A Framework for Success

Occupational therapy, bipolar disorder's missing link in treatment.

I write this article as a professional licensed occupational therapist and an individual living with a bipolar diagnosis. It is my experience and belief that the occupational therapy approach provides a critical supplement to existing medication options and psychotherapy treatment models. Medication provides a physiological shift within the brain to help regulate neurotransmitters to a more functional level. Psychotherapy helps one mourn the loss of ability as well as understand and deal with symptoms of the disorder and the emotional/mental processes affected. It teaches the individual to track and regulate symptoms, minimize triggers and manage the illness.

But the question that remains, and the one that challenged me the most, was, "How do I live with it?" Life was passing me by while I was waiting for the right medication combination and trying to track my moods and identify my triggers. How do I see beyond the disease and experience my life?

My Bipolar Diagnosis
I will never forget lying on the bed in the mental health hospital feeling defeated and scared. I had been admitted for a major depressive episode. When the doctor, who had a class following him on rounds, asked me, "Why did you let yourself get this bad?," I felt that I was a failure at life and had no idea what to do. I grew up with a "pull yourself up by your bootstraps" mentality, so the possibility that I had a mental illness had never entered into my thought process.

The ability to objectively perceive and problem solve through a situation becomes quite difficult in the oppressive mental fog of depression. I was left with the question, "If I can't even take care of myself, how do I build a life?" Lying in that hospital bed, I felt that I had given this thing everything I had and it had beaten me.

Other critical questions I experienced were: How do I live out the roles that are important to me while experiencing an episode? How do I modify my environment to reduce stressors that can help trigger episodic events? What activities are important to me and what activities were influenced by grandiosity? How do I create a successful life beyond managing an illness?

Let me explain a little bit about what it is to have a depressive episode and what it is to have a manic episode. By explaining what my episodes were like I hope to help dispel some myths and help ground an understanding for individuals who are not familiar with the diagnosis.

What is Depression?
First off, stop thinking about depression as "sadness." While sadness may develop into depression, or the emotional feelings associated with sadness and depression may overlap, there is a very distinct difference. Depression is not about how I feel emotionally. It is about how I feel physically. I want to liken this to having the flu. When you have the flu you don't want go to work. But if you isolate the different symptoms of the flu, you find that there is one symptom specifically that keeps you home -- the fatigue and mental grogginess associated with having the flu. That heaviness, discomfort, sense of "Oh my God would someone just shoot me!" - that is the experience of depression.

With depression comes a decreased ability to regulate sensory input. I believe this is the reason for withdrawal. It's easy to become overwhelmed with external stimuli and therefore the withdrawal is an instinctive self-protection act. It's a way to minimize the noise that the brain has to work through and organize.

What is Mania/hypomania?
Mania/hypomania are very unique and intoxicating emotions. I would compare them to the excitement felt after accomplishing an important and challenging goal. The feeling of strength and invincibility, being larger-than-life, truly excited with a world of opportunity before you, this is hypomania. It is when everything seems to click, you are most successful, and everything you touch turns to gold. It is very powerful state. The problem is when hypomania triggers into full-blown mania.

Mania is like the dog walking the owner. Thoughts you have are so fast you don't get to complete one without another starting. There is always this sense of what could be and what would be. Because of that, there's no real sense of consequence. As far as the delusional pieces - thinking you're someone like Napoleon or Alexander the Great, for example - I myself have not been there and can't offer a strong comment on that. But what I do know is that there is a feeling of being greater than your body and that "everything is going to work out," like you are the cool kid on campus who everyone else wants to be like.

What I Experienced
My hospitalization with depression was like a skiing wipe-out. Everything was scattered. I hurt physically and mentally. I was completely embarrassed. The process of gathering myself together was exhausting. My confidence was shattered because I was facing a complete failure at managing my life. So, while I had been stabilized on medication and had strong family support, I had no idea how I was going to live.

Medication and symptom management are what I was provided following hospitalization. I had to rebuild a sense of identity and confidence, grieve the loss of my hypomanic state and accept the medication side-effects of weight gain and grogginess. It was anything but easy to let go of the state that made me feel successful and embrace the increased challenges of medication side-effects for the hope that, someday, the right balance of medications would be found. 

"How do you feel today?" became an overused cliché. I got tired of talking about my feelings. I was watching my life pass before me. I felt out of control waiting for the right meds to work, and the most frustrating part was that it would take a good month or two per attempt! Bills still needed to be paid; I still needed to function in my day; friendships and relationships still required interaction to built/maintain. My life wasn't waiting for my meds.

I now had a chronic condition and felt it meant I would always be sick or broken. As I continued down my journey of recovery I learned that my bipolar condition was expressed by rapid cycling. As I experienced highs and crashes I felt that it meant that I was sick again. "But I was doing so well." echoed in my mind for days after each event.

Eventually, with the help of a vocational counselor, I changed focus from being sick to living with the condition - living during flare-ups - and building a desired life addressing the needs of the condition along the way. I rebuilt my confidence through accomplishing meaningful activities while going through uncomfortable challenges. I found I needed an external structure to support me during times of distress and that my disorder made the need for healthy life skills more evident. I developed a structure based upon reading personal effectiveness books outside the mental-health paradigm. I found that these skills, while good for everyone, are simply more necessary with my disorder. For example, a healthy diet is good for everyone, but an athlete or individual with diabetes experiences the need more.

How OT Can Uniquely Help
My education in occupational therapy provided me with the tools to build a framework for success. I found the person/task/environment approach a powerful way to address the disorder in my life. I found both medicine and talk therapy addressed the needs of my "person" but did not help modify the tasks or environment. I found that occupational therapy's approach of finding the therapeutic value in everyday activities the missing link in truly "living life to its fullest."  The unique OT perspectives that help me are sensory integration to help balance my nervous system and temper my episodes, energy conservation for effectively completing responsibilities during depressive episodes, developing a routine of activities to help regulate my energy levels, and developing structures in my finances that help protect me from myself. 

While doctors figure out the medicine and psychologists help with the emotional process involved with understanding a mood disorder, bills still need to be paid and dishes still need to get washed. We still need to live life and not put it on hold while hopefully waiting for the right combination of medicine and feeling. I feel that there is value looking at bipolar disorder not as a disorder of moods, but rather a nervous system disorder with erratic moods as a symptom. Thus, feeling better is not the focus but rather the result. I suggest occupational therapy as the missing link and would love to hear from anyone interested in exploring or developing this further.

Stephen J. Nawotniak, OTR/L, works as a traveling therapist through Supplemental Health Care and is currently writing a book outlining the techniques and applications used in his transformation from patient to therapist.  He may be reached at sjn81575@gmail.com.


As a parent of a 43 yr old bipolar son I think occupational therapy will be a great benefit to the success of dealing with this disorder. Keeping productively busy will enhance his feeling of self worth and will begin the process of him feeling better. It can take a great deal of time to find the "cocktail" he needs to
help him cope .

katie McGuirl April 27, 2015
Miami , FL

I am in school to become a Occupational Therapy Assistant and I am doing a study on a patient with bipolar manic episodes.I found your story to be very helpful and inspiring!! Thank you for sharing :)

Katelin  McGuire ,  student October 07, 2013

Thanks again for all your comments and the numerous inquires on the book I am writing on the topic. I am in the process of setting up a website to share the info through and post the progress on the book. Feel free to send a note to my personal e-mail and I will post the website address when it is established. Jen, I'd love to chat. Just send me an e-mail and we can set up a time.

I love the comments and am glad this article is helping.

Stephen NawotniakDecember 14, 2011

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