Psychosocial factors to consider
Stigma in the workplace. Although most coworkers are tolerant of and fair-minded about the functional difficulties common in symptomatic bipolar disorder, some will have biased, inaccurate views about psychiatric conditions. Advise bipolar individuals to make case-by-case decisions about whether to provide personal information to other employees and, if so, how much.
As with most medical conditions, the default choice will be to not discuss personal information in the workplace. Some coworkers, however, might appreciate learning of the bipolar condition (for example, a supervisor who seems empathic to an employee’s seeming stressed state).
Realistic expectations. Most clinicians recognize that relief from a syndromal bipolar state is achieved more quickly than a sustained recovered status in which symptoms are minimal. Attaining functional capacity in a normal range also lags, both in time and in the proportion of persons who ever achieve sustained good function.12 Patients, their families, and often employers may have unrealistic expectations about early resumption of work after a depressive or manic episode resolves.
Ethnic considerations. Some literature suggests ethnic differences in the initial presentation of bipolar disorder, with more severe manifestations in some populations particularly if psychosis is a component symptom.13 Additionally, some cultural views about stigma from illness can add to patients’ or family members’ reluctance to re-enter the workplace.
Socioeconomic status. Sometimes bipolar illness puts out of reach the occupational activities that an individual has previously undertaken or that are characteristic of the family’s experience and expectations. Resistance to a change in self-concept can add to the difficulty in successfully moving a patient to consider employment that is more routinized and less intellectual or decisional in nature (Box 3).14
Divergence in education vs work status. Persons with bipolar disorders often have substantial divergence between high educational attainment and lower work performance. When this is the case, all or most of the factors reviewed in this article probably have contributed. Mrs. S’s experience illustrates this aspect of our care for persons with bipolar disorders.
Overcoming patient fixation on the idealized working self
An employment barrier for some bipolar patients is that a brief, often long-past period of high intellectual or vocational performance serves as the benchmark for their capabilities. Patients with this characteristic resist revising their self-concept. Some treat the loss of this idealized image as an unfair consequence of their illness or society’s reaction to bipolar disorder. Their stubbornness tends to prevent realistic engagement socially or vocationally at levels that are presently feasible for them.
Resistance to change associated with this characteristic often is difficult to manage effectively with short, relatively infrequent medication-focused visits. Specific psychosocial interventions may be more effective.14
CASE CONTINUED: Finding a new balance
After leaving the stressful high-level job, Mrs. S next resolved to limit her search to half-time positions and took a job with limited responsibilities in a bookstore. Her work productivity was outstanding, but she became easily flustered when asked to assume additional responsibilities. Some of these required quick learning of new skills in inventory re-supply or interacting with dissatisfied customers.
As she became more confident and less fearful of being fired, Mrs. S talked with 2 supervisors about her illness management. This halted their well-intentioned efforts to promote her, based on their perception of her as talented and engaging.
Attention to these workplace issues took up approximately half of the time in her regular psychiatric appointments for more than 1 year. Through this process, Mrs. S developed increasingly effective insight into the complex mix of her accomplishments and resilience on one hand and her fluctuating social and vocational impairment on the other. She also recognized that subsyndromal symptoms continued at times, despite her overall good functional state. These insights and her greater self-confidence helped Mrs. S resolve and manage the divergences in her own and others’ perceptions of her capabilities and potential.
Related Resource
- Coping with depression or bipolar disorder at your job (patient information). Depression and Bipolar Support Alliance. www.dbsalliance.org/site/PageServer?pagename=Employment_Information.
Disclosure
Dr. Bowden reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.