The Experience Of Bipolar Disorder At Work


Dr. Menna M. Jones, DClinPsy
    Clinical Psychologist

The Centre for Doctoral Training in Clinical Psychology,
Whitchurch Hospital, Whitchurch, Cardiff. CF14 7XB


 

Abstract
People experiencing bipolar disorder have a strong desire to maintain employment, and display high academic achievement compared with people with other forms of affective difficulties. AIMS: To explore the views of people with bipolar disorder (BD) about how their experiences of BD influences their employment, and how being in work can change their experience of BD.

METHOD
Eleven semi-structured interviews were conducted with people with BD who had been in employment. Grounded Theory was used as the framework for analysing the data.

RESULTS
A complex interaction between BD and work functioning emerged. These included phases of mutually disruptive and mutually beneficial influences between people’s health and work. Transition from one phase to another occurred over time.

CONCLUSION
The experience of being a worker can be greatly enhanced as well as compromised by bipolar disorder.

KEY WORDS:
Bipolar, employment, rehabilitation, recovery

Introduction
Paid employment is a high priority for users of mental health services (Pozner & Jones, 1994). Among users of these services, people with bipolar disorder (BD) are associated with some of the highest rates of open employment. They do not, however, have higher rates of employment than people with other forms of affective disorders, despite their relatively greater academic achievement. Following diagnosis of BD, people achieve greater educational success than matched people with unipolar depression, but with no evidence of better occupational status or higher likelihood of being in employment (McGlashan, 1984).
 
BD is a form of affective disorder that results in severe, enduring and pervasive consequences on people’s lives (Coryell, Scheftner, Keller, Endicott, Maser & Klerman, 1993). Moreover, high relapse rates are associated with BD (Keller, Lavary, Kane, Gelenberg, Rosenbaum, Walzer & Baker, 1992). For both professionals within the mental health services and potential employers, attitudes towards the employment of such individuals are associated with fear and uncertainty (e.g. Black, 1992; Scheid & Anderson, 1995). Mental health professionals often discourage patients from seeking employment (Crowther & Marshall, 2002), and in the workplace any person who is known or is thought to have a mental illness may be subject to severe stigmatisation (Harding, Strauss, Hafez & Lieberman, 1987).
 
The impetus to extend knowledge of the experience of individuals with mental health problems in the workplace is currently being provided by an increasing focus on supporting such individuals within governmental legislation, both in the health and the employment domains. The necessity for incorporating employment support into community mental health service provision was crystalised within the National Service Frameworks (NSFs) for adult mental health services in England (Department of Health, 1999) and subsequently in Wales (Welsh Assembly Government, 2002). Similarly, employers’ responsibilities towards employees with mental health problems were enshrined in the publication of the Disability Discrimination Act in 1995.
 
A model for understanding the interaction between the experience of BD and the experience of being at work is provided by the Interactive Developmental Model (IDM: Strauss & Carpenter, 1981). It provides a structure that aims to define the interaction of an individual’s vulnerability from experiencing BD with the stress arising from environmental events or factors. In contrast with the diathesis-stress model, it proposes that the course of disorder is strongly affected by interactions between the individual and the environment. Within these interactions, either the individual or the environment can act as the initiator of change. Secondly, the individual develops over time, in that the person’s strengths and vulnerabilities change over time.
 
There are relatively sparse data on work functioning for people with BD. The information that does exist indicates that job functioning and status may be independent of the person’s recovery from symptoms (e.g. Dion, Tohen, Anthony, & Waternaux, 1988). For instance, Anthony and Jensen (1984) concluded that there seemed to be no symptoms or symptom patterns that were consistently related to individual work performance. More recently, it has been proposed that it is the long-term nature of such chronic conditions as BD, rather than the specific symptoms, that impact detrimentally upon work outcome (Anthony, Cohen, & Farkas, 1990).
 
With no substantive direct impact of BD symptoms upon work functioning, a number of indirect routes to work impairment have been evidenced empirically. Work productivity has, for instance, been found to be negatively correlated with the psychopathology of conceptual disorganisation for workers of BD (Massel, Liberman, Mintz, Jacobs, Rush, Giannini, & Zarate, 1990). Secondly, such mental health problems have been reported to form a barrier to effective coping with stress which is compounded by the impact of side-effects from medication (Secker, Grove, & Seebohm, 2001). Thirdly, the disabled status of people with mental health problems has itself been referred to as an impediment to work functioning (Massel et al., 1990). Finally, poor occupational functioning by people with BD (but not other forms of mental health problems) has been associated with negative labelling by friends and relatives (Beiser, Bean, Erickson, Zhang, Iacano, & Rector, 1994). Empirical exploration of the positive impact of experiencing BD on work functioning has largely been limited to the proposed association between the illness and heightened creativity (Andreasen, 1987). Some evidence is also available supporting an indirect link between bipolarity and high occupational achievement, mediated by the effect of socioeconomic advantage (Coryell, Endicott, Keller, Andreasen, Grove, Hirschlield, & Scheftner, 1989).
 
The impact of work on the experience of BD is thought to be both negative and positive. To address the negative forms of impact firstly, entering work entails an increase in psychological distress and loss of function (Anthony & Jensen, 1984). Entering work likewise entails removal of the potential for continued access to social and therapeutic support networks. Relapse of symptoms of BD have moreover been associated with work-related critical events, and events involving some aspect of goal-attainment more broadly (Johnson, Sandrow, Meyer, Winters, Miller, Solomon, & Keitner, 2000). Work activity was once regarded as a central component of comprehensive psychiatric treatment due to the emphasis placed on its therapeutic effects. It provides social identity and status, social contacts and support. It structures and occupies a person’s time in addition to providing a valuable alternative to the ‘patient’ role, and assists in decreasing symptomology and dependence on services (Bennett, 1978; Rowland & Perkins, 1988; Shepherd, 1984;).
 
It is apparent that the interactions between experiencing BD and workplace functioning involve a complex array of positive and negative influences. These are likely to be different for different people, as well as varying considerably over time. The extent and type of support will therefore also vary according to these interactions at any given time. It was therefore the aim of this study to survey the perspectives of people with BD on how their employment had impacted upon their experience of BD, and vice versa. In achieving this aim, knowledge would be gained of how to support workers with BD effectively, and inform the decisions they make regarding employment.


Method
Design
Data collection and analysis were led by the principles of Grounded Theory (Glaser & Strauss, 1967), in line with the study’s exploratory nature. This involved a multiple case study approach, during which people with BD were engaged in semi-structured interviews.
 
Participants
The participants were 11 adults (8 men and 3 women) who had received a formal diagnosis of BD (or manic depression), and who had been in employment at some time since their initial experiences of BD symptoms. Establishing whether or not potential participants had received such a formal medical diagnosis was based on their verbal report only. For the purposes of this study, employment was defined as any part-time of full-time work activity for which there had been a formal arrangement to receive a salary from an employer. By this definition, employment did not include periods of self-employment, voluntary work, education of vocational training.
 
Participants were recruited via non-statutory independent organisations throughout South Wales that provided information and support services for individuals experiencing mental health problems (e.g. Mind; the Manic Depression Fellowship; non-affiliated community services). People who wished to participate in the study contacted the researcher directly after being fully informed about the nature of the study and its purpose. They did this by posting signed participant consent forms to the researcher. The participants’ ages ranges from 37 to 68 years (with a mean age of 47.5 years and a standard deviation of 10.1 years), and all were first-language English speakers. 4 of the 11 participants were in paid employment, 2 of whom were employed on a full-time basis and 2 part-time. Both of the full-time workers and one of the part-time workers were in employment with a non-statutory mental health organisation.
Data Collection
Each participant met individually with the researcher on only one occasion, when a semi-structured interview was held. These interviews took place either at the participants’ places of employment, at the bases of the organisations where they were undertaking voluntary work, or at their homes. The duration of the interviews varied between 50 minutes and 1½ hours, mostly lasting between 1 hour and 1 hour 10 minutes. The schedule for the semi-structured interviews comprised of a series of key areas to discuss with each participant. These included their views of the perceived positive and negative effects of experiencing BD on their employment, and vice versa. Each interview was tape recorded and subsequently transferred to a typed transcript, when all identifying information were removed from the data.
 
Data Analysis
In line with the principles of Grounded Theory, the process of data analysis adhered to the guidelines outlined by Miles and Huberman (1984), and Strauss and Corbin (1998). Three phases of analysis were undertaken (Henwood & Pidgeon, 1995): During the first phase, open coding facilitated ‘data reduction’, where transcripts were read and reviewed repeatedly to identify and catalogue apparent themes and categories. During the second phase of data analysis, the data was organised in such a way as to facilitate interpretation, through axial coding. For each preliminary concept, all the corresponding data were identified and compared in order to consolidate categories of concepts. The third and final phase of data analysis saw the categories and their dimensions being integrated to construct an explanatory scheme.
 
 
Results

 
The following section provides an overview of the dominant themes to emerge from the data. In order to facilitate the account of the findings, categories and their subcategories are printed in bold type, and concepts are given in underlined type. Within the text, numbers given within parentheses indicate the number of participants to have contributed to the relevant category or concept. A diagrammatic representation of the links connecting the categories and concepts is given in figure 1.
 
Participants reflected extensively on the dilemmas encountered as people with BD who were either in employment or wished to be in work. A key issue involved attempting to maintain good health (in this respect entailing minimising the severity of BD-related symptoms) while also maximising work involvement. The interaction of BD and work appeared to fluctuate between a phase of mutually disruptive effects and a phase of mutually beneficial effects in line with such variations. In this sense, a disruptive interaction would involve predominantly detrimental effects of working on the experience of BD at the time. By contrast, a beneficial interaction would involve predominantly beneficial effects of working on the experience of BD at that time.
 
BD was described as influencing people’s experiences at work in a detrimental way in two ways: The negative effects of BD on work included both immediate situational effects, and also an indirect impact of having a history of episodes of BD on a general experience of being in employment. An example of such an indirect effects was the legacy of a disrupted work history (n=2) frustrating attempts to gain secure employment. This also entailed being unable to provide a good reference for future employment and a sense of being stigmatised as a potential employee:
 
Ian:
“Things aren’t going well. I’m in a bit of a catch-22 situation. Part of me wants to get another job, which hopefully would be better. But I can’t really, because I just can’t get a reference from my manager. And I’ve got a sick record, a bad sick record. So I’m stuck there.”
 
A second form of indirect impact of BD upon working life was in terms of the side-effects of medication (n=2). This included tiredness from taking tranquilliser medication, and sleepiness as a result of a regimen of depot injections, as illustrated by Dawn:
 
Dawn:
“I’m not blaming the doctors, the doctors have been quite good. But I was left on heavy medication for a lot of years, which affected the way I could work, actually, because even though I was working, I was very very tired. So obviously when you’re on sort of twenty tablets for a long time, you know, it’s quite difficult, and they were heavy tranquillisers.”
 
The direct and immediate effects of experiencing BD symptoms on work were expressed in several ways. Effects of depressive symptoms on work task performance (n=4) included compromising ability to make decisions, social withdrawal within the workplace, and a sense of being detached from one’s surroundings. For instance, Albert described an array of difficulties that appear to be regularly associated with depressive symptoms and which impacted detrimentally on his working life:
 
Albert:
“Oh, I was crying, not concentrating, I couldn’t do anything, I couldn’t take any decisions, I saw everything in terms of worries, rather than problems that come up in the course of things. And although I’d been quite successful in the six months, I was, well, in a bad way.”
 
Limitations of decision-making were not only attributed to depressive symptoms, however, as the effect of ‘being high’ on decision-making (n=2) was also noted:
 
Dawn:
“You go so high that you can’t think straight at all and you are absolutely talking rubbish. And it’s not the fact you’re talking rubbish, but it’s distressing, all those thoughts. Thoughts that are not coherent or anything. It’s a horrible time.”
 
 Changes in attitude to work responsibilities (n=4) varied both across the participants who commented on this area, and also individual participants described different experiences at different phases of their illness. The depressive phase of BD was perceived as causing both a strengthening and weakening of the sense of responsibility at work for different participants, and a manic phase of the illness was described as bringing an unrealistic tendency to assume responsibility for resolving colleagues’ work -related difficulties. Moreover, manic symptoms were implicated in the disruption of social relations in the workplace (n=3).

Barbara:
“When I’m ill I don’t think about responsibilities, or they don’t seem as important as what I want to do.”
 
Keith:
“And the worst time for me was on the down side, because I wasn’t doing what I should have been doing, and that’s consequently followed by guilt.”
 
Harry:
“When it went too far I started thinking that I could kind of help people at work who were kind of having problems, and I could change the course of events.”
 
Fred:
“I talked to people I worked with ever since, and what they’re always coming up with was they never knew what mood I was going to be in from day to day. . . They just couldn’t cope.”
 
The negative effects of being in employment on the experience of BD as identified by the participants were threefold. In all three examples, BD was affected in a detrimental way by work, where participants spoke of the precipitation of BD-related symptoms by events in the workplace. These events encompassed work scenarios involving stressful changes, interpersonal difficulties, and excessive pressure of demands. As examples of stressful changes (n=3) at work, participants referred to events over which they felt they had little control, such as needing to adapt to organisational changes in the workplace or changes in personal roles and responsibilities:
 
Craig:
“I was their manager, and I was being told that the department was going to remain in force, but by September of that year I was told that the department and all its activities was closing down. At the same time as all that happened, the managing director of that company and my immediate line manager also moved away.”
 
 Interpersonal difficulties (n=4) in the workplace were also implicated in the onset of manic symptoms. These included conflict with superiors, working to support clients who were in distress (as in Gail’s experience included below), and frustrations related to an unreciprocated attraction towards a colleague:
 
Gail:
“Just the pressure from the every-day problems when we’re working with that kind of group of people where there’s a lot of stress as well. Dealing with a lot of unhappy people.”
 
 The pressure of demands (n=3) at work emerged as a perceived precipitant of manic symptoms, with these people attributing the onset of such symptoms to over-work, and pressure of performing work duties, with also a possible role of performing undemanding work.
   
Harry:
“The main thing I can remember is that I was in charge of the commissioning team, and that became too much for me. . . We ran into problems, and I needed a bit of guidance, but my boss at the time was a different boss, and I didn’t know who to turn to.”
 
The positive effects of BD on work life were identified by participants in three areas. These included an effect of experiencing manic symptoms of enhancing task performance (n=5) in undertaking work duties, in improving participants’ general attitude to the work (n=3) that they engaged in, and finally in improving interpersonal relations in the workplace (n=4). In all three of these areas, work functioning was thought to be facilitated by the immediate and direct effects of experiencing the manic symptoms that are associated with episodes of BD, and also by the cumulative effects of having a history of BD episodes. By contrast, the experience of depressive symptoms were not identified as facilitators of work functioning in any particular way.
 
The effects of manic symptoms in improving task performance was portrayed mainly in terms of enhancing productivity and creativity, as described by Keith:
 
Keith:
“Somebody said once that I had a kangaroo mind, because I could think about four or five different problems at the same time. And I could handle them. So in that respect, being high helped.”
 
 The experience of such symptoms was thought to enhance attitude to work in that people with BD were portrayed as good workers. This was described in terms of loyalty to the employing organisation, punctuality, responsibility of attitude, energy and enthusiasm:
 
Ian:
“I guess that people who are slightly mad, they’ve got more energy, and they’ve got more joie de vivre, you know, got more enthusiasm. And I have heard of some people who try to adjust their medication so that they’re always sort of slightly a little bit manic.”
 
 The impact of experiencing BD on interpersonal relations in the workplace was highlighted by participants in two ways: Firstly, the experience of manic symptoms appeared to facilitate social interaction with others. Additionally, a history of BD episodes enhanced the workers’ empathy with they colleagues  and clients, as in Craig’s case:
 
Craig:“I think that my illness had made me a stronger manager because of that. I could see people getting stressed-out, visibly, within their working environment.”
  2 of the 11 participants identified positive effects of being in employment on BD. One of these (Dawn) highlighted the effects of employment in providing application to work tasks (n=1) and also in serving as a distraction from preoccupation (n=2) related to mental health problems, which was echoed by a second participant:

Dawn:
“I think the work has helped me to have structure and motivation and all sorts of thing, really. . . It’s quite important to work as far as possible, and keep a routine, I found, that’s really helped with my highs. Recently I’ve had a few low moods with the change in the anti-depressants, but it hasn’t lasted that long. It’s something that comes over me. But the work would actually take my mind off it actually. And being sort of focused.” 

The profile that was gained of such interactions provides an indication of where participants’ focus lies in thinking about being a person with BD at work. Participants’ contributions varied widely, and the breadth of their individual and collective accounts can provide an insight into the issues that they prioritise within this discussion. For instance, the impact of BD on work was commented upon more widely by participants than the impact of working on BD. These findings may suggest that the issue of being a worker with BD was dominated by thoughts of how BD impacts on work, more than how work affects BD. The positive and negative effects of BD on work were reflected upon equally by participants.

Discussion
There appeared to be common themes within the changing interaction of BD and work over time. These indicated phases of disruptive and beneficial influences between the domains of health and work in participants’ lives. Transition from one phase to another occurred over time, with the main determining factor being the presence of BD-related symptoms. Specifically, in the absence of BD symptoms, participants reported being able to maintain good work functioning, while the negative influences of a history of BD (e.g. a legacy of disrupted work history and medication side-effects) were out-weighed by such positive effects of BD as facilitating interpersonal relations in the workplace and attitude to work. This beneficial interaction of work and health was enhanced by engaging in work activities that reduced the likelihood of BD symptoms emerging, such as providing application to work tasks, and distraction from preoccupation. 

Episodes of BD-related symptoms occurred with varying frequency within the participant group, with each participant reporting at least one occasion when they endured such symptoms whilst at work. The onset of BD episodes was attributed by the participants to a range of causes, amongst which were work-related events such as stressful changes in the workplace or their own work duties, feeling the pressure of work demands in the absence of adequate support, or interpersonal difficulties at work. Regardless of the cause, onset of BD symptoms typically catalysed the transition of participants from experiencing a beneficial interaction of health and work to a more disruptive interaction of influences. 

Many of the factors that were operating in the beneficial interaction phase remained present at all times. However, with the onset of symptoms these were commonly accompanied by symptom-dependent negative influences between work and health. This was particularly clear from accounts of times when depressive symptoms were ongoing, which disrupted participants’ performance of work-related tasks and their attitudes to work responsibilities. These work-related consequences of depressive symptoms in turn increased the pressure of demands they endured from their responsibilities, thus establishing a cyclical pattern of deteriorating health and work functioning.

In the case of onset of manic symptoms, there appeared to be a period of time early in the episode when symptoms enhanced work performance and attitude towards some participants’ duties, while also disrupting ability to make decisions and maintain appropriate social relations in the workplace. Such positive effects of manic symptoms appeared, however, to be relatively short-lived, or over-shadowed as further increases in the severity of symptoms led to continued deterioration in the ability to perform tasks and function in the workplace.

A number of identifiable phases in the course of a disorder are laid out by the IDM, and there was considerable evidence of such phases in the accounts in the present study. For instance, during a moratorium phase, individuals are thought to experience stability in symptoms and functioning, when little measurable change in symptoms is occurring. This notion of a moratorium phase may apply to the periods when participants reported being in work in between episodes of BD. At these times, symptoms were minimal, and participants were able to benefit from their BD histories in the workplace in a sustainable way. For instance, a history of BD enhanced participants’ interpersonal skills and sense of empathy with their colleagues and employees. Change points in the course of disorder focused on participants’ accounts on the onset of BD-related symptoms. These were perceived as being caused by stresses in the working environment and the accumulation of work pressure in the absence of adequate support.

The research findings were intended to inform the integration of employment issues within the remit of both generic community mental health services and the development of more specialist employment services for people with mental health problems. For instance, within a generic service, the process of assessing clients’ difficulties and clinical needs might be enhanced by considering the impact of their employment on their experience of BD symptoms. With a knowledge of how stressful changes and processes in the workplace can precipitate the onset of symptoms, episodes of illness can be predicted beforehand and avoided. Secondly, the possible ways in which BD can affect experiences at work (both positively and negatively) and vice versa could be summarised for clients at the point of diagnosis. Clients would then be able to make informed decisions about whether or not to seek employment can be prepared for the challenge and opportunities that arise. Relevant to the context of specialised employment services, it was clear that people’s experiences of the interaction between an illness and the working environment change over time. An employment service would therefore need to be flexible enough to be sensitive to those changing needs and provide different levels of support at different times.