Bipolar Basics 1 - Client Manual - Updated 17NOV2021

Bipolar
Basics
Client
Manual
Property of CAMH – Do not distribute
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Written and Compiled by:
Naomi Mitchell, Arkadiusz Andrusieczko, Anka Krivokuca,

Theresa Bernard, and Helena Roche.
Special thanks to:
Dr. Abigail Ortiz for her comments and contributions
Formatting and design by:
Jasmine Ahmadinia, Elissa Pendergast, and Emilyn Narraway
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Session 1 |What is Bipolar Disorder: Identifying and Monitoring Symptoms
• Group Guidelines
• Treatment Goals
• Ice-breaker exercise
• Meaning of diagnosis
• Identifying symptoms of depression & (hypo) mania
• Using a Mood chart
• Relaxation
• Homework
Session 2 | Impact of Diagnosis & Symptoms & Goal-setting
• Homework review
• Relaxation
• Identifying Myself
• Impact of Bipolar Disorder
• Goal-setting using SMART steps
• Homework
Session 3 | Managing and Preventing (Hypo) Mania
• Homework review
• Relaxation
• Creating awareness about & preventing (hypo) manic episodes:
o The Pull of Mania: Pros and Cons
o Identifying triggers and sources of stimulation
o Managing Impulsive Behavior
o Strategies to organize ideas and activities
• Safety Plan + Hope Pamphlet
• Homework
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Session 4 |Biology of Manic Episodes, Maintaining Wellness and Next Steps
• Homework review
• Relaxation
• Biology of Manic episodes:
o Neurobiology of Mania
• Pros & Cons of preventing Mania (Decisional Balance)
• Review of skills learned
• Maintaining wellness
• Next Steps
Appendices
A. Learning to Sleep
B. Staying Well
C. Breathing Exercise
D. Progressive Muscle Relaxation
E. Mindfulness
F. Colouring Templates
G. Resources:
o Books
o Online Resources
o Community Resources
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Session #1
What is Bipolar Disorder: Identifying & Monitoring Symptoms

Agenda:
• Ice-breaker exercise
• Meaning of Diagnosis
• Identifying symptoms of Depression & (Hypo) Mania
• Using a Mood Chart
• Relaxation
• Homework assigned
Homework:
• Mood Chart
• Complete Symptom Summary worksheets
• Read sessions 1 and 2 of manual
• Appendices: Learning to Sleep
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GUIDELINES FOR GROUP THERAPY
1. Format of group and sessions. The group will meet for 4 sessions, every week for two
hours. Sessions will include a review of information and homework from the previous
session, new content and skills, a relaxation/mindfulness practice and exercises to
complete over the next week.
2. Focus of group. This group will focus on skills that can help you manage and prevent
symptoms of bipolar disorder [depressive and (hypo) manic symptoms]. We are aware
that group members may be dealing with other important issues; we may not be able
to focus on these issues in the group - we can help with finding resources, as needed.
3. Confidentiality: Please respect each other’s privacy and confidentiality. You can
discuss what you are learning in group with others, but please do not share personal
information provided by other group members with people outside of the group.
Confidentiality enables all group members to feel safe and comfortable.
4. Come on time, and come every week. Each session builds on the previous session.
Please contact the group leaders if you are unable to attend a session. Missing sessions
can interfere with the group process and your ability to benefit most from the
treatment. If you miss two group sessions and do not connect with us, it may be
challenging to catch up, and it will be assumed that you are no longer interested in
participating, and lead to discharge from the group.
5. Do the activities, exercises, and homework. Each session consists of learning new skills
and new ways to manage difficult emotions and challenging situations. Practicing
and using these skills regularly in and between sessions will help you manage and
prevent symptoms. You will get the most out of the group by completing homework.
We encourage you to use the worksheets as they reinforce the development of skills
and understanding of how the illness impacts your functioning.
6. Participation. Doing the homework and sharing situations that you find difficult will help
the therapists gain a better understanding of your experiences and treatment goals.
We encourage you to ask questions and interact with the other group members.
7. Equal time for all. It you tend to be very vocal and quick to respond, sit and give other
members an opportunity to speak. If you tend to be quiet and less likely to participate,
challenge yourself to participate more. We ask that one person at a time speaks;
please avoid side conversations.
8. Be constructive. Avoid criticism and judgments, and give constructive feedback. Be

caring, thoughtful, and respectful of differences. Try to keep it practical and focus on
solutions.
9. Commit to practice adaptive coping skills. Please do not attend group under the
influence of alcohol or other substances as it may interfere with the treatment
optimization. You will be asked to leave the session if under the influence of
substances.
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10. Respect for each other and group facilitators. This includes turning off and not using
electronic devices such as cell phones or laptops during group sessions; allowing
others to freely express ideas and opinions; being on time; being mindful of
differences in symptoms, stages of recovery, and treatment experiences.
11. Getting in contact with group facilitators. CAMH encourages clients to contact
CAMH staff via phone rather than email, as email is not a confidential method of
communication. Please be advised that any email messages received by members
of the MAAS will be copied into your health record. Please refer to the excerpt below
from CAMH policy on use of electronic communication (last update June 7, 2016;
item 6.3.2):
a) Emails will only contain communication related to routine matters such as

scheduling and confirming appointments, conveying certain routine test results or
providing general update information on a client/patient’s progress.
b) Emails will not be used to exchange information related to sensitive health
information or emergency/crisis/urgent health matters.
12. Your referring (family) physician remains your primary care-giver while you attend
the group. If you require emergency intervention while attending the group please
contact your family physician or other outside care provider or go to the emergency
department or local hospital.
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Treatment Goals
• Gain a better understanding of Bipolar Disorder and learn to identify symptoms of
depression, mania, and hypomania
• Learn to recognize triggers and early warning signs of depression, mania, and
hypomania and develop strategies to intervene early
• Learn self-monitoring and goal-setting tools and about resources (health care, social,
peer support)
• Learn coping strategies (enhance/develop routine; sleep, daily activities) to manage

stress, mood fluctuations and symptoms, to ultimately reduce the personal costs
associated with Bipolar Disorder and achieve greater stability
• Identify and begin working toward goals to increase functioning (self-care, social,
leisure, occupational/educational), establish and maintain wellness, and improve
quality of life
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• The majority of people go through life euthymic/well, with mood fluctuations within a
reasonable range (in response to daily and life events)
• For those diagnosed with Bipolar Disorder a drop in mood occurs and can persist.
Mood will still fluctuate depending on circumstances but stays in the low range.
• Similarly the mood goes up resulting in (hypo) mania (2 zones for elevated mood) and
then a crash into depression
It is possible to remain in the euthymic state with medications, routine, and a good
support system. We will help you identify what wellness looks like for you and how to
maintain it.
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What is Bipolar Disorder?
Bipolar Disorder, is characterized by extreme fluctuations in mood, energy and activity levels
that can impact cognition and overall daily functioning. These mood and energy shifts
disrupt self-care, work, study, relationships and other responsibilities. There are three main
types of bipolar disorder; all involve distinct changes in mood, energy, and activity levels.
These moods range from periods of extremely “up,” elated, and energized behavior (known
as manic episodes) or less severe, referred to as hypomanic episodes---to very sad, “down,”
or hopeless periods (known as depressive episodes).
Three Main Types of Bipolar Disorder

Bipolar Disorder Type 1 Includes manic, depressive, or mixed episodes.
Depression: period of low mood, low energy and
anhedonia lasting at least 2 weeks.
Mania: an episode distinct from your baseline, when
one feels euphoric, talkative, full of energy, with
decreased need for sleep, has racing thoughts, can
engage in dangerous/risky activities. Some people
can also experience psychotic symptoms. Mania
lasts at least one week.
Mixed episode: an episode where one experiences
depressive and manic symptoms (low mood but
increased energy).
Bipolar Disorder Type 2 Alternating episodes of depression and hypomania.
Symptoms last at least 4 consecutive days.
Bipolar Disorder not otherwise Symptoms do not clearly fit with the intensity or
specified duration for either types of episodes.
1. Duration:
• Depression: at least 2 weeks.
• Hypomania: at least 4 days.
• Mania: at least one week OR any duration if admission is required.
2. Bipolar disorder subtypes:
• Bipolar type I: Depressive episodes, at least one full manic episode, can include
mixed episode(s)
• Bipolar type II: Includes hypomanic episodes and depressive episodes
3. What is a manic episode: it is an episode distinct from your baseline, when you feel
euphoric, full of energy, with decreased need for sleep, have racing thoughts, can
engage in dangerous/risky activities, and are talkative. Some individuals can also
experience psychotic symptoms
4. What is a mixed episode? It is an episode where you can experience symptoms from
both depressive and manic polarities. You can have low mood but increased energy;
or can be irritable and tired at the same time. These episodes are difficult to
distinguish and treat.
5. What is a depressive episode? These are the most frequent episodes for most
diagnosed with bipolar. You feel tired, sad, tearful, sluggish, may sleep a lot, yet wake
up tired, cannot concentrate, appetite can either be increased or decreased, there is
no motivation and no enjoyment. When severe, one can also have thoughts of death
or suicide.
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Why is Bipolar Difficult to Diagnose?
The main reason is that the first episode is usually a depressive one. So, it is hard to say who is
going to have more depressive episodes or who is going to (eventually) have a manic or
hypomanic episode. The second reason is that bipolar disorder is what we call
“heterogeneous”. This means that no mania / hypomania or depressive symptoms are the
same, and that patients respond to different treatments and combinations.
However, there are a few clinical indicators that make it easier to diagnose bipolar disorder,
even when presenting during a depressive episode:
1. Early age at onset: patients with bipolar disorder generally debut with depressive
episodes in their teenage years. This might not be a full-blown episode, but symptoms
such as sadness, lack of energy, issues with school, etc.
2. Long and frequent depressive episodes: patients with bipolar disorder tend to have
frequent and long (lasting months or years) depressive episodes.
3. Atypical characteristics: Sleeping a lot, eating more than usual and gaining weight,
feeling very sluggish (physically and mentally) are clinical characteristics of what we
call “atypical symptoms”. This subtype of depression is more common in patients with
bipolar disorder.
4. Psychotic symptoms: Patients with bipolar disorder can also experience hallucinations
(hearing voices) or delusions (feeling paranoid, feeling that someone is out to harm
them) when depressed. This is another indicator of a probable bipolar illness.
5. Postpartum depression: There are recent studies suggesting that women who suffer
from postpartum depression have a higher risk of being later diagnosed with bipolar
disorder.
6. Migraine co-morbidity: Migraine is more common in patients with bipolar disorder than
in those with unipolar depression. This is why it is important to share with your physician
all medical information, as this can also orient your treatment.
7. Lack of response to antidepressants: In keeping with the above-mentioned points,
when bipolar disorder patients get depressed for the first time, they receive
antidepressants as treatment. This is a common occurrence, as mentioned before,
because it is difficult to know who is going to switch to bipolar. For some patients,
having an antidepressant on board will switch them to mania or hypomania, but this is
not the case for all. For some patients, their depression can worsen, their sleep can be
all over the place, or they can be suicidal while on antidepressants. This is why it is
important to check in frequently with your doctor when you are prescribed
antidepressants. And yet for another group of bipolar patients, a low dose of a mild
antidepressant might be needed to fully stabilize their mood.
Although not everybody with any or all of the above will eventually have a diagnosis of
bipolar disorder, they are more likely to be diagnosed with bipolar if these symptoms are
present.
Dr. A. Ortiz - December 10, 2019
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Symptom Summary Worksheet - Sample*
When When feeling When
Category depressed OK (hypo) manic
Mood Sad Content Irritable

I’m the only one with a
Attitude toward self I hate myself I think I am capable of a lot
brain
Self-confidence No self-confidence I think I am capable of a lot Very self-confident
Work. Clean house. Starting but not finishing
Usual activities Lay in bed or watch TV
Exercise tasks
I don’t want anyone to see Can’t stand to be around
Social activity Visit with family/friends
me people
Sleep habits Sleep all the time 7-8 hours/night 4 hours/night
Appetite/Eating habits I’m not hungry I like to eat I forget to eat

Stare at a page, but can’t Pretty good, I can read the
Concentration Can’t hold on to thoughts
read paper
My mind is slow and
Speed of thought I’m usually a quick thinker Fast and disorganized
sluggish
Very creative until I reach
Creativity No creative thoughts Can be creative at home
my peak
Interest in some things,
watching a game and
Interest in having fun Interest in nothing reading a book are usual Interest in everything
interests
I don’t want to move off I like to keep busy and
Restlessness Very hard to sit still
the couch keep moving
Sense of humour Nothing is funny Like to tell jokes More sarcastic
Energy level None Enough to get things done High. Nervous Energy
I don’t hear what’s going
How noise affects you on It doesn’t usually bother me Noise gets on my nerves
around me
I’m not certain what
Outlook on the future There is no future Anything is possible
tomorrow will bring
Have difficulty forming Talkative, but do not
Speech patterns Talk fast and incessantly
words; silent interrupt others
Decision-making ability Cannot make decisions Can make good decisions Decisions made impulsively
Concerned about what
Concern for others Considerate of others Not worried about others
others will think
Others better off without
Thoughts about death I don’t think about it Thoughts about God
me
Can function with a lot of
Ability to Function Function normally At my best for a while
effort
Can’t stop thinking about
Sex Drive No interest Rarely interested
sex
*from Basco & Rush (2007), Cognitive-Behavioural Therapy for Bipolar Disorder, pp. 66-67
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Common Symptoms of Depression*
Mild Form of Sx Moderate Severe
Blue, down or neutral mood Cry more easily Severe sadness
Not in the mood to socialize Less involved with others Lack of interest in usual activities
Usual activities are not as much fun

Have fun until activity is over Decreased pleasure
as expected
Blame self-more readily when things

Self-critical Excessive and inappropriate guilt
go wrong; see own faults
Not as hungry as usual; can skip

meals occasionally and not feel Eating brings less pleasure Decreased appetite
hungry
Clothes fit slightly looser; no big

Noticeable weight loss Significant weight loss
weight loss (e.g. 1-3 pounds)
Sleep seems less restful; ruminating Insomnia – cannot fall asleep easily;
Takes much longer to fall asleep;
at bedtime; falling asleep takes a wake up during the night and stay
wake up briefly during the night
little longer awake
Lose interest in tasks such as reading;

Must reread text; thoughts cannot
get frustrated with tasks that are Impaired concentration
be focused well
lengthy
Slowness in movements is noticeable

Feel as if you are moving slowly; not
to others; long pauses before Psychomotor retardation
mentally sharp
answering questions
Thoughts that life may not be worth

Wish pain would go away; thoughts Suicidal ideas or attempts; not
living; hopeless; can’t imagine
of running away; pessimistic caring if you die
feeling better
Low self-esteem; dislike appearance;

Self-doubt; some self-criticism Feelings of worthlessness
feel like a loser
*from Basco & Rush (2007), Cognitive-Behavioural Therapy for Bipolar Disorder, pp. 61-62
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Common Symptoms of Mania*
Mild Form of Sx Moderate Severe
Everything seems like a hassle;

More easily angered Irritability
impatience or anxiety
Happier than usual; positive Euphoric mood, on top of the

Increased laughter and joking
outlook world
More talkative; better sense of In the mood to socialize and

Pressured or rapid speech
humor talk with others
More thoughts; mentally Disorganized thinking, poor

Racing thoughts
sharp, quick; lose focus concentration
More self-confident than Feeling smart, not afraid to try, Grandiosity – delusions of
usual; less pessimistic overly optimistic grandeur
Plan to make changes;

Creative ideas; new interests; Disorganized activity; starting
disorganized in actions,
change sounds good more things than finishing
drinking or smoking more
Fidgety; nervous behaviors like Restless, preferring movement Psychomotor agitation;

nail biting over sedentary activities cannot sit still
Not as effective at work;

Not completing tasks, late for Cannot complete usual work
having trouble keeping mind
work, annoying others or home activities
on tasks
Uncomfortable with other

Suspicious Paranoia
people
Increased sex drive – seeking

Sexual dreams, seeking out or
More sexually interested out sexual activity; more
noticing sexual stimulation
promiscuous
Noises seem louder, colors
Distractibility – have to work
Notice sounds and annoying seem brighter, mind wanders
hard to focus thoughts or
people; lose train of thought easily; need quieter
cannot focus at all
environment to focus thoughts
*from Basco & Rush (2007), Cognitive-Behavioural Therapy for Bipolar Disorder, p. 60
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Symptom Summary Worksheet*
Category When depressed When feeling OK When (hypo)manic

Mood
Attitude toward self
Self-confidence
Usual activities
Social activity
Sleep habits
Appetite/Eating habits
Concentration
Speed of thought
Creativity
Interest in having fun
Restlessness
Sense of humour
Energy level
How noise affects you
Outlook on the future
Speech patterns
Decision-making
ability
Concern for others
Thoughts about death
Ability to function
OTHER AREAS:
*from Basco & Rush (2007), Cognitive-Behavioural Therapy for Bipolar Disorder
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Why Use a Mood Chart?
It is important to be aware of subtle shifts in mood in order to catch them and intervene
early. Waiting too long can make it more difficult to intervene effectively
• Important part of learning BAD symptoms specific to you; the chart will look different
for everyone
• Helps clarify baseline for “wellness”
• Daily self-monitoring is especially important during periods of change and transition,
when people become more vulnerable to stress and mood fluctuations
• Helps make connections between specific triggers in their environment (arguments,
stressors) that affect mood and provides opportunity to target and reduce stressors
• Your internal clock (Circadian clock) is synchronized with the external environment
and functions best when routinely reset by activities like regular sleep, meals, activities
and routines and the external environment (daylight/darkness)
• People who struggle with Bipolar Disorder have greater sensitivity to minor disruptions in
their circadian clock that can result in worsening of and vulnerability to mood
episodes
• Helps establish/maintain stable social and biological rhythms related to healthy
functioning (people and activities function as external time clock/regulators of
routines: regular social interactions and meal times: partner has dinner with you, get
up at same time to get ready for work, school, walk dog, eat)
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Instructions for Completing Mood Chart
This may seem like a busier chart than the mood trackers available on the internet. However,
it’s important to become familiar with the basics of one’s functioning before streamlining. We
ask you to use this chart over the next four weeks.
This chart is for an entire week. Record any details that may be important later for making
connections between activities, moods, sleep, appetite, social functioning.
MOOD ratings for morning & afternoon are a way to acknowledge that not every difficult
day indicates depression or each great day means elevated mood. Fluctuations in your
mood occur throughout the day in response to different factors. You just got a job with
higher pay; feel great about it, or your pet just died and you’re feeling very sad and
melancholy.
MEALS & SNACKS: Research shows it is important to have steady sugar levels throughout the
day, especially for people with the diagnosis of bipolar disorder. Make a note of how many
MEALS you have, including snacks (2m+3s). You can also note if you crave particular types of
food or drink.
TOTAL HOURS OF SLEEP/NAPS: Disrupted sleep is a common symptom in depressive and

(hypo) manic episodes. Establishing and maintaining a regular, consistent number of hours of
sleep per night is a strong protective factor against mood episodes in Bipolar Disorder.
Record the number of hours of sleep for each day. If today is Thursday you will record the
number of hours you slept from Wednesday and are starting Thursday with. NAPS are
sometimes welcome, but can become a barrier to a good night’s sleep.
WHEN DID YOU GO TO BED/WHEN DID YOU GET OUT OF BED

Consistent wake up and bedtime schedules help maintain balanced biological and social
rhythms associated with daily routines. Tracking these will help you target or make
adjustments to protect against mood episodes.
ALCOHOL and other SUBSTANCES are generally not beneficial to mood and overall health, to
cope and regulate mood. Often people underestimate their use and minimize the impact.
Also if taking medication, alcohol and other substances may have adverse or unsafe
interactions. Record your intake. If at any point you think you need help reducing or
abstaining from alcohol or other substances, we can provide you with resources/information
to receive the help you need.
PHYSICAL ACTIVITY is important for both physical and mental health. It can regulate sleep
and reduce stress. When you start tracking this activity, you may notice the connection with
other items on this chart (sleep, meals, and mood).
RELAXATION: What relaxes people varies: yoga, walking, being with people, pets, doing
something pleasurable, taking a break. It is important to incorporate into your daily routine. A
simple breathing exercise or going to a comfortable place can reduce stress.
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SOCIAL CONTACTS: Socializing and social contact contributes to overall wellbeing. Check off
in-person or by phone interactions (texting and other social media while part of daily life
aren’t considered direct social contact).
MEDICATIONS: If you take medications, note if you have taken them as directed.
This gives you a sense if medications are working and if there are challenges taking them.
Even one missed dose intentionally or unintentionally may have a strong impact on mood
and energy. Many people take SUPPLEMENTS for a variety of reasons. If any are particularly
important to you, note if you have taken them.
The MOOD RANGE refers to the bipolar states. While bipolar diagnosis means people
experience both mood depression and elevation, these extremes do not happen all the
time. Many people go through long periods of stability. Depression and Hypo (Mania) are
states or episodes of illness, also identified as RELAPSE. Neither of these states identify who
you are as a person. YOU HAVE BIPOLAR – YOU ARE NOT BIPOLAR.
DEPRESSION (below baseline):

Managing to function: Functioning with minimal changes to routine
Struggling to function: Functioning with great effort
Unable to function: Incapacitated/Hospitalized
EUTHYMIA/Stable (Baseline):
Optimal functioning
HYPO (MANIA) (above baseline):

Hyperactivity: Energized with slight changes to routine
Struggling to function: Difficulty with goal-oriented tasks/work
Unable to function: Incapacitate/Hospitalized
ENERGY LEVELS: A feature of Bipolar Disorder is the variability in energy levels during
depressed or (hypo) manic episodes. The chart can provide a view of these extremes, and
also map a more typical range of energy levels related to periods of wellness, associated
with daily routines and activities, differentiating them from bouts of illness. Two sets of
batteries help you identify your energy level:
• Green batteries depict energy levels ranging from empty (depressed) to full for
euthymia.
• Full red batteries represent the energy level for mania.
LIFE EVENTS are any significant events that are stressful or positive for you and affect your
daily mood, how you view yourself and life in general. Describe event and note the date
(job loss, relationship stress, new job, argument)
Other/ANXIETY: While it is expected that we all experience variations in moods daily.

sometimes we feel “extremely anxious,” or “everything is wrong,” worrying is more prevalent
and intense. If you struggle with any of those moods, track them.
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WEEK OF ………………… DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7
My mood in the morning

My mood in the afternoon
Meals (#)
Snacks (#)
When did you go to bed?
When did you get out of bed?
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION
Choose the battery that

ENERGY
maches your energy that
LEVEL
day
UNABLE TO FUNCTION
STRUGGLING TO FUNCTION
HYPERACTIVITY
EUTHYMIA/OPTIMAL FUNCTIONING
MANAGING TO FUNCTION
UNABLE TO FUNCTION
LIFE EVENTS
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Session #2
Impact of Diagnosis & Symptoms and Goal-Setting

Agenda:
• Homework review:
o Mood Chart
o Readings
o Symptom Summary worksheets
o Smart Step
• Relaxation
• Identifying Myself: Who I am
• Impact of BAD diagnosis (self-care, relationships, overall quality of life)
• Goal setting using SMART STEPS
Homework:
• Mood Chart
• Identifying How Bipolar Disorder illness has Impacted Me
• Identifying Myself
• Complete 1 SMART Step
• Read materials from sessions 2 and 3 in this manual
• Appendices: Learning to Sleep
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Framework for Identifying MYSELF
It can be helpful to think of the concept of self as a house with steady and permanent
structures: foundation, roof, windows, and doors. The self is composed of permanent
structures: likes, dislikes, values, skills, talents and interests. Bipolar is like a force that disrupts
the interior of the house.
The foundations of the self are constant. However, you may need to reorganize the rooms of
the house both as a response to disruptions of illness and as a preventive measure.
Take time to consider what features define you as a person. You still know how to play the
piano or speak two languages regardless of your mood state. Your skills and talents remain
despite changes in how you express yourself during mood episodes.
Others know you in various roles and relationships: loving friend, partner, family member, co-
worker, creative individual.
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Identifying Myself
Key Aspects of My Identity
Physical: (my height, eye colour)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Social role (child, parent, partner, student)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Skills and abilities (languages spoken, artistic talents, knowledge, vocational skills and
credentials)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Preferences (music, tea over coffee)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Habits (always start brushing on same side)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How do I interact with people (as a listener/talker, energized, empathetic, vocational skills)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What do others identify as my unique qualities? (talented, witty, supportive)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Identifying How Bipolar Illness Has Impacted Me
An important step in coping with Bipolar illness and learning to manage its symptoms, is
recognizing what aspects of your life have been negatively affected. The next step is to
begin identifying what you want to change. This worksheet will help you begin to think of
some general goals for therapy.
Self-Care
Hygiene
Nutrition
Physical Health
Laundry Vocation &
Medication Education
Appointments School
Exercise Career
Social
Connection Effective
Depression Communicati
Family
Hypomania on
Friends
Listening
Initiamte Mania
Assertiveness
Communicty
Responsbilities Leisure &

Houshold Interests
Chores Hobbies
Work Art
Family Fun
Other
Identify two general goals you would like to work on. You can refer to your Mood Chart (is
something important out of balance: sleep routine, meals)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Goal setting
A goal is a change in behavior that results in improvement in quality of life.
Why Use Smart Steps?

You identified various domains of your life that have been affected by Bipolar Disorder. What
changes can you make now that will contribute towards improving and managing your
mood? It can feel overwhelming to tackle multiple problem areas at once. By setting smaller
goals using SMART STEPs you will experience a sense of accomplishment and improvement in
mood.
Small/Specific: Make your goal as small and specific as possible.

Make sure that it is a behavior.
Measurable: How can you determine that you are making progress (if you can’t
measure it, it probably is not a behavior).
Attainable: Is it within your reach. See where you are today and set your goal just
outside your grasp.
Relevant: Do you really want to do it, or you think you should. How will it positively
impact your mood/routine?
Time bound: Set a deadline.
Internal Resources
Compassion
Time
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Identifying a general goal and making it into a SMART GOAL:
1. What is your general goal?
I want to be healthier.
2. Where are you now exactly?
I don’t go to the gym.
3. SMART Goal: Where would you like to be?
I want to exercise two times a week at my gym.
4. Do you need to break down your goal into smaller, more manageable steps?
Make sure each one includes SMART principles.
• I’ll go online tonight, buy a gym membership & decide which classes I want to take.
• I’ll call Mom tomorrow to set up babysitting for Mondays and Thursdays.
• I’ll buy a t-shirt, shorts, and shoes at the mall on Wednesday afternoon.
• I’ll tell Alex about my exercise plan tonight.
5. What are the possible problems or barriers to reaching your goals?
• Mom might not always be available for babysitting.

• There are days I might feel too tired to go to the gym.
6. What are some strategies/solutions to overcome those problems/barriers?
1. I’ll check with Riya to see if she’s is free to babysit on Mondays & Thursday as backup.
2a. I’ll ask Chris to be my workout buddy to increase my motivation and commitment.
2b. I’ll use the 5-minute rule – go for at least 5 minutes and then stop if that’s all I can do.
26
SMART GOAL
27

Meals (#)
Snacks (#)
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION

ENERGY
LEVEL
day
UNABLE TO FUNCTION
HYPERACTIVITY
UNABLE TO FUNCTION
LIFE EVENTS
28
Session #3
Managing & Preventing (Hypo) Mania

Agenda:
o Mood Chart
o Readings
o Smart Step
o Identifying Myself
• Relaxation
• Creating awareness around & preventing (hypo)manic episodes:
o The Pull of Mania: Pros and Cons
o Identifying triggers and sources of stimulation
o Strategies to reduce stimulation and prevent impulsive behavior
o Strategies to organize thoughts and ideas
• Building a Safety Plan
Homework:
• Mood Chart
• Complete 1 Smart Step
• Complete Safety Plan
• Sources of Stimulation
• Review: Types of Impulsivity & preventive strategies
• Information sheets on Mania
29
Common Symptoms of Mania*
Mild Form of Symptoms Moderate Severe
Everything seems like a hassle;

More easily angered Irritability
impatience or anxiety
Happier than usual; positive Euphoric mood, on top of the

Increased laughter and joking
outlook world
More talkative; better sense of In the mood to socialize and

Pressured or rapid speech
humor talk with others
More thoughts; mentally Disorganized thinking, poor

Racing thoughts
sharp, quick; lose focus concentration
More self-confident than Feeling smart, not afraid to try, Grandiosity – delusions of
usual; less pessimistic overly optimistic grandeur
Plan to make changes;

Creative ideas; new interests; Disorganized activity; starting
disorganized in actions,
change sounds good more things than finishing
drinking or smoking more
Fidgety; nervous behaviors like Restless, preferring movement Psychomotor agitation;

nail biting over sedentary activities cannot sit still
Not as effective at work;

Not completing tasks, late for Cannot complete usual work
having trouble keeping mind
work, annoying others or home activities
on tasks
Uncomfortable with other

Suspicious Paranoia
people
Increased sex drive – seeking

Sexual dreams, seeking out or
More sexually interested out sexual activity; more
noticing sexual stimulation
promiscuous
Noises seem louder, colors
Distractibility – have to work
Notice sounds and annoying seem brighter, mind wanders
hard to focus thoughts or
people; lose train of thought easily; need quieter
cannot focus at all
environment to focus thoughts
*from Basco & Rush (2007), Cognitive-Behavioural Therapy for Bipolar Disorder, p. 60
30
Sources of Stimulation*
Internal External
• Racing thoughts • Noise, clutter, construction zone

• Making plans for activities, travel • Traffic
• Thinking about creative ideas • Loud conversations
• Mulling over creative thoughts or ideas • Loud music
• Starting multiple projects • Social media, phones, computers
• Ruminating about the past or worrying • Group settings, social events, crowds
about emotional events • Seasonal changes, travel
• Yearning for excitement • Substance use
• Impulsivity • Interpersonal conflict
What can I do about What can I do about

Source Source
it? it?
*adapted from Basco & Rush (2007), Cognitive Behavioural Therapy for Bipolar Disorder
31
Types of Impulsivity
Hypo (Manic) episodes can contribute to behavior that doesn’t
align with your values or goals (gambling, shopping sprees,
investing in risky schemes, unsafe sex, infidelity). These urges start
gradually so it is important to pay attention to their progressing any
further, to mitigate consequences.
Urgency. You want something now, not later. So, you act rashly,
giving in to your desire to avoid the negative feelings associated
with resisting what you want.
Lack of Planning. You don’t think about the future. You act before
you plan, and your big ideas rarely get off the ground.
Sensation Seeking. You crave excitement and have an intense

need for the positive feelings associated with risky actions. You act
without regard to consequences.
Strategies to Prevent Impulsive Actions
• Notice the urge/trigger without judgment

• Pause; notice your sensations, urges, feelings
• Seek another perspective (involve others-ask for input/opinion)
• Surf the urge: ride it out; the desire will fade
• Sleep on it (delay the decision until the next day)
• Play the tape to the end; imagine the negative outcome of your impulsive action
• Follow the plan not the feeling
• Spend only within your budget
• Use grounding techniques to manage your urges/feelings
• Practice harm reduction
32
Preventing Mania
Behavioural Changes in Mania
One of the hallmarks of bipolar disorder is the distinctive behavioural changes that take
place when a patient begins to experience hypomania and mania. Activity levels and libido
increase and hours spent in sleep decrease. This cycle of increased activity and decreased
sleep (or physical rest) can itself perpetuate and escalate the mania.
These changes in activity levels usually begins slowly and builds over time. As such, activity
levels can be used as a measure for tracking the progression of the elevation in mood. When
you recognize that your mood begins to be elevated, it is important to begin monitoring your
activity levels. If your activity levels begin to consistently and progressively increase, your
early intervention strategies should be activated to prevent a full-blown episode of mania.
Here are two strategies you can incorporate into your early intervention plan.
Preventing Sleep Disruption
Research has shown that sleep deprivation can be both a trigger to, and a consequence
(symptom) of, mania. Some patients find that with little or no sleep, they become exhausted,
but cannot slow down enough to fall asleep.
These symptoms may escalate into a full-blown episode of mania and possibly psychosis.
Other bipolar patients may enjoy the increased energy and vigor but find that this level of
energy and activity cannot be sustained without negative consequences, such as irritability
and paranoia.
The best strategy for coping with sleep disruption is to prevent it. If it is possible, try to forecast
or identify times when your normal sleeping habits are likely to be disrupted (e.g., when
having to rush for a deadline, travelling, going on holidays, etc.)
Here are some good sleeping habits to maintain, so that you can prevent a hypomanic or
manic episode:
• going to bed and waking up at the same times each day

• avoid napping if it causes night-time insomnia (or don’t take too long a nap)
• try to minimize sleep disruptions (e.g., share night- time responsibilities, bring favourite
pillow on holiday, use ear plugs or eye shields, or medications)
• avoid overstimulation (e.g., too much physical activity before bedtime, caffeine)
• avoid thinking too much at night (do some relaxation exercises or calming activities)
33
Preventing Mania Cont’d
Limiting Your Activities
Besides pharmacological intervention, there are some strategies you can implement to
prevent mild or moderate mood elevation from becoming a full-blown manic episode. The
key principle for any behavioural intervention for preventing mania is to limit activity and to
keep activity levels to a “normal” level. While you are well, plan and organize your regular
week and ensure that there is a balance of responsibilities, pleasant activities, and time for
sleep and/or rest. Try to keep to this schedule as closely as possible. Then, when you begin to
suspect that your mood might be becoming elevated, monitor your activity level and
compare it to your “normal” and balanced schedule. If you find that your activity levels
have increased significantly, try to get yourself to slow down and return to your normal
weekly schedule. You could also ask a friend or family member to help you do this.
So remember …
Preventing mania is all about slowing yourself down, relaxing, and having enough rest. These
are things you could easily do once you recognize some of your early warning signs. For
example, if you realize that you’re beginning to feel a little keyed up and restless or more
energetic, you could take a slow and relaxing walk somewhere nice or take a nice long
bath. These strategies are recommended not to stop you from feeling happy but to prevent
your good mood from escalating toward mania. Many bipolar patients have said they love it
when their mood is slightly elevated but do not enjoy the experience of full-blown mania. This
is where you can learn to better manage your moods so that you can prevent them from
escalating to full-blown episodes.
This document is for information purposes only. Please refer to the full disclaimer and
copyright statement available at http://www.cci.health.wa.gov.au regarding the
information from this website before making use of such information.
34
Organizing Your Ideas
During mania and hypomania, there is often a flood of new ideas and interests. People with
hypomanic symptoms frequently overestimate how much can be accomplished in a given
day. They underestimate the time it takes to complete tasks and underestimate the costs
involved in implementing certain ideas. Coupled with the optimism and increase in self-
confidence, patients in an elevated mood may take on too many (and perhaps, risky)
projects, thus making it more likely that projects are not completed or are not successful. In
addition, they run the risk of becoming exhausted from doing too many things.
When you begin to realize that your mood is becoming elevated and you begin to have
many creative ideas, it is important that you begin organizing and evaluating these ideas.
The purpose of this exercise is to help you take a step back and to slow down a little. It also
helps you keep a record of your creative ideas and to set yourself up to succeed in doing
some of these projects (be they small or large) because you will have thought through some
of the important details before you start doing anything. The mini- worksheet provided on the
right side of this page is an example of how you can record your ideas and work through this
exercise.
First, write down all the ideas for activities or projects that you have. Then, evaluate ALL your
ideas, projects, or actions by asking yourself:
• What are the costs and benefits of trying out this idea, or embarking on this project,
taking on this new responsibility, or carrying out this action?
• What resources do I need?
• What are the steps I must take to carry out this idea/project successfully?
It is important that you do this for every idea, project, new responsibility or action that you
have in mind. After you have evaluated your ideas, list them in order of priority.
Also, for each idea or project, you might want to set a deadline for yourself as to when the
project should be completed. Then, carry out the idea or project that you placed as the TOP
priority. Remember, before you begin carrying out a new idea or project, you must have
completed the previous one. In this way, you can ensure that you limit your activity levels,
while focusing your energy and resources on one important project at a time, thereby
increasing your chances of success. This will also help you prevent a full-blown episode of
mania, likely hospitalization, and total exhaustion.
By doing this exercise, you will not only slow yourself down, you will also have a record of all
your creative and interesting ideas, and ensure that some, if not all, of these ideas will be
carried out successfully.
35
List of Ideas or Projects
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Idea or Project: __________________________________________________________________________
Costs Benefits
Resources Specific Steps
Idea or Project: __________________________________________________________________________
Costs Benefits
Resources Specific Steps
Ideas or Projects in order of PRIORITY Deadline for Completion
1. _________________________________ _________________________
2. _________________________________ _________________________
3. _________________________________ _________________________
36
Cognitive Changes in Mania
The onset of mania or hypomania can often be a pleasant experience for people with
bipolar disorder. Positive changes in mood can be quite dramatic, and people often feel
energized, excited, and optimistic. On the other hand people sometimes find that mania
and hypomania begin with irritability and agitation, or that they experience both feelings of
dysphoria and euphoria at the beginning of a manic episode. For those who experience
mixed episodes, quick changes can occur between being in a good mood and extreme
irritability.
The cognitive changes associated with mania or hypomania include changes in the way
people or situations are viewed, and changes in the amount and quality of new ideas. These
changes can act as a signal that a manic episode is developing, and that action needs to
be taken to prevent the symptoms from getting worse.
Increased Optimism & Grandiosity
When people are manic or hypomanic, the most common symptom is the development of
an unusually positive view of self, the future, and the world at large. When people are
becoming manic, they often find themselves feeling particularly self-confident and
experiencing a general sense of well-being. This is often accompanied by beliefs that
include overestimating their abilities, an optimism that causes them to view the world as
particularly helpful, or an underestimation of the negative consequences of their behaviour.
Sometimes this self-confidence can progress to the point where the person’s thinking is
grandiose and delusional.
When people are becoming manic or hypomanic they may develop a wealth of new ideas
and plans that often have the potential to be successful. Unfortunately, when people are
manic, it can be difficult to distinguish between good ideas and grandiose delusions. The
other thing that often happens during a manic episode is that a person’s ability to
concentrate and follow through with plans is impaired (particularly when they are
overactive or not sleeping much). All of these factors, together with little or no planning, can
cause even the best ideas to fail.
During a manic or hypomanic episode, people may forget to consider the potential
negative consequences of their behaviour. There is a tendency to rush into an activity or
make a decision without carefully considering the pros and cons associated with each
choice. They may also be feeling so optimistic that they dismiss the potential negative
consequences anyway.
37
Cognitive Changes in Mania Cont’d
Paranoia
Early in the development of mania or hypomania, paranoid thinking is often evident, and
may manifest as suspiciousness of others. This suspiciousness is often based on very real
events and a history of bad feelings between the person experiencing mania, and the
target of his or her paranoia. The paranoia is often maintained by focusing on evidence that
confirms the paranoid thoughts. Interactions with the target person are likely be tense
because of the suspicion involved, and the target person is likely to react in some way to the
tension and hostility. This reaction can then be read by the person as confirming their
paranoia.
Increased Fluency of Ideas
During mania and hypomania, there is often a flood of new ideas and interests. People with
hypomanic symptoms frequently overestimate how much can be accomplished in a given
day and underestimate the time it takes to complete tasks. The increase in mental activity
that accompanies mania acts to distract people from these tasks they have started doing,
making it even more difficult to complete activities.
Thinking Errors in Mania
Social judgement can be impaired in hypomania and is usually quite impaired during manic
episodes. People with bipolar disorder often experience a decreased sense of self-
awareness during their interactions with others. They may say or do unusual things, or fail to
notice the impact that their words or actions have on other people.
Recognizing Symptoms
The symptoms of mania, hypomania, or mixed episodes usually emerge over a period of
days to weeks. Often people become aware of a pattern in the development of their
symptoms, for example, hypomania or mania may begin with one symptom such as
insomnia, and then progress to other symptoms (e.g., increased sexual interest, feelings of
euphoria). Changes in the nature of people‘s thoughts, or preoccupation with certain ideas
can also be part of this progression. Some people learn to recognize these changes in their
thinking and can say, “It’s happening again. I always start thinking that way when I’m
getting high.” This recognition can be a critical step for intervening early to prevent a full-
blown manic episode.
Some people may think they have special powers, particularly in the areas of creativity and
personal interactions. These beliefs are maintained when people focus only on events that
appear to confirm the belief, while ignoring evidence to the contrary.
38
SAFETY PLAN - COPING WITH SUICIDAL THOUGHTS*
Name: ___________________________ Date: ____________________________
What activities can I do to calm/comfort myself?

__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
These are reminders to myself of my reasons for living:

__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
What can I do to reduce the risk of acting on suicidal thoughts?

__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
What warning signs or triggers make me feel less in control of suicidal behaviour?
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
What have I done in the past that has helped? What coping skills can I use now?
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
What can others do to help?

__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
39
Call a friend or family member:
Name: ___________________________ Phone: ____________________________
Call a backup person if person above is not available:
Name: ___________________________ Phone: ____________________________
Call a care provider (general practitioner, psychologist, psychiatrist, therapist):
Name: ___________________________ Phone: ____________________________
Call my local crisis line:
• Phone, Gerstein Centre: 416-929-5200

• Distress Centre of Toronto: 416-408-4357
• Canadian Mental Health Association - crisis response: 416-498-0043 (North York and
Etobicoke)
Others:
_______________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________
_______________________________________________________________________________________
This is a safe place where I can go:

__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
I can go to the Emergency Room at the nearest hospital.
If I feel that I can’t get to the hospital safely, I can call 911 and request transportation to
the hospital. They will send someone to transport me safely.
Review Date: ___________________________
*This document was adapted from Dr. Joti Samra, R.Psych. & Dr. Dan Bilsker, R.Psych. (2007). [CAMH: D0312A.
F0551-20111202]
40
Privacy and The Hope by CAMH app
Confidentiality was developed through
Hope by CAMH will not collect consultations with
any information you provide and
your anonymity will be CAMH Clinical experts
maintained at all times. CAMH Patient advisors
This app will not track your
CAMH Family members
location and cannot store or AN INTRODUCTION TO
access your personal
CAMH Privacy & Security
information such as your name, CAMH Legal Services
address, phone contacts, or the
information you add to your
Hope by
41
safety plan.
Within the Terms of Use section,

CAMH
you will be informed that:
All information (including text
and phone numbers) is stored
directly on your personal
If you are experiencing
mobile device and not sent to thoughts of suicide, you are
any external servers. deserving of help and can call
1-833-456-4566. If you feel safe
You also have full control over in the moment, follow up with
your family physician or care
who you choose to e-mail a GET IN TOUCH: team. If you require immediate,
copy of your safety plan to, if in-person emergency care, go to
For technical questions about your nearest emergency
you choose to do so. department, or call 911.
the app, please email
appsupport@camh.ca
Where can you App Overview
Hope by CAMH is a access the app?
FREE smartphone
app through which Hope by CAMH
you can: webpage
Scan the QR code below to
visit our website
Create a personalized
suicide safety plan
Practice wellness
activities
42
Safety plan: A customizable safety plan
Access crisis based on clinical guidelines and best
resources practices.
Here you will find:
Links to download the Wellness Activities: Activities such as
Learn about suicide journaling, boxed breathing, progressive
app on the Google Play muscle relaxation, and grounding
risk factors or iOS App stores technique to help you cope during a difficult
time.
Link to a detailed
Obtain information guidebook on how to use Resources: A list of crisis resources that can
the app be accessed by phone, text, or in-person
for family & loved visits, sorted by location (province, region).
ones Link to the app Terms of
Use General Information: Information and
statistics about suicide and risk factors,
including resources for family and friends.

Meals (#)
Snacks (#)
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION

ENERGY
LEVEL
day
UNABLE TO FUNCTION
HYPERACTIVITY
UNABLE TO FUNCTION
LIFE EVENTS
43
41
SMART GOAL
44
42
Session #4
Biology of Mania, Maintaining Wellness & Next Steps

Agenda:
o Mood Chart
o Smart Step
o Safety Plan
o Sources of Stimulation
o Impulsivity and Strategies to
o Readings from manual
• Relaxation
• Neurobiology of Mania:
o Biological impact
o Decisional balance: sticking with treatment; pros and cons
• Review of skills learned:
o Maintaining Wellness
• Next Steps
Homework:
• Continue to practice skills learned:
o Mood Chart
o Complete 1 SMART Step
o 101 Coping/Grounding Skills
o Decisional Balance
o Teeter Totter
o Staying Well & entire appendices
45
43
102 Coping/Grounding Skills
1. Identify early warning signs and 21. Set up exposures to face anxiety
intervene early provoking situations
2. Goal setting- Set small SMART goals 22. Use affirmations
daily 23. Do a thought record
3. Change your environment- e.g. get 24. Track you mood/anxiety/sleep
out of bed and sit at kitchen table 25. Do something sensory—shower,
4. Increase social support- call a friend mindfully eat a meal
5. Use assertiveness to make request, or 26. Take a walk
let someone know how you feel 27. Do some exercise
6. Set limits with others for emotional 28. Set up regular sleep routines
self-care 29. Decrease caffeine
7. Create a gratitude journal 30. Decrease substance use
8. Find a creative outlet- writing, art,
drumming 31. Avoid toxic people/situations
9. Listen to music 32. Get dressed—don’t stay in
10. Use relaxation technique- like deep pajamas
breathing 33. Write in a journal
34. Write a list of your strengths/things
you like about yourself
35. Pamper yourself for an hour
36. Distraction: Read, watch a movie,
play with a pet, do a craft
11. Do progressive muscle relaxation 37. Plan healthy meals
12. Put on guided imagery CD, or 38. Do some stretches
imagine yourself in peaceful place 39. Ask for help
13. Use mental grounding technique- 40. Do a Cost-Benefit Analysis to weigh
naming colors in the room, count options (pros and cons of decision
backwards from 100 by 7
14. Use physical/sensory grounding
15. techniques, press your feet into the
floor, eat something with sharp taste,
feel a rock in your pocket 41. Use positive & encouraging self-
16. Use soothing grounding techniques- talk
feel something soft, imagine a loved 42. Attend a group
one/supporter 43. Set aside worry time
17. Get more information- about 44. Keep track of “ah-ha” moments in
resources, medication (e.g. talk to a journal to read later
pharmacist), community supports 45. Do relaxation instead of napping
18. Do a planned pleasurable activity 46. Identify distorted thinking
19. Do a planned mastery activity- do 47. Change “shoulds” to “coulds”
something productive no matter 48. Remind yourself of your reasons to
how small change
20. Set up daily schedule to follow 49. Pray or do something spiritual
50. Respond rather than react- stop,
regulate emotion, plan response
46
44
51. Identify top 3 priorities for the week
52. Use or seek out humour 71. Dress up, shave, put on make-up,
53. Make a list of activities that paint your nails
energize you 72. Do yoga, tai chi
54. Replace the word “BUT” with the 73. Visualize a pleasant memory (“The
word “AND” in your daily language Sweet Spot”)
55. Acknowledge successes in difficult 74. Go somewhere to sit and people
situations watch
56. Do action opposite to urge (e.g. if 75. Write a letter to someone (to send
urge=isolate, action=reach out) or not send)
57. Exercise compassion with yourself 76. Walk and take pictures
58. Take some private time, then come 77. Make a cup of tea
back 78. Use radical acceptance
59. Get a bit more organized 79. Do a Body Scan
60. Take it slow 80. Get up at the same time every day
81. If you are prone to impulsive

61. Accept help spending, bring only $10 with you
62. Accept compliments- write them when you go out.
down! 82. Use the “10 minute rule”: do
63. Separate your behaviour from something you’ve been putting off,
yourself but only for 10 minutes
64. Surround yourself with good people 83. Walk your dog or someone else’s
65. Remember QTIP: Quit Taking It dog
Personally 84. Do a behavioural experiment to
66. Read quotes, motivational saying test a core belief
67. Go to the library 85. Call a warm line or a crisis line
68. Get some sunlight 86. Listen to a CD of nature sounds or
69. Recognize when you are over- use a nature sound app
scheduled- let something go or 87. Remind yourself that “This too shall
delegate pass”, or “No feeling is final”
70. Do a puzzle, crossword, Sudoku 88. Do some free writing
89. Make “coping cards” to put in your
wallet, with things written on it that
you find helpful
90. Take a relaxing bath
47
45
pleasurable ones
91. Try some aromatherapy – light a 98. Take care of your physical health-
candle, put on lotion, use oils or follow up with any physio, dentist,
rooms sprays specialist appointments
92. Dance to your favourite song 99. Accept or let go- “choose your
93. Use Mandelas or colour in a book battles”
94. Visit a pet store, feed animals 100. Say “No” or “yes…with limits”
outside, go to the High Park Zoo 101. Get in touch with your inner
95. Let go if perfectionism—allow one child- do something playful,
thing per day to be left undone, or fingerpaint, use PlayDoh, go on a
not done perfectly swing
96. Connect with a peer agency-e.g. 102. Spend time in nature, do some
MDAO, AA gardening
97. Chunk up activities, alternate with
DECISIONAL BALANCE
BENEFITS COSTS
ENGAGE IN TREATMENT
STAY THE SAME
48
46
Teeter Totter
+10
High
Balance (0)
-10
Low
Low(er) mood More balanced High(er) mood
What I think/feel/do/urges: What I think/feel/do: What I think/feel/do/urges:
How to cope: How to keep How to cope:

balance:
Resources: Resources: Resources:
49
47

Meals (#)
Snacks (#)
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION

ENERGY
LEVEL
day
UNABLE TO FUNCTION
HYPERACTIVITY
UNABLE TO FUNCTION
LIFE EVENTS
50
48

Meals (#)
Snacks (#)
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION

ENERGY
LEVEL
day
UNABLE TO FUNCTION
HYPERACTIVITY
UNABLE TO FUNCTION
LIFE EVENTS
51
49

Meals (#)
Snacks (#)
Total sleep
Naps (#)/ time
SUBSTANCE
USE
PHYSICAL ACTIVITY
RELAXATION
SOCIAL CONTACTS
MEDICATION

ENERGY
LEVEL
day
UNABLE TO FUNCTION
HYPERACTIVITY
UNABLE TO FUNCTION
LIFE EVENTS
52
50
SMART GOAL
53
51
54
52
Appendices
A. Learning to Sleep
B. Staying Well
C. Breathing Exercise
D. Progressive Muscle Relaxation
E. Mindfulness
F. Mindful Colouring & Templates
G. Resources:
o Online
o Books
o Community Resources
55
53
Appendix A:
Learning to Sleep
This is a summary of all the information below.
Breathe
Continue calm breathing both during the day (5-
min practice) and at night while lying in bed.
Relax
Practice progressive muscle relaxation once a day
while awake for 15 minutes.
Use a Routine
Use bedtime wind-down and putting the day to
rest.
Prepare Your Body and Mind

Practice healthy sleep hygiene:
• Eliminate caffeine, nicotine, alcohol; monitor
diet and exercise; optimize bedroom
environment (bed comfort, temperature, lighting).
Make the Connection

Sleep only in bedroom; use the bedroom for sleep only.
Get Up
Follow 15-minute rule: if you are not asleep within 15 minutes, get up and out of bed, do
something relaxing, and return to bed when sleepy.
Limit Time in Bed

Wake up at the same time every morning and restrict time spent in bed.
56
54
How Can I Train My Body for Sleep?
• You must be able to relax to sleep.
• PTSD-relate d insomnia is part of physiological over arousal.
• Relaxation training can reduce over arousal and facilitate sleep.
• Like any training program, learning to relax takes time and practice.
• Set aside 15 minutes during the day to practice progressive muscle relaxation (or
another form of relaxation training).
• Practice when you are awake and alert so you can learn what it feels like to be
relaxed.
• Practice when you are already relaxed or not too stressed.
• Practice at night as you are lying in bed to help your body relax.
How Can I Train My Brain for Sleep?

Do you tend to lie in bed with thoughts running through your mind?
Do you feel like you can’t turn off your mind and that your thoughts keep you awake at
night?
• Put the day to rest (Don’t try to solve your problems in bed).
o Early in the evening, think about your day.
o Write down in a notebook any concerns or worries from the day.
o Anticipate what might come to mind in bed tonight and write it down.
o Write a "to -do" list for tomorrow.
o Use this time to feel more organized; close the notebook when you are finished.
o At bedtime remind yourself that you have already dealt with worries and
concerns.
o If new thoughts come up, leave the bedroom and write them in the notebook.
o Focus on positive thoughts and memories in bed.
• Develop a bedtime wind-down routine
Do the same routine every night. Your brain is a creature of habit. Use the same relaxing
routine every night in the hour before bedtime. This will get your brain into the habit of
expecting sleep to follow. Be sure to choose activities that are calming and relaxing, not
ones that are energizing or take too much effort.
Here are some examples of relaxing bedtime wind-down activities:
• Practice calm breathing or other relaxation exercise

• Listen to relaxing music
• Do some light reading
• Take a warm (not hot) bath or shower
• Meditate or pray
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Practice progressive muscle relaxation
Tensing and releasing muscle groups in the body can help us get into a relaxed state. The
final part of today’s session will be devoted to practicing progressive muscle relaxation.
Practicing relaxation on a daily basis can help reduce hyperarousal, manage stress, and
help with sleep.
Practice at a time when you are already feeling relaxed, not when you are tense.
Calm Breathing Instructions
1. Take a normal breath in through your nose with your mouth closed. Hold your breath
for 5 seconds.
2. Exhale slowly through your nose with your mouth closed, letting all the air out of your
lungs, while saying silently to yourself a word you find relaxing (like c-a-a-a-l-m or r-e-e-
e-l-a-a- x).
3. Pause for a count of 4 and then take the next breath in.
4. Practice this exercise several times a day and at night while you are in bed preparing
to sleep
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WHAT ARE LIFESTYLE FACTORS THAT CAN INTERFERE WITH SLEEP?
Caffeine Diet
Nicotine Exercise
Alcohol
How Can I Change My Lifestyle So I Am Not Working Against My Goal of

Improved Sleep Quality?
Limit or eliminate caffeine

Caffeine is a stimulant: it can elevate heart rate and blood pressure and make you feel
more alert, adding to bipolar-related hyperarousal and disrupting sleep. Caffeine is found in
coffee, hot tea, iced tea, soft drinks, energy drinks, chocolate, and some pain medications.
Experts in sleep disorders recommend total elimination of caffeine from the diet. If you
cannot eliminate caffeine, restrict your intake to 1-2 caffeinated beverages per day, before
12 noon.
Limit or eliminate nicotine

Nicotine is also a stimulant. It increases heart rate, blood pressure, breathing rate, and makes
you feel more alert. Nicotine is found in cigarettes, cigars, chewing tobacco, and other
tobacco products. Smoking within several hours of bedtime may interfere with sleep.
Serious physical health consequences are associated with nicotine use. It leads to chemical
dependence, and quitting smoking can be difficult. At the same time, heavy smokers may
experience withdrawal symptoms when trying to cut back.
Quitting smoking will be helpful to your sleep and your health in the long run. However, in the
short run there may be some impact on sleep from nicotine withdrawal. CAMH has a
Nicotine Dependence Clinic that can provide assistance and nicotine replacement therapy
(NRT), and you can self-refer by calling (416) 535-8501 extension 77400.
Limit or eliminate alcohol

Alcohol can be sedating. Some people with bipolar turn to alcohol to “chase the high” or in
an effort to calm down and go to sleep. While alcohol may help you to fall asleep, it will
disrupt the second half of your night. Hangovers are caused in part by alcohol's sleep
disruption.
Alcohol use is associated with increased dreaming (and nightmares) in the second half of
the night. Even a small amount of alcohol as much as 6 hours before bedtime can increase
wakefulness during the night. For people with past heavy alcohol use, even after years of
abstinence, sleep patterns may never completely return to normal.
Eliminate alcohol use if possible. Otherwise, limit alcohol use by not drinking after dinner.
Never use alcohol as a sleep aid. It only makes the problem worse. Never mix alcohol with
other medications, especially sleeping pills.
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Manage diet
Large meals in the evening can make it harder to sleep at night. Try eating a smaller meal
early in the evening. Avoid heavy, spicy, or high-sugar foods. Reduce fluids after 7 pm.
Foods that are rich in tryptophan (turkey, chicken, dairy products), and carbohydrates such
as bread or crackers might help you to relax.
Manage exercise
Exercise is good for sleep because it increases your metabolism. Exercise helps reduce the
risk of developing many health problems and appears to reduce symptoms of depression
and anxiety. Try to engage in thirty minutes of a moderate exercise routine everyday early in
the day (get your doctor’s permission first). Avoid heavy exercise late in the day, as this may
interfere with sleep.
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WHAT ARE ENVIRONMENTAL FACTORS THAT CAN INTERFERE WITH
SLEEP?
Noise Air Quality

Lighting Bed Comfort
Room Temperature Partner Support
How Can I Change My Environment So I Am Setting The Stage For Sleep?
Limit noise
Evaluate your sleep preference and make changes to your environment as needed. Some
people like a steady background noise to mask outside noises that might wake them up.
Other people sleep better in a room that is quiet. If you like background noise, try using the
radio low and tuned in between stations, or try a fan or a "white noise" machine. Don’t use
the TV for this purpose. Watching TV is a wakeful activity and should not be done in the
bedroom.
Make sure the lighting is right

Set your biological clock. Get exposure to sunlight each day, including early mornings (after
awakening) and early evenings. Avoid lying around a dimly lit house at these times.
Keep bedroom lighting low. When you walk into your bedroom at night, use a small lamp or
other low lighting rather than a bright overhead light.
When going to the bathroom or any other room at night, keep the lighting as dim as
possible. Even a little light exposure at night can interfere with sleep.
Manage room temperature

A drop in body temperature is associated with sleep onset. Keep your bedroom cooler at
night.
Improve air quality

Make sure your room is well ventilated. If the room is too stuffy, it will be harder to sleep.
Improve bed comfort

Make sure your mattress and pillows are comfortable. Try to replace a mattress after 10 years
with the highest quality you can afford. Sleep with pajamas or comfortable clothes that are
different from your daytime clothes. At times of acute trauma people may have slept in
clothes to be ready to run or fight at any moment. Today, changing into pajamas is another
way you can prepare your mind and body for relaxation and sleep.
Talk to your partner

Making changes to your bedroom will require your partner’s understanding and support.
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HOW CAN I REGAIN THE BED = SLEEP CONNECTION?
When we can’t sleep for weeks, months or even years, a kind of unconscious learning
occurs. Without being aware of it, we learn to associate the bedroom with frustration, fear,
and being awake rather than sleep. When that happens, then simply going to bed, turning
off the lights, and laying down for sleep brings out those frustrating feelings and the chance
for sleep diminishes. This is called conditioned insomnia which helps to explain why it might
be easier to fall asleep in the recliner in front of the TV rather than in your own bed. But you
can break this connection…
Use the bedroom for sleep only… zzZzzzZzz
• Use the bedroom for sleep (and sex) only. Avoid engaging in any “wakeful activities”
in the bedroom.
• Your bedroom should have a strong association for you with going to sleep. When you
walk into your bedroom, your body and brain should automatically associate getting
into bed with going to sleep.
• Using the bedroom for wakeful activities will weaken this connection and make it
harder for you to sleep. Examples of wakeful activities: eating, reading, watching TV.
These and other wakeful activities should be done in another room.
• Watching the clock is another wakeful activity. Face it away from your bed.
• Remove items in your bedroom that are a signal or cue for arousal or anxiety. Being on
"guard duty" requires wakefulness and alertness and is not compatible with sleep.
• Resist the urge to get up and check every little noise – stay in bed instead.
• Do not sleep in any other room.
• Avoid daytime napping if at all possible. Even a brief nap during the day can take
away from your ability to sleep at night. The goal is to strengthen the connection
between sleeping more at night and your bed. Daytime napping will weaken this
connection. If you must nap during the day, keep it under 20 minutes and end it
before 2 pm.
These are wakeful activities to do outside of bed:
• Watch TV
• Argue or have difficult discussions with my significant other
• Read
• Eat
• Use the computer, text, check phone
• Pay bills, balance accounts
• Think or worry about things
• Feel frustrated about not sleeping
• Lie awake in bed
• Watch the clock
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Follow the 15-Minute Rule:
Often we stay in bed when unable to sleep with the idea that "at least I am resting" or "if I am
in bed long enough I will eventually get enough sleep." However, staying in bed when you
are not asleep PROMOTES insomnia.
• Lie down in bed only when sleepy: stay awake and out of bed until you feel drowsy.
This will help make the BED=SLEEP connection.
• If you are not asleep within 15 minutes of lying down, get up out of bed and go to
another room. Go back to bed when you're feeling sleepy.
• Continue to get up if you're not asleep after 15 minutes, even if you awaken in the
middle of night. Getting out of bed to promote better sleep may seem like a strange
idea, but the reason we do it is to strengthen the BED=SLEEP connection.
• Repeat the previous step as often as necessary throughout the night. You may need
to do this several times a night for a period of time. Be persistent and don't give up!
Repetition is the key.
• Don’t watch the clock for the 15 -minute rule – just use your best estimate.
• Remember that watching the clock is a wakeful activity.
Before you go to sleep, plan where you will go and what you will do if you wake up during
the night. For example, set up a chair in another room with your relaxation tape or reading
material so if you need to get up during the night it will be ready for you.
Set an alarm clock and get up at the same time every morning regardless of how little you
slept during the night. This helps you develop a consistent sleep-wake cycle.
Practice this 7 night per week with no exceptions. This might be frustrating at first and you
may have to get up several times a night and may not get much sleep. However, it will be
easier to fall asleep over the next several nights as your sleep deprivation increases. Typically,
this takes one to two weeks.
Stick to your schedule and continue to practice these strategies even if you think it is not
working. Retraining your brain to help you get a better-quality sleep requires ongoing
practice over a period of time.
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How do I know when I am getting the sleep I need?
• As long as you are not falling asleep at the wheel or during other important daytime
activities, you are getting enough sleep.
• Feeling bad during the day because of insomnia is usually caused by worry about
sleep, feeling frustrated, anticipating another bad night, and feeling drained from all
of the worry.
• Your body will let you know when it is time to sleep.
• See exercise on the last page of this handout!
How Do My Beliefs About Sleep Add To My Sleep Problems?

• Keep your expectations realistic: Not everyone needs 8 hours. There are individual
differences in sleep needs; short sleep is not always abnormal.
• Why do you think you are having trouble sleeping? Examine your thoughts about this
to be sure you are not causing yourself extra worry or stress.
• Don't blame all daytime problems on sleeplessness.
• Don't think the worst after a poor night's sleep: Worries and fears about sleep problems
can increase sleep difficulties.
• Don't give too much importance to sleep. Don't change your activities based on
sleep.
• Develop a tolerance to effects of sleep loss: Go on with activities even after a poor
night's sleep. Do something pleasurable to disconfirm belief that a good night's sleep is
essential.
• Never try to sleep: Sleep can't be achieved on command. Trying too hard often
backfires. All you can do is create favorable circumstances and let it come.
• Learn to recognize when your night-time behaviors and beliefs are based on past
traumatic experiences rather than present reality. Catch yourself when your “bipolar is
talking.” Talk with your therapist about past experiences to reduce their power in the
present.
How Can I Get A Better Quality Sleep?

• Sleep that is broken (a few hours here and a few hours there) is not as refreshing as the
same amount of sleep all in one block of time.
• Spending more time in bed, either by going to bed early or sleeping late, makes it
more difficult to fall asleep the next night.
• Think about how much total sleep time you get now on average (add up the separate
blocks of sleep you get on a typical night).
• See exercise on the last page of this handout!
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Exercise: Learning to Sleep
• I get about __ hours of sleep.

This is your average sleep time, and you will spend no more time in bed than your
average sleep time. *If your average sleep time is less than 5 hours, use 5 hours.
• Decide on a set rising time and put that into practice daily. A set rising time acts like an
anchor to hold the sleep pattern in the same position.
I will get out of bed at __ am.
• Consolidate your sleep. Decide on a time for getting into bed by subtracting sleep
time from rising time. For example, if you need to get up by 6 am, and you get a total
of 5 hours of sleep per night, do not get into bed until 1 am. Going to bed early to
catch up on sleep, later to feel more tired, or just because it is bedtime is not a good
strategy for falling sleep quickly or easily.
The earliest I will go to bed is __ pm (bedtime), but only if I am sleepy by that time.
• Get into bed only when sleepy (lack of energy, aching muscles, yawning). Don't go to
bed until you are sleepy __ after your bedtime.
• Build on your success: Once the broken sleep has been consolidated (90% of your
time in bed is spent sleeping), add time in bed by 15 minutes per night for one week.
• Follow this program 7 nights per week.
My Sleep Plan
• My total sleep time is __ hours (don't go below 5 hours).

• I want my awake time to be __ o'clock every day, 7 days per week.
• I will get into bed no earlier than __ o'clock, and only when I am sleepy.
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Appendix B
Staying Well
Learning to be aware of your wellness is an important part of recovery. Noticing signs of
distress early can help you to take steps to eliminate or reduce the level of distress and can
help you to put into place preventative plans and actions in order to return to wellness as
quickly as possible. It can be difficult to predict just when you are moving away from
wellness, and it can occur without warning. Recognizing and managing these warning signs
is extremely important and addressing symptoms in a timely manner may minimize the need
for hospitalization. Many things can lead to an increase in distress - increased stress, changes
in family situations, financial worries, substance use and/or medical illness can also affect
your mental health and wellbeing.
Here are some examples of situations or stressors that can affect your wellbeing (check those
that apply to you):
Home or Environmental Triggers

Changes to my family structure; separation, divorce
Loss of any kind; family member or friend due to death or relocation
Fights or arguments with siblings, loved ones or friends
Conflict or arguments with my parents or children
Strained relationships with loved ones, room mates
Changes in friendships
Loss of my family pet
Trauma (past or present)
Financial concerns
Moving to new apartment or neighborhood
School/Work Triggers
Feel overwhelmed by homework/workload
Feel singled out by peers or feelings of loneliness
Pressure at school/ work, transitions between classes and school activities
Bullying at school/work
Pressure by peers
Mounting pressure, anxiety about deadlines
Misunderstanding with co-workers, teachers, and/or peers who may not understand
that certain behaviours may be warning signs of my increased level of distress.
Other Triggers
Not taking my medication or missing a few doses.
Starting new medication / new dosage of current medication
My medication stops working
Use of drugs or alcohol abuse
Pending court dates
Being in crowds / large groups of people
Changes in my relationship with boyfriend, girlfriend, partner or significant other
Other triggers that you may identify:
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You may be able to return to a better level of wellness quickly by noticing the early changes
in your behavior; noticing unusual reactions to daily tasks, increase in stress levels, etc.
Sometimes people find it helpful to keep a journal or calendar to better understand factors
that lead to changes in their overall wellbeing.
The following are some important warning signs that may indicate you need to take steps to
regain your wellbeing (yours may differ from this list):
Home or Environmental Triggers

Changes to my family structure; separation, divorce
Loss of any kind; family member or friend due to death or relocation
Fights or arguments with siblings, loved ones or friends
Conflict or arguments with my parents or children
Strained relationships with loved ones, room mates
Loss of my family pet
Trauma (past or present)
Financial concerns
Moving to new apartment or neighborhood
School/Work Triggers
Feel overwhelmed by homework/workload
Feel singled out by peers or feelings of loneliness
Pressure at school/ work, transitions between classes and school activities
Bullying at school/work
Pressure by peers
Mounting pressure, anxiety about deadlines
Misunderstanding with co-workers, teachers, and/or peers who may not understand
that certain behaviours may be warning signs of my increased level of distress.
Other Triggers
Not taking my medication or missing a few doses.
Starting new medication / new dosage of current medication
My medication stops working
Use of drugs or alcohol abuse
Pending court dates
Being in crowds / large groups of people
Changes in my relationship with boyfriend, girlfriend, partner or significant other
Other triggers that you may identify:
You may be able to return to a better level of wellness quickly by noticing the early changes
in your behavior; noticing unusual reactions to daily tasks, increase in stress levels, etc.
Sometimes people find it helpful to keep a journal or calendar to better understand factors
that lead to changes in their overall wellbeing.
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The following are some important warning signs that may indicate you need to take steps to
regain your wellbeing (yours may differ from this list):
Inability to Cope with Daily Tasks

I have been unable to bathe, brush teeth, comb /brush hair
I am not eating or eating too much
I sleep all day or find it very hard to get out of bed
I am unable to sleep
I feel hopeless
Rapid Mood Swings

I have an increase in energy
I am unable to stay still - pacing
My mood is depressed
Increased Agitation
I make verbal threats
I have violent out-of-control behavior
I destroy property
I am cruel to animals
Displays Abusive Behavior

I hurt others
I cut myself
I engage in alcohol or substance misuse/abuse
Loses Touch with Reality (Psychosis)

I am unable to recognize family or friends
I am easily confused and think strange ideas
I think I am someone that I am not
I have difficulty understanding what people are saying
Isolation from School/Work, Family, Friends

I have no or little interest in extra - curricular activities
Not initiating or returning contact with friends and family
I stop attending school/ work, and/or stop doing homework/projects
Unexplained Physical Symptoms

My eyes and facial expressions look different
I experience an increase in headaches, stomachaches; I don’t feel well
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Appendix C:
Three-Minute Breathing Space
What we actually do with our time from moment to moment, from hour to hour, can be a very
powerful influence on our general well-being and ability to deal skillfully with symptoms of depression,
anxiety or other moods.
Helpful for:
• When you are feeling overwhelmed, sped up, agitated

• When you are stuck in your thoughts ruminating or worrying
• You feel are not present (and are distracted by your thoughts, feelings, worries)
• It helps you stay in the present moment
Each of the three steps to this exercise takes one minute:
1. Awareness:
Bring yourself to the present moment, by asking yourself, “What emotions am I experiencing right
now as thoughts… feelings…and bodily sensations? Acknowledge and register your experience,
even if it is unwanted.
2. Gathering:
Redirect your attention to your breath by focusing on inhalation and exhalation, the movement in
your diaphragm or nostrils. Your breath can function as an anchor to bring you back to the
current moment and help you tune into a state of awareness and stillness.
3. Expanding:
Expand your awareness to encompass all the physical sensations of your entire body, including
breathing, as well as any sounds in the environment.
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Appendix D:
Progressive Muscle Relaxation (PMR)
How to Tense Muscle Groups
Body Scan: Close eyes and scan body from head to toe looking for muscle tension
Lower Leg: With feet flat on the ground, lift heels until you feel tension in your calf muscles.
Upper Leg: Extend leg so it’s straight, point toe upward towards knees.
Thighs: Pull knees together until upper legs feel tense.
Abdomen: Pull in stomach toward back.
Chest & Breathing: Take a deep breath and hold it for10 seconds, then release
Lower Arm: Make fist, palm down, and pull wrist up toward arm
Upper Arm: Tense biceps. With arms by side, pull upper arm toward side without touching. (Try
not to tense lower arm while doing this, let lower arm hang loosely).
Shoulders & Lower Neck: Shrug shoulders, bring shoulders up until they touch ears.
Back of Neck: Put head back and press against back of chair.
Lips: Press lips together, don’t clench teeth or jaw.
Eyes: Close eyes tightly but don’t close too hard.
Lower Forehead: Pull eyebrows down (try to get them to meet)
Upper Forehead: Raise eyebrows and wrinkle your forehead
Remember:
a. Tense each muscle group for 5-10 seconds
b. Attend to the sensations of tension in that particular muscle group and area of the
body
c. Then relax the muscle
d. Notice the difference between the tension and relaxation
e. For limbs, do right then left, then both together
f. Between each muscle group allow for 10-20 seconds.
g. During the 20 seconds focus on statements such as:
i. Just continue to relax
ii. Pay attention to breathing
h. After going through the tension relaxation exercises go through the deepening exercise
by counting from 1 to 5
i. Then concentrate on breathing and the word “RELAX”
j. Then go through the “reverse deepening counting from 5 to 1
k. At 2 open eyes and at 1 normal state of alertness
It is recommended that you practice PMR twice daily, for 20 minutes.

With practice, one can learn to become deeply relaxed fairly rapidly.
It is impossible to be tense and relaxed at the same time. You can learn how to relax when you
notice that you are becoming tense and anxious
cci.health.wa.gov.au | Progressive Muscle Relaxation Information Sheet | anxietycanada.com
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Appendix E:
Mindfulness
Mindfulness is about being present; paying attention to what is happening right now. Without
judgment. Without overthinking. Without analyzing your experience. Mindfulness involves
acceptance of the present moment and provides an opportunity to suspend judgment and
liberate our natural curiosity about the workings of the mind to approach our experience with
warmth and kindness—toward oneself and others.
Mindfulness can be challenging to practice. Our brains are hard-wired to judge, create stories
and time travel; pulling us away from the moment. No one can be mindful all the time.
However, the development of mindfulness is an effective way to reduce symptoms of anxiety,
stress and depression and enrich our experiences. Some of the many ways to practice
mindfulness are included below.
How to be mindful: (be aware of the present moment)
Observe: Attend to thoughts, feelings, events, and behaviors without trying to change them
(just observe them “on a conveyor belt”). Do not push them away. Use a “Teflon mind”; let
things slide off your mind and body. Observe within and outside of yourself (breathing,
thoughts, sensations, things in the external world)
Describe: Describe what’s happening with facts, without judgement, trying to control it or
change it: (“I notice I am having a thought about…my heart is pounding”)
Participate: Pay full attention to a task or experience.
Be non-judgmental: Just notice things without placing a value judgment on them (good or
bad, smart or stupid, should or should not’s, comparing with others).
How to practice mindfulness in daily life:
Observe with your senses: Pick up an object (flower, fruit, soap) examine it closely as if you were
seeing it for the first time. Bring your attention to (scent, shape, taste, colour, how it feels; texture,
weight). Each time your mind wanders, bring it back to the present moment and the object.
Sounds: Listen to the sounds around you for a moment (listen for sources of sounds, rhythm, pitch,
someone’s voice)
Observe feelings/urges: Observe your feelings and urges to act. Imagine your urges as a
surfboard you are standing on, riding the waves. Notice urges to avoid something. Locate the
urges in your body, try to breathe into them and just sit with them. Try to notice subtle changes in
their intensity. No need to act on them. They will eventually pass.
Describe feelings: Describe your feelings as they arise: “A feeling of anger is emerging.” Accept
the feeling being there without judgement. It is just in your body/mind at this moment. Notice the
sensation of the feeling. Breathe into the feeling.
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Observe thoughts: As you notice thoughts coming and going through your mind, just notice them
without the need to pursue each thought. Imagine your thoughts as leaves flowing down a
stream. Identify your thoughts (worry about past, plans to do something). Give yourself permission
to let them go. If your worry thoughts keep circling through, shift your attention to the sensations in
your body. It may take time for them to float away.
Walking Meditation
• When you do a walking meditation in nature, or elsewhere, it is best to walk alone. Walking
with somebody will likely distract you.
• Begin by reminding yourself that you are going to perform a practice; not just a stroll in the
park.
• Stand still and close your eyes for a few moments. Start by feeling your body standing still.
Notice your breath going in and out. Continue being aware of your breathing for a few
moments and then open your eyes. Take a good look at your surroundings while also being
aware that you are standing still.
• Without losing focus of your surroundings, focus on your left leg and move it a step forward.
Now repeat with your right leg.
• Continue walking but do not walk fast. It is important that you are aware of your feet moving,
and of your environment.
• If you get distracted by thoughts; past or future, stop. Pause for a moment and observe your
thoughts or emotions without judgment. Be aware of what was going on in your mind.
• Continue your walk and enjoy.
Eating Mindfully
• Notice yourself breathing. Do this for a few minutes with your eyes closed.
• Look at your food and see the colors and shapes on your plate.
• Notice the smells coming to you. Can you distinguish different ones.
• Take a bite of your food and chew slowly. Savor all the tastes that fill your mouth. Try to keep
your attention on the taste; do not let your mind wander.
• When it does wander, gently bring it back to the food.
• You can also combine mindful eating with a gratitude practice. You can be grateful that you
can eat this wonderful food, and for those who produced it and cooked your meal.
Mindful Listening
Listen to a song mindfully. Notice the different instruments. Try to identify each one of them.
Now choose one and just pay attention to it. If you really focus, at some point you will stop
listening to the other instruments. Switch to another instrument and repeat the exercise. Now
listen to the entire song all over again. Pay attention to all instruments playing together. You
will enjoy a much richer experience. Try another iteration. Notice the lead instrument — the one
that plays the melody of a piece. What role does it play? How do the other instruments come
and go? If you listen to jazz, you’ll notice how the various instruments take turns as the lead.
The power of this exercise goes beyond listening mindfully — paying attention helps us
notice all the parts within the whole.
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Appendix F:
Mindful Colouring for Stress
Mindfully colouring pre-drawn illustrations provides an opportunity to suspend our inner

dialogue and engage in an activity that disregards the flow of negative thoughts that can
dominate our lives.
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Appendix G:
Resources
White, Ruth C, Preston John, D. (2009). Bipolar 101: A practical guide to identifying triggers, managing
medications, coping with symptoms and more.
Simon, Lizzie. (2003). Detour: My Bipolar Road Trip in 4-D. Washington Square Press.
Federman, Russ. (2010). Facing bipolar: The young adult's guide to dealing with bipolar disorder. New
Harbinger Publications.
Otto, Michael W; Reilly-Harrington, Noreen A; Knauz, Robert O; Henin, Aude; Kogan, Jane N;
Sachs, Gary S. (2008). Living with bipolar disorder: A guide for individuals and families (updated)
Oxford University Press.
Lowe, Chelsea; Cohen, Bruce M. (2010). Living with someone who's living with bipolar disorder: A
practical guide for family, friends and coworkers. Jossey-Bass.
Amsel, Peter. (2010). Narratives of Mental Health Survivors. Living with the dragon: The long road to
self-management of bipolar II. Ch. 6, 58-75. doi.org:10.1002/9780470970362.
Fast, Julia A. (2006). Take charge of bipolar disorder: A 4-step plan for you and your loved ones to
manage the illness and create lasting stability. Grand Central Life & Style.
Miklowitz, David J. (2002). The bipolar disorder survival guide: What you and your family need to
know. The Guilford Press.
Miklowitz, David J; George Elizabeth L. (2007). The bipolar teen: What you can do to help your child
and your family. The Guilford Press.
Ramirez Basco, Monica. (2005). The bipolar workbook: Tools for controlling your mood swings. The
Guilford Press.
Bloch, Jon P. (2006). The everything health guide to adult bipolar disorder: Reassuring advice to help
you cope. Simon & Schuster.
Basset, Thurstine and Stickley, Theo (2010). Voices of experience: Narratives of mental health survivors,
eds. Wiley-Blackwell.
Pavuluri, Mani. (2008). What works for bipolar kids: Help and hope for parents. The Guilford Press.
Last, Cynthia G. (2009). When someone you love is bipolar: Help and support for you and your
partner. The Guilford Press.
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Online resources:
Bipolar Disorder Sanctuary – www.MHSANCTUARY.com/BIPOLAR/
BP, the healthy living magazine for those with bipolar – www.BPHOPE.ca
Canadian Mental Health Association – www.CMHA.ca
Canadian Network for Mood and Anxiety – www.CANMAT.org
FYRENIYCE, Australian bipolar website – www.WANTREE.com.au/~FRACTAL1/
Medline Plus Health Information – www.NLM.NIH.gov/MEDLINEPLUS/
The Organization for Bipolar Disorders – www.OBAD.ca
Bipolar(s) Supporting Bipolars – https://BSBWEBSITE.com/
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Community Resources
ABUSE
Abrigo Centre 416-534-3434
Advocacy Centre for the Elderly 416-598-2656
Barbara Schlifer Clinic 416-323-9149 x 234
Boost - Child & Youth Advocacy Centre 416-515-1100
Canadian Centre for Victims of Torture 416-363-1066
Children’s Aid Society 416-924-4646
Women’s College Hospital – WRAP (Women Recovering from Abuse) 416-323-6400 x 4863
Victim Services 416-808-7066
ADDICTIONS
Access CAMH (Centre for Addiction & Mental Health) 416-535-8501 Option 2
The Access Point (www.theaccesspoint.ca) 1-888-640-1934
Breakaway Addiction Services 416-234-1942
DART - Drug and Alcohol Registry 1-800-565-8603
Ontario Problem Gambling Helpline 1-888-230-3505
The Salvation Army Homestead 416-431-4379
Toronto Detox 1-866-366-9513
Women’s College Hospital Rapid Access Addiction Medicine (RAAM)
Clinic: 76 Grenville Street, 3rd floor
Monday, Tuesday, Thursday, 10:00 a.m. to 12:00 p.m.
Walk-in clinic - arrive before 11:30 for registration.
ANGER MANAGEMENT
Access CAMH 416-535-8501 Option 2
(Centre for Addiction & Mental Health)
Central Toronto Youth Services 416-924-2100
Family Service Association of Toronto 416-595-9618
John Howard Society 416-925-4386
Salvation Army, Correctional & Justice Services 416-304-1974
(by referral from probation officers only)
Tropicana Community Services 416-439-9009
Yorktown Family Services 416-394-2424
ASSERTIVE COMMUNITY TREATMENT (ACT)

BEREAVEMENT
Bereaved Families of Ontario-Toronto (Multi-Faith) 416-440-0290
Better Living Centre 416-447-7244
Distress Centre - Homicide Survivor Support 416-595-1716
Distress Centre - Suicide Survivor Support Program 416-595-1716
Equinox Centre for Grief and Trauma Counselling 416-926-0905
Wellspring Downtown Toronto 416-961-1928
Wellspring Westerkirk House at Sunnybrook 416-480-4440
Woodgreen Community Services 416-572-3575
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CASE MANAGEMENT SERVICES
CONSUMER INITIATIVES
MDAO (Mood Disorders Association Ontario 416-486-8046
Bipolar groups/Depression peer groups
A-Way Express Courier Service 416-424-2266
Consumer/Survivor Information Resource Centre 416 595-2882
The Empowerment Council 416-535-8501
Fresh Start Cleaning and Maintenance 416-504-4262
Ontario Peer Development Initiative 1-866-681-6661
Peer Support Facilitator Training - Mood Disorders Association of Ontario 1-888-486-8236
Sound Times Support Services (West) 416-234-9245
Sound Times Support Services (East) 416-979-1700
Working for Change 416-504-1693
CMHA Recovery west drop in (Brampton) 905-451-3934
Friends and Advocates (Peel region) 905-452-1002
Our Place Community of Hope 416-598-2919
6 St Joseph house (yellow door) 416-923-8836
COMMUNITY HEALTH CENTRES

Etobicoke
LAMP Community Health Centre 416-252-6475
Rexdale Community Health Centre 416-744-0066
Rexdale’s John Garland Satellite 647-288-0281
Stonegate Community Health Centre 416-231-7070
North York
Access Alliance Multicultural 416-760-8677
Community Health Centre and West End Non-Insured Walk-in Clinic
The Four Villages Community Health Centre 416-604-3362
Black Creek Community Health Centre 416-249-8000
Flemingdon Health Centre - Don Mills-Eglinton 416-429-4991
Flemington Health Centre - Don Mills-Sheppard 416-640-5298
Unison Health and Community Svcs - Bathurst-Finch 647-436-0385
Unison Health and Community Svcs - Jane-Trethewey 416-645-7575
Unison Health and Community Svcs - Keele-Rogers 416-653-5400
Unison Health and Community Svcs - Lawrence Hts 416-787-1661
Scarborough
Access Alliance Multicultural Community Health Centre
416-693-8677
Scarborough Centre for Healthy Communities 416-642-9445
Scarborough Centre for Healthy Communities Satellite 416-297-7490
TAIBU Community Health Centre 416-644-3536
East York
East End Community Health Centre 416-778-5858
South Riverdale Community Health Centre 416-461-2493
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Downtown Toronto
Access Alliance Multicultural Community Health Centre 416-324-8677
Anishnawbe Health Toronto 416-360-0486
The Anne Johnston Health Station 416-486-8666
Centre Francophone de Toronto 416-922-2672
Davenport-Perth Neighbourhood Centre 416-656-8025
The Four Villages Community Health Centre 416-604-3361
Parkdale Community Health Centre 416-537-2455
Parkdale Community Health Centre Satellite 416-537-8222
Parkdale Queen West Community Health Centre 416-703-8482
Regent Park Community Health Centre 416-364-2261
Sherbourne Health Centre 416-324-4180
Women’s Health in Women’s Hands 416-593-7655
CRISIS SUPPORT/DISTRESS LINES

Anishnawbe 24/7 (Aboriginal clients)
Mental Health Crisis Management Service 416-891-8606
Assaulted Women’s Helpline 416-863-0511
Distress Line 416-408-4357
Gerstein Crisis Centre (Downtown) 416-929-5200
Good2Talk (post-secondary student mental health helpline) 1-866-925-5454
Kids Help Phone 1-800-668-6868
Scarborough Hospital (Scarborough, East York) 416-495-2891
Senior Crisis Access Line 416-217-2077
Toronto Rape Crisis Centre 416-597-8808
Warm Line (8pm - 12am) 416-960-9276
York Support Services (North York) 1-855-310-2673
Youthdale’s Crisis Support Team 416-363-9990
COUNSELLING
Counselling (By Appointment)
519 Church Street Community Centre 416-392-6878 x 4000
Clinic for Person Centered Psychotherapy 416-229-2399
Family Service Toronto 416-595-9618
Malvern Family Resource Centre (Youth & Family) 416 284-4184 x 212
Polycultural Immigrant and Community Services 416 233-0055 x 1237
Your local community health centre may have counseling available
Counselling (Walk-In Clinics)

Family Service Toronto 202 -128A Sterling Road 416-595-9618
Wed from 3:30 pm-7:30 pm
Catholic Family Services 101-1155 Yonge Street 416-921-1163
Tues 9:00 am-7:00 pm
Catholic Family Services 300-5799 Yonge Street 416-222-0048
Thurs 9:00 am-7:00 pm
LAMP Community Health Centre 416 252-6471 x 235
185 Fifth Street, Etobicoke Mon 1-4 pm, Thurs 4-7 pm
Woodgreen Community Services 416 645-6000 x 1100
815 Danforth Avenue, Suite 100 Wed 4-8 pm
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DEVELOPMENTAL DISABILITIES
Developmental Services Toronto www.dsto.com 1-855-372-3858
Griffin Centre 416-222-1153
EARLY INTERVENTION IN PSYCHOSIS PROGRAMS

EATING DISORDERS
The National Eating Disorder Information Centre
(NEDIC) - Helpline 416-340-4156
North York General Hospital 416-635-2400
Sheena’s Place 416-927-8900
Sick Kids-Eating Disorders Program 416-813-7195
Toronto General Hospital 416-340-3041
EMPLOYMENT / VOCATIONAL
Booth Packaging & Supportive Services 416-255-7070
CMHA Toronto 416 789-7957 x 3441
Corbrook 416-245-5565
COSTI 416-789-7925
Gateway Opportunities Program 416-466-7489
JVS Toronto 416-787-1151
Plus & Transitional Employment Program 416-693-2116
Volunteer Toronto 416-961-6888
FAMILY SUPPORT
CMHA Toronto
– Living Life to the Full (Caregivers 55+) 416 789-7957 x 3342
CMHA Toronto – Family Outreach and Response 416-539-9449
Centre For Addiction and Mental Health 416 535-8501 Option 2
Concerned Parents of Toronto 416-492-1468
Family Association for Mental Health Everywhere 416-207-5032
Family Navigation Project (for families with youth) 1-800-380-9367
Family Support Program - Michael Garron Hosp. 416-461-2000 x 223
Family Support Program - Toronto Western 416-603-5747
Hong Fook Mental Health Association 416-493-4242
Mood Disorders Association of Ontario 416-486-8046
Schizophrenia Society of Ontario 416-449-6830
FINANCIAL SUPPORT
Canada Pension Plan (CPP) 1-800-277-9914
Canada Revenue Agency-General Inquiry 1-800-959-8281
Credit Counseling Service of Toronto 416-228-3328
GST Refund Cheque Information 1-800-959-1953
Office of the Public Guardian and Trustee 416-314-2800
Ontario Disability Support Program 416-325-5666
Ontario Works (OW) 416-397-0330
OW or ODSP Social Benefits Tribunal 416-326-0978
Workplace Safety and Insurance Board (WSIB) 416-344-1000
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FOOD BANKS
Daily Bread food Bank 416-203-0050
Foodshare Foodlink Hotline 416-392-6655
Street Health 416-921-8668
The Stop Community Food Centre 416-652-7867
GOVERNMENT / HEALTH SYSTEM

Local Health Integration Networks (LHIN)
Central 905-948-1872
Central East 905-427-5497
Central West 905-455-1281
Toronto Central 416-921-7453
Ombudsman Toronto 416-392-7062
Ombudsman Ontario Complaints Line 1-800-263-1830
Mental Health Commission of Canada 613-683-3755
HEALTH CARE
Association of Ontario Health Centres 416-236-2539
Aids and Sexual Health Info Line 416-392-2437
Birth Control & STD Clinic (OHIP not required) 416-789-4541
Hassle Free Clinic 416-922-0566
Health Care Connect 1-800-445-1822
Health Centre-Queen West (OHIP not required) 416-703-8482
National Home Doctor Service 416-631-3000
Public Health Clinic 416-392-6683
(Low Cost Dental Services for Children & Seniors)
Service Ontario 416-314-5518
Street Health Community Clinic 416-921-8668
Telehealth Ontario 1-866-797-0000
Toronto Public Health 416-338-7600
University of Toronto (Low Cost Dental Services for Adults) 416-864-8000
HEALTH CLINICS - offering services for refugees with no or limited interim federal health (IFH) coverage
Access Alliance
761 Jane Street 2nd Floor Mon & Thurs 4-7:30pm 416-760-2815
Canadian Centre For Refugee & Immigrant Health Care 647-267-2176
4158 Sheppard Avenue East, Tues & Thurs 5-8pm
Muslim Welfare Centre (call for clinic schedule) 416-291-1027
FCJ Refugee Centre 208 Oakwood Ave. 416-469 9754
Wed. 9:30am-12pm, Sat. 9am-1pm
Women’s College Hospital Crossroads Refugee 416-323-6031
Clinic 76 Grenville Street, 3rd Floor Mon-Fri 8 am-4 pm
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HOMELESSNESS/SHELTERS/OUTREACH
416 Drop In Centre (Women) 416-928-3334
Adelaide Centre for Women 416-392-9243
Agincourt Community Services 416-321-6912
Central Intake - Emergency Shelter Services 1-877-338-3398
Christie Refugee Welcome Centre Emergency Shelter 416-588-9277
Cummer Avenue Clinic (Wed 8 am-2 pm) 416-222-5417
Haven Toronto 416-366-5377
Hostel Outreach Program - COTA (Men) 416 785-9230 x 1311
Hostel Outreach Program – Fred Victor (Women) 416-482-4103
St. Stephen’s Corner Drop In 416 925-2103 x 3000
(primary care and psychiatry consults available)
Street Health (Downtown) 416-921-8668
Streets to Homes Assessment & Referral Centre 416-392-0090
The Meeting Place Drop In 416-504-4275
Youth Hostel Outreach Program - CTYS 416-504-6100
HOSPITALS
Most hospitals have mental health services which may include Psychiatric Assessments, Psychologists,
Psychiatrists, Social Workers and other professionals.
Programs offered typically include:

• Outpatient programs, where one comes to the hospital for mental health services;
• Day treatment, or partial hospitalization programs, where a person comes for treatment for
longer periods or more frequently, for more intensive therapy than one would receive from
simply seeing an outpatient therapist or clinician;
• Inpatient programs, where a person is admitted to hospital in order to provide a high level of
supervision and care until the condition improves enough so that the person can be treated
as an outpatient.
Baycrest 416-785-2500
CAMH (Centre for Addiction and Mental Health) 416-535-8501
Humber River Hospital 416-242-1000
Michael Garron Hospital 416-461-8272
Mount Sinai 416-596-4200
North York General 416-756-6000
Scarborough and Rouge Hospital: Birchmount Site: 416-495-2400
Centenary Site: 416-281-7318
SickKids 416-813-1500
St Joseph’s Health Centre 416-530-6717
St Michael’s 416-864-5120
Sunnybrook 416-480-6100
Toronto General Hospital 416-340 3111
Toronto Western Hospital 416-603 2581
Trillium Health Partners 416-259-6671
William Osler Health System 416-494-2120
Women’s College 416-323-6400
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HOUSING HELP CENTRES
Albion Neighbourhood Services (South Etobicoke) 416-252-5990
Albion Neighbourhood Services (North Etobicoke) 416-740-3704
COSTI (North York) 416-244-0480
The Housing Help Centre (THHC) 416-285-8070
Thorncliffe Neighbourhood Office 416-424-2900
West Toronto Housing Help Services 416-531-0841
Woodgreen (East York) 416-645-6000
Unison Health & Community Services 416-653-5400
Toronto Western Hospital 416-603 2581
Trillium Health Partners 416-259-6671
William Osler Health System 416-494-2120
Women’s College 416-323-6400
HOUSING
Federation of Metro Tenants’ Associations 416-921-9494
Landlord and Tenant Board 416-645-8080
Housing Connections 416-981-6111
INFORMATION & REFERRAL

Access Toronto 311
CAMH - McLaughlin Information Centre 416-595-6111
Findhelp Toronto 211
Home and Community Care 416-506-9888
Hospice Palliative Care of Ontario 416-304-1477
MAAR-Metro Addiction Assessment Referral Services 416-599-1448
Mental Health Service Information (Connex) 1-866-531-2600
Obsessive Compulsive Disorder Helpline 416-920-5887
Ontario Society of Psychotherapists 416-923-4050
JUSTICES OF THE PEACE

444 Yonge Street (Toronto) 416-325-8967
60 Queen St West (Old City Hall) 416-327-5179
1000 Finch Ave West (North York) 416-314-4213
1911 Eglinton Ave East (Scarborough) 416-325-0354
2201 Finch Ave West (Etobicoke) 416-314-3973
LEGAL/ADVOCACY
ACE (Advocacy Centre for the Elderly) 416-598-2656
ARCH Disability Law Centre 416-482-8255
Canadian Civil Liberties Association 416-363-0321
Community Legal Education Ontario (CLEO) 416-408-4420
Equality Rights in Accommodation 416-944-0087
Legal Aid 416-979-1446
Ontario Human Rights Commission 416-326-9511
Ontario Human Rights Legal Support Centre 416 597 4900
Psychiatric Patient Advocates Office 416-327-7000
Schizophrenia Society of Ontario 416-449-6830
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LGBTQ+ SERVICES
Rainbow Health Ontario - Sherbourne Health Centre 416-324-4100
Supporting Our Youth (SOY) - Sherbourne Health Centre 416-324-5078
Pride & Prejudice - Central Toronto Youth Services: 416-924-2100
The 519 416-392-6874
David Kelley Services - Family Service Toronto 416-595-9618
LGBT Youthline 1-800-268-9688
PROFESSIONAL ASSOCIATIONS
Canadian Counselling and Psychotherapy Association 1-877-765-5565
Canadian Psychiatric Association 613-234-2815
College of Physicians & Surgeons of Ontario 416-967-2600
College of Psychologists of Ontario 416-961-8817
Ontario Association of Consultants, Counsellors,
Psychometrists and Psychotherapists 416-298-7333
Ontario College of Social Workers and Social Service Workers 416-972-9882
Ontario Psychological Association www.psych.on.ca
Ontario Society of Psychotherapists 416-923-4050
SENIORS
Home and Community Care (prev CCAC) 416-310-2222
Community Seniors Mental Health Services www.csmhas.com
Geriatric Mental Health Services - COTA 416-785-9230
Geriatric Psychiatry Service - Toronto Rehab 416-597-3422 x 3041
Malvern Family Resource Centre 416-284-4184
Neighborhood Link Support Services 416-691-7407
Psychiatric Services for the Elderly - Sunnybrook 416-480-4663
Seniors Helpline 416-217-2077
MENTAL HEALTH & JUSTICE NETWORK

MENTAL HEALTH & JUSTICE PREVENTION PROGRAMS
North Toronto - COTA Health 416-785-9230
East Toronto - CMHA Toronto 416-458-9466
South Toronto - Sound Times Support Services 416-979-1700
West Toronto - Reconnect Mental Health Services 416-248-2050
City-Wide (ages 16 - 24) - CTYS New Outlook 416-924-2100
Fred Victor Centre 416-364-8228
POLICE MOBILE CRISIS INTERVENTION TEAM

NW Toronto – Humber River Hosp. & Div 12, 13, 31 416-808-2222 or 911
SW Toronto – St. Josephs & Div 11, 14 416-808-2222 or 911
East Toronto – Tor. East Gen & Div 54, 55 416-808-2222 or 911
Scarborough – Scar. Hosp. & Div 41, 42, 43 416-808-2222 or 911
Downtown – St. Michaels & Div 51, 52 416-808-2222 or 911
COURT AND CUSTODY-BASED MENTAL HEALTH SERVICES

College Park Court – Fred Victor 416-598-8103
East Toronto - Scarborough Court - CMHA 416-285-4177
North Toronto - North York Court - COTA Health 416-667-0933
South Toronto - Old City Hall Court – Fred Victor 416-364-8394
West Toronto - Finch Court - Etobicoke - CMHA 416-745-5775
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RESIDENTIAL SERVICES
The Access Point (www.theaccesspoint.ca 1-888-640-1934
Safe Bed Registry (CMHA, COTA, Reconnect, Gerstein) 416-248-4174
SETTLEMENT SERVICES
Access Alliance 416-760-8677
Afghan Women’s Organization 416-588-3585
Bloor Information & Life Skills Centre 416-531-4613
Catholic Crosscultural Services 416-757-7010
Culture Link 416-588-6288
Malvern Family Resource Centre 416-281-1376
Polycultural Immigrant & Community Services 416-533-9471
Scadding Court Community Centre 416-392-0335
South Asian Women’s Centre 416-537-2276
Toronto Chinese Community Association 416-977-4026
Working Skills Centre 416-703-7770
SOCIAL ACTIVITIES/GROUPS
Among Friends (Lakeshore & Islington) 416-251-8666
Jane Finch Community & Family Centre - Getting in Touch 416-663-2733
Our Place Community of Hope (Davenport & Ossington) 416-598-2919
Salvation Army-PLUS (Lawrence & Don Valley) 416-693-2116
Progress Place (Church & Wellesley) 416-323-0223
Routes (North York) 416-781-4199
Sistering (Bloor & Dovercourt) 416-588-3939
Sound Times East (Dundas & Parliament) 416-979-1700
Sound Times West (Bloor & Dundas) 416-234-9245
WoodGreen Community Services (Danforth) 416-645-6000
SUPPORT GROUPS / SELF HELP

Choices For Living (Women’s Support Group) 416-961-5446 x261
Emotions Anonymous (www.emotionsanonymous.org)
FindHelp 1-888-340-1001
Mood Disorders Association 416-486-8046
North York Women’s Centre 416-781-0479
Scarborough Women’s Centre 416-439-7111
The Scarborough Hospital Mental Health App Library www.tsh.to
(listed on their Adult Mental Health Outpatient Program Page)
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TRANSPORTATION SERVICES
Toronto Transit Commission (TTC) 416-393-4636
Wheel Trans 416-393-4111
East York
Call A Service Inc./ Harmony Hall Centre for Seniors 416-752-8868
Neighbourhood Link Support Services 416-691-7407
Storefront Humber 416-259-4207
Woodgreen Community Services 416-572-3575
North York
Circle of Care 416-635-2860
Better Living Health & Community Services 416-447-7244
Lumacare 416-398-5510
NeighbourLink North York 416-221-8283
North York Seniors Centre 416-225-1231
Scarborough
Agincourt Community Services Association 416-321-6912
Warden Woods 416-694-1138
Carefirst Seniors and Community Services Association 416-502-2323
St. Paul’s L’Amoreaux Seniors’ Centre 416-493-3333
Scarborough Centre for Healthy Communities 416-847-4125
Trans Care Community Support Service 416-750-9885
Toronto
Canadian Red Cross Society 416-236-3180
Dignity Transportation Inc 416-398-2222
Dixon Hall Neighbourhood Services 416 962-9449 x 31
West Neighbourhood House 416-532-4828
West Toronto Support Services 416-653-3535
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TRAUMA SUPPORT SERVICES
Polycultural Immigrant & Community Services 416-233-0055 x1237
-Crisis Counselling (Newcomers, refugees) Elizabeth Fry Society
-Healing from Abuse & Trauma Services 416-924-3708
(Women who are, have been, or are at risk of conflict with the law (both in community and
institutions)
YWCA Breakthrough Program (Women who have experienced violence or abuse) 416 487-7151 x266
Canadian Centre for Victims of Torture 416-363-1066
Canadian Centre for Men and Families (CCMF) 647-479-9611
(Men who have experienced or are experiencing domestic violence, sexual assault and all forms of
trauma)
CAMH Women & Trauma Service Access CAMH 416 535-8501 Option 2
(Women who have a history of trauma in combination with mental illness. Psychiatrist or GP referral
required)
The Gatehouse (Adult survivors of childhood sexual abuse) 416-255-5900
Victim Services Toronto 416-808-7066
Distress Centre-Survivor of Suicide or Homicide Loss Support 416-595-1716
Family Services Toronto – Trauma Counselling (Adults) 416-595-9618
Barbara Schlifer Clinic (Women) 416-323-9149 ext. 234
Shoniker Clinic (Youth 19 and under) 416-281-7301
Assaulted Women’s Helpline Toronto: 416-863-0511
- 24/7 in over 200 languages Toll free: 1-866-863-0511
Toronto Rape Crisis Centre - 24/7 416-597-8808
YOUTH
Central Toronto Youth Services 416-924-2100
Children’s Mental Health of Ontario 416-921-2109
East Metro Youth Services 416-438-3697
George Hull Centre 416-622-8833
Kids Help Phone 1-800-668-6868
MDAO-Youth Living Well Group 416-486-8046 x237
Shoniker Clinic (RVHS) 416-281-7301
Sick Kids Centre for Community Mental Health 416-924-1164
Skylark 416-482-0081
Stella’s Place 416-461-2345
Yorktown Family Services 416-394-2424
YouthLink 416-967-1773
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Bipolar Basics 1 - Client Manual - Updated 17NOV2021

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Bipolar Basics 1 - Client Manual - Updated 17NOV2021

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Bipolar

Property of CAMH – Do not distribute

Naomi Mitchell, Arkadiusz Andrusieczko, Anka Krivokuca,

Special thanks to:

Dr. Abigail Ortiz for her comments and contributions

Formatting and design by:

Jasmine Ahmadinia, Elissa Pendergast, and Emilyn Narraway

Session 2 | Impact of Diagnosis & Symptoms & Goal-setting

Session 3 | Managing and Preventing (Hypo) Mania

What is Bipolar Disorder: Identifying & Monitoring Symptoms

8. Be constructive. Avoid criticism and judgments, and give constructive feedback. Be

a) Emails will only contain communication related to routine matters such as

• Learn coping strategies (enhance/develop routine; sleep, daily activities) to manage

Three Main Types of Bipolar Disorder

Dr. A. Ortiz - December 10, 2019

Mood Sad Content Irritable

Appetite/Eating habits I’m not hungry I like to eat I forget to eat

Mild Form of Sx Moderate Severe

Blue, down or neutral mood Cry more easily Severe sadness

Usual activities are not as much fun

Blame self-more readily when things

Not as hungry as usual; can skip

Clothes fit slightly looser; no big

Lose interest in tasks such as reading;

Slowness in movements is noticeable

Thoughts that life may not be worth

Low self-esteem; dislike appearance;

Mild Form of Sx Moderate Severe

Everything seems like a hassle;

Happier than usual; positive Euphoric mood, on top of the

More talkative; better sense of In the mood to socialize and

More thoughts; mentally Disorganized thinking, poor

Plan to make changes;

Fidgety; nervous behaviors like Restless, preferring movement Psychomotor agitation;

Not as effective at work;

Uncomfortable with other

Increased sex drive – seeking

Category When depressed When feeling OK When (hypo)manic

TOTAL HOURS OF SLEEP/NAPS: Disrupted sleep is a common symptom in depressive and

WHEN DID YOU GO TO BED/WHEN DID YOU GET OUT OF BED

DEPRESSION (below baseline):

HYPO (MANIA) (above baseline):

Other/ANXIETY: While it is expected that we all experience variations in moods daily.

My mood in the morning

Choose the battery that

Impact of Diagnosis & Symptoms and Goal-Setting

Physical: (my height, eye colour)

Social role (child, parent, partner, student)

Preferences (music, tea over coffee)

Habits (always start brushing on same side)

What do others identify as my unique qualities? (talented, witty, supportive)

Responsbilities Leisure &

A goal is a change in behavior that results in improvement in quality of life.

Why Use Smart Steps?

Small/Specific: Make your goal as small and specific as possible.

1. What is your general goal?

2. Where are you now exactly?

I don’t go to the gym.

3. SMART Goal: Where would you like to be?

I want to exercise two times a week at my gym.

5. What are the possible problems or barriers to reaching your goals?

• Mom might not always be available for babysitting.

6. What are some strategies/solutions to overcome those problems/barriers?

1. What is your general goal?

Name: _ Date: __

Name: _ Phone: __

Name: _ Phone: __

Name: _ Phone: __