Bipolar TherapyBipolar TherapyClient of Korean DescentAncestr.docx

// Bipolar TherapyBipolar Therapy
Client of Korean Descent/Ancestry
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who
presents to her first appointment following a 21-day
hospitalization for onset of acute mania. She was diagnosed
with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with
things on your desk and shifting from side to side in her chair.
She informs you that “they said I was bipolar, I don’t believe
that, do you? I just like to talk, and dance, and sing. Did I tell
you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”
SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5
hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been
medically worked up by a physician who reported her to be in
overall good health. Lab studies were all within normal limits.
You find that the patient had genetic testing in the hospital
(specifically GeneSight testing) as none of the medications that
they were treating her with seemed to work.
Genetic testing reveals that she is positive for CYP2D6*10
allele.
Patient confesses that she stopped taking her lithium (which was
prescribed in the hospital) since she was discharged two weeks
ago.
MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event.
She is dressed quite oddly- wearing what appears to be an
evening gown to her appointment. Speech is rapid, pressured,
tangential. Self-reported mood is euthymic. Affect broad.
Patient denies visual or auditory hallucinations, no overt
delusional or paranoid thought processes readily apparent.

Judgment is grossly intact, but insight is clearly impaired. She
is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015).
Cytochrome P450 2D6 genotype affects the pharmacokinetics of
controlled-release paroxetine in healthy Chinese subjects:
comparison of traditional phenotype and activity score systems.
European Journal of Clinical Pharmacology, 71(7), 835-841.
doi:10.1007/s00228-015-1855-6
Decision Point OneSelect what the PMHNP should do:Begin
Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS

Chapter XX:
Chapter Title
Chapter 3:
Communication Skills
Copyright © 2016 Wolters Kluwer • All Rights Reserved
Learning Outcomes

Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Spell and define the key terms
2. List two major forms of communication
3. Identify styles and types of verbal communication
4. Identify types of nonverbal communication
5. Recognize barriers to communication
6. Identify techniques for overcoming communication barriers
7. Recognize the elements of oral communication using a
sender-receiver process
8. Identify resources and adaptations that are required based on
individual needs, that is, culture and environment,
developmental life stage, language, and physical threats to
communication
*
Learning Outcomes (cont’d)
9. Discuss examples of diversity:
Cultural
Social
Ethnic
10. Discuss the role of cultural, social, and ethnic diversity in
ethical performance of medical assisting practice
11. Discuss the role of assertiveness in effective professional
communication, and relate the following behaviors to
professional communication:
Assertive
Aggressive
Passive

12. Discuss the theories of:
A. Erik Erikson
B. Kübler-Ross
13. Explain how various components of communication can
affect the meeting of verbal messages
14. Define active listening
15. List and describe the six interviewing techniques
16. Give an example of how cultural differences may affect
communication
17. Discuss how to handle communication problems caused by
language barriers
18. List two methods that you can use to promote
communication among hearing-, sight-, and speech-impaired
patients
Learning Outcomes (cont’d.)
19. Discuss how to handle an angry or distressed patient
20. List five actions that you can take to improve
communication with a child
21. Discuss your role in communicating with a grieving patient
or family member
22. Discuss the key elements of interdisciplinary
communication
23. Explore issue of confidentiality as it applies to the medical
assistant

Psychomotor Domain
1. Respond to nonverbal communication (Procedure 3-1)
2. Use feedback techniques to obtain patient information
including the following:
A. Reflection (Procedure 3-1)
B. Restatement (Procedure 3-1)
C. Clarification (Procedure 3-1)
3. Coach patients appropriately considering the following:
A. Cultural diversity (Procedure 3-2)
B. Development life stage (Procedure 3-2)
C. Communication barriers (Procedure 3-2)
*
Affective Domain
1. Demonstrate
A. empathy
B. active listening
C. nonverbal communication
2. Demonstrate respect for individual diversity including:
Gender
Race
Religion
Age

Economic status
Appearance
*
3. Use appropriate body language and other nonverbal skills in
communicating with patients, family, and staff
4. Demonstrate awareness of the territorial boundaries of the
person with whom one is communicating
5. Demonstrate sensitivity appropriate to the message being
delivered
6. Demonstrate awareness of how an individual’s personal
appearance affects anticipated responses
7. Demonstrate recognition of the patient’s level of
understanding in communication
8. Analyze communication in providing appropriate
responses/feedback
9. Demonstrate the principles of self-boundaries
10. Respond to issues of confidentiality
*
ABHES Competencies

1. Identify and respond appropriately when working/caring for
patients with special needs
2. Use empathy when treating terminally ill patients
3. Identify common stages that terminally ill patients go
through and list organizations/support groups that can assist
patients and family members of patients struggling with
terminal illness
4. Advocate on behalf of family/patients, having ability to deal
and communicate with family
5. Analyze the effect of hereditary, cultural, and environmental
influences
6. Locate resources and information for patients and employers
7. Be attentive, listen, and learn
8. Be impartial and show empathy when dealing with patients
9. Communicate on the recipient’s level of comprehension
10. Serve as liaison between physician and others
11. Recognize and respond to verbal and nonverbal
communication
Communication is sending and receiving messages, verbally or
otherwise. Until the message is received accurately,
communication has not taken place.
The ability to communicate effectively is a crucial skill for
medical assistants. The medical assistant is usually the first
person the patient meets in the medical office. Thus, your
positive attitude, pleasant presentation, and use of good
communication skills will set the tone for future interactions.

message: words sent from one person to another; information
sent through spoken, written, or body language
Back to Learning Outcomes
Introduction
In your role, you must accurately and appropriately share
information with physicians, other professional staff members,
and patients.
Basic Communication Flow
Communication requires three things
Message
Sender
Receiver
Two or more people act as sender and receiver as they seek
feedback and clarification
feedback: in communication, the response to input from
another
clarification: explanation; removal of confusion or uncertainty
Basic Communication Flow (cont’d.)
Good communication entails:
Clarifying confusing messages
Validating patient’s perceptions
Adapting messages to patient’s understanding level
Asking for feedback to ensure that the messages you sent were
received by the patient or other persons as intended

Figure 3-1 Flow of communication.
Checkpoint Question
What three elements must be present for communication to
occur?
Checkpoint Answer
For communication to occur, these three elements must be
present:
A message to be sent
A person to send the message
A person to receive the message

Forms of Communication
Verbal Communication
Verbal
Uses words or language
Most common form, so important to use clearly
Types
Oral
Written
Gear speech to patient’s educational level
Example—heart attack vs. myocardial infarction
You need good verbal communication skills when
performing such tasks as making appointments, providing
patient education, making referrals, and sharing information
with the physician.
Forms of Communication (cont’d.)
Research indicates that primary message transmitted more by
the way it is said than by the words that are used:
Paralanguage
Voice tone
Quality
Volume
Pitch
Range
paralanguage: factors connected with, but not essentially
part of, language, e.g., tone of voice, volume, pitch

Nonlanguage
Laughing
Sobbing
Signing
Written
Should be clear and concise
Reinforces oral
The ability to write clearly, concisely, and accurately is
important in the health care profession.
nonlanguage: not expressed in spoken language, e.g.,
laughing, sobbing, grunting, sighing
Checkpoint Question
List five examples of paralanguage.

Checkpoint Answer
Examples of paralanguage are:
Voice tone
Quality
Volume
Pitch
Range
Nonverbal Communication
Also called body language
Kinesics
Facial expressions
Body and eye movement
Gestures
Proxemics
Physical proximity
Personal space — usually about 3 foot diameter
Varies among individuals and cultures
Medical care involves entering personal space
Some patients tolerate it better than others
culture: the way of life, including commonly held beliefs, of a
group
of people

Touch
Therapeutic — convey support and caring
Some patients find it uncomfortable
Seek cues from patient’s demeanor
therapeutic: having to do with treating or curing disease;
curative
Figure 3-2 Therapeutic touch conveys caring and concern.
demeanor: the way a person looks, behaves, and conducts
himself or herself
Defense Mechanisms
Can imped communication
The process in the brain that makes you forget or ignore painful
or disturbing thoughts, situations, etc.
Be unaware exhibiting

Must be aware of various barriers and respond appropriately
Active Listening
Importance of active listening
Ensures that listener understands patient message
Ensures that patient understands information
Components of active listening
Give patient full attention
Minimize interruptions
Watch for nonverbal cues — especially where they conflict with
verbal message
To listen actively, you must give your full attention to the
patient with whom you
are speaking.
Interview Techniques
Main requirements for effective interview:
Listen actively
Ask appropriate questions — prepare ahead of time
Record answers
Conduct interview in private place — introduce yourself
Be organized
To conduct either type of interview, you must use effective
techniques: listen actively, ask the appropriate questions, and
record the answers.

Figure 3-3 Begin the interview by introducing yourself.
Interview Techniques (cont’d.)
Do not answer phone calls or attend to other distractions
Let patients know what will happen next and approximate time
Six interviewing techniques:
Reflecting
Paraphrasing
Clarification
Asking open-ended questions
Summarizing
Allowing silences
Reflecting
Repeat what you heard patient say
Leave sentence unfinished

Do not overuse
Paraphrasing or Restatement
Repeat what you heard in your own words
Allows patients to clarify and correct
Asking for Examples or Clarification
Clarifies and reinforces patient’s statements
reflecting: repeating what one heard using open-ended
questions
paraphrasing: restating what you heard using your own words
Asking Open-Ended Questions
What, when, or how questions
Patient can’t answer only yes or no
Avoid why questions
Avoid closed-end questions that allow only a “yes” or “no”
answer
The best way to obtain specific information is to ask open-
ended questions that require the patient to formulate an answer
and elaborate on the response.
Summarizing
Reiterate what has been discussed
Allowing Silences
Allows patient to add information or ask questions
Allows patient to formulate thoughts
Allows listener to organize thoughts and form questions

Briefly reviewing the information you have obtained, or
summarizing, gives the patient another chance to clarify
statements or correct misinformation.
summarizing: briefly reviewing the information discussed to
determine the patient’s comprehension
Checkpoint Question
What are the six interviewing techniques?
Checkpoint Answer
When interviewing patients, you can use six different
techniques:
Reflecting
Paraphrasing or restatement
Asking for examples or clarification
Asking open-ended questions
Summarizing
Allowing silences.

Factors Affecting Communication
Many factors can influence communication effectiveness
Use of cliché
Message unclear or inappropriate to the situation
Personal distractions (pain or anxiety)
Environmental distractions (noise)
Cultural differences
Stereotyping or biases
Language barriers
Hearing or sight impairment
Factors Affecting Communication (cont’d.)
Cultural differences
Perception is guided by cultural, social, religious beliefs
Avoid preconceived ideas about people from different cultures
Individuals vary within cultures
The way a person perceives situations and other people is
greatly influenced by cultural, social, and religious beliefs or
firmly held convictions.
To help avoid miscommunication and offending patients,
you must be sensitive to these differences in all of your patient
interactions.

Stereotyping and Biased Opinions
Should not let personal values or bias affect communications
Stereotyping and prejudice are deterrents to establishing
therapeutic relationship
Example—patient who lives in homeless shelter
bias: formation of an opinion without foundation or reason;
prejudice
stereotyping: to place in a fixed mold, without consideration
of differences
As a health care professional, you are expected to treat all
patients impartially, to guard against discriminatory practices,
remain nonjudgmental, avoid stereotypes, and have a
professional demeanor.
discrimination: making a difference in favor of or against
someone
Language Barriers
Some patients don’t speak English well or at all — problem to
convey and obtain accurate information
Use of interpreters
Staff or family member

Lacking interpreter, written references contain common medical
questions and answers
If office serves speakers of particular language, obtain phrase
book for that language
Try to use someone same sex as patient
Guidelines:
Do not shout
Demonstrate or pantomime as needed
Speak to patient, not interpreter
Speak slowly; use simple sentences that require simple answers
Avoid slang
Avoid distractions; find a relaxed, quiet environment
Learn basic phrases in appropriate language(s)
Special Communication Challenges
Sensory impairments
Motor (speech) impairments
Patients with limited understanding
Very ill or sedated patients
Very frightened or traumatized patients
Young children
Patients must feel that they are part of the process even if
their condition
requires involvement by family members or other caregivers.

Special Communication Challenges (cont’d.)
Hearing-Impaired Patients
Impairments:
Conductive — interference with sound conduction
Sensorineural — lesions or problems with nerves or the cochlea
Anacusis
Sign language, interpreters or other tools
Presbycusis
Often in denial, hearing aids or other amplification devices
presbycusis: (also: presbyacusis) loss of hearing associated
with aging
anacusis: complete hearing loss
Methods for communicating with hearing-impaired patients (use
tact, diplomacy, and patience):
Touch patient gently to get his or her attention
Talk face to face
Ensure good lighting makes your face visible
Lower vocal pitch; speak distinctly and with force but do not
shout
Use note pad and demonstrations
Use pictograms
Use short sentences, short words; enunciate clearly but do not
exaggerate facial expressions
Eliminate distractions

Figure 3-4 Pictogram for instructing a patient on medication
routine.
Checkpoint Question
How does the TDD system work?

Checkpoint Answer
The caller types a message, and the patient reads the message
and types a response.
TDD: Telecommunication device for the deaf
Sight-Impaired Patients
Range from blurred vision to total blindness
Different conditions can result in impairment
Cataracts
Glaucoma
Macular degeneration
Retinal detachment
Hyperopia
Myopia
Nyctalgsia
Retinopathy
Strabismus
Presbyopia
Patients who cannot see lose valuable information from
nonverbal communication.
Methods for communicating with sight-impaired patients:

Identify yourself by name at each visit
Do not raise your voice
Explain fully exactly what you’re about to do; alert patient
when you will touch him or her
Orient patient spatially by having him or her touch furniture or
walls
Offer to escort patient while he or she holds your arm
Tell patient when you leave room; knock when entering room
Explain sounds of equipment used and what each machine will
do
Speech Impairments
Dysphasia
Dysphonia
Stuttering
Methods for communicating with speech-impaired patients:
Allow patient time to gather thoughts
Allow ample time for patient to communicate
Do not rush conversation
Do not appear impatient
Offer note pad for writing questions
Discuss with physician the possibility of speech therapist
dysphasia: difficulty speaking
dysphonia: impairment of voice; hoarseness
Checkpoint Question
What is the difference between dysphasia and dysphonia?

Checkpoint Answer
Dysphasia is difficulty with speech, usually the result of nerve
problem.
Dysphonia is a voice impairment, usually caused by a physical
condition.
Mental Health Illnesses
Create broad range of communication challenges:
Uncontrollable outburst
Mute conditions
Hear voices
See objects that do not exist
Communicating with patients with moderate to severe disorders
required indepth training
Methods for communicating with patients with mild mental
illnesses:

Tell patient what to expect
Keep conversations focused and professional
Do not force or demand answers
If you feel unsafe, speak to your supervisor or the physician
Do not confirm hearing voices or seeing nonexistent objects
Orient the patient to reality as appropriate
Your communication should be professional,
nonjudgmental, and encouraging when appropriate.
Angry or Distressed Patients
Contributing factors:
Frustration
Long wait times—keep patients informed of long wait times
Illness
Financial strain
Billing or insurance problems
Bad health news
To improve communication:
Be supportive
Take to private area
Stay calm
Be open and honest
Do not provide false reassurance
Do not belittle problem or concern
Ensure own safety if angry patient becomes aggressive or

threatening
The key to communicating with upset patients is to prevent
an escalation of the problem.
Developmental
Need to understand stages of development
Erik Erikson, developed theory of 8 stages of development
Each stage has different accommodations to be made when
interacting with patients
Children
To facilitate communication:
Place child at your eye level or lower yourself to child’s eye
level
Keep voice gentle and low-pitched
Make movements slow and visible
Rephrase question until sure child understands
Tell child when you will touch him or her
Expect that a child will return to an earlier developmental phase
when ill
Use play and toys to phrase questions
Allow child to express feelings

Adolescents:
May wish to be seen without parent
Do not show shock or disapproval — will stop communicating
Figure 3-5 The medical assistant communicates at the child’s
eye level.
Checkpoint Question
What is the stage of development in which trust versus mistrust
is developed?

Checkpoint Answer
The developmental stage where trust versus mistrust is
developed is the infant stage, ages 0 to 1 years.
Communicating with a Grieving Patient or Family Member
Loss of loved one
Death
Loss of relationship
Loss of body part
Loss of health
Dr. Elisabeth Kübler-Ross’ five distinct stages of grief in On
Death and Dying— mourning can occur over months or years:
Denial: Patient does not believe diagnosis
Anger: Toward doctor or facility
Bargaining: Attempt to trade diagnosis
Depression: Quiet, withdrawn, uncaring
Acceptance: Acknowledgment of situation
grief: great sadness caused by loss
mourning: to demonstrate signs of grief: grieving

(cont’d.)
(cont’d.)
Grief when a patient dies:
Normal to feel sad
Focus on empathy, not sympathy
Empathy = feeling with
Sympathy = feeling for
Empathy can help you recognize a patient’s fear and
discomfort so you can do everything possible to provide support
and reassurance.
Checkpoint Question
What are the five stages of grieving?
Checkpoint Answer

The five stages of grieving are:
Denial
Anger
Bargaining
Depression
Acceptance
Establishing Positive Patient Relationships
Proper Form of Address
Use proper form of address to show respect and set a
professional tone
Use last name unless otherwise instructed by patient
Calling patients by pet names, such as sweetie, granny, gramps,
or honey, can offend the person
Avoid referring to patient by his or her medical condition
Pet names denigrate the individual’s dignity and put the
interaction on a personal, not professional, level.
Establishing Positive Patient Relationships
Professional Distance
Avoid revealing intimate information about yourself
Choose general topics and keep the conversation light
You should not become too personally involved with
patients because doing so may jeopardize your ability to be
objective.

Establishing Positive Patient Relationships (cont’d.)
Teaching Patients
Be knowledgeable about current medical issues, discoveries,
and trends.
Be aware of special services available in your area.
Have pertinent handouts or information sheets available.
Allow enough teaching time so that you are not interrupted or
rushed.
Find a quiet room away from the main office flow if at all
possible.
Establishing Positive Patient Relationships (cont’d.)
Give information in a clear, concise, sequential manner; provide
written instructions as a follow-up.
Allow the patient time to process this new information.
Encourage the patient to ask questions.
Ask open-ended questions in a way that will allow you to know
whether the patient understands the material.
Invite the patient to call the office with additional questions
that may arise.
Professional Communication
Assertiveness in Professional Communication
An assertive person:
Sets clear boundaries for himself or herself and others
Knows how to set limits

Clearly and politely communicates his or her wants and needs
Can say “no” without offending another person
Understands the appropriate time for assertiveness versus
passive compliance
Professional Communication (cont’d.)
Refuses to be inappropriately dominated or “handled”
Considers the feelings and roles of others
Voices differences of opinion without being rude or overbearing
Stands up for what he or she believes when appropriate
Holds himself or herself with confidence and maintains eye
contact
Looks for compromise, not conflict
Speaks firmly but pleasantly
Respects others
Understands when he or she is about to “step over a line” and
pulls back
Is honest and fair
An aggressive person, conversely, is:
Hostile
Threatening
Demanding
Loud
Annoying
Sarcastic
Angry

Mean
Communicating with Peers
Must remain professional
Minimize discussion of non-work-related topics
Minimize loud talking, laughter, whispering
Remain honest
Become active in local professional organization
Involvement in local community organizations and support
groups is also beneficial to promoting you and your profession.
Communicating with Physicians
Address with professional title
Use correct medical terminology
Do not use slang
Display confidence
Communicate clearly
Be honest if you do not know something
Communicating with Other Facilities
Maintain patient confidentiality

Observe legal requirements for dispensing patient data
Use caution with fax machines, e-mail, and other electronic
devices
Provide only facts
Always be nonjudgmental
Confirm receipt of message
// Bipolar TherapyBipolar Therapy
Client of Korean Descent/Ancestry
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE Client returns to clinic

in four weeks Client informs the PMHNP that she has been
taking her drug “off and on” only when she “feels like she
needs it” Today’s presentation is similar to the first day you
met her
Decision Point Two
Select what the PMHNP should
do next:Increase Lithium to 450 mg orally BID
RESULTS OF DECISION POINT TWO Client returns to clinic
in four weeks Client returns reports that she is still taking the
medication when she feels that she needs it She remains quite
manic and reports that her family is getting really upset because
she likes to play her new guitar at night
Decision Point Three
do next:Assess for rationale for non-compliance and educate

client
Guidance to Student
The PMHNP should further assess for
dangerousness to self or others. The client should be assessed
for self-care, to including hygiene, eating, sleeping, etc.
Hospitalization may be indicated if the client remains non-
compliant and is a danger to self. If the client is not a danger to
self, and hospitalization is not indicated, the PMHNP needs to
assess for rationale for non-compliance. Many clients enjoy
mania as it is a nice feeling to be consistently happy. When
clients are successfully treated for mania, they often describe
themselves as feeling ‘down’ or ‘flat.’ The PMHNP needs to
assess for depression at this point as opposed to normalization
of mood. Abilify is also FDA approved as monotherapy for
mania and mixed presentations, but at a dose of 15 mg. day., so
although you may be tempted to begin Abilify- be certain to use
correct dose. Also, because it can be “activating” you need to
dose this drug in the morning. However, the client is non-
compliant and therefore, eliciting reasons for non-compliance is
essential to the care of this client.
Start OverConsider hospitalization
Guidance to Student

Start OverChange to abilify 10 mg orally at HS
Guidance to Student

Start OverAssess rationale for non-compliance to elicit reason
for non-compliance and educate client re: drug effects, and
pharmacology
in four weeks Client states that the drug makes her nauseated
and gives her diarrhea Client states that she stops taking it until
these symptoms abate, at which point she re-starts only to
experience the symptoms again
do next:Change to Depakote ER 500 mg at HS

Guidance to Student
In this case, the client is having nausea
and diarrhea, classic side effects of lithium therapy. Changing
the client to an extended release formulation can often prevent
these symptoms while at the same time affording the client the
benefit of lithium’s mood stabilizing properties. Also, lithium is
a good choice for control of mania and has also been shown to
decrease risk of suicide, which adds to its overall benefits.
Depakote may be an option if changing to sustained release
lithium does not alleviate the side effects. Oxcarbazpine
(Trileptal) is an option, but is a second line therapy and is not
appropriate at this stage as the client has not had an adequate
trial of first line agents.
Start OverChange Lithium to sustained release preparation at
same dose and frequency
Guidance to Student
In this case, the client is having nausea
and diarrhea, classic side effects of lithium therapy. Changing
the client to an extended release formulation can often prevent

Start OverChange to trileptal 300 mg orally BID
Guidance to Student
In this case, the client is having nausea and
diarrhea, classic side effects of lithium therapy. Changing the
client to an extended release formulation can often prevent
Start OverSwitch to Depakote ER 500 mg orally at HS
in four weeks Client reports that she has been compliant and
you notice a marked reduction in manic symptoms. Young
Mania Rating Scale was 11 (50% reduction from first office
visit) Client reports that she has gained 6 pounds over the last 4

weeks and wants to stop the medication because of this
do next:Educate client regarding diet/weight loss and continue
client on the same drug/dose
Guidance to Student
The PMHNP should begin by educating
the client regarding weight loss/and importance of diet/exercise
while taking Depakote which can cause weight gain. Decreasing
the dose of Depakote would not be appropriate as she still has
symptoms and decreasing dose of Depakote may result in some
weight loss, it may result in a return of manic symptoms. The
PMHNP can switch to Zyprexa but if weight gain is the issue,
then this will be compounded by Zyprexa which is associated
with significant weight gain (up to 20 kg over a 24 month
period).
Start OverDecrease Depakote ER to 250 mg orally at HS
Guidance to Student

The PMHNP should begin by educating the
client regarding weight loss/and importance of diet/exercise
period).
Start OverSwitch medication to Zyprexa 15 mg orally daily at
HS
Guidance to Student
The PMHNP should begin by educating
the client regarding weight loss/and importance of diet/exercise
period).
Start Over

Bipolar TherapyBipolar TherapyClient of Korean DescentAncestr.docx

Bipolar TherapyBipolar TherapyClient of Korean DescentAncestr.docx

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