Role of a ‘Stay Well’ Approach in the Management of Bipolar Disorder

The World Health Organization ranks bipolar disorder as the world's sixth most disabling condition [1]. There is a spectrum, however, in the way people experience the symptoms of bipolar disorder. Some people experience severe episodes of both mania and depression throughout their lives; others experience less severe symptoms less often. In addition, people respond differently to medical treatment. Despite these differences in the ways that bipolar disorder is experienced, research indicates that the illness trajectory of bipolar disorder may be influenced by a stay well plan.

Initial research focused on 100 people who lived well with bipolar disorder [2]. This research examined the role of social, environmental, cultural, personal, psychological and medical factors that promote and maintain wellness. The main finding from this research was the importance of a stay well plan in preventing episodes of illness [3]. The findings from this research led to two new research questions. First, can people with bipolar disorder be taught skills to assist them to develop a stay well plan? and second, can health-care professionals and carers be taught skills to assist people with bipolar disorder to develop their own stay well plan? To answer these questions, a multidisciplinary team, including people with bipolar disorder, developed curricula for two innovative programmes: a Stay Well Programme for people with bipolar disorder and a Stay Well Workshop for health-care professionals and support people (i.e. carers).

This editorial describes the theoretical principles and professional values that underpin the stay well approach. It also compares the stay well approach to other psychosocial interventions.

Concept of a stay well approach

‘Stay well plan’ is a term that refers to a specific approach to managing a chronic illness. The stay well approach focuses on wellness, not sickness. This approach has been applied to a range of conditions, both physical [4–7] and, more recently, psychiatric [1], [2], [8], [9]. The theoretical principles that underpin the stay well approach are based on the Ottawa Charter for health promotion [10]. According to the Ottawa Charter, health promotion is the ‘process of enabling people to increase control over, and to improve, their health’. The Ottawa Charter also advocates a ‘strengths-based approach’ [11]. Rather than focus on ‘what is wrong’, a strength-based approach identifies a person's positive abilities and resources. The stay well approach values the expertise of both health-care professionals and people with bipolar disorder. The National Health and Medical Research Council (NHMRC) Statement on consumer and community participation in health and medical research referred to ‘those most affected and intimately acquainted with the issues’ as providing important insights into health research [12]. People with bipolar disorder also provide insights into practice.

The stay well approach is distinct from, yet complements, other psychosocial education programmes. The stay well approach is unique because it incorporates physical, psychological, social, environmental, economic, and cultural factors (commonly referred to as the ‘biopsychosocial’ model) with a ‘wellness’ model. The stay well approach is also unique in the way that these two models are combined.

Combining medical and wellness models

Within the medical model, health-care professionals provide information and advice to patients. This advice is often based on evidence. But many people, including people with bipolar disorder, do not follow advice given to them by health-care professionals. This mismatch between what is prescribed in terms of medication or lifestyle changes and what patients actually do is commonly referred to as ‘non-compliance’. The literature largely interprets non-compliance as a problem located in irrational patient beliefs that contradict scientific evidence, or in patients’ lack of knowledge or understanding [13]. To improve compliance, health-care professionals design ‘compliance-enhancing’ interventions such as improved therapeutic communication and psychosocial education programmes. One of the stated aims of bipolar disorder psychoeducation programmes is to improve patient compliance, particularly compliance with medication [14].

Within a stay well approach, the concept of non-compliance is rejected [13]. Rather than label people who do not follow health-care professionals’ advice as ‘non-compliant’, and basing interventions on assumptions of patient irrationality or recalcitrance, a stay well approach provides the basis for understanding the aspects of patients’ lives that are contributing to their decisions. The stay well approach accepts people with bipolar disorder as experts in their own lives and their health choices.

The stay well approach brings together the expertise of health-care professionals with the expertise of a person with bipolar disorder. Within the stay well plan approach, health-care professionals provide expertise in medical, psychological and social treatments. This expertise involves health-care professionals ensuring a correct diagnosis, prescribing the right medication at the right dose, providing psychological treatments (e.g. cognitive behavioural therapy, counselling) and recommending social interventions (e.g. self-help groups, work, housing etc). In addition to professional expertise, a stay well approach positions people with bipolar disorder as experts about their own lives. A stay well approach recognizes the mediating effect of social, economic, environmental and cultural context.

Comparing Stay Well Programme with other structured programmes

Self-management is widely accepted for people with chronic physical illnesses, particularly illnesses such as heart failure, diabetes mellitus, asthma, HIV and arthritis. Self-management programmes are increasingly being used for people with bipolar disorder. There are now psychoeducational programmes promoting compliance to medication; promoting sleep and daily routine; monitoring moods; detection of early warning signs; and general coping strategies. There is evidence to show that these structured programmes have beneficial effects in preventing relapses [15]. For example, a randomized controlled trial (RCT) investigated the effectiveness of a new psychosocial education programme, the Collaborative Therapies Programme [16]. The RCT demonstrated significantly improved functioning (as measured on Global Assessment Functioning) and a positive trend in reducing relapses.

The Collaborative Therapies Programme is an example of a psychosocial education programme that is based on different principles to those used within a stay well approach. Within a stay well approach, people design their own interventions that are suitable to their social, economic and cultural contexts. The intervention is not prescribed. In contrast, the Collaborative Therapies Programme prescribes a specific intervention: the programme provides each participant with a ‘collaborative therapy journal’ to record stressors, early warning signs, coping strategies and goals [16]. Although ‘journalling’ is therapeutic for some people with bipolar disorder, others choose not to complete journals and mood charts. Research identified several reasons for people choosing not to journal: journalling made some people obsess about their illness, while others said that they did not have the time to journal. Some simply said that they were not good at writing – writing was not one of their strengths.

Like the Collaborative Therapies Programme, the Stay Well Programme teaches people to identify their triggers and warning signs. A range of educational activities, designed to accommodate different learning styles, assists participants of the Stay Well Programme to identify common triggers and warning signs. These activities also assist participants to become mindful of their specific triggers and their own early warning signs. During the Stay Well Programme, people with bipolar disorder learn how to maintain a lifestyle that is conducive to maintaining their mental wellness.

Developing a stay well plan

The stay well approach works with people's strengths to facilitate the development of a stay well plan. A stay well plan is not prescriptive– it is a guide. A stay well plan is developed by the person with bipolar, for the person with bipolar, often with the assistance of family, friends and health-care professionals. A stay well plan often needs to be updated and revised regularly as an individual's personal circumstances change. For example, when a person get married, divorced, has children, changes jobs, moves into a new neighbourhood, a stay well plan needs to respond to a person's new circumstances. Also, triggers and warning signs may change with time.

Since the term ‘stay well plan’ was first applied to bipolar disorder in the psychiatric literature [2], the terms ‘stay well plans’ and ‘well-being plans’ have been used to describe markedly different processes to the stay well approach [17–19]. In addition, a ‘Staying well with bipolar disorder’ fact sheet was published [18]. This fact sheet gave prescriptive instructions about how to formulate a stay well plan. Although fact sheets are educational tools that provide information to patients, prescriptive descriptions of a stay well plan are contrary to the theoretical principles of a stay well approach. The fact sheet described a stay well plan as a written document, despite the fact that there is no requirement that a stay well plan is a written document. Examples of stay well plans include fridge magnets, songs, poetry, paintings or any other creative expression. One participant in the Stay Well Programme formed a ‘Stay Well Committee’ as her stay well plan. This participant acknowledged the importance of ‘outside insight’ [9] in helping her to manage her illness. People on her Stay Well Committee were given permission to communicate any concerns about her mood. In addition, members of her Stay Well Committee were told explicitly what she wants them to do whenever they think things are not right for her. The participant described her Stay Well Committee as a ‘huge thing’ for her.

A stay well approach requires health-care professionals to shift their role from (i) an expert who gives advice to (ii) a professional who facilitates a person to develop their own stay well plan. This facilitation process is fundamental to the development of a stay well plan. It not only shifts power and authority towards patients, but accepts people with bipolar disorder as experts in their own lives and their health choices. But the Stay Well Workshop demonstrates some of the difficulties that health-care professionals may experience when they attempt to shift from an expert who provides prescriptive advice to the role of a facilitator. For example, the final session of each workshop includes a role play in which an experienced actor plays the role of ‘Jorja’. During this exercise, Jorja works with the workshop participants to develop a stay well plan. Several workshop participants have suggested that Jorja develops a daily routine. One participant wrote a timetable for her. This timetable included Jorja keeping a daily journal and recording her moods on a chart. Jorja then asked the participant if she could use the pen to write her own timetable. In addition, Jorja told the health-care professional that, with two young children, she did not have time to keep a daily journal or record her moods on a chart. She told the participant that she would not be able to ‘comply’ with the prescribed timetable.

Conclusion

A stay well approach brings the expertise of health-care professionals together with the expertise of a person with bipolar disorder. Within a stay well plan approach, health-care professionals provide expertise in medical, psychological and social treatments while the people with bipolar disorder provide expertise about their own lives. Rather than prescribe specific interventions, a stay well approach requires health-care professionals to work with people to assist them to design specific interventions that are suitable to their social, economic and cultural contexts. A stay well approach requires health-care professionals to shift their role. Rather than adopt the role of an expert who gives advice (and expects people to follow that advice), health-care professionals are facilitators. They facilitate a person to develop their own stay well plan.