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When the patient doesn’t want to be cured

Individuals’ positivity about aspects of long-term conditions such as bipolar can be hard for nurses to understand

Individuals’ positivity about aspects of long-term conditions such as bipolar can be hard for nurses to understand


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Living with any long-term diagnosis brings with it many challenges. As it becomes more certain that the condition will be a permanent situation, then changes will have to be made.

In physical illness we often hear of living space being ‘adapted’, but what if the condition is a mental one? How do people adapt their internal living space?

We know in physical illnesses that the identity of a person soon becomes entangled with the demands of their condition. It’s common to hear people referred to by their diagnostic label. So you may refer to someone (or indeed yourself) as a diabetic rather than someone who has diabetes.

This seems more acceptable in some situations than others. We would probably cringe if someone was described in a cursory way as ‘an epileptic’, and rightly we are impatient with such insensitive and reductive approaches.

Beware a rush to stereotype

However, what if the condition you have developed has aspects you consider to be enjoyable and desirable?

If you could have spells of unlimited energy, great ideas and a feeling of extreme well-being when you believe you can do anything you set your mind to, wouldn’t that be wonderful? Or what if, as we head into a drab, cold and miserable winter, you could feel like you were on a sunny beach?

Such beliefs and experiences can be found in the moments of high mood associated with bipolar disorder. As clinicians working, however briefly, with individuals who have this label we need to be sensitive to the individual presentation that each person makes and not be hasty to seek confirmation of a stereotype.

‘Seeking and developing a good understanding of a person’s unique relationship with their bipolar diagnosis is essential to developing a therapeutic alliance’

New research from the University of Manchester suggests that while most people with bipolar would choose a full recovery, a significant minority would like to retain the highs associated with the condition because they see them as part of their make-up.

The authors of the study ‘The Button Question’: A mixed-methods study of whether patients want to keep or remove bipolar disorder, published in the Journal of Affective Disorders, call on clinicians to take a more individualised approach to treatment. For some people, this would mean focusing on depression and anxiety rather than the condition as a whole.

The idea that someone finds pleasure or enjoyment in any long-term condition may seem to run counter to our cultural values and professional education. Yet it is a wise and compassionate clinician who is prepared to ask difficult questions in a sensitive manner that enable the person fully to explain their lived experience.

Revisiting our own values and attitudes

Consider our reaction in any clinical setting, whether community, the emergency department or in mental health, when we meet a person who has engaged in self-injurious behaviour as a method of coping with extreme distress. Do we have the skills to ask ‘how does doing this help you?’ or do we consider this in some way reinforces the undesired behaviour and is a conversation we should avoid?

Similarly, seeking and developing a good understanding of a person’s unique relationship with their bipolar diagnosis is essential to developing a therapeutic alliance. This alliance, even if only transitory and enacted in a cubicle of an emergency department, enables trust and engagement with the person to begin.

It’s quite feasible that we have been exposed to a value system in our professional education that prompts us to evaluate all experience of mood disorders as negative and undesirable. However, listening to clients and their lived experience can enable us to see there are some aspects that are not only creative, functional and enabling but may actually be desirable to the individual.


Ian Hulatt is consultant editor of Mental Health Practice  

 

 


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