Chapter 3: Treatment Contracts

On the Bipolar-Lives website, one of our main concerns is making sure spouses, family members and other trusted supporters are kept informed and involved.
In 12 Step programs, it is often explained that folks are “only as sick as the secrets they keep”. Sometimes the symptoms of bipolar disorder also lead us to keep secrets and hold back important information from our loved ones.
However, as I myself have discovered the hard way, once an episode of mania or depression fully develops, it becomes almost impossible to make good choices. Instead, we are likely to behave in ways that are destructive to ourselves and the people around us.
This is where a Treatment Contract comes in. Your Treatment Contract is an agreement you make ahead of time, when you are well and able to make good decisions.
When we are well, that is not experiencing an episode of mania or depression, we are able to help ourselves by making good choices and taking actions that promote stability and keep our lives running smoothly.
Examples range from ordinary, day-to-day activities like showering and taking care with our appearance, to more demanding tasks such as attending school or work regularly, and those things that sometimes require discipline, but are important to protecting our health and keeping our lives running smoothly, such as exercising every day, eating right, staying on top of mail, bill paying, and filing personal papers.
Sometimes we may get feedback from the people around us about other aspects of our behavior. One good friend of mine has talked to me about how I am more irritable and argumentative when I am becoming manic. My spouse has noticed that I get more anxious when I am becoming manic. Any major mood swing, either towards depression or mania, usually means I am less communicative and tend to withdraw from people exactly at the time when I most need their help.
This is dangerous because if the depression or mania goes too far, a very self-defeating pattern develops where a person with bipolar disorder becomes increasingly unwell and increasingly likely to engage in destructive behaviors. For example, when manic this could mean spending sprees or rash financial “investments”, and when acutely depressed this could mean suicide attempts or other forms of self-harm.
Substance abuse and “self-medication” is a common way of trying to cope with a mood swing in either direction.
What makes it all worse is that during a serious mood episode we become less connected with reality and with the people around us. This makes it harder to short-circuit negative behaviors, especially if we are being secretive or feel paranoid or in other ways deluded about the “rightness” of our actions. Instead of understanding intervention from loved ones and our medical team as well intentioned and necessary, we may resent it and feel convinced they are the ones who “do not understand”.
The solution?
Create a Treatment Contract ahead of time that clearly identifies:
• signs of wellness
• signals of an impending episode
• symptoms of full blown mania or depression
• actions we will take to help ourselves

• actions we empower members of our support team to take in order to help us get well and to protect us from doing things we may later regret.
The Massachusetts General Hospital Bipolar Clinic & Research Program defines a Treatment Contract like this:
“A treatment contract is a document that you write while you are feeling well to plan for the times when you do not feel as well. It is written so you, your family, friends, and doctors can recognize your symptoms of illness and can comply with your wishes for treatment.”
Remember, a Treatment Contract is NOT something that is imposed on you. Instead, it is YOUR PLAN made ahead of time to ensure that you get prompt treatment based on your own choices and instructions if you become unwell.
Suggested contents
1. PURPOSE
Just like with a legal contract, begin with a brief statement of WHY the Treatment Contract is being created.
2. WHO
List the people who you would like to be involved in your care. This usually includes your spouse or other trusted family and/or friends, and your health professionals, for example your psychiatrist, doctor and therapist.
3. BASELINE/SIGNS OF WELLNESS
This describes the ways that you and others can tell that you are well and your mood is stable. “Stable” means you are not manic or depressed. Signs of wellness may include things like keeping a regular sleep schedule, sticking to your budget and managing finances responsibly, and regularly attending work or school. The examples later will make all this clearer – but remember, this works best when PERSONALIZED with YOUR details.
4. SIGNS OF DEPRESSION
Describe your symptoms of depression. Provide a checklist of the “red flags” that signal a depressive episode.
5. AGREED INTERVENTIONS FOR DEPRESSION
This will be different for everyone. It requires identifying tools that YOU find help keep depression at bay. For example, some things I have included in my contract with my spouse is that if I show signs of depression I will follow The Bipolar Diet, exercise for at least 40 minutes every day, abstain totally from alcohol, and that we do something enjoyable together every day.
6. SIGNS OF MANIA
Describe your symptoms of mania or hypomania. Provide a checklist of the “red flags” that signal a manic episode or dangerously elevated mood.
7. AGREED INTERVENTIONS FOR MANIA
For me this includes things like keeping a regular sleep schedule, even if I have to take sleep aid medication, handing over my credit cards, and IMMEDIATELY discussing possible medication changes with my shrink.
8. IN AN EMERGENCY
If a mood swing escalates into full-blown mania or depression, your supporters need to have the power to act in your own best interests.

However, by then you may be no longer able to use good judgment and may resent “interference” or resist getting help.
This is why a detailed Treatment Contract includes permission for selected family or friends to communicate directly with your medical team. It may even involve a power of attorney.
However, keep in mind that the purpose of your Mood Chart, Wellness Plan, and Treatment Plan is to identify EARLY WARNING SIGNS so that there can be EARLY INTERVENTION to prevent episodes from becoming serious.
If an acute bout of depression or mania does set in, then your supporters must be able to take the necessary steps to help you.
Hospitalization may be necessary if there is a risk of suicide, or a history of previous suicide attempts.
How about dealing with acute mania? Decisive action may be necessary, Restricting or monitoring Internet use, or cutting off access to finances may sound heavy handed. However, as someone who destroyed a wonderful marriage and my financial security when manic, I believe these actions can be necessary, constructive and loving.
What are some examples of “decisive action”?
1. Restrict or monitor Internet use. This is to avoid both online shopping and gambling, and sex related activities such as pornography or cybersex. It may also help prevent the bipolar person from isolating and retreating into themselves too much.
2. As much as you can, take cash, credit cards and ATM cards for safekeeping. If things seem like they could get really out of control, also consider taking the car keys.
3. A dear friend of mine is married to a lovely bipolar guy. He is a musician who has a long history of substance abuse as well as his bipolar. My friend manages their money by giving him a monthly allowance. He has an ATM card to access this account at all times, but if he goes off his meds or seems to be getting hyper, she cuts off all other access to their finances. This way he always has some autonomy and dignity but can't get them into financial trouble.
4. Some experts suggest cutting up credit cards but this can be a problem. For example, a non-bipolar spouse will still need to pay bills and buy groceries. Finding a way to divide finances like my friend does with her musician husband is more practical.
5. Watch both email and conventional postal mail very carefully as credit card companies are still sending out credit card applications and those seductive little convenience checks.
6. If you are lucky enough to have any kind of portfolio, you may need to confide in your investment advisor or broker. Although financial professionals are bound to carry out the client's instructions, a heads-up can encourage them to insist on written instructions and a face to face meeting. Ideally agree that they will notify a spouse, doctor or other appropriate person if any unusual transactions are requested.
The process of creating your Treatment Contract is much easier if you have been Mood Charting and already have a Wellness Plan because you have a ready-made list of symptoms, triggers, and preventative strategies to draw on.
You can also use the instructions, examples and template Contract from the Massachusetts General Hospital Bipolar Clinic & Research Program.