The role of work in recovery from bipolar disorders

Abstract

Being in recovery from bipolar disorder involves work-related concerns. The specific aims of this study are to: 1) understand the role of work in recovery from bipolar disorders, and 2) understand how people with such disorders deal with work-related challenges. These topics are examined from the stance of the recovery process, in which work-related activities were explored. Semi-structured, qualitative interviews were conducted with persons who had experienced recovery from bipolar disorder. Analysis was performed through thematic and phenomenological analysis, with hermeneutic phenomenology and reflexive methodology as a framework. The findings are presented through the following themes: 1) many types of work – finding meaning and a focus; 2) helpful roles and contexts – to be much more than a person with an illness; 3) making work possible – the role of supportive relationships and supportive medications, and 4) the costs of working too much – finding a meaningful and healthy balance.

Keywords

Mental health qualitative secondary analysis subjectivity work

Introduction

How can working life contribute to the process of recovery in bipolar disorders? Work is a central part of most people’s lives, and having a job provides a reasonable guarantee for income, predictable life conditions, personal growth and social contacts. Apart from the family, work can be the primary arena for achieving social status and social identity. These factors are also relevant for people experiencing severe mental illnesses such as bipolar disorders, and being in recovery naturally involves work-related concerns. However, a complicating factor is that psychosocial stress seems to have a negative impact on bipolar disorders (Post and Leverich, 2006), and working life may well involve social contexts with high demands and pressures upon both the self and others. An important area of investigation is to explore how people with a long-term history of bipolar disorder experience the opportunities and challenges of working life in their recovery process. What is the role of work in recovery from bipolar disorder? And when we examine this in the context of recovery: What is defined as work? Is it ordinary paid work, or are other types of meaningful activities involved? These are the questions we wanted to investigate in this study.

Background

The term recovery has emerged as an influential vision of what mental health services should look like over the past decades and around the world, despite being inconsistently understood and used. The term has been mentioned in consumer/survivor self-help efforts since the 1930s (Ralph and Corrigan, 2005) and became more prominent through social movements during the 1960s and 1970s. The research literature on recovery typically defines the term as an outcome or as a process (Borg and Davidson, 2008; Davidson, 2003; Ralph and Corrigan, 2005). Traditional psychiatry has more narrowly interpreted recovery as a clinical outcome (Resnick et al., 2005), or what Warner (1994) has called ‘total recovery’ where all original symptoms described and diagnosed have disappeared subjectively and objectively. Recovery, conceptualized as a process, is greatly supported by service users, being understood as finding ways of living and dealing with mental health problems and their consequences, and building on the strengths and interests in order to have a life and identity beyond that of a psychiatric patient. (Davidson, 2003; Deegan, 2005; Slade, 2009). Another discussion in attempts to conceptualize recovery is whether it should be seen as primarily an individual process or a social one. A great part of the research field continues to characterize recovery in individualistic ways (Anthony, 1993; Deegan, 2005). Although this can be a valuable contribution, it may well fall short when it comes to recognizing environmental and social impacts and the dynamics and relationships between the social and material contexts and the person (Borg and Davidson, 2008; Topor, et al., 2009; Tew, 2005). For the purpose of this study, the phrase ‘being in recovery’ refers to ‘learning how to live a safe, dignified, full and self-determined life, at times in the face of the enduring symptoms of a serious mental illness’ (Davidson et al., 2009: 324).

The role of work in recovery has been demonstrated in recent studies (Borg and Kristiansen, 2008; Krupa, 2004; Marwaha and Johnson, 2005; Perkins et al., 2009). One issue which is emphasized is the way work can offer a natural context for being a complete person with both strengths and weaknesses. Having a job provides conditions for the development of a unified sense of self that reconciles health and illness through the organizational structures of work.

Recovery research reveal that when people with the lived experience of mental distress are asked about their primary motivation for work, the prospects of being a worker, belonging to the normal, being needed and having expectations and hopes for recovery and empowerment are described (Borg and Kristiansen, 2008; Gewurtz and Kirsh, 2009; Krupa, 2004). There is relatively sparse data on recovery research exploring the meaning of work and the work functioning of people with bipolar disorders. Nevertheless, research from more than 25 years ago indicates that symptoms should not be considered a proxy measure for vocational functioning among persons experiencing severe mental disorders such as bipolar disorder (Anthony and Jensen, 1984). They concluded that there seemed to be no symptoms or symptom patterns that were consistently related to individual work performance. Jones (2005) reports from a study that the experience of being a worker can be greatly enhanced as well as compromised by bipolar disorder. The transition from one phase to another occurs over time, with the primary determining factor being the presence of related symptoms. In the absence of symptoms, participants reported a good work performance, while the presence of problematic symptoms was outweighed by such positive effects of bipolar disorders as facilitating interpersonal relationships in the workplace and the attitude towards work. The dynamic interaction of work and health was enhanced by engaging in work activities that reduced the likelihood of mental health problems emerging, such as providing engaging work tasks, and distraction from preoccupation. Michalak et al. (2007) describe the complexity of bipolar disorder with the typical combination of mood swings and how this can affect working life. Five themes emerged from these data: a lack of continuity in work history, a loss of time at work due to mood episodes, the building up of the capacity for symptom management, stigma and disclosure in the workplace and interpersonal problems. Even so, there has been a limited amount of attention to the complex relationship between work and bipolar disorders in terms of how working life can be of help in recovery.

Although severe mental illnesses such as bipolar disorder can have complex and long-term consequences on people’s lives in general as well as in their work performance, living with bipolar disorder is also associated with the experiencing of strong emotions, engagement and vitality. These experiences however can be challenging, as they tend to fluctuate between elated mastery and paralyzed anxious isolation, and of having or not having control over one’s own life (Karlsson, 2004). There are recent studies that examine self-management strategies in bipolar disorders, which reveal helpful strategies in dealing and living with the distress and symptoms in everyday life contexts (Michalak et al., 2007; Suto et al., 2010; Veseth et al., 2011a).

Being included in the ordinary workforce and mainstream society is a central goal of international mental health policies (Waghorn and Lloyd, 2005). Still, there has been a tendency to investigate the causes of unemployment, rather than to explore the service users’ potential and positive experiences at work (Boyce et al., 2008). Furthermore, psychiatric symptoms and their causes have been more attended to than service users’ resources, preferences and potential. Recovery research represents a contrast to this by emphasizing exploring subjective experiences of overcoming or learning to live with severe mental illness, as well as on the impact of contexts (Borg and Davidson, 2008; Davidson and Roe, 2007; Topor, et al., 2009). The specific aims of the current study are to: 1) understand the role of work in recovery from bipolar disorders, and 2) to understand how people with bipolar disorder deal with work-related challenges.

Methods

This article draws on data from a broader qualitative research study that explores recovery in bipolar disorders, with the primary purpose of identifying factors and experiences that supports the process of recovery. In-depth interviews were conducted using a hermeneutical-phenomenological approach developed within a reflexive-collaborative framework (see Veseth et al., 2011a; Veseth et al., 2011b). This combined method offers a context for approaching the experiential horizon of the participants, while also acknowledging that understanding their lived experience can only be accomplished through the interpretation of meaning (Kvale and Brinkmann, 2008; van Manen, 1990). Following Smith (1994) and Alvesson and Sköldberg (2000), we have put an emphasis on reflectively exploring how our intentions and preconceptions as researchers may have influenced the present study. In the participants’ narratives, a recurring theme was that work and work-related activities played an important role in the recovery process. The selected material in relation to the meaning of work in people’s lives provides the empirical basis for this article. The researchers in this study have all been professionals in mental health care, and have experiences from qualitative research. The first author is an occupational therapist, and the other three are clinical psychologists; the first author is a professor in mental health care, the second is a research fellow in clinical psychology, the third author is a professor in clinical psychology, and the fourth is associate professor in social work.

Participants

The participants were recruited through the four local health trusts of the Western Norway Regional Health Authority and through advertisements placed in local newspapers. The sample included adults with experiences from various subtypes of bipolar disorders and co-morbid clinical syndromes who were receiving or have received treatment for bipolar disorders, who also had varied educational, occupational and social backgrounds. They reported experiencing symptoms of bipolar disorder over the past 2 to 30 years, with a mean period of 18 years. Current hospitalization was an exclusion criterion. Seven women and six men participated in the study, ranging in age between 27–65 years old with a mean age of 47 years, though the majority were in their mid-forties. Seven of the participants were on a disability grant, and three were working full-time and three part-time in ordinary jobs. The participants on disability grants described a variety of occupations they were involved with during the week such as building and maintaining houses, being a caretaker for a family, self-help activities and hobbies, gardening, fishing and handicrafts, with some of these occupations giving them income. Eight participants were married or in a relationship and had children, one was in a relationship with no children and one was a single parent with adult children. None of the participants expressed any financial worries.

Semi-structured interviews

The second author conducted all the interviews. Semi-structured, qualitative in-depth interviews were chosen to facilitate an explorative dialogue about each participant’s experience of recovery, together with an invitation to reflect over their illness experiences as well as their journey of recovery. The interviews lasted between 45 to 110 minutes, with most lasting approximately 80 minutes. All interviews were transcribed verbatim by the second author, and the interview data were analyzed by means of thematic and phenomenological analysis (Cresswell, 1998; Davidson, 2003). The analysis was performed in the native language and translation of concepts and quotes was done in the final steps. The thematic and stepwise approach employed was an expansion of the methodology applied by Davidson et al. (2001). The first two steps involved an analysis of individual interviews to determine units of meaning related to work and occupations, and then across individual interviews, which was followed by grouping the material into provisional thematic patterns. These first steps were carried out independently by the first author. The third step involved the first three authors reflecting upon findings and modifying the patterns, in addition to searching for deeper connections (Smith et al., 2009). In the fourth step, the first author returned to the interview transcripts to verify and supplement the findings. Concepts, findings and discussions were reflected upon and discussed within the research group. The fourth author had a key role in the discussion part of the paper. Four major themes from the findings about the role of work in the recovery process were identified, and are presented and discussed in this article. In the findings, fictitious names are given for the participants when referring to citations.

Ethical considerations

The study was approved by the Regional Committee for Medical and Health Research Ethics Region West and by the National Social Science Data Service. The names of the participants used in this article are pseudonyms.

Findings

In the context of reanalyzing the interviews and focusing on the participants’ work experiences, we were concerned about having an open mind to their narratives and did not have any predefined definitions of work. As a result, we were in a position to explore a variety of activities and work-experiences of the participants and what they considered helpful in recovery. Six of the participants had ordinary work, whereas most of the other seven reported participating in regular activities in which some of them were work-like and provided them with some income. Our findings are presented through the following themes: 1) many types of work; 2) helpful roles and contexts; 3) making work possible, and 4) the costs of working too much.

Many types of work – finding meaning and a focus

The participants described a variety of jobs and activities, and work was not necessarily a paid job, but could be related to hobbies and skills that gave them some income. They talked about fishing, making fishing flies, baking or knitting, or voluntary work or interests they had had for a long time such as gardening, physical activities or cultural activities. Helping others who had problems was also highlighted by several of the participants as an important activity. The various activities offered meaning and structure, and were an important focus of attention during the day as expressed by Nina:

I just try to live a normal life and have stable routines and … . try to avoid too much stress if I can.

Nina explained that she had learned to take precautions in order to have a good and fulfilling life by being careful with alcohol, getting enough sleep, being aware of her emotional state and paying attention to signs of mania or depression. She also said, ‘Physical activity and nature is very good therapy’, and in regard to reading books:

That’s OK because you kind of enter another world and the other thoughts disappear for a while. Or you can do pottery, painting or knitting. Having some projects to work towards. That can be very important.

For many of the participants the amount of time spent at work was important. Some had been involved in ordinary full-time work, but had chosen to give it up due to stressful work conditions or because they felt it could not be combined with persistent symptoms. Others reduced their working hours in order to have a more flexible day and fill it with other activities. This also permitted the necessary rest and balancing of one’s energy during the day, which was essential for Ruth among others. In the interview, she was asked what she did to cope with her mental distress. Ruth explained:

Ruth: No, the most important that I do is to sleep … . I sleep 3–4 hours midday and also during the night ……

Interviewer: So it is important that you give yourself time to sleep?

Ruth: Yes, and that I work so much that I can sleep well. I work four hours as a cleaner and then a couple of hours in the garden and this makes me sleep well. It is just like medication really.

Ruth found sleeping and a sense of balance in her everyday life that was filled with meaningful activities she could master to be her best medication, as she expressed it. Another participant, Simen, who was unemployed, had developed what he called a solution-focused everyday life approach. He emphasized rational and positive thinking, getting enough sleep, physical activity, careful attention to medication and focusing on the future, just to mention some of his many strategies. Simen had spent recent years restoring the property where he grew up, and told of his experience:

… but I mean that there are great opportunities and resources in a person in spite of having setbacks mentally due to the illness. The entire time one must think resources, resources, resources. If you have resources, use those resources. It is very, very important; otherwise you get stuck in your patterns and dig yourself down in the shit.

The participants described how they had explored ways of living over the years with the coexistence of work and activities and persistent symptoms of bipolar disorder. They had expended a great amount of effort in finding the proper balance between rest and activity, being on their own or being sociable, and in being open for trial and error when it came to coping with the impact of the mood swings on their daily life. A common aspect in the recovery narratives was on the value of having meaningful activities or a work situation to be involved with during the week, in which they could use their skills and resources, and do something that had meaning for themselves as well as others.

Helpful roles and contexts – to be much more than a person with an illness

When talking about recovery in general, the participants frequently mentioned working life. Having a job made them feel better about themselves and their situation, being at work gave meaning to their life and the job was important in giving structure to their day and could sometimes be helpful in coping with the bipolar symptoms. Being a worker represented a role outside the illness role. Working was a ‘time-out’ from illness contexts and identities. Contextual features of work were also described, and some of these supported their working role while others could be a barrier. Typical examples included having a good working environment and being given a space where he or she could function and contribute, despite their bipolar symptoms. This was experienced as giving them encouragement and hope, and as being a helpful contrast to the focus in their lives on all their symptoms and problems. Setting goals, challenging oneself and having supportive contexts were experienced as positive. Maren reported two factors that had been particularly important in her recovery process:

I would say taking a university degree and using it in a qualified position has been most … I believe, most important. And I must add, combined with the respectful psychiatrist I’ve had, whom I’ve had sporadic meetings with, but more frequently now. That he all the time has acknowledged that it was crucial for me to be working.

Having a supportive professional who believed in him/her and encouraged them to work, as well as access to places that gave the feeling of being ‘normal’, was important. The experience of being seen as ‘normal’ could be about the pleasure of having an ordinary job, creating a job out of a hobby or simply experiencing the feeling of being needed and contributing. It could also be about the joy of functioning, of going to work in the morning and coming back home in the evening like most people in the neighbourhood. The participants talked about having the opportunity to be part of the ‘flow of things’ in everyday life. The concern of being ‘normal’ was not merely an individual phenomenon in the participants’ stories – they also referred to the value for their entire family, as experienced by Per:

Yes, having colleagues …. A lot of people’s social network of today is through work. That fact that I can say, I work with this and that. My kids can say it, my wife can say it, my parents can say it. It means a lot for them too. But the most for me, of course. And my health, that I have a structure to my life.

Work also offered the participants a context in which they could use their skills and resources, and several mentioned that work gave them the opportunity to make an effort and take chances. Fulfilling the expectations and functions of a job seemed to offer hope and courage that life could be fulfilling in spite of their mental distress. Turid described how she went to work no matter what:

I usually say that everyone has something they struggle with. I have this. It is tough. When you feel you’re run up and down. You feel you never can stay in the middle and kind of relax for a while. You’re running up and down. It is a terrible illness actually. But – I go to work every day …

Turid explained that her job was very important for her and that she had some good colleagues who took care of her in certain situations – who asked her to calm down if she got too ‘high.’ She continued:

I really care for that job … I feel that if I lose it, I have nothing.

Work could be helpful in handling the bipolar symptoms even if it wasn’t the ‘cure.’

Daily life with bipolar disorders can take its toll and following the participants’ stories there is rarely a simple solution, but people find their own ways of getting through tough periods. In spite of some complicated situations, the participants referred to work as a valuable and often stabilizing arena for belonging somewhere outside their house and family where they could be someone: a teacher, an industrial worker, a social worker or a service assistant.

As well as the positive sides of having a job, several of the participants dwelled on the contrasts in terms of how a longer, shorter or present unemployment situation caused distress for both them and their family. Unemployment was frequently associated with feelings of shame, of feeling small and of having no value, and was mentioned to be of difficulty in social settings.

Making work possible – the role of supportive relationships and supportive medications

Being a worker with a mood disorder also involved support and help from others, such as family, friends and professionals. Maren described how crucial it was that her psychiatrist encouraged her to work and that someone actually believed she could. Throughout the narratives, it was reported that this support was sometimes easily available, though hard to find and access at other times. General practitioners, mental health care workers and NAV (The Norwegian Labour and Welfare Service) were mentioned as being places where they had found faith, encouragement and practical assistance. For some of the participants, a well coordinated team of helpers was crucial in order to deal with both work and their general life situation. One issue that was highlighted was finding medication that functioned well with their job, meaning that it did not have any troubling side effects. The participants had lived with their bipolar problems over the course of many years, and had a great variety of experiences with medication. Being able to work meant that the medication must support the working role and not represent a barrier.

Supportive family members were also a recurrent theme when reflecting on what had been helpful for recovery in general, in addition to being related to working life or regular activities. Eight of the participants were living with a partner and had children, and in the context of being a family member, work was associated with having a socially accepted and valued role. Understanding partners were mentioned in various ways, such as being encouraging, taking on extra family duties in troublesome periods or simply being a stable person who represented continuity amidst all the ups and downs. It could also be parents or sisters or brothers who took responsibility in situations when needed, such as helping out with children or practical affairs and matters.

In concrete work situations, managers and colleagues played important roles. Solveig mentioned how the manager had prepared the situation for her on returning to work. First, she sent Solveig a letter, saying that they missed her, mentioning all her strengths and skills and inviting her for a cup of coffee when she felt up to it:

That letter was just so fantastic that …. I do not think I would have returned to work for a long time if it hadn’t been for that letter.

Coming back to her job, Solveig had this experience:

And she had planned things so well for me, so …. coming back …. she did everything she could to make me feel well when I came back …. she made it easy for me to come back, really …. the self-esteem isn’t that great when you’ve been off sick, so … the fact that she was able to convey that it was important to have me back, how important it was that I work … … and how important the job I did was …

Some final issues highlighted were flexibility in working or activity tasks and hours, to have frequent breaks and other practical arrangements that made work activities easier for each individual. Friendly and including colleagues were also mentioned, as well as people who could give feedback when needed or just be someone to chat with during working hours or on lunch breaks.

The cost of working too much – finding a meaningful and healthy balance

Many of the participants described long periods of very hard work and long working hours, and several related their first episode of mental illness to a period of working extremely hard, working day and night, and of having a very busy time for life in general.

Solveig was one of these people, and outlined how at Christmas time she felt extremely stressed, although she did not realize that something was seriously wrong:

No, … I … it was probably because I was working very hard, both at home and at my job, and it was soon Christmas, so it was this kind of stressful situation that in a way exposed it.

… … .

It was very scary, as it felt just like a speeding train was running in my head day and night. But I didn’t realize that I was ill, I just thought I was very stressed.

Another participant with a similar experience was Magnus, who had been a truck driver. He enjoyed working, felt he had succeeded in his tasks and was well-liked by his colleagues. He described how he gradually worked more and more and that there was quite a bit of alcohol in the evenings. In the same period, he was building a house for his family. He reports how he finally lost control over the stressful situation, became psychotic and was admitted to the local psychiatric hospital.

The participants talked about periods of life transformation from youth to adulthood, with the traditional expectations and challenges associated with. Some of them had experienced difficulties during childhood and adolescence, while others did not. However, what they all had in common was being an adult with a bipolar diagnosis and many years of great effort in finding ways to live a more or less fulfilling everyday life with a long-term mental health problem. Part of this effort was devoted to finding and establishing proper work. Working too much did not necessarily mean that their actual working hours were too many for their well-being, but rather in relation to work in the context of their everyday life in general, such as the combination of doing your job properly, taking care of your family, social responsibilities and getting enough sleep. In addition, many were concerned with staying well and controlling their situation. Like Maren explains on the question about what she does to cope with her mental distress:

What I do to cope with them? I’m not sure I cope with them all the time, no, I don’t do that, but I use a lot of willpower. Even when I’m depressed, I can manage that. I force myself to do things I know work.

Maren worked three days a week at the time of her interview, but was hoping to work full-time. Even though it could be difficult to work and stay concentrated and motivated for her job, she was one of those who found it helpful to make an effort, have strenuous days and simply be in a setting where she had to use her intellect and cognitive capacity. She felt it was helpful to be challenged.

Maintaining a work-rest balance seem to be an individual matter, according to the lived experiences of the 13 participants. Some expressed great concern and avoided situations of working too much, whereas others found it helpful to have challenges and going to work whatever the situation. The participants’ stories are a reminder of the complexities and coherence of everyday life.

Discussion

The findings of this study yield a complex picture of what being a part of the workforce meant for the participants. On the one hand, having full- or part-time work could be a goal, which for some related to the actual meaning of life. On the other hand, the participants described in detail the different challenges of work, such as finding work, problems associated with symptoms or simply coping with the psychosocial stress in working life. Being in a working context was seen as crucial to the recovery process for some participants while others found work a risk. There were also fluctuations reported; in some periods work was a central arena for practicing recovery while experiences were different at other times.

Work as a recovery-nurturing environment

Being in an ordinary environment and outside the illness context offered the participants opportunities for identity-building and developing a feeling of ‘being someone,’ which again gave hope for the future. As demonstrated in previous studies focusing on recovery contexts, work offers a framework for connecting to others in an ordinary everyday setting, for being an active agent in your life and having a respected role, as opposed to being a psychiatric patient (Borg and Davidson, 2008; Borg and Kristiansen, 2008; Topor, et al., 2009; Davidson, 2003; Tew, 2005). The content and context of work described by the participants varied, but common to all those activities was that they gave the person and his/her social network an understanding and view of the person not as a patient or service user, but as someone doing normal things and participating in a normal daily life. Through work and other meaningful activities the person achieves a new, normal role in relation to him/herself, to the social network and to society at large. This in turn provides contexts for different social interactions than that of the patient-professional, thereby helping to create a more positive sense of the self. For some participants work was of such importance, that losing it was apprehended as a loss of ‘everything.’ Another important aspect of the work context was that through the fulfilment of various tasks, the person experienced very concrete ways of overcoming the limitations of their illness. Several previous studies addresses the value of work in recovery (Borg and Kristiansen, 2008; Krupa, 2004, Marwaha and Johnson, 2005; Perkins et al., 2009). This present research adds to the knowledge base some insight into recovery oriented contextual aspects of work.

Dealing with work-related challenges

Managing problems in working life with bipolar disorder means dealing with the ordinary challenges of a workplace, as well as the presence of stress that maybe triggers one’s problems. The findings in this study may expand on previous ones (Michalak et al., 2007; Perkins et al., 2009; Suto et al., 2010) by putting an emphasis on the helpful aspects of work in recovery and strategies for overcoming barriers. To have a bipolar diagnosis and be a worker involves certain difficulties and some strategies were reported as helpful in managing risk situations: be aware of early signs and plan how to act, medication without too impairing side effects, a supportive social network, supportive colleagues and managers, and avoid drinking and partying. A common aspect of the participants work conditions was that they made it possible to normalize their social life. Work offered the opportunity to contribute to a common task and to help other people fulfil their obligations. Being part of a team created situations of reciprocity and interdependence. The ability to stay in the labour market could also be connected to a good relationship with health professionals, who included work and working life in the collaborative therapy process. Lessons learned by this study are that the demands put on a person by his/her job have to be taken into account by mental health professionals. As emphasized in much of the recovery literature, helpful relationships with professionals involves being seen as a person in the social context (Topor, et al., 2009; Krupa, 2004; Tew, 2005). Health and social care professionals need to acknowledge that appropriate work and meaningful activities improve mental health and well-being and that most people with mental health problems can pursue successful careers (Perkins et al., 2009).

Work as a risk

Several of the participants connected unhealthy and extreme work situations to their first episode and to relapses of their illness. Periods with cumulative stress were described by high expectations at work, high demands on themselves and an overloaded situation outside work. What seems to be important is a balanced daily life, in which there is neither too much nor too little in relation to activities and demands. Likewise, it seems important that the person living with bipolar problems gradually adds experiences and strategies in dealing with both social and work-life barriers, as well as recognizing and coping with individual warning signs. Although the importance of work for people in general has been well documented from health, social, economic and quality of life perspectives, recent research paints a more complex picture. Starrin and Jönsson (2006) argue for the need for more careful attention to employment conditions and psychosocial conditions when it comes to health risks and ill health. While unemployment has typically been correlated with poor health, low self-esteem and the risk of social exclusion and stigma (Marwaha and Johnson, 2005), it is well documented that disempowering and insecure work conditions also have psychosocial risks (Starrin and Jönsson, 2006). There is a great variation in people’s working contexts in terms of psychosocial and environmental factors such as being an influence on the workplace and tasks, social support, opportunities for personal development and bullying (Kristensen et al., 2009), which must be looked at further in order to obtain and maintain inclusive work environments.

Recovery as a framework

In this study, recovery is used as a framework for understanding and exploring work experiences of persons with a bipolar disorder: In accordance with reflexive methodology (Alvesson and Sköldberg, 2000), such a preconception can be understood as a prerequisite for addressing and understanding the phenomena under study as well as a limitation. Recovery as a framework makes possible a dialogue with our participants about their role as active agents in both their relationships to symptoms and their life as a whole; one of our main assumptions is that such agency and health are possible despite the symptoms. In contrast, a more traditional medical approach to persons with bipolar disorders may help to bring other aspects of the role of work in these persons’ lives into focus.

One important limitation of this study is that the centre of attention was on the positive sides of work in recovery for persons diagnosed with a bipolar syndrome, and this study is limited to persons in recovery. Future studies could also include participants who are experiencing setbacks in their recovery process due to work-related issues, and could focus more on the complexities in the relationship between work, mental health and recovery. Exploring the role of work in cultural settings other than this Norwegian sample is also important when examining the possible generalization of our findings.

Conclusions

Being regarded as a normal citizen involved in normal activities was revealed as having an important impact on the recovery process of the participants. In order to maintain an active work role, they developed a range of creative adjustments to their work situation, to themselves and to other people. The results from the study portray that a person with a bipolar diagnosis is an active agent in dealing not only with symptoms of their illness, but also with a range of situations in their daily life. This illustrates how important work and meaningful activities are in building a positive sense of the self, and how this sense of the self helps the person to fight against the experiences and consequences of his/her illness.

Most people with mental health problems who are out of work would like to be in paid employment. A combination of prejudice, discrimination, low expectations, lack of attention to people’s employment needs in mental health services and failure to provide tailored support, continue to deny many the opportunity to work (Perkins et al., 2009). Citizens with mental health problems remain among the most excluded within our society, and nowhere is this exclusion more evident than in the workplace. Perkins et al. (2009) argue that addressing the employment needs of people with mental health problems in assessments, consultations and treatment and support plans is essential. Like the participants of this study they remind us that many could be helped within existing work contexts if the structures and support were better integrated and tailored to the employment needs of the individual. Increasing access to paid work is essential in changing the way in which people with mental health problems like bipolar disorders are viewed in services as well as in our society.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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