What does self-management mean?

The phrase ‘Self-Management’ is thrown around freely by users and professionals as being key to recovery and relapse prevention. Some people with bipolar disorder seem to have it nailed. They have good self-management routines that work for them and are vital to their recovery. From what I read in people's tweets and self-reports they just need an odd tweak, redirection, to refocus to a particular area or time-out, to attend to them and keep them going. To me, these are the lucky ones. I know they will have worked hard at it, but my circumstances have not permitted it- I am not one of these people.

My bipolar disorder is Rapid Cycling. I have frequent episodes of severe bipolar depression across the year interspersed with a week or two of mania either before or afterwards. I have found it extremely hard to set up a robust self-management plan, even after many many years of illness and all the knowledge I have gained with it. In my opinion, setting up self-management is easier when you are well. Although you can start with small steps when you are ill and develop further in recovery, the more robust it becomes when well, the more you can draw on it when well. My problem has been not being well for long enough to set up a robust routine.

After an episode, I am dealing with residual symptoms, picking up the pieces my illness has left behind and attending to neglected business, admin, cleaning, seeing people, giving extra attention to my daughter and compensating for the impact that may have occurred when ill. I can’t fully immerse myself in a 'me programme', but I am starting to see how I can do both. I recognise now that it doesn’t have to be perfect. It doesn’t have to read like the literature you might be given, and a few changes can make a big difference.

I went on a 10 week self-management course a couple of years ago. It was full of ideas. It covered every possible aspect of the illness and every possible strategy to deal with it. It covered everything you could do to prevent and deal with depression and mania. There was handout after handout. It was good information, but it was like a full-time job. You could tell it was written by a psychologist and not by someone who actually has the diagnosis. For me self-management needs to be realistic; we can do more but we needn’t do everything, most of us can’t do everything and it needn’t be perfect otherwise it becomes stressful in itself and you can end up doing nothing. We feel like we have failed. That is my experience anyway.

Realistic activities for self-management

In this article I would like to explore self-management recommendations and share what I have done with them to prompt you to think what you could do with them to make them your own. Are there small changes you could make without having a complete life overhaul when you are too ill to get out of bed? It's important to remember that it is hard to try to completely change the way you live- people without this debilitating illness find such things difficult, let alone people with Bipolar Disorder and the additional challenges we face from day-to-day.

  

Diet

It is recommended that we follow a ‘healthy diet’. This would be 3 meals a day with a mix of food groups, protein, carbohydrate and your 5-a-day of fruit and vegetables.

That’s quite a standard recommendation and my eyes almost glaze over when I read it. It’s also not very realistic for me. When I am depressed I have little appetite and if I do have appetite it is for sugar in the form of sweets and chocolate. Obviously this is unhelpful as it causes such dips and rises in energy, along with the copious amounts of coffee I reach for.

There must be a middle way. I decided since I don’t mind breakfast I would always try to have that. If I am depressed it will be toast smothered in something sweet. If I am motivated I might make muesli with some yogurt and berries or some porridge. If I am in between I’ll grab a bowl of standard non-sugary cereal like cornflakes, Weetabix or Special K.

Lunch I just can’t seem to do. I spoke to a dietician about this as I am seeing one for IBS. I’m rarely motivated for lunch and often feel that is too much for me to be thinking about making two meals a day. She wasn’t overly bothered about me skipping lunch, but we did discuss swapping my snacks. I’m now having sweet oat biscuits for lunch rather than a piece of cake or chocolate. She has encouraged me to think about making eggs on toast for lunch, as it’s easy and I’ve done this a number of times or even in the morning. However, she’s not pushing the standard blanket dietary plan or insisting on a standard lunch and this flexibility is helpful as it makes me feel satisfied that I’m doing OK.

I always make sure I have one balanced meal a day that fits the criteria in the evening. Then I make sure I get all the food groups. I’m not always getting my five-a-day, but I’m getting some fruit and vegetables and taking vitamins. I do hope to improve, but I’m not stressing on it. It could be worse.

My motto for this article could be:

Improvement not perfection

And that would apply to many of the things we are talking about. You might be given a recommendation, but for the first time I’ve started just doing what I can do not trying to do everything that's on the list. In the past, looking at the recommendation has often lead me to doing nothing or making no changes at all as it’s just too much.

Exercise

What recommendations do we see?

'30 minutes 3-5 times per week'

'Join the gym'

'Do a Yoga class'

Those tend to be the standard recommendations and if they work for you that's great, but I’m writing here for the people who don’t get on with these standard recommendations. My recommendation would be whatever you can manage, although I do recommend trying to put it into a routine.

I’ve tried many forms of exercise, only to be thwarted by an episode, unable to carry on and not returning to it afterwards. I’ve had gym programmes and yoga programmes of various types in the past. I’ve reduced the pressure now and I am keeping it simple-n walking. Something I hope I can continue on some level if I am ill and really step up when I am well. I started when I was ill just walking with my daughter to school 10 minutes per day. I also walked for a while with a friend but I found I didn’t like keeping up with her pace, the social pressure, or being linked with someone else’s routines. I am now walking someone’s dog. It is amazing. I get to walk for over an hour, it is mindful, the forest is beautiful in the morning, the ground under my feet, and it is pet therapy. I started by putting two slots per week in my diary and was getting so much mental and physical benefit I increased it to four times per week. It is also a great way to notice what is going on with your thoughts and slow them down.

At some point I will add a resistance routine at the gym maybe twice a week, at least that is a casual goal. For now I’m taking things at my own pace and not putting any pressure on myself. I want to establish things in my own time and feel happy and relaxed.

Sleep

I feel obliged to describe textbook self-management for sleep routines as mine isn’t very good. I’m fortunate that my sleep isn’t overly bad, and when it is I take sleeping pills. Evenings are difficult for me. I’m usually very tired by the time I’ve finished dealing with with my daughter and just getting through the day. I also often feel anxious which I think is something to do with the loss of my husband and being alone at night. So often in the evening I want to go to bed soon after my daughter, meaning I haven’t had much wind-down time or time to do anything nice at home. I do force myself to read a little in bed, which I find is a great way to slow things down. When I turn out the lights, if my mind is still going, I try to do a mental gratitude list as a distraction and often fall asleep doing it. But in honesty if my thoughts are really too fast or I can’t sleep I will medicate.

Disturbed sleep can have a profound consequence to those with Bipolar Disorder and it is important to have a healthy sleep routine. Self-management experts suggest you:

• Reduce activity before bed
• Read or listen to music or the radio at low volume
• Reduce screen time - I did actually put a timer for my phone to go off at 9.30pm
• Have a warm bath with herbs (Lavender, Rosemary, Lemongrass)
• Make sure your bed is warm and comfortable
• Empty your head of ruminations or put plans onto paper
• Do not drink Caffeine 3-4 hours before bed, instead try a milky drink
• Do not eat rich food in the evening
• Use images of tranquil places if you can’t sleep

I have tried to list suggestions that I have found helpful, with that are practical and don’t require too much effort. For me a bath at night would be a lot of effort, but I might use a Lavender oil burner as an alternative when I'm not feeling well, for example.

Activities for depression

Activity level is probably the key self-management tool in depression and one of the most difficult to implement, due to difficulties with motivation, energy, and fatigue. But managing it can have powerful effects. I am familiar myself with thoughts of:

“I should be” followed by

“I can’t”

“I don’t want to”

“I can’t be bothered”

“I can’t face it”

“I can’t move”

I also find that staying focused for long enough to initiate activity can be difficult, so even if I get close to making a decision to doing something, I get ‘stuck’ where I am, in my thoughts, unable to move and have to start the whole process of self-persuasion all over again.

According to the experts, activities in depression should be balanced around pleasure and achievement. For me, activities should be based around whatever it is you can manage. I find that managing to do some simple activities will automatically bring some pleasure. Achievement brings a sense of pleasure in itself. I tend to think about trying to do ANYTHING I can realistically do.

I was looking at one of my handouts from the self-management course and there are two pages of things you could do for self-care and pleasure and there is not one of them I could do in a depressive episode. Perhaps instead we need to be thinking about what is our self-management plan when depressed and how can we step it up when we are well.

For example, trying to watch a movie at home for pleasure when depressed and going out to the cinema when well and trying to maintain. Looking up some art that interests you on the Internet when depressed, going to a gallery when well. Washing your hair when ill, going to the hairdressers when well. Speaking to a friend by text or phone when ill, having them over for a cup of tea as you are improving.

So back to self-management in an episode. There are two approaches I have taken so I will share both. The first is scheduling which I do in half-day portions. When I have managed to get up, I will divide the time I have into manageable segments and assign activities to the time segments. Activity is stimulating when you are depressed and that is what is needed most. It might look like this:

10-10.45 shower, dress, make bed

10.45-11 break

11-11.45 wash up and tidy surfaces

11.45-12.45 Internet food shop

12.45 lunch

They may look like incredibly boring, pleasureless tasks, but I’ve found in depression they can be very rewarding. My environment gets completely chaotic when my mood is low. These are big achievements. I find that once I’ve done one, it is easier to move on to the next. It’s getting started that’s the thing, but once I've gotten started I find that there are always many outstanding things to do, as usually I’ve gotten behind on things on my way into a depression so I don’t usually run out of things to do. It is good to add some relaxing pleasure options in too, like reading or craft or another relaxing activity.

I don’t always complete the list. I don’t always do it in order. But it gets me moving and I get some things done. I can’t do this when I’m so depressed I’m nearly catatonic but there’s a point in depression where I can start to push myself. This is a starting point to recovery. A starting point to self-management. The building bricks to the next steps of being able to do things outdoors. In the meantime you are functioning at home, getting your home life back together, feeling a sense of accomplishment, moving around, finding some pleasure, gathering strength, and surprising yourself in what you can do.

The pleasure and sense of achievement you get from your morning list often gives you some motivation and energy that you can use to do some ‘nice’ things for yourself or with yourself in the afternoon.

These days I don’t always use the schedule. I either just write a list with a few things on it or I just start being active. But on reflection the scheduling is less chaotic and more gets achieved. Things work better if I do use it. There will always be a call to go back to bed (for me anyway), and I don’t deny myself that if I have made some achievement, but I try to put a limit on it. I get a certain amount of things done. I set an alarm and give myself a specific amount of time and then try to get up again. This can be difficult and a bit of a setback but with the fatigue of depression sometimes I don’t really have an alternative.

It’s an overused suggestion, but still a good one, that finding a creative activity helps. Anything will do. I’m not skilled at all but I’ve tried various things at home, drawing and painting, and a project that required sticking sequins into a pattern onto a piece of wood with wood glue. During this last episode I found collaging. I went onto a recycling website and got people to send me their old magazines and made collages depicting depression and mania. It was so therapeutic cutting out all the words and images and arranging them how I wanted to.

In terms of contact with other people I don’t have much. I have one person who I text regularly throughout my episode who understands me best. Family aren’t nearby. There isn’t really anyone to come over. I probably would allow a close friend over for a cup of tea. I’d probably find it difficult to go out. But that could be a goal- If I’d managed to shower and dress on the schedule then it would be a possibility. This is an area I would benefit from looking at, using the small social network I have.

As I do more inside, I find gradually my ability to do more outside returns. I’ll gradually start going to the shops, post office, seeing people, so keeping some self-management during an episode is clearly important. Activity when well will depend whether you are working, volunteering, what other commitments you have. Balancing activity is of course important to reduce risk of hypomania. I was working until my husband died of cancer. Since then I have been volunteering in a school for the deaf, writing and keeping busy as a mum and trying to self-manage.

Working or volunteering for self-esteem

I do recommend some sort of work for self-esteem, the sense of accomplishment and feeling that you're mastering a role, even if you're only able to manage a few hours a week. It also provides social interaction if your social contacts are limited. There is something very valuable about giving. There are many exciting volunteer options, it can inspire you for your future. I don’t think self-management can be all about pleasure, exercise, sleep and getting your diet right. Those things are key, but for me, my life can’t be all about that. Even with all the time in the world I’d never get it perfect, so I might as well put some other things in my life too. There will never come a time that you’ve got it all so right that you can't add something else. Maybe paid work needs to be at the right time, but volunteering for the few hours you need to be well enough to do it can be really rewarding.

The good thing about volunteering is you can walk away if you become unwell. That is the reason I haven’t taken a permanent job presently- I feel I need a longer remission time to feel confident enough to do that. However, my self-management is developing and I’m happy with that. Finally I’m away from my all-or-nothing approach and I’m allowing myself to bring things into action at my own pace. It’s also allowed me to explore new skills like writing. I would never have written a book if I’d been in my permanent job, although I do need to get off my backside and find a publisher.

Managing activity in mania/hypomania is more challenging in some respects. Everything is going so fast, you are so full of ideas and the energy of motivation, getting so many things done, and this means you are faced with the opposite task of trying to slow down and reduce activity. You also need to have spotted it. Not only spotted it but be willing to change it. I think a willingness to change it must come from knowing the consequences of what will happen if you don’t. There's a common phrase that comes to mind, the definition of insanity:

“Doing the same thing again and again and expecting different results"

Not managing mania effectively will nearly always end in disaster. It is vital to attend to early warning signs and act accordingly. I fully understand the desire to go along with the buzz, to go along with the creativity, the productivity, but the end result is never good. It's also common for the symptoms to become unpleasant as your mood elevates, so as soon as you notice your mood elevating it is an ideal time to do a 'costs and benefits evaluation' as a sort of reality check. You can keep coming back to this as the desire to override your management strategies comes into play.

Management strategies to control stimulation in mania

• Reducing activity level
• Making time for calming activities
• Simplify your routine and stick to it
• Using the word “STOP” internally if you notice thoughts racing or activity level increasing again and find something else to focus on
• Try to eat regularly
• Practice listening to the person you are with instead of talking, sit on your hands, look at their face, tell yourself to listen
• Don’t make any big decisions without seeking 3^rd party advice
• If you are excited by a plan or an idea, wait 48 hours before making a decision. Write the idea in a book with advantages and disadvantages

Controlling stimulation through your five senses is also something you can employ. For example:

Sight - You may like to simply sit and close your eyes to reduce stimulation. Sitting and watching a candle can help. Or imagining a peaceful scene.

Smell - I am a great fan of lavender oil. Recently my mood was elevated and I couldn’t find the burner. I was desperately trying to slow myself down, so I simply lay on the sofa and periodically inhaled it from the bottle. You may have your own calming scents.

Taste - Some people find certain drinks calming. I am not one of those people, but I know people who really do find relaxing teas and milky drinks another useful addition.

Sound - Music can have a profound effect on mood. When my mood was elevated recently I didn’t realise quite how much the music I was listening to was elevating it further. Relaxing music is good, at a low volume or even apps with relaxing sounds. Some people might like to lay down with earplugs in to shut out stimulation completely.

Touch - Can be used in a number of ways. Pets are wonderful. If you don’t have a pet then a sensory art material. Make something just to squeeze or mould, clay for example, or even using a decent stress-ball. Swimming if it's done calmly, mindfully focusing on the water. A massage can be helpful as long as you are clear that it should be relaxing and calming. Finally, that good old failsafe- a warm bath. I always find it a predictable suggestion, but you can treat yourself to something really sensory like a bath bomb or some other kind of addition that will turn it into a spa-like experience. I find if my mood is elevated, I have to force myself to stay in and benefit from it.

If none of it works and you have emergency medication or a PRN, don’t forget to use it.

Watching for triggers

Negative thinking is probably the biggest trigger for depression and the biggest maintaining factor. CBT is really helpful, but again, during an episode most people don’t want to get out a pad of paper and fill out all the columns to analyse a particular thought. If you can, use the STOP technique here that I introduced in mania. An example of this might be that you notice yourself ruminating on “She didn’t text back, she doesn’t like me anymore, she thinks I’m a freak”. If you can put a STOP in and just ask yourself “Is there any other possible reason why she didn’t text?” you might then find yourself able to say “Oh yes she has a full-time job where she is a manager, she is caring for her sick Mum, she has a football match today, she is taking her son after school”.

It might not be enough, you might still be waiting for that text. You might need to repeat the process the same day. You might need to ask yourself “What is the evidence she likes me?”. Play around with the idea. But putting a STOP in and forcing yourself to reframe can help. At least it works for me. Another thing that works for me to a degree is trying to limit rumination time. I say to a degree as its hard to implement, but for example I might set 2 times where I give myself space to ruminate: 11am and 5pm. These are your 'worry times' where you have 10-15 minutes to ruminate. The rest of the time you need to use the STOP technique and say "No it’s not time, I’m doing ………whatever your doing now and worry time is later".

Anxiety for me comes mostly in the form of shallow breathing, and a feeling of unease and I need to address it more consistently as I tend to push on with it until it triggers depression. Once I’ve seen that happen I’m trying to be more mindful. The only things I’ve found useful for my anxiety are sitting down, laying down, following my natural breath in these positions, and writing a journal.

Perfectionism - I’m putting this in, not because it’s so much of an issue for me now but it used to be, so I guess it’s been part of my journey. Someone mentioned to me that it’s a common trait in people with bipolar disorder. I don’t know if this is true, but what I am going to say is relevant whether it is or not. It is simply about your best being good enough. My self-management is more helpful to my illness now I have accepted that. My ideals for it used to be so high that if I didn’t meet them I felt like I had failed and wasn’t helping myself.

Mindfulness

You would think I would have covered this already. The reality is, I’ve done Mindfulness courses, read Mindfulness books, I know how to do Mindfulness. It can be of enormous value as a treatment support in bipolar so if you can do it and it suits you, your physician supports it and you like it that’s wonderful.

The reality for me is that often I didn’t really like it. I had a few experiences of unpleasant imagery and it just wasn’t for me. But I don’t think that was the main reason it didn’t work, it was just the timing and my ability to be disciplined to incorporate something like that into my home life.

For me I am exploring how to find mindfulness in different ways. Walking meditation is an accepted for of mindfulness for example. This I love. On the commons, in the forests. Mindfulness that isn’t of the traditional lying down sort is something I would like to explore further.

But it doesn’t have to have the ‘Mindfulness’ label. Basically any form of relaxation can help with bipolar and is worth exploring and you will probably be more inspirational than I am at getting it into your routine.

It is recommended that you build up from 5 mins, 10 mins, 15 mins a day etc. It is supposed to be a daily practice, but again this article isn't in the business of setting expectations that are too high- see what you can do.

On my walks on the common, I find I naturally step into a mindfulness section when I am ready. I become aware of the birds, the trees, the terrain, the sky, the weather. I’m combining this with the use of positive affirmations and it is having excellent results.
I complete feeling peaceful and contented.

What are your protective factors?

Protective Factors refer to the things that protect you from becoming unwell or help you to recover more quickly, or in some case keep you alive. I am talking about my own case and that is my little girl.

I’m going to write a list of some general protective factors, but it might be worth thinking about any that are specific to you that are not on the list:

• Taking medication regularly
• Contact with family
• Contact with friends
• Contact with an animal
• Regular routines (sleeping, eating)
• Being organised/avoiding chaos
• Avoiding confrontations
• Not taking on too much
• Taking a regular break/time-out/holiday
• Keeping a journal
• Taking part in regular exercise
• Enjoying a regular hobby
• Forward planning for celebrations/holidays etc

 

Use a mood scale

Getting to know a mood scale if you don’t already, can be really helpful both to identify when you are going up or slipping down and also to communicate with professionals, as they should be familiar with them and if they are not you can share. The Bipolar UK options are easy to use and you can always make a more personal version with your own specific symptoms. If you use the mood rating scale, you can make timely interventions in terms of increasing your activity level or decreasing it and be mindful of keeping your self-management approaches established.

It is hoped that if you are well you will now be:

• Making some improvement to your diet
• Introducing some exercise to your week
• Be ready to maintain structure when you are depressed and increase activity when you are well
• Be proactive at sensibly managing a hypomanic mood
• Be proactive at maintaining good sleep hygiene
• Have some simple strategies for dealing with other triggers
• Explore using a mood scale if you haven’t already
• Trying a mindfulness meditation

This is probably a good place to end. So if you came to this article thinking your self-management wasn’t very good, I suppose there are many different possible outcomes. You may be thinking actually it’s not bad, it’s better than hers, in which case good for you. Or maybe you found this article helpful and as I intended feel the subject has been a little demystified. And more importantly you can see with an illness like bipolar disorder you don’t have to do it perfectly, any effort will have a positive benefit and is a starting place from which you can develop - who knows into an athlete or an expert on diet or outstanding at a particular thing. But to me, you need to lay the seeds that you are capable of laying, at a particular time remembering things go up and things go down, without putting unnecessary pressure on yourself to be perfect.

 

@Blosseyfrida