Why Autonomy Is at the Center of Bipolar I Treatment

For someone living with bipolar I disorder (BD-I), the usual wellness advice — better sleep, a balanced diet, less stress — only tells part of the story. Roger Rivera, DNP, PMHNP, explains that for people managing a serious mental illness, wellness has to account for a more complex reality: consistent sleep as a mood stabilizer, ongoing medication management and enough day-to-day stability to still pursue relationships and personal goals. Rivera also discusses how he works with patients to build treatment plans that protect their sense of autonomy rather than undermine it, since a diagnosis that feels like a loss of control can become its own barrier to wellness.

Rivera also pushes back on how mainstream wellness culture, often centered on lifestyle habits and self-care, can unintentionally alienate people whose path to stability requires more structured medical support. He explains why staying committed to a working treatment plan matters even after symptoms improve, and shares what he wants more people to understand about the real relationship between psychiatric treatment and everyday well-being.

For someone living with bipolar I disorder, what does "wellness" really mean beyond the usual advice about sleep, diet and stress management?

Roger Rivera, DNP, PMHNP: Everybody’s mental health journey is their own. For someone living with a serious mental illness like BD-I, conversations about wellness should reflect their needs. For example, the importance of consistent sleep is amplified, so much so that I describe it as the thermostat for one’s mood. In BD-I, sleep management and symptom management can be closely aligned.

Part of wellness is also building self-awareness relative to BD-I. The two are mutually supportive; understanding the condition can contribute to understanding their own experience of it, and vice versa. And the more both are understood, the better equipped someone is to recognize and minimize future symptoms. But wellness is not simply the absence of symptoms. It is also having enough stability to participate in relationships, pursue personal goals and live a life that still feels like their own.

Wellness also means accessing the right help. That includes medication management, continuity of care, education about treatment and resources, and a personal support system. All of it goes hand in hand. To me, wellness starts with an accurate diagnosis and a sensitive approach to what each person needs to continue living their life.

How do you help patients set goals around both their treatment plan and their personal priorities without one undermining the other?

RR: First, I aim to understand the person through their lens. I cannot assume that, just because I’m a medical professional, I know what wellness, stability or success would be for my patient.

That extends to treatment decision-making and tailoring a plan based on holistic and precision care. What does each person need for medication or support services? Is there a family dynamics component? What is happening in their work, their relationships or their daily life?

The biggest thing is creating autonomy. It’s not uncommon for my patients to share frustration that their BD-I diagnosis makes them feel unlike themselves or as though they have lost control of their lives. Because autonomy is so important, the treatment plan needs to provide medical stability without taking away the person’s sense of self or independence. Prioritizing tolerability can be an important part of medication selection, because a treatment that feels unmanageable can become another barrier to living well.

In what ways does the broader wellness conversation, focused on self-care and lifestyle, sometimes create stigma for people managing a serious mental illness?

RR: When wellness gets reduced to self-care and lifestyle themes like exercising more or thinking positively, it misses the complexity of serious mental illnesses like BD-I. For many people living with BD-I, staying well also means daily medications, psychoeducation and frequent trips to health care providers. Society should never make others feel they are falling short of wellness goals simply because they need more structured medical care or support. Wellness should not become another benchmark that people feel they are failing to achieve.

Lifestyle is part of the approach, but it is far from the whole strategy. True wellness starts with understanding one’s diagnosis, strength, vulnerabilities and how to function at their best. That kind of self-awareness can take time, education and support to develop. Good care and true wellness have to look at the biological, psychological and social pieces together, and then be tailored to the specific individual. For many people with BD-I, medication, therapy, routine and healthy habits work together rather than existing as separate paths to wellness. Self-care is important but variable, and, as a social phenomenon, can inadvertently exclude people with more nuanced medical needs.

Why is staying committed to medication, even after symptoms improve, such a critical piece of long-term wellness for patients with BD-I?

RR: With BD-I, symptom improvement is something to recognize and build on, indicating that the medication and routine are helping create greater stability. When a treatment plan is working, the best clinical advice I can give is to stick with it to help protect a patient’s progress and reduce the likelihood of symptom relapse.

BD-I is a lifelong, chronic condition generally addressed through a combination of medication, self-awareness, routine and support systems. The ultimate goal of a treatment plan is to be effective, tolerable and individualized, so patients can maintain stability while continuing to live according to their own priorities.

What's one thing you wish more people understood about the relationship between psychiatric treatment and everyday well-being?

RR: Everyday well-being should be both the objective and outcome of a successful psychiatric treatment plan. People may think treatment is exclusive to a medical appointment, but it’s also what helps somebody manage the ordinary moments of life.

Ultimately, treatment should help people understand their condition, protect their health and continue moving through their lives. The goal of psychiatric treatment is not simply to suppress symptoms. It is to help someone build enough stability to participate fully in the relationships, goals and everyday experiences that make their life feel like their own. I frequently tell my patients, you do not owe anyone a version of yourself that costs your stability. Putting yourself first and seeking the right help is not separate from well-being. It is well-being.