What to Do When a Client May Be Hypomanic but Denies It

By Steff Du Bois, PhD

Therapists who work with clients who may be experiencing hypomania can face a difficult challenge: compassionately and effectively informing the client of their current clinical impression. Almost inevitably—largely due to the nature of hypomania— clients may deny that their current experience is problematic at all, let alone clinically diagnosable.

Addressing this situation requires a multipronged approach of compassion; knowledge; directive communication; getting client buy-in; and collaborative, future-focused planning. Specific steps I recommend taking include:

1. Nonjudgmentally reflecting back the client’s current cognitive, emotional, and behavioral patterns; and, how these may differ from baseline functioning. Clinicians might note, “You know, it seems to me that you’re experiencing things at an amplified level right now—you’ve got lots of thoughts, you’re being super-duper productive, and whatever you’re feeling, you’re feeling it bigger than you usually do.”

2. Curiously noting that these observations are consistent with criteria for something that’s in your and the collective mental health provider knowledge bank, e.g., “This all seems consistent with something that can happen to people, and something that I and my colleagues have seen before: Clients enter periods of feeling ‘up’ for a period of time—maybe a few days, a few weeks, even sometimes a few months. When this happens, it can be exhilarating for the client, but also can come with some downsides.”

3. Communicate directively with the client to convey the potential seriousness of the situation: “After thinking about the evidence you’ve shared with me today—things like you’re sleeping very little and you’re making some big life changes; and also thinking about how we’ve been communicating, you’re sharing with me lots of ideas and you’re very, very focused on some of them—I think we may be dealing with an official episode that we’d refer to as hypomania.”

4. Cultivate client buy-in into this conceptualization, specifically by framing the current experience as incongruent with the client’s stated therapy goals, e.g., “I hear you when you say things feel great right now, and you’re operating seemingly at 100 percent. But I also want to point out that some of the things I know you’ve been working on— your romantic relationship, consistency in your performance at work, maintaining self-care—those seem to be compromised recently. It’s like much of the hard work you’ve put in is being threatened by this current experience of feeling so up.”

5. Collaborate with the client both on how to move forward, e.g., “How do you think we can find the balance between feeling good—which you do now—and also sticking to our established goals for you? What are some metrics we can keep an eye on during this time?” These metrics likely should include things that will promote routine and structure, e.g., adhering to a consistent sleep schedule, limiting “big decisions” made during this time, not immediately believing all the thoughts they have, and limiting substance use.

Note that if you believe your client is experiencing mania and not hypomania, some of the above may be useful; but your own response may be scaled up, particularly because hospitalization may be indicated.

Steff Du Bois, PhD, (he/they) is a clinician with their own private practice, and associate professor of psychology at the Illinois Institute of Technology (IIT). They have published over forty peer-reviewed manuscripts, presented research at numerous national and international conferences, and received multiple research grants to fund their work. After earning their doctorate from the University of Illinois at Chicago, they now lead the Du Bois Health Psychology Laboratory. There, they mentor graduate and undergraduate psychology students, and conduct health psychology research using community-based participatory research approaches to examine health behaviors, health equity, and health in romantic relationships.