This is the third article in a 3-part series. The author recommends reading the first article and second article before reading this one. 

Bipolar disorder is a big, hairy beast of an illness. It can be intimidating, scary, and unpredictable. But by using management strategies, we can fight the beast and win. Management strategies are the third side of what I call the relapse prevention triangle. Combined with spotting early warning signs and understanding triggers and vulnerabilities, you have a lot of power to prevent relapses. 

What is a management strategy? 

A management strategy is a method you use to maintain or regain stability. Whereas triggers push you in the direction of a mood episode, management strategies push you in the direction of stability. In the fight against the bipolar beast, triggers score points for the beast while management strategies score points for you. 

Management strategies can be divided into two categories: 

1. Prevention strategies: These are regular practices that help keep you stable and the beast at bay, for example: 

• Following a regular medication regimen 
• Getting adequate sleep 
• Sticking with a regular exercise routine 
• Having frequent opportunities for social contact. 

2. Timely intervention strategies: Despite prevention efforts you’ll likely encounter early warning signs at times, as well as triggers you need to manage. Timely intervention strategies empower you to fend off the beast when you need to. Examples include: 

• Taking prescribed “as needed” medication in accordance with your prescriber’s recommendations (e.g., for sleep or severe anxiety)
• Getting some extra rest and relaxation 
• Getting some extra exercise 
• Calling a friend or family member for support, or your mental health provider for advice.

What types of management strategies are there?

Because bipolar disorder is a complex condition involving body, mind, and spirit, there’s a vast arsenal of tools to tackle it. I’ve compiled a list of 10 strategies shown to be effective for many people (I’ve used most myself), represented by the acronym SUCCESSFUL. What I describe here are broad types of management strategies – there are individual differences in the specific methods people find most helpful.

1. Skills: As I mentioned in my last post, deficits in skills such as communication, decision making, and problem solving can be vulnerabilities that make you more susceptible to being triggered. Learning these and other skills can help you overcome vulnerabilities and stand strong. 

Two powerful sets of skills are cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) skills:

• CBT includes self-management skills such as those I’m covering in this series (which is based in CBT and was inspired by a training I did with one of its founders, Donald Meichenbaum). It also offers skills that help you change cognitive distortions and perceive yourself, other people, and the world in more balanced ways. Mind over Mood is a tried-and-true workbook for learning CBT skills. 
• DBT is a twist on conventional CBT that also emphasizes acceptance of yourself and reality. I’m writing a series of posts on DBT for Addiction.com, the first one on mindfulness, which provides a good overview. I recommend The Dialectical Behavior Therapy Skills Workbook or The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder as self-help resources.

2. Using substances less: I mentioned in my last post that substances such as alcohol, nicotine, marijuana, and caffeine can be strong triggers, and that substance use disorders can be vulnerabilities. Cutting out or minimizing harmful substances can help tremendously. If you have an addiction, you will likely need help. With alcohol and drug addiction, it’s important to find help that addresses both bipolar disorder and chemical dependency. For more information check out Depression and Bipolar Support Alliance’s information page on dual diagnosis and recovery.

3. Chemical support: Bipolar disorder has its roots in brain chemistry, so prescription medication is a primary defense for most people. Because this series is aimed at people who are in treatment and relatively stable, I’m making the assumption that most readers take medication. But I chose to include it here anyway because it’s so important – and because even the most well-intentioned person can be tempted to go off their meds at times.

4. Crisis prevention: A crisis, simply put, is when internal or external difficulties outweigh your current capacity to cope. There may be times when symptoms escalate quickly and you find yourself on the verge of a crisis. Preventing a crisis requires fierce timely intervention, so it’s important to have a plan of attack in place ahead of time. Some examples of timely interventions that can be used to prevent a crisis include: 

• Minimizing stress and clearing your schedule of unnecessary commitments
• Increasing self-care behaviors like eating nutritious foods and exercising
• Taking prescribed “as needed” medication (but again, only in accordance with your prescriber’s recommendations)
• Asking for help from loved ones
• Contacting your prescriber or therapist for advice.

5. Expecting success: As champion fighters know, attitude is everything. You have to believe you can succeed. That means having confidence that you can manage bipolar disorder and live a full life. Seek inspiration from those who have been successful at fighting bipolar disorder or other challenges. For example, watch videos from Healthline’s You’ve Got This campaign.

6. Spirituality: Spiritual practices can help you manage bipolar disorder and build overall resilience. These can include anything that gives you a sense of meaning and helps you see the bigger picture beyond your identification as someone with bipolar disorder, for example:

• Prayer or meditation
• Attending spiritual services
• Art or other creative activities
• Charitable service
• Spending time in nature.  

7. Social connection: Getting support from other people and maintaining social connections provides protection against relapse. It’s good to have a variety of options for social support and connection, such as:

• Formal and informal
• Intimate and superficial
• Planned and unplanned.

Remember that social support and connection is a two-way street – finding opportunities to contribute to others can increase your well-being by taking your mind off your own problems and making you feel valuable.

8. Forgiveness: If you have bipolar disorder, you’ve undoubtedly been through your share of difficulties and have probably been hurt along the way. Research shows that the practice of forgiveness is connected with mental health. Forgiveness isn’t about condoning other people’s bad behavior – it’s about letting go of anger and hurt so it stops weighing you down. A good self-help book for learning to forgive is Forgiveness is a Choice.

9. Undoing the effects of trauma: Many people with bipolar disorder have a history of trauma, and many have a co-occurring diagnosis of post-traumatic stress disorder (PTSD). Unresolved trauma is another vulnerability that can thwart your recovery. Symptoms of trauma can include:

• Nightmares or flashbacks
• Avoidance of things that remind you of a traumatic experience
• Negative emotions related to the traumatic experience, such as fear, horror, or guilt
• Hypervigilance (being in a very high state of arousal and frequently scanning the environment for threats).

If you have these or other trauma symptoms, treatment by a therapist who specializes in trauma can help you recover and move on. As a self-help resource I recommend The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms.

10. Lifestyle changes: Based on the list of common triggers I gave in my last post, there might be lifestyle changes you can make as prevention strategies. Here are some examples of things you can do to develop a lifestyle that supports recovery:

• Have regular times for waking, sleeping, eating, work, and leisure activities.
• Follow a regular exercise routine and include movement throughout your day.
• Learn about nutrition and eat a healthier diet.
• Have a work schedule that supports stability.
• Avoid or minimize activities and environments that cause sensory overload.

When it comes to making lifestyle changes or implementing other management strategies, don’t try to do an overnight overhaul. Make changes little by little. Fight battles you can win, even if they seem small, and in the long run you will win the war.

How do I become aware of which management strategies work for me and use them effectively?

Using management strategies to tackle bipolar disorder has three parts:

• Identifying which management strategies work for you
• Using prevention strategies on an ongoing basis
• Applying timely intervention strategies when needed.

Learning to use management strategies is similar to the process I described in my last two posts. It’s a process of gaining and maintaining awareness – the underlying ability needed for all parts of relapse prevention. Let’s go through the guide once more as it relates to management strategies:

1. Educate yourself. In the fight against bipolar disorder, knowledge is power. Take advantage of the large amount of reliable information available these days in print, online, and in-person formats. If you need a good starting place, IBPF’s Healthy Living With Bipolar Disorder is excellent. When it comes to new management strategies, use the mindfulness skill called beginner’s mind. In other words, don’t assume a strategy will or will not work for you – keep an open mind, try it out, and see what happens.

2. Reflect on previous mood episodes. Reflecting on previous mood episodes can help you recognize what management strategies might have helped prevent them. This isn’t about beating yourself up over what you could have done but did not – it’s about thinking through what happened and identifying what you might do differently next time. Also think about times you have been well. What management strategies were you using then, even if you weren’t consciously aware you were using them?

3. Keep a mood chart. A mood chart can help you make connections between management strategies and mood, anxiety, or other symptoms. As an example, this mood chart from Depression and Bipolar Support Alliance has places to track eating, exercise, and social support behaviors. You might notice, for instance, that you have less depression on days you participate in a particular social activity, or less anxiety on days you exercise. You can customize your mood chart to include whatever management strategies you want to track.

4. Develop mindfulness skills. Mindfulness keeps you aware of your thoughts, feelings, behaviors, and environment so you can stay one step ahead of the beast. Mindfulness has many benefits. It is itself a management strategy that – among other things – empowers you to stay calm and centered enough to cope with unexpected difficulties. In addition, it helps you:

• Get more out of your management strategies – for example, you’ll probably get more benefit from exercise if you focus mindfully while doing it rather than talking on the phone or watching videos
• Notice how management strategies impact you
• Remember to use your prevention strategies and keep their importance in mind
• Notice when you need a timely intervention – the more mindful you are, the more quickly you can recognize early warning signs, identify potential or actual triggers, and respond with effective management strategies.

Mindfulness can also include what I call remindfulness – finding ways to remember your management strategies. Remindfulness can include using sticky notes, posters, lists, smartphone apps, or whatever works for you. I’ve also created a line of Beat the Beast products featuring the image at the top of this post, designed to remind people that they have the power to manage bipolar disorder.

5. Gain insight. As with triggers and vulnerabilities, insight helps you gain awareness of cause and effect. While insight into triggers and vulnerabilities allows you to recognize what decreases your stability, insight into management strategies allows you to recognize what increases it.

Insight can motivate you to use your prevention strategies even when you don’t want to – because you trust that they increase your well-being and clearly understand the consequences of not using them. For example, insight allows you to accept that you need to stay on your meds even when you feel good and don’t think you need them.

Insight is also helpful in choosing timely intervention strategies. It enables you to assess a symptom or behavior and address it effectively. I’ve developed an Applying Timely Intervention Strategies worksheet that can help you gain insight.

6. Learn which timely intervention strategy to use when. With time and practice, you can learn to tailor your maneuvers against the beast. The best timely intervention strategy to use in any given situation depends on a number of factors:

• The nature of the symptom or behavior (for example, you may need different strategies to decrease depression, to decrease mania/hypomania, and to decrease anxiety)
• The severity of the symptom or behavior
• What triggers and vulnerabilities are involved
• Your level of recovery and current capacity to cope.

When choosing intervention strategies, it’s usually best to err on the side of caution. In other words, when in doubt take the situation seriously and use a strategy like contacting your mental health provider, calling a suicide hotline, or going to the emergency room. With time, you’ll likely learn to manage more on your own – but in the battle against the beast, it’s better to be humble than overconfident. 

7. Get help from others. Other people can be allies in beating the beast. For example, they can:

• Help you recognize which management strategies work and don’t work for you
• Join you in strategies like exercise or leisure activities
• Remind you to do things that support your recovery
• Support you in times of impending crisis.

Going to a therapist on a regular basis can itself be a management strategy – plus the right therapist can help you identify and implement effective management strategies.

8. Be on a constant lookout. Bipolar disorder is an illness that needs to be managed continuously – so you have to keep on your toes. Fighting the beast requires you to cope with, prepare for, or recover from early warning signs and triggers on an ongoing basis – which I call practicing CPR. While you’ll always have to maintain awareness, over time you can learn to cope more effectively, prepare more thoroughly, and recover more quickly.

By implementing the relapse prevention methods I’ve covered in this series, you can minimize future relapses and develop a high level of recovery. As a way of helping you put all the pieces together, I’ve created this Relapse Prevention Triangle chart. You can keep it where you will see it and update it regularly. 

It may not always be possible to prevent relapses – and it’s important that you don’t feel bad about yourself or like a failure if it happens. Just learn what you can and move on. The most important thing is to never, ever throw in the towel.

You can find the rest of Carrie’s IBPF posts here or read additional articles on her Addiction.com blog.