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Josh is a 45-year-old Caucasian male who has been diagnosed with bipolar I disorder. He recently had a manic episode that lasted roughly eight days. During this time, Joshan otherwise very responsible and demure persondrained his checking account with large purchases, including a new car; did not report to work, stating "I could build a better company;" and made frequent visits to his ex-wife's house, where he sought to "get back together" after three years of being divorced. After his fourth visit, his ex-wife hesitantly called the police and Josh was retained and ultimately taken to the ER for observation and treatment. Josh was hospitalized for three days during which he consulted with the psychiatrist on staff and was administered lithium. He was released upon stabilization and referred to you for ongoing counseling and to his existing psychiatrist for medication management. History Josh was diagnosed with bipolar I in his early twenties stemming from a similar manic episode. He has had two other manic episodes since this time (excluding his most recent), all of which have reflected the same pattern of grandiose thought, excessive spending, decreased sleep, and hyper-focus on some relational or work-related activity. Each of these periods of mania have been punctuated by a major depressive episode that last between three and four weeks at a time, in which he displays symptoms of hopelessness, guilt, a lack of concentration, and a generally depressed mood. Josh is a highly insightful man. Outside of his periods of mania or depression, he is highly functional, amiable, and has demonstrated great success in his work. He was married to his ex-wife for 14-years, during which time they had a daughter. He remains very close to his teenage daughter, who he sees frequently, and has maintained a close co-parenting relationship with his ex-wife. Josh does acknowledge his marriage ended as a result of his last manic episode. He reports that though his ex-wife was initially sensitive to his disorder, she became frustrated by his inconsistent use of medication and lack of follow-through on his counseling. This, coupled with the consequences of the manic episodes namely the need to rebuild financially each timeresulted in her filing for divorce three years ago. Josh acknowledges that this was extremely painful for him, and that he continues to hope for reconciliation with his ex-wife. Josh reports that he has been on lithium off-and-on since his original diagnosis. He finds the medication highly helpful to him, but also notes that as time passes he feels he no longer needs it and will stop taking it without medical consultation. He also reports that he has attended counseling, but typically only after an episode and for a short duration, feeling it is an unnecessary waste of money after he has already depleted his funds. Developmental Considerations Josh had no major developmental concerns as a child. Outside of a broken leg he suffered from a bicycle accident at age eight, he reports no major accidents or traumas. He reports that he was raised by his mother after his parents divorced when he was 10, although he maintained a good relationship with his dad after the divorce. Josh acknowledges that his mother suffers from major depression and that bipolar I disorder runs on her side of the family. Relational Considerations From a relational perspective, Josh has had a good deal of support throughout his life. He was close to his mother in childhood, and although he reports some difficulty in feeling connected with her during her periods of depression, he said he felt he always had the support of his dad in those tougher times. Both of his parents were supportive of him when he was originally diagnosed with bipolar I at age 22; they have often served as a safety net for him after his manic episodes by providing him and his family financial assistance and helping to pay off some of his debt. Josh is particularly close with his daughter and notes that his biggest frustration about the disorder is the distance it creates with her. He carries a great deal of guilt about the way he behaves, particularly the financial impact that he believes has cost her a stable two-parent home. He states that although she always forgives him after these episodes, he knows she is growing older and more frustrated by his behavior and he fears she will pull away as her mom did. Multicultural Considerations Josh is a fairly successful businessman who, when not in manic periods, can amass great wealth. As a result, Josh lives in a very affluent part of his community. One of the particularly challenging aspects of his bipolar disorder is his excessive spending, which has each time resulted in his need to move or otherwise sell off significant assets to recover. This results in a great sense of shame for him, particularly when it has impacted his daughter or ex-wife. Diagnosis Diagnostically, Josh's most recent manic episode would have been categorized as "severe" (American Psychiatric Association [APA], 2013, p. 126) at the point of admittance to the hospital. Now that he is more stabilized the formal diagnosis would shift to bipolar I, manic, in partial remission (APA, 2013).

considerations to bear in mind relative to choosing an appropriate intervention for Josh

Remember, consider his familial relationships, cultural considerations, diagnosis, and where he is in his current treatment needs.