approve of—like having sex a lot, using substances, or not thinking of consequences before you do fun things?”

“Well, sure, I’m a 17-year-old boy,” Marcus said.

Dr. Jackson smiled. “Yes, you’re a 17-year-old, bright and handsome boy who is the life of the party, has tons of friends, and likes to take chances. Your mother also said that you were suspended from school four times and have stayed out all night when your parents didn’t know where you were. So, from her point of view, things aren’t ideal. How have you been sleeping?”

“Hey, who needs sleep anyway. I’m a virile young man with a life to live,” Marcus replied, only partly sarcastically.

“There are exciting things in your life. Are there any issues that may not be so good?” Dr. Jackson asked, hoping that Marcus might report some insight.

“Not much—except to get my abusive father off my case.”

“Did he hit you when you were younger, too?”

“Oh, yeah. The belt. Parents can’t do that anymore—perhaps my dad didn’t get the memo. And now he just hits me with his fist. Same guy, different weapon.”

“Oh, I’m so sorry you have been hurt in so many ways. I’m glad you told the school social worker, so your dad can get the help he needs to treat you right. And you? Anything that you want to say about how you act?”

“My girlfriend broke up with me yesterday. She said that I cheated on her, and I was too overbearing and demanding,” Marcus offered.

“That must have really hurt,” Dr. Jackson said empathically.

“Yeah, but I’ll find another girlfriend soon. There’s more than one fish in the sea.”

“Do you think those things are true? Cheating on her and being overbearing and demanding?”

“I’m a 17-year-old boy.”

“And what age is she?”

“My age. What do you think I am, a pedophile?” Marcus started pacing around the room.

“Has it gotten bad enough that you want to hurt or kill yourself?” Dr. Jackson inquired, cognizant that he may not tolerate many more questions.

“Nah, I just said that. But sometimes I feel like it when everyone is on my case—like I should just run and keep running until I find a bridge.”

“Did you think of that today?”

“Not really. I was too mad.”

“And did you think of how you would hurt your dad or ex-girlfriend or anyone else?”

“Not really. I might want to slap them, but nothing big. I’m too strong. They say that when I get mad, I get superpowers. Like super strong. I’m scared I could, like, really hurt someone if I let that strength get away from me. When you get this big rush of adrenalin and then nothing hurts, and you have so much strength. Some people can even pick up cars.”

“Yes, that much strength could be really scary,” Dr. Jackson mused. “Marcus, I like you. You are smart, and honest, and funny, in a dark humor sort of way. You have a lot going for you. But I am worried about you. Things are getting out of control at home, and you aren’t making good decisions. I would like to work together to decide on a plan that can help turn some of this around. Your mother said that you think therapy is a waste of time. But it seems to me that you are on edge and sleep deprived. I think you need a place to mellow out, de-stress, and get some really intensive treatment,” Dr. Jackson said matter-of-factly.

“You want to send me to the crazy house?” Marcus replied.

“I don’t think that really describes the adolescent unit in the hospital. You wear your usual clothes, get to know other teens that have their own struggles, have groups, individual therapy, and meet with doctors and nurses so they can get to know how to help you. Oh, and they have hoops outdoors and ping-pong indoors. We have two adolescent units: one at this hospital and one at Mercy Hospital across town. Your choice,” Dr. Jackson finished.

“And if I say I won’t go?”

“I don’t want to get into some power struggle about it. I just want you to be safe and get the care you need. Your choice of which place,” Dr. Jackson said empathically, but firmly.

“Will you be my doctor?” Marcus asked, looking hopeful.

“As much as I would like to, I won’t be. But I will talk to your doctor and come by to be sure you are settled in this evening. Your mother will go with you,” Dr. Jackson answered reassuringly.

“I don’t want to see my dad!” Marcus blurted.

“OK, we will not put your father on the visiting list until you decide you want to see him.”

Engagement and Collaboration With a Patient With Bipolar Disorder

Individuals with bipolar disorder often demonstrate very little insight into the impact of their behavior on themselves and others during the manic or hypomanic phase. Patients love the euphoria, energy, and feelings of creativity—until this experience gets out of hand. Then, poor judgment, irrationality, and, perhaps, suspiciousness may thwart attempts at treatment engagement. This pattern may be particularly true of young patients, whose brain architecture for judgment and impulse control are not fully developed. Normal bids for individuation and autonomy may present as oppositionality. Sensitivity to interpersonal relationships and stress may present as moodiness. These traits may complicate the diagnosis of bipolar disorder among younger individuals. For each individual, careful documentation of medical history, evidence of a clear pattern of behavior change, and investigation into other disorders or substances that may mimic bipolar disorder are required (15).

Early identification, early effective treatment, and early patient engagement in treatment, with as much autonomy as is developmentally appropriate, are essential to enhance adherence and potentially mitigate the more virulent course of early-onset bipolar disorder. Treatment alliance requires an open-minded exploration with the patient about their attitudes and beliefs regarding medication and psychosocial treatments, family attitudes, knowledge, stigma, and practical matters that may affect access to treatment (16–18). Some factors that affect treatment adherence are important to identify but may be difficult or impossible to eliminate. These include patient demographic characteristics, illness severity, a history of trauma or adverse childhood experiences, and adverse effects of medications. The clinician can, however, modify the effectiveness of the therapeutic alliance through active listening, open discussion, and utilization of a concordance approach to treatment: “The cornerstone of the concordance approach rests on open discussions of mutual views about taking medications, and a shared decision-making alliance between patients and clinicians while retaining the primary of patients’ choices” (16).

In working with pediatric patients, a dual alliance is required. In addition to the therapeutic activity between the doctor and patient, patients’ parents or guardians play an essential role. Communication must be sensitive to the developmental stage of the patient and convey hope, while not inflating expectations for a magical cure. Psychological aspects of pharmacotherapy for children and adolescents are derived from the characteristics of the young patient, the characteristics of the important adults in the youth’s life, and the characteristics of their social environment. It is important to elicit the child or adolescent’s self-perception of what it means to be taking psychotropic medication (18, 19). Especially for children in the throes of manic symptoms, transferring a sense of calm and genuine interest in the patient’s needs and wishes may be best accomplished by using respectful, clear limit setting. The goal is to build rapid rapport and a sense of safety with the youth. Honest communication builds trust, even if what is being said is not what the patient wants to hear. A manic, hypomanic, or agitated patient likely is processing very little of what is said. Successful engagement is enhanced by calm, simple sentences and nonthreatening gestures and tone of voice (20).

Helpful strategies for engaging a young patient with bipolar disorder depend upon the severity of the illness, patient’s level of insight, and the child’s availability for collaboration. Compassionate de-escalation of the agitated patient often leads to greater trust in the caregivers and the organization. Allowing patients as many choices as possible without compromising safety also helps.

Each early encounter for a patient newly diagnosed as having bipolar disorder leads to increased trust, therapeutic engagement, and working alliance. Special attention must be paid to using developmentally appropriate language, creating a suitable treatment environment, and engendering the patient’s understanding of the treatment. Therapeutic engagement is also essential with parents, guardians, and other family members. Close collaboration between all caregivers and the patient will help optimize adherence and possibly improve the patient’s lifetime prognosis.

Tips for Enhancing Collaboration and Treatment Adherence With Young Patients With Bipolar Disorder

The following recommendations can be used to enhance treatment adherence and strengthen the therapeutic alliance with young patients diagnosed as having bipolar disorder (16–19, 21–23):

1. Protect self-esteem. Younger children in particular may interpret the need for medication as evidence that they have been “bad.” Parents may feel guilty for “causing” of the child’s illness by contributing genetic vulnerability or poor parenting. Other patients may feel embarrassed or fearful about their disorder, possibly feeling humiliation about behaviors they displayed during a manic episode. Respect, eye contact, engagement with the patient (not just the guardians), and not “talking down” to the patient are all keys to protecting the patient’s self-esteem (21).

2. Emote a measure of understanding and acceptance. Nonjudgmental acceptance of the patient (not the behavior) is crucial. Elicit the patient and their family members’ points of view, and make sure to articulate them. Discuss those points of view, along with the physician’s point of view, to collaborate in the treatment planning (19, 21).

3. Provide a sense of the future. Bipolar disorder diagnoses may carry the stigma associated with a lifetime of disability. Discussion about expectations for treatment that acknowledges patients’ fears or even hopelessness may preserve opportunities for change (21).

4. Thorough evaluation and clinical conceptualization should guide the choice of medication. The process of frequent re-evaluation and alteration to the clinical formulation, when needed, is ongoing.

5. Create and sustain all relationships necessary to address the youth’s needs, including relationships with parents and other caregivers, teachers, collaborative therapists, primary care providers, and others important to the patient.

6. Provide honest psychoeducation about potential adverse reactions to the medication while remaining sensitive to patient and family concerns. Review potential adverse effects in enough detail to be understood but without excess jargon or insinuation. (Children and adolescents are particularly sensitive to placebo and nocebo effects.) Include the positive attributes of the medication, anticipated timeline of effectiveness, and when and how the patient may get other questions answered or receive assistance quickly for their concerns. Providing a written review of the positives and potential negatives of the medication may be comforting for patients (23).

7. Attend to the doctor-patient treatment alliance first by actively engaging patients and families, encouraging active participation, and implementing methods for adherence success (such as daily medication journals or symptom charts).

8. Schedule sufficient time for office visits to allow time for questions, concerns, and alliance strengthening.

9. Ensure that a safety plan is in place. Ensure that it has been discussed and is in writing.

10. Clarify clinician availability and methods of communication—by phone, e-mail, or health information portals. This protocol should be written to provide families with a sense of security and to decrease miscommunication about dosing and side effects.

11. Less frequent and simplified dosing improves medication adherence by simplifying the process. Students may be averse to having to go to the nurse midday for dosages. If longer-acting medications are available, these are preferred after initial stabilization.

12. Ask about the patient’s ability to swallow pills and types of preparations available for a given medication (including cost and insurance coverage) to ensure the medication can be secured and taken.

13. Solicit feedback from patients and their guardians about their experience of the organization and the treatment relationship. Addressing organizational difficulties (parking, wait times, potentially unfriendly staff) and concerns about the treatment alliance should be regularly discussed and openly addressed. The more often these topics are broached, the more physicians may “course correct” in the treatment, with the result of enhancing adherence.