Shared Dilemmas in the Management of Bipolar Disorder

Introduction

Researchers vary in the understandings they promote in a diverse range of published literature. Some place emphasis on the biological processes within a person which can cause emotional instability. Others provide psychological models and some argue for understanding at an interpersonal level. In contrast, this article reports on a phenomenological analysis during which the researcher sets existing knowledge aside; engaging with the manner in which participants experience the condition while interacting with others. Rather than excluding some levels of analysis, phenomenological methodologies attempt to capture complexity by turning back to experience. Experience is examined before asking who experiences or whether experience is individual or interpersonal. This form of research is conducted with a reflexive awareness of the potential for control or abuse, attending to the manner in which meanings are imposed within dominant knowledge systems. The researcher has worked to engage with participants as fellow humans who face common dilemmas.

Bipolar disorder is most often understood as a functional mental health problem, which has a profound influence on an individual’s mood, energy, and social functioning. Intermittent extreme mood swings are observed, usually between periods of normal emotional functioning, but often with some symptoms of depression remaining (Mitchell & Malhi, 2004). It is found that a combination of mood-stabilizing medication and psychosocial therapy can reduce the frequency and severity of the individual’s altered emotional states. But those who suffer from this condition place greater emphasis on the quality of their relationships with health professionals, where issues of control, empowerment, or involvement are a concern (Skelly, 2013). Also, a culture is identified in which a biomedical interpretation of risk is promoted and this can be dehumanizing when people are understood as objects to be managed (Liebert, 2013). These problems are increased where people who struggle to manage their moods must depend on other people (Rusner, Carlsson, Brunt, & Nystrom, 2010).

People who suffer from bipolar disorder often report feelings of being out of control (Crowe et al., 2012). They value relationships with relatives, friends, and professional workers, particularly when these people remain vigilant to the influence of fluctuating moods (Doherty & MacGeorge, 2013). However, they can experience difficulties with attachment (Gilbert, McEwan, Hay, Irons, & Cheung, 2007) and relationship conflict, when they struggle with identity, trust, and self-confidence (Fernandez, Breen, & Simpson, 2014; Rusner, Carlsson, Brunt, & Nystrom, 2009). Managing issues of control, power, trust, and self-confidence are central to the process of delivering mental health care. But researchers in this setting often ignore these complexities by measuring concrete entities, such as the “individual” and their “disease.” This simplification means that complex interpersonal difficulties are attributed to the “treatment resistant disease,” or the “problem patient,” whereas influential factors acting at psychological or social levels are neglected.

People are free to act impulsively, freely following their intuitions and emotional desires, but in their encounters with others they need to formulate a rational justification for their choices (Wharne, 2014). If emotions are inconsistent and vary alarmingly, then the mundane self-accounting that people perform in a moral social order will be troubled. Tensions can develop in relationships and people can struggle to experience each other as coherent capable deciders. When suffering from bipolar disorder, the experience of low mood will cause delays in decision making, whereas impulsivity is a problem during an elated period (Gilbert et al., 2011). Then in periods of stability, people who take treatment for this condition are not sure if they are still unwell and they question the need to continue with that treatment (Inder et al., 2010).

Experiencing extreme emotional states can make is more difficult for a person to account for themselves. But those who are employed in mental health care also face dilemmas. They gain a sense of achievement by getting to know and help people, but they must give a rational account of their actions to other health care professionals (Elstad & Hellzen, 2010). They must be both caring and professional; they must not be too emotionally involved, maintaining service standards, while at the same time they must express empathy (Billig et al., 1988; Genuis, 2012). Failing to achieve self-coherence when facing these conflicting demands can cause practitioners to feel “burned-out” or “depersonalized” (Onyett, 2011).

Mental health practitioners are required to follow professional guidance and to deliver evidence based practice so that their actions are regulated, rather than personally chosen. This can cause difficulties because people who seek their help want a personal relationship built on mutual trust (Wharne, 2014). There can be a mismatch between professional care systems and an individual’s needs in a personal journey toward the recovery of their mental health; as identified in the survivor movement (Adame, 2014).

When researchers employ theoretical models, it is difficult to include the complexities of interpersonal encounters in human relationships. Our human capacity to make rational choices is often naively assumed in simplistic models and then thought of as impinged on by mental disease (Donovan & Blake, 1992). While other factors such as psychological trauma, developmental problems, or social exclusion can also be thought of as limiting capacity. But placing emphasis on the vulnerability of the individual does not clarify our understanding of mutual decision-making or associated interpersonal emotional processes.

The material analyzed in this article is taken from a broader study of decision making in mental health care (Wharne, 2014), in the United Kingdom. Interviews were conducted with 16 participants who were recruited through posters displayed in community mental health services. They were not categorized as “suffering from mental illness,” “mental health professional,” or “family caregiver,” as most would have fallen within at least two of these definitions. However, where participants spoke about the same issues, these narratives were brought together for analysis.

Three participants spoke in detail about bipolar disorder. The aims of the research included the question of how treatment plans are agreed. Qualitative research methods were chosen as a means to retain the sense of personal choice and mutual understanding that is central to this enquiry. The interview questions prompted conversational reflection; where participants spoke about how they were required to make choices and the dilemmas they faced in the various settings of mental health care; while contrasts were also drawn with decision making in other contexts.

Methodology

Hermeneutic phenomenological analysis is not relativist in the sense that conflicting views are approached as more than alternative perspectives or truths. But on the other hand, the analysis is not intended to generate one version of reality in which the views of one participant are found to be correct and another’s incorrect. The only access we have to reality is through the flawed, contested but reflexive experiences of participants. In this reality, the meaning of experiences and the nature of individuals are in constant flux, so that our shared human condition and the associated existential dilemmas we face are the only grounds on which understanding can be built.

An analysis was conducted following van Manen (1990). This is an approach originally developed in educational research, but it is now established in health care settings (Lindseth & Norberg, 2004). Conversational relationships were developed with each participant in semistructured interviews and shared meanings were generated. There was, therefore, a partnership of similarity in which joint understandings were constructed (Gadamer, 1975). However, through this process, along with the use of prompt questions, descriptive narrative material was gathered, driven by the experiences of participants. Deeper understandings of particular aspects of human existence became possible in a partnership of difference. Interviews were recorded, transcribed into easily read English. Preconceptions were put aside as a close reading of the resource lead to descriptive annotation, in which themes were built as headings for organizing further examination (Sadala & Adorno, 2002).

The epoch was employed, so as to engage with experience as it is lived. The researcher moved continuously between part and whole in a hermeneutic circle, employing holistic, selective, and detailed reading (van Manen, 1990). These processes started with a close reading and the identification of themes, whereas sententious phrases were selected capturing and illustrating the fundamental meaning or significance of what was experienced. The researcher moved from an empathic engagement with the specific experiences that were described, to a reflexive consideration of the material as a whole and then back to empathic engagement. Each selected phrase was examined again in further sentence by sentence readings to verify their centrality to that which was experienced.

Although participants have unique experiences, a hermeneutic phenomenological approach opens the possibility that their lives might be made accessible and understandable. The researcher does not categorize participants or assume that experience is mediated by social identities or labels. In Husserl’s original thinking, we ask “what is experienced” before asking “who is experiencing” (van Manen, 1990). Meanings are not limited to one place or time, as we all face similar dilemmas whenever or wherever we live. In this approach, the researcher should have a personal interested in the topic, albeit within the constraints of a rigorous phenomenological encounter with data. Ethical approval was gained from three required institutions. The author is employed as a mental health practitioner and manager, involved daily in the issues explored here.

Findings and Discussion

Although Anna, Greta, and Frank have probably never met each other, they describe a similar scenario. This is a scenario in which someone who is diagnosed as suffering from bipolar disorder is prescribed treatment, but they believe that they have a right to choose whether to take that treatment or not. Anna and Frank are service users in this kind of encounter, whereas Greta is a nurse.

We might expect that practitioners should promote professional understandings of mental illness and place emphasis on the need for treatment, while this is resisted, but a more complex picture is found. All three participants seek to experience autonomy while feeling that this is hindered by the interpretations that others impose.

Three themes were identified: Self-experiment while feeling left out, Being watched and challenged, and Becoming autonomous; being responsible.

Conclusion

In the analysis explored in this article, participants are caught up in conflicting understandings. Some participants struggle because their moods change and the choices they have made no longer seem right for them. Choices such as continuing with treatment, or not, can be experienced as a rational attempt to feel in control. But others can interpret this as lacking an understanding of the illness (“lack of insight”) and as “suffering a relapse.” The participant who is a nurse tries to support a woman’s wellness, along with her autonomy. But this can also be interpreted negatively by others who are more concerned with treating illness. These participants are not just dealing with a disease process. They are trying to experience themselves as coherent decision-making agents in difficult encounters with other people.

Hermeneutic phenomenological approaches do not reduce participants to static measureable objects. From an existential perspective, they are “becoming,” in the sense that the nurse might become trustworthy for the person she is helping, but then might also become negligent if she fails to call for assessment under mental health law. Participants who have a diagnosis of bipolar disorder might become more able to regulate their moods by accepting recommended treatment, by avoiding the use of alcohol. But they might also become less independent, not making their own choices. These kinds of “becoming” are never complete. The truth of these events can never be fully established and there is always scope for further interpretation and disagreement.

Although moods have a biological basis, we cannot be certain that someone has made a decision under the influence of an illness, or through their own volition. Biological changes might be enacted through a chain of causal events, but human affairs are mediated by meanings which can be contested and retrospectively revised. If the workers in these scenarios could be certain about causality and somehow ensure that treatment is taken, whether the person taking it agrees to or not, the nature of what it means to be human would be lost.

Most theoretical approaches in mental health assume that it is the experience of extreme emotions that is the problem. Models are proposed at biological, psychological, and social levels. The autonomy of the person is seen as undermined so that others must intervene, but this can fail to theorize the notion of freewill. Theoretical models construct divisions within us so that our emotions are no longer treated as an expression of our being in response to experience, no longer ours to make sense of. Emotions are separated from us and are thought of as in need of management. However, while concerns are raised about the risks that are associated with uncontrolled emotion and mental illness, our freedom to act as an individual and our relationships with others also need to be considered.

This study was designed to analyze a specific social interaction, by including participants who have different but complimentary experiences. This has enabled an understanding of experiences in mental health care which includes the dilemmas that we all face; “doing what others people want” or “going our own way.” This understanding also charts out processes of interpersonal negotiation and the influence of family and professional networks. The difficulty of becoming a person who can be held to account is observed. Mental health service users struggle to recover autonomy, as their choices can be understood as influenced by a disease process. At the same time, workers also struggle to express autonomy, because they are acting within a professional role as a member of a team. Participants in this study wanted to act with an understanding of the self as autonomous, complex, and reflexive, but are hindered by alternative interpretations.

The assessment of mental capacity is an increasing concern, particularly when this fluctuates (Owen, Freyenhagen, Richardson, & Hotopf, 2009). Dilemmas are created, where the right to choose is claimed or denied and judgements are made about who holds responsibility. In law, a person is held to account for their actions when their capacity is limited; if they have brought that state on themselves through drinking alcohol, or failing to take treatment for diabetes, for example, but this does not apply for mental health problems (Mitchell, 1999). Many factors can hinder our decision-making processes but in this situation, our biology is given special consideration.

Paradoxically, it is when our capacity is challenged and our options are limited that we feel the true nature of our being is revealed (Frankl, 1959). Disease, trauma, loss, and social isolation could be challenges which bring us into being as a resilient individual, rather than problems which undermine our autonomy. We might even choose hardships as a means of developing our capacity and our self-understanding. Practitioners might take up employment opportunities which stretch their ability and present them with interesting challenges. We place value on our freedom to make our own choices as individuals but, in rhetorical disputes, people are often positioned as if their decisions are determined by their narrative identity. An understanding of help seeking in health care is informed by social positioning theory, (Genuis, 2012) and issues of identity and self-congruence are important.

When people cannot be held to account for their choices, decision-making structures are imposed. This use of power is regulated through a proliferation of various guidelines, published by health care regulators. These normative structures are an understandable response to the anxiety we experience in an unpredictable existence. However, the material analyzed here suggests that “evidence based practice,” “managed health care systems” and other systemized organizational structures will never solve our individual dilemmas. Health practitioners are not just treating and managing illnesses. They are dealing with people. Managing illness by imposing treatment does not address the need to help people make sense of themselves, their emotions, or the decisions they must make in their lives.