In this study, ‘staying well’ meant different things to each
participant. For some, it meant being free of symptoms and behaving ‘normally’.
For others, it meant being able to make choices and take control of their illness.
A 29-year-old university student described how managing her symptoms had given
her a sense of control over her illness “One of the best things I can
say about my illness now is that I am not scared of it anymore. I believe that
I have the power to control it. I have learnt how to manage my symptoms.” By
gaining greater control over the illness, many participants became less fearful
of the illness. With time, experience and insight, they described learning
to minimize the impact that the illness had on their lives. Although they were
all aware that the illness could not be cured, participants felt able to prevent
relapses of illness. For many participants, staying well involved separating
themselves from their illness. Although several participants stated that the
illness was not a character flaw, personality trait or sign of personal weakness,
they were aware that the diagnosis of bipolar mood disorder was perceived negatively
within the community. They felt that community attitudes were largely influenced
by the way the diagnosis was applied. When participants were described as ‘manic
depressive’ or ‘bipolar’, the medical diagnosis became a
label that defined the whole person, not just the illness. A 40-year-old lawyer
rejected this labeling. “At some point I must loosen the tag on my forehead
that says ‘bipolar’ and just get on with it. Otherwise I become
obsessed about my illness and then I become my illness.” The data indicate
a range of strategies that were used to stay well. The individual stay well
strategies were based on participants’ specific needs and social contexts.
Acceptance of diagnosis
The first step in learning to stay well was receiving the correct diagnosis,
and then accepting it. Unfortunately, many participants initially received
an incorrect diagnosis. For them, the misdiagnosis of manic depression, and
the subsequent mistreatment with incorrect medication, had serious implications
for their quality of life. The most common misdiagnoses were clinical depression,
schizophrenia, anxiety disorders, borderline personality disorder, and attention
A 35-year-old social worker felt health care professionals needed to take more
care when taking a history. “Unfortunately, the initial diagnosis and
treatment was for schizophrenia, which was a bit of a nightmare only because
the medication was all wrong and the doctor was not open to changing it. I
needed to change doctors to get the correct diagnosis. My new doctor took a
proper history, not just the presenting symptoms. With the correct diagnosis
and treatment, I took more control over my illness.” Those participants
who received the wrong diagnoses found the diagnosis of bipolar mood disorder
a relief. Once he was correctly diagnosed, a 47-year-old librarian educated
himself about bipolar mood disorder. “Once you know what it is, you can
deal with it. I’ve had bipolar
mood disorder all my life, but it was not until I knew what it was that I could
deal with it.” For many other participants, the diagnosis of bipolar
mood disorder came as a shock. Data indicate that there was often a period
of denial in which the diagnosis was not accepted.
The data indicate the importance of participants remaining ‘mindful’ that
they have bipolar mood disorder. ‘Mindfulness’ involved participants
being aware of themselves and how they were responding to their physical, mental,
emotional, social and physical environment. By maintaining a degree of vigilance,
participants were able to recognize when they needed to intervene with strategies
to prevent episodes of illness. Mindfulness helped the following participant,
a 52-year-old school teacher, to control the illness and minimize its impact
on her life. “I now understand the illness and its impact on my body.
I move swiftly to intercept a mood swing.” According to the data, health
care professionals often advised people with bipolar mood disorder to ‘take
their medication and forget about the illness’. Participants described
this as ‘bad advice’. Data indicates that people with bipolar mood
disorder benefit from maintaining an awareness of the illness’ presence.
A 57-year-old parks and gardens superintendent believed his mindfulness assisted
his wellness. “I am able to assist in my wellness by being aware and
observing what is happening to me. Sometimes I need to make changes to stay
well.” Participants made many different changes to their lives in order
to stay well. Data indicate that there was often a period of ‘trial and
error’ in which participants learnt what strategies worked for them and
what did not work.
Data indicates the importance of people with bipolar mood disorder learning
about the illness. Participants learnt about bipolar mood disorder through
books, health care professionals, mental health organizations, seminars,
support groups, internet and talking with people. Participants felt that
the sooner they accepted their illness, and learnt about it, the better chance
they had of managing it. In addition to being educated about bipolar mood
disorder, participants described the importance of learning about their own
individual response to the illness. Participants described the value of life
experience, including episodes of illness, as a learning process. A 39-year-old
mother and factory worker accepted her limitations. “Many people hope
for instant recovery. It takes time to learn how to control it. We learn
to monitor ourselves and accept what our bodies can do.” Participants
described the importance of time and life experience in learning to recognize
their individual trigger and warning signs.
Identify trigger factors
Insight into bipolar mood disorder involved participants knowing what factors
trigger episodes of illness. Participants were able to identify specific
things that triggered their episodes of bipolar mood disorder. According
to the data, the most common triggers were stress and sleep deprivation.
The relationship between stress and sleep was complex. In some cases stress
caused disruption to sleep. In other cases, a lack of sleep caused a low
resilience to stress. Participants also identified a number of other factors
that may trigger an episode of illness. These included fatigue, jet lag,
fluctuations, change of seasons, all night partying and recreational drugs.
Recognize warning signs
Participants described health care professionals advising them to watch for
expansiveness and undue enthusiasm, involvement in excessive numbers of projects,
poor judgment and changes in sexual and financial behavior. However participants
felt that these were late signs of an impending episode of mania. Participants
felt it was much better for them to recognize their early warning signs.
Participants described the importance of observing small changes in their
physical, mental and emotional status. Participants were particularly mindful
of small changes in sleep, mood, thoughts, and energy levels. They felt it
was important to take small changes seriously. Several participants relied
on close friends and family to help them to monitor their moods and behavior.
When participants experienced early warning signals, they implemented interventions
to ensure they avoided episodes of illness. According to the data, there
were many different types of interventions. Responses to early warning signs
included canceling work and social engagements, exercise, sleep, yoga and
meditation. In some cases participants increased/changed medication and made
an appointment with a health care professional. Participants had developed
strategies that worked best for them.
Managing sleep and stress
Data indicates that managing stress and sleep were crucial to staying well.
Most participants were vigilant about their sleeping patterns. They kept
regular bedtimes and avoided intellectual stimulation at night. Participants
described trying to avoid situations likely to disrupt their sleeping routine.
However, disruptions were sometimes hard to avoid. When sleep was disrupted,
participants did not hesitate to take medication to help them to sleep. Participants
developed various strategies to minimize the impact of stress. Many of these
strategies were related to managing workplace stress. These included regular
holidays, changing jobs, part-time work and regular counseling. Some participants
increased their medication during periods of increased stress. A 42-year-old
chief executive officer learnt to manage his work stress. As a result, he
also managed his illness. “Stress is a big trigger for me. To a large
extent, managing my illness is about managing my stress.”
Make lifestyle changes
Participants identified a number of lifestyle factors that helped them to stay
well. They included eating healthy foods, exercising, drinking less alcohol/caffeine,
sleeping well, spending time with loved ones, having quiet times, managing
stress, and laughing. These lifestyle factors help all people to stay well,
not only people with bipolar mood disorder. In addition to trying to maintain
a healthy lifestyle, participants described making specific changes in their
lives to stay well. Some lifestyle changes were small such as remembering
to take medication and being mindful about sleep. Others made significant
lifestyle changes such as adopting a quieter lifestyle in a rural community
and changing to a less stressful job. A 30-year-old woman left a stressful
job in the corporate sector to work part time in community health. “I
had to make huge changes in my life to stay well. Taking medication religiously
would be the smallest of these changes. I now lead a different but full life.”
Participants relied on a range of support networks to stay well. This included
partners, parents, children, brothers, sisters, friends, colleagues, pets,
churches, community and mental health groups and health care professionals.
With assistance from their support networks, participants described learning
to set limits and boundaries, establish safety nets and set up harm minimization
strategies. In particular, many participants enlisted the help of their personal
support networks to help them to recognize early warning signs. Participants
in this sample joined local community groups such as writing groups, book
clubs, music groups and sport clubs. They rarely joined mental health support
groups. A 50-year-old accountant disapproved of mental health support groups. “You
mix with the same people as in hospital. You drink coffee, smoke and talk
about the same things – hospital
admission, drug reactions and Centrelink. These groups do not encourage you
to get on with your life and get back to work.” Most participants received
some sort of professional psychiatric support, though the quality of the professional
psychiatric support varied enormously. Many participants shopped around to
find the type of professional support that best suited them. Many participants
found the process of choosing their own psychiatrist affirming. In addition
to shopping around for the most suitable health care professionals, several
participants preferred to work with a number of different mental health professionals
(GPs, psychiatrists, case managers, psychologists, social workers and counselors).
A 26-year-old speech pathologist acknowledged that psychiatrists and psychologists
had different expertise. “My visits with the psychiatrist are quick and
infrequent. I see him twice a year. He just prescribes medication and arranges
blood tests. My psychologist is more instrumental in helping me to get well.
We talk things through.” Several participants in this sample saw their
psychiatrist only once or twice a year. Their appointments were for routine
matters such as prescriptions and/or blood test requests. Participants were
generally happy with this arrangement. The data indicated that taking control
of bipolar mood disorder often involved knowing when to ask for help. It also
required knowing who to ask for help.
Stay well plans
The main finding from this research was the importance of stay well plans in
preventing episodes of illness. All participants described their own stay
well plan. Participants developed, adapted and revised their stay well plans
as their circumstances required. These plans identified their trigger factors.
They also identified their early warning behavioral changes and outlined
strategies for themselves and others to ensure that the participant stayed
well. In some cases, stay well plans were a verbal understanding with partners,
family, friends and health care professionals. In other cases, stay well
plans were an informal written document. Having a documented stay well plan
enabled participants to clearly identify their own triggers and warning signs.
It also helped partners, family and friends to feel comfortable with any
intervention that may be required.
- Russell, Sarah J. and Jan L. Browne; Staying Well with Bipolar Disorder;
Australian & New Zealand Journal of Psychiatry; Mar2005, Vol. 39 Issue
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #12
The preceding section contained information
about “stay well strategies” for clients with bipolar disorder. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
According to Russell, what are the eight steps in creating a “stay
well strategy”? Record the letter of the correct answer