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Treatment Contracts: A Powerful Tool for Living and Loving with Bipolar Disorder

I destroyed my first marriage through infidelity, wild spending sprees, outbursts of rage, and many of the other hallmarks of uncontrolled bipolar mania. People who know the ugly details of my story are often surprised to learn that my second marriage is so successful and solid. How can my spouse trust me? How can I trust myself?

In my other life I am a lawyer and my particular passion is contract law. To me, contracts are never sterile or boring. You see, contracts are all about risk management. Because I care about my clients it is easy for me to feel passion about protecting them - about shielding them from harm. I have discovered that a contract can also help me in managing my bipolar disorder. Contracts are not just restricted to the world of commerce. The most personal and intimate of relationships – marriage - is often understood as a contract. The Bible is built around the contract between God and his people. Contracts can play a central and highly effective role in managing our most cherished, private, special connections. Put simply, a contract is an exchange of promises. Promises that are enforceable. Promises that are guarantees. And since coming to terms with my bipolar disorder, I have discovered another very empowering, mutually protective contract – the Treatment Contract.

I first learned about Treatment Contracts from The Bipolar Clinic & Research Program at the Massachusetts General Hospital. This is how Mass General describes this wonderful tool:

“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.” In other words, a Treatment Contract is an agreement you make ahead of time, when you are well and able to make good decisions. It is critical to understand that 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.

Right now my medication and other treatment strategies are working wonderfully and it is a long time since my last episode. But that is only part of why we feel so good about our marriage and so confident of coping with whatever the future may bring. For both of us we have added security and peace of mind because we have the safety net of a comprehensive Treatment Contract. 

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, I am likely to behave in ways that are destructive to myself and the people around me. 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. There are no hard and fast rules about how to do this. Do what works in your situation, based on the issues that have come up in the past. Because of my history of bipolar hypersexuality and infidelity, my spouse and I are especially concerned with identifying the signs that a manic episode is developing. At the first signs of mania we want to try and stop the episode from becoming more extreme. W e also want to make sure that no matter how acute the mania may become, the practical consequences are minimized.

How do we do this? Strong, decisive action may be necessary. This means a proactive intervention aimed at containment. What are some examples of “strong, 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 guy with bipolar disorder. 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. 
Does restricting or monitoring Internet use, or cutting off access to finances sound heavy handed? Please listen – I destroyed a wonderful marriage and my financial security when manic, so I KNOW these actions can be necessary, constructive and loving. Managing bipolar is a lot easier with the right tools, and Treatment Contracts are a tool I strongly recommend.

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