Treating the Highs & Lows of Bipolar Adults

One of the obvious impacts on psychosocial functioning by psychiatric disability is in the domain of paid work or employment. Yet, despite this challenge being placed before us as health professionals over fifty years ago by those visionary men and women responsible for establishing services to help individuals achieve their vocational goals, the challenge remains largely unfulfilled today. "Vocational integration" as opposed to "vocational rehabilitation" has been chosen as the title for this paper. It is felt that "integration" more accurately reflects the process being outlined as opposed to "rehabilitation" which implies a change or therapeutic intervention taking place primarily in the client. It can be argued that changes within the service provider system, societal attitudes and within work-related legislation are also needed to ensure the successful placement in the workforce of those with psychiatric disabilities. Furthermore, the vocational integration of persons with psychiatric disability is a task shared by many service providers and practitioners from diverse professional backgrounds demanding, in turn, trans-agency and trans-disciplinary collaboration to ensure the necessary employment services are both available and effective.  The present study set to meet two main objectives: 1. To explore factors supporting an individual within the employment arena in terms of achieving his/her vocational goals. 2. To outline a theoretical framework that describes and explains the wide variations in vocational success seen between individuals with BD.

Factors that help people with BD achieve their vocational goals
This section aims to examine the various factors that helped people with BD return to work. Again, these factors appeared to be inter-related and, as previously, sub-themes were identified from the participants’ data in order to provide a more detailed understanding of the role these factors play in helping the process of vocational integration.

Factors which were related to the client • I was determined to succeed • I was a good worker • I had a professional qualification  • I had faith in God
Factors related to the job or work place • I gained a lot from having a job. For some participants the very fact of having a job, especially one that was paid and well supported, gave satisfaction and meaning to their lives and helped the participants keep the job. • The nature or structure of the work helped me stay on task.
Factors related to support from the client’s  family, friends and professional people • I had good support from family and friends  • I had good support from professionals and community support groups.
Factors related to my health • I was able to manage my illness effectively. A participant talked about how she coped at work when not feeling very well: "I’ve had to be aware that days when I wasn’t quite on top of things if somebody told me something I wrote it down. I wrote down exactly what I had to do. • I returned to work only when I was ready.
Factors related to support in the work place • I had a good manager/boss • I had good support from work-mates • I could take time off when unwell.
Factors related to people’s attitude • I have not experienced any stigma

Findings from the data outlined above suggested that factors assisting people with BD to integrate into paid work can be broadly divided into four categories: i) personality factors, ii) social upbringing and attitudes, iii) available support and iv) systemic factors including societal attitudes and government policies.  Mary and John belong to an older age group in this small selection of six people. Vocationally they both achieved reasonably well despite having had BD for over 20 years. Mary did not report any impairment in her daily functioning when interviewed in 1998. One year later, a meeting with her daughter revealed Mary’s ongoing mental well being. She established a new routine after retirement, spending time with her granddaughter and her friends. John lived with his wife and three boys. As with Mary, John did not report any functional impairment. Review of the interview transcripts and the participants’ case notes revealed that they were able to cope with their disorder while continuing to practice professionally over the years due to the following reasons. • Both Mary and John’s bipolar illness was effectively managed and did not cause much disruption to their work. • Their mental health needs were known, and accommodated by their employers.
• Both were determined to succeed in their career and to continue to work. • Both participants spoke of the great sympathy they received from management and workmates in their workplace and from their husband/wife or children. • Both found strength in the meaning, professional nature and structure of their work. Because of their professional qualifications, work was readily available to them. In addition, Mary developed a reputation of being a highly skilled professional. Holidays also provided John with the opportunity to rest and enabled him to spend time with his family and while working on his professional development.

The emerging theory
One of the main findings from the present study was the wide variability with which individuals with BD are able to engage in paid work. Most research participants saw the individual’s stage of recovery from his/her bipolar disorder, and/or effective management of the disorder as pivotal in ensuring vocational success. Specifically, reasonable control of the clinical symptomatology associated with BD determined whether or not a person was ready to enter the vocational integration process although it did not mean that a person must wait until he/she was totally symptom free. Another important theme emerging from the data to help explain the vocational outcome of people with BD was the notion of "goodness of fit". Four key components emerged from the data in this respect. These were: i) the individual; ii) support; iii) work and iv) wider context components. For instance, a participant who recovered from BD might still have a variety of functional impairments such as a short attention span, lack of confidence or inadequate organizational skills. These difficulties did not have to result in disability, however, providing the employer was willing to accommodate his/her employee’s increased requirements and did not erect barriers to employment by stigmatizing or even discriminating against that person. What appeared to matter most was not only how well an individual coped with his/her illness per se, but also how well an individual’s disability due to BD was accommodated by his/her employers. In other words, a person
who had very frequent hospital admissions might still be able to secure a paid job if there existed "goodness of fit" between his/her absences and leave entitlements and between his/her mood swings and the flexibility and creativity required from the job.  Furthermore, a participant’s potential to return to work might be significantly enhanced through the provision of a flexible work schedule with frequent, short breaks, temporarily simplifying expected tasks and the provision of extra support for the person and his/her workmates. In the long-term, if an individual was able to hold down meaningful work for a significant length of time it could have a beneficial effect upon that person’s recovery from BD. In turn, the better the recovery from mental health problems the greater the opportunities people with BD would have to improve their career prospects resulting in a better outcome to the vocational integration process.

The vocational integration model comprises several interacting components. The "Individual Component" relates primarily to a person’s personality attributes, his/her determination to succeed vocationally and how the re-occurring nature of the illness, the disturbances caused by the illness, the adverse side effects of medication, stress in workplace and, finally, loss of confidence is dealt with. The "Support Component" refers to all positive, enabling supports a person with BD receives from a wide variety of sources including family, social networks, professionals and community support systems. The "Work Component" includes factors such as the meaning and satisfaction of a job to the individual, a job’s flexibility and structure along with the match between a job’s demands and a person’s abilities and/or disabilities. Finally the "Wider Context Component" encompasses such issues as societal attitudes, the consequences of government health and disability policies, income support policies and the overall economic status of the country. For any given individual, one particular component might play a more significant role in determining his/her vocational outcome than the others. Findings from the data suggested that the four components "interacted" with each other to influence the overall success, or otherwise, of a person’s employment outcome. The importance a particular component played also appeared to depend upon an individual’s current stage of illness. The present study proposes that being employed should not be viewed as the end of the rehabilitation process in itself. Achieving an employment status can potentially act as a catalyst to prompt the person concerned to further advance his/her career pursuits and recovery from BD.
- Tse, S. and M. Yeats; What Helps People with Bipolar Affective Disorder Succeed in Employment: A Grounded Theory Approach; Work; 2002; Vol. 19, p. 47
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #9
The preceding section contained information about creating a healthy work environment for bipolar clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 23
What four components affect the establishment of a successful work environment for a bipolar client? Record the letter of the correct answer the CEU Answer Booklet.