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Summary: What happens after hospitalization for bipolar disorder is most often a step down to a less immersive level of care that allows a patient to consolidate the stability achieved during hospitalization and continue working to meet treatment and recovery goals.

Key Points:

  • While hospitalization is about stabilization and safety, stepping down levels of care involves beginning the rebuilding process and working toward independence.
  • Less immersive levels of care may include residential inpatient treatment programs, partial hospitalization programs (PHP), intensive outpatient programs (IOP), and outpatient programs (OP).
  • When a patient is ready to return home, which may happen during PHP, IOP, or later during OP, it’s essential for a patient and family members to have a crisis plan for mental health emergencies, such as extreme manic episodes.

Planning for What’s Next: After Hospitalization for Bipolar Disorder or After Residential Treatment for Bipolar Disorder

When a loved one or family member has bipolar disorder and needs hospitalization, many family members wonder what comes next. In most cases, what happens after hospitalization for bipolar disorder is treatment at a less immersive level of care. Patients typically step down – the official term for moving to a less immersive level of care – to a level of care called residential treatment or inpatient treatment.

At that level of care, patients receive a full day of care, engage in evening program, and live at the treatment center.

After residential treatment, a patient with bipolar disorder may move to PHP, IOP, or in some cases, straight to OP. At these three levels of care, a patient might live at home instead of living at the treatment center. When this happens, family members – whether their loved one returns to live with them, or returns to their own place – often need help understanding how they can best offer effective support.

They know to offer unconditional love, support, and healthy, positive and consistent interaction, because that’s an important part of the recovery process.

But what about when things don’t go well?

What happens in crisis?

For instance, how would they handle an extreme manic episode where safety becomes an issue, either for them or their loved one?

One possible answer to that question is to work with the treatment team at the treatment center to develop a crisis plan. In this article, we’ll describe a specific type of mental health crisis plan called a Wellness Recovery Action Plan, a.k.a. a WRAP.

What is a Wellness Recovery Action Plan (WRAP)?

Dr. Mary Ellen Copeland developed the WRAP concept in the 1990s in response to what she perceived as an incomplete approach to mental health treatment in the U.S. At the time, the dominant paradigm resembled the way we approach physical illness or injury: diagnose, prescribe medication, and relied as much – or more – on the medication as we relied on therapy, lifestyle changes, and a full range of enriching, complementary, personal and social supports.

Her insight revolved around the fact we mistook absence of symptoms for presence of health. That’s an understandable mistake to make, but it’s one we found, ultimately, left our approach to mental health treatment lacking – and in some cases, ineffective.

When we consider how the World Health Organization (WHO) defines health, we can understand her point of view:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

To address this mismatch, she led a retreat with a group of mental health providers to brainstorm ideas about how to better offer complete support to people during mental health treatment and in their lives at home after treatment or between treatment sessions.

They identified eight (8) things people in mental health treatment need for complete recovery:

  1. Ways to meet and maintain treatment goals and overall wellness.
  2. Effective and practical techniques to support ongoing wellness.
  3. Meaningful ways to define and discuss wellness and what it means for each person.
  4. Effective techniques/methods to recognize triggers.
  5. How to know when wellness may be going in an unhealthy direction.
  6. What do to when wellness may be going in an unhealthy direction.
  7. How to react when in crisis.
  8. How to develop a practical and effective crisis plan.

The providers at the retreat, along with Dr. Copelan, developed a framework for what providers use regularly in mental health treatment, a Wellness Recovery Action Plan, or a WRAP.

The Contents of a WRAP: What Should it Include?

Creating a WRAP tailored to specific needs unique to the individual can make all the difference during crises. An effective WRAP will include:

1. Important phone numbers:

    • Counselors
    • Psychiatrists
    • Primary care/relevant specialist physicians

2. Trusted people who know how to help:

    • Family/spouses/partners
    • Close friends/chosen family
    • Treatment peers

3. Contact info for everyone on the list in #2.

4. Locations of nearby support:

    • Mental health crisis centers
    • Local hospital emergency options

5. Help line/Crisis Numbers:

6. Current, updated personal identification/contact info to keep on person.

7. Identification and contact info for family/people capable of making medical decisions.

8. Updated health info:

    • Any earlier crises
    • Mental health records
    • Documentation of prior suicidality if applicable
    • Alcohol/substance use/misuse history if applicable

9. Helpful lists:

    • Triggers for relapse of symptoms/triggers for crises
    • What helps during crises

Once you see the list above, it’s clear why having an emergency action plan is essential. Most treatment centers help develop some type of plan, with similar information. We use the format above because it’s comprehensive and patient centered.

That’s what the plan should contain. However, in its individualized form, that’s not what a WRAP will look like. We’ll share that below.

What’s in a Personal WRAP?

A personalized WRAP may look more like the following. It should highlight exactly what that individual might need in times of crisis, as defined by that person, likely in collaboration with their primary counselor/therapist from their treatment program/programs.

1. When I’m thriving, here’s how you can tell:

    • I’m going to work.
    • I’m doing my hobbies.
    • I stay connected to friends.
    • I never miss… [family dinner on Sunday].

2. When I’m feeling overwhelmed, here’s how you can tell:

    • I stop doing my hobbies
    • I withdraw from friends and family
    • I’m exhausted by work.
    • I’ll find an excuse to miss… [family dinner on Sunday].

3. If my behavior causes distress or harm to the people I know and love, please take the following steps:

    • Ask if I’m on my medication (almost always a factor in bipolar crises/relapses).
    • Contact peers on my list.
    • Contact the providers on my list.

4. When things escalate to a crisis, these people can help me most:

    • Best friend.
    • Mom.
    • Therapist.
    • Psychiatrist.

5. When things escalate to a crisis, I don’t want these people around:

    • Name names.

6. If my family or the people I name as part of my support system have different ideas about how to manage the situation, here’s what I want you to do:

    • Do what my psychiatrist says.
    • Listen to my mom.
    • Give my spouse the final word

7. During a crisis, I need:

    • My medication
    • To talk to my… [psychiatrist, therapist, counselor]
    • These people to know (name names),
    • Option to return to inpatient treatment.

8. During a crisis, do not:

    • Ignore it.
    • Assume it will pass without following the specific steps on this list.
    • Discuss it with anyone not on my support list.

9.If I have a crisis and am unable to meet my daily responsibilities or in the hospital and temporarily out of reach, please help in the following ways:

    • Childcare: talk to my partner/spouse/coparent about filling in gaps.
    • Contact my employer, inform of medical emergency.
    • Pet care: check on and feed my furry friendsl

10. You’ll know my crisis is over, or that I’m okay, and stop following the WRAP when:

    • I’m back in treatment.
    • I’m back doing everything in item #1 on this list.

When making a WRAP, or devising an action plan by any name, it’s essential to be specific, include details, and talk through the plan with the people that matter. It’s best if everyone in the plan knows about the plan, especially if they’re an emergency contact or labeled as someone I want around/can help me the most.

Specifics For Bipolar Disorder: What Happens After Official Treatment Ends?

A common phenomenon occurs when a person with bipolar disorder spends time in treatment, steps down through levels of care, and returns home:

They achieve stability, feel better, and decide to try going off their medication, which is most often a mood stabilizer such as lithium.

Please understand that we encourage every person with a mental health disorder to exercise agency in their treatment, guide their own treatment goals, process, and recovery, and embrace the license – and their right – to manage their own healing and growth.

At the same time, when a person with bipolar disorder makes progress with a combination of medication and therapy, and they decide to discontinue a core component of their treatment, they may experience a relapse of symptoms.

In bipolar disorder, that can mean a return of manic episodes that can be frightening for family members, friends, and loved ones. Helping them know exactly what to do and how best to support their loved one during a manic episode is why having a WRAP – or some kind of action/crisis plan – is essential. The same is true for depressive episodes, too. However, since manic episodes often involve excessive, outward-directed, risky behavior, family members and loved ones may recognize them first, and feel the need to respond in a proactive, protective manner.

With a personalized WRAP or action plan, family members and loved ones will know exactly what to do during manic episodes, depressive episodes, or any mental health crisis anticipated by the treatment team, the person with bipolar disorder, and/or the contents of the plan.