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Research
Self-management techniques
for bipolar disorder in a sample
of New Zealand Chinese
Grace Wang, Samson Tse, Erin E. Michalak
Aims: The aim of the study presented in this article was to consider how New Zealand Chinese
with bipolar disorder manage their condition, regain and maintain wellness through the use of
self-management techniques.
Methods: Nine New Zealand Chinese with bipolar disorder type I or II who had reasonable performance
in role functioning were interviewed. Data analysis was guided by the inductive approach.
Findings: In contrast to Western psychosocial interventions, which emphasize the individual’s
independence, self-advocacy and self-identity, New Zealand Chinese are more likely to value
themselves through relationships with others. Most participants emphasized the importance of
harmony with self and others, and adopted passive and nature-oriented attitudes encouraged by
Taoism to deal with life stress. Strategies of ‘taking it easy’ and ‘looking at problems in others’ shoes’
were frequently used when dealing with interpersonal conflicts.
Conclusions: The concepts of health and life as part of traditional Chinese culture were found to
be the fundamental elements influencing the participants’ coping patterns. There is a strong need
for facilitating the connection between health professionals and clients. This study indicates that to
do this, health professionals must be aware of the importance of cultural sensitivity when delivering
health care in a multicultural environment.
Key words: n acculturation n bipolar disorder n culture n wellness management
Submitted 16 July 2009, sent back for revisions 25 August; accepted for publication following double-blind peer review
1 September 2009
Grace Wang is Research
Assistant, Department
of Psychological
Medicine, University of
Auckland, New Zealand;
Samson Tse is Associate
Professor, Department
of Social Work and
Social Administration,
University of Hong
Kong, Hong Kong;
and and Erin E.
Michalek is Assistant
Professor, Department
of Psychiatry, University
of British Columbia,
Vancouver, Canada
Correspondence to:
S Tse
E-mail: [email protected]
602
H
igh rates of relapse and other poor
psychosocial outcomes remain for
some individuals with bipolar disorder
(BD), even after syndromal remission
has been achieved (Bauer et al, 2006; Michalak
et al, 2006). Increasing emphasis is now being
placed on the interplay between restoration of psychosocial functioning and recovery in BD (Tse
and Yeats, 2002; Michalak et al, 2006; Miklowitz
et al, 2008). Recent studies have suggested that
self-management strategies can play a key role in
determining psychosocial outcomes, such as social
roles, quality of life and vocational performance
(Rizvi and Zaretsky, 2007; Miklowitz et al, 2008;
Krupa et al, 2009) .
To date, few studies have examined the self-management strategies used by non-English speaking
cohorts with BD who reside in Western countries,
such as the UK or New Zealand. It is evident that
the methods used by Chinese people to maintain
health and the meaning behind these methods
are different from those used by Western people
(Zheng and Berry, 1991; Chen, 1996; Tsai, 2001;
Yip, 2005). Such methods are often influenced
by a person’s religious upbringing. For example,
Buddhism explains everything in the form of cause
and effect and encourages people to do good and
to follow the right path, and thus receive good in
turn, while Taoism emphasizes integration with the
law of nature and encourages people to remain in
a state of ‘nothingness’ and let everything happen
naturally (Yip, 2004). Generally speaking, Chinese
people consider health as being related to harmoniousness, which could be influenced by state of
mind, regardless of the external environment and
social conditions. The social environment includes
all things and events that surround an individual,
such as the air, plants, people, society, death, illness
and even spiritual thoughts. In order to harmonize
oneself with the social environment, a person has
to accept what happens in life and modify themselves to best fit in with it.
International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11
Studying New Zealand Chinese expands understanding of the effects of culture and ethnicity on
illness self-management strategies. The aim of the
study discussed here was to demonstrate how New
Zealand Chinese with BD manage their condition, regaining and maintaining wellness by using
self-management techniques. In this study,
self-management strategies refer to actions people
initiate, or activities they are involved in, to maintain or regain wellness, such as taking medication,
relaxation and maintaining a sense of hope.
Methods
Participants
The study was approved by the Northern X
Regional Ethics Committee and the respective District Health Board ethics committees.
The authors recruited people aged over 18 years
who were Chinese, who had a diagnosis of BD
type I or II, and had reasonable performance in role
functioning. Inclusion criteria dictated that participants needed to have a minimum global score of
2 on the clinician-administered Multidimensional
Scale of Independent Functioning (MSIF) (Jaeger
et al, 2003) which facilitates the assessment of
functioning across work, residential and educational domains and has been validated for use in
BD (Berns et al, 2007).
A purposive sampling method was used to
select people with significant experience of coping with BD and knowledge of the application of
self-management strategies, the main focus of the
study. The authors initially approached local case
managers from stated-funded community mental
health centres and asked them to recruit potential
participants. Once verbal approval was granted
by possible participants, case managers gave their
contact details to the authors, and the authors contacted the possible participants to arrange a time
and place for an interview. Prior to the interviews,
all participants signed a consent form and the
researchers went through the details provided on
the participant information sheet with them.
A total of nine participants met the criteria and
consented to participate in the individual interviews. Two participants were born in New Zealand
and the remainder in Hong Kong or mainland
China. Clinical and demographic details for the
sample are presented in Table 1. With participants’
permission, further information regarding clinical characteristics and treatment variables was
obtained from the participants’ case managers.
Interviews
The interviews took place in a venue nominated
by the participants. The prompt questions used in
Table 1.
Clinical and demographic characteristics of the sample (n=9)
Characteristics Number
Gender: Female
Male
5
4
Age (years):
41±12 (20–56)*
Employment status:
Part-time tertiary education
Paid part-time employment
Housewife (looking after dependent children)
Unemployed
2
4
1
2
Age at first diagnosis (years):
30±9 (14–41)*
Years with illness:
10±6 (4–22)*
Number of hospitalizations:
1–2
3–5
6
6
2
1
*Number shows mean, standard deviation and range (years)
the interview included: ‘Could you describe what’s
going on in your life when you’re feeling well?’,
‘How do friends, family and co-workers affect
your ability to stay well?’, ‘How do you know it is
the right time to start using self-management strategies?’. The exact patterning of questions varied
across the interviews depending on the participants’ response to each question.
Six interviews were conducted with the authors
in Chinese (either Mandarin or Cantonese) and
three were conducted in English. The first author is
fluent in Mandarin and English, the second author
is fluent in Cantonese and English. With participants’ permission, the interviews were audiotaped and field notes were taken. Four participants
refused to have their interviews taped, so extensive
notes were recorded.
Analysis
The audiotapes were transcribed immediately after
the interviews to improve the quality of transcription, and maximize the recall in terms of the context of the conversation. The data was analysed in
the primary language in which the interview was
conducted to reduce translation-generated error.
The quotes reported in this paper were translated
from Chinese to English by the first author when
necessary. To minimize error, translated quotes
were randomly audited by an independent bilingual translator and a native English speaker with
a psychology background. Four face-to-face or
telephone follow-up interviews were conducted
with participants to verify the accuracy of the
general themes that emerged from the first round
of interviews.
The data analysis of the present study was
guided by the inductive approach as outlined by
International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11
603
Research
Ulin et al (2005), which included the following
steps: reading, coding, displaying and reducing.
Reading is the process used to gain an overview
of emerging themes raised by participants. Coding
is the attaching of particular codes to the chunk
of text that represents those themes. Once the
transcripts have been coded, each thematic area is
explored in detail through displaying the information relevant to each category. Lastly, the information is reduced to its essential points. All interview
transcripts were read by the first and second author
and the themes identified independently.
Findings
Four themes were identified from the interview data.
All the participants’ names were changed – pseudonyms are used here.
Viewing the current condition through a more
positive framework
Experiencing a relapse was the biggest challenge
for all participants, and the process of rebuilding
a sense of hope very difficult. Hope was expressed
by some participants in the form of following their
perceived notion of fate as a guidance mechanism,
for example, ‘time will heal the wound’ or ‘time
will solve the problem’. The participants with this
belief tended to accept their conditions with a neutral attitude and were able to keep a sense of inner
peace despite calamity. In their view, patience is
important in dealing with the stress and frustration
caused by recurrent episodes, and it helps in sustaining their motivation for achievement:
‘I tell myself that the sun will rise from the
East, tomorrow is another day, be tough...
I believe time will solve problems, I would
not be like this forever, I will be fine.’ (Fen,
female, early 20s).
In contrast, some participants felt that the
Western concept of independence and autonomy
significantly changed their perspectives of themselves and the illness, which helped them feel
more positive towards the future and gain a sense
of control over the course of recovery from BD:
‘In China, the doctor is a driver, whereas
the patient is an assistant. In New Zealand,
it is the opposite. The patient becomes the
driver, whereas the doctor is an assistant.
When I went to see a doctor in China, I
must take my family with me, which made
me feel worthless. Here I could go by
myself, I have a lot of control.’ (Jun, male,
early 30s)
Family responsibility and support also cultivated
a sense of hope among several participants, for
example, one individual believed that parental
responsibility toward her children forced her to
604
stay positive in facing the challenges and adverse
effects related to BD, such as financial hardship
and parenting issues. In her words, she would
have committed suicide if it were not for her
dependent children:
‘My children are still young. If I am dead,
who will take care of them? I think belief
and children are very important to keep
my hope.’ (Jie, female, 40s)
Another participant echoed this sentiment:
‘When I am in a difficult situation and
want to give up, my family would
encourage me by saying, ‘You can do it’.
Their support makes me keep going.’
(Hua, female, 40s)
Religious belief was also cited by participants
as their source of hope. De, a male in his 30s
described God as always being with him and helping him to find a way out, regardless of the situation. Another participant (Jun, male, early 30s)
recently became a Christian and reported feeling
‘more positive after believing in God’, and ‘having conversations with him when I feel a difficulty
with coping’.
Understanding the importance
of taking medications
Although all nine participants acknowledged the
importance of taking medications in sustaining
their recovery, several participants failed to take
medication as prescribed. Those who did not take
the medications as prescribed expressed feelings
of neglect by their doctors and felt less satisfied
with their treatment than others. In their view, their
doctors did not know how to treat them aside from
prescribing medication:
‘You have to rely on yourself for most
things. The doctor only asks you to take
pills, which makes you feel dizzy and gives
you a headache.’ (Jie, female, 40s)
‘No doctor can cure me. During those
years, I had to rely on myself to find a way
to deal with my illness.’ (Ping, female,
late 30s)
By contrast, other individuals who reported
taking their medication reliably expressed a deep
feeling of trust and respect towards their treating
doctors. In their view, taking medication was not a
bad thing, and the doctor would help them manage
the side effects of medication and reduce the dosage as necessary:
‘Taking medication for the rest of your life
is not a bad thing. Medication definitely
has side effects but the doctor will
gradually reduce the amount you intake.’
(Zhi, male, 40s)
International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11
‘Medication always leads to side effects…
I had this experience before. I could not
do anything when I took one medication.
Then I told my doctor and he changed it to
another one for me. Now I don’t feel any
strong side effects and it works.’
(Bei, female, 50s)
Maintaining harmony
With the exception of one individual, all of the
participants lived with their families. Family was
a primary social support for most Chinese participants in the study. As a result, Chinese participants
strongly emphasized the importance of family connection. Having interpersonal conflicts with family
members was considered to be the main source of
daily stress by half the sample. In order to avoid
conflicts, participants had learnt to adopt the attitude of ‘taking it easy’, and ‘looking at things in
others’ shoes’ to deal with interpersonal stress:
‘Going through many relapses has changed
my world-view and belief a lot… I started
to put myself in others’ shoes and look at
things from other peoples’ perspectives. I
also became more understanding of others
and stopped forcing others to listen to
me.’ (Zhi, male, 40s)
Others mentioned that willingness to compromise helped them to better manage their negative
emotions and improved relationships with others:
‘I tried to avoid conflict with my mother-inlaw. She is old fashioned and always has
different perspectives. But I know she had
good intentions.’ (Hua, female, 40s)
Being vigilant and cautious when disclosing
the illness to others
Coping with stigma related to mental illness posed
a big challenge to Chinese participants. Some people dealt with stigma by ‘keeping it a secret’ or ‘not
telling others’. In particular they mentioned ‘not
to tell Chinese people as they can’t accept it’ (Jun,
male, 30s), as they experienced strong discrimination from their Chinese friends. In the present study,
none of the Chinese participants reported any experience of being actively discriminated against by
Western people after disclosing their illness:
‘I have a friend who practices Chinese
medicine. One day he saw me with red
eyes and asked me what had happened.
I answered ‘nothing – just that I was in a
bad mood, I have depression’. He asked
whether I become physically violent
when I am sick. His words made me
very disappointed. He was a doctor, but
made such a comment. Don’t disclose the
illness to Chinese people as they really
discriminate against people with mental
illness.’ (Jie, female, 40s)
Another male participant had a similar experience:
“Chinese people find it hard to accept this
illness. Some of my old friends stayed
away from me after knowing about my
illness, although we used to be very close.
They thought I was worthless.” (Jun, male,
early 30s)
A few participants also described the difficulty in
developing romantic relationships.
‘Because of taking medication every day,
I could not find a boyfriend. Which man
would like to see you take pills every
day?’ (Ping, female, later 30s)
‘It is difficult to have a girlfriend. I can’t
talk about my illness to others. If I tell
them, they may be afraid of me and think
I become violent when I am sick.’ (De,
male, 30s)
However, three participants denied having any
experience of discrimination. More specifically,
two participants who were born in New Zealand
felt comfortable about their illness and stated that
‘if others ask me, I will tell them’.
One participant believed that stigma was actually about her own perception.
‘That’s funny, because the only person
who stigmatizes me is myself. Most of my
friends, even those that learned I have
this problem – it does not bother them. I
am the only one who stigmatizes myself.’
(Bei, female, 50s)
Bei went on to describe how her attitude has
changed since moving to New Zealand. She
believed that being able to disclose the illness to
others was a way to get the best help.
‘We are Chinese; we don’t want people
to know our mental illness. This is a
problem I had when I was in Hong Kong.
I hid from others. I didn’t want them to
know that I was crazy. Only here (in New
Zealand) after this episode, I am willing to
say it aloud. I don’t feel shame any more.
Especially here in New Zealand, there
are lots of information and tools to help
people with mental illness to speak up.
Once you speak up, you get assistance.’
(Bei, female, 50s)
Discussion
The majority of Chinese people in the present
study tended to prefer Chinese language, living
style, values and philosophies. Even in the case
of the two locally born participants, they were
International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11
605
Research
somewhat influenced by Chinese traditional values that were held by their family members. The
concepts of health and life, developed from traditional Chinese culture, were found to be the fundamental elements influencing the participants’
coping patterns.
The authors observed that the virtues of tolerance and endurance seemed to assist the Chinese
participants in enduring their suffering and developing a sense of hope when facing the hardships
associated with living with a chronic, recurrent
illness. An important way to regain mental wellness was to self-cultivate emotional coping strategies to maintain harmony within oneself and with
others. According to Western culture, these kinds
of ‘passive acceptance’ and ‘emotional coping’
are considered to be maladaptive, especially when
facing stress which demands immediate actions
(Friedman, 1990; Mattlin et al, 1990).
Several participants in this sample described
how religion or spiritual beliefs helped them to
cultivate their sense of hope against the recurrent
episodes of bipolar illness. Spiritual beliefs facilitate coping, can act as a protective factor against
substance abuse and suicide, and also have a positive effect on adherence with medications (Mohr
et al, 2006). However, integrating spirituality and
mental illness can be problematic and, in particular, difficulties may occur when spiritual beliefs
become entangled with psychotic symptoms in
BD (Michalak et al, 2006). Research has shown
that over 30% of people who are non-adherent
with their medications report a conflict between
their spiritual beliefs and their attitudes towards
pharmacological/therapeutic interventions (Borras
et al, 2007). Thus, it may be important for the
clinician to open a dialogue with their client about
the client’s spiritual beliefs and explore whether
this affects the approach they wish to take to managing their life with BD.
In this sample, there was a clear relationship
between participants’ connection with their medical doctors or health professionals and their attitudes towards medication. Shin (1996) has argued
that, according to Chinese social expectations,
health professionals are thought to be kind, gracious and sensitive with respect to others’ feelings and to regard their patients as their ‘family’.
Consistent with current literature (Fisher, 2005;
Martins and Reid, 2007), the present study indicated that there is a strong need for facilitating
the connection between health professionals and
patients. Health professionals should not only
give instructions about the treatment, but gain better understanding of their patients from diverse
cultural and linguistic background. For instance,
Mitchell and Selmes (2007) reviewed stud606
ies on medication non-adherence, and suggested
that health professionals should facilitate a collaborative communication style and make a joint
therapeutic plan with patients in order to improve
satisfaction with medication, and reliability of
medication use.
This may be of particular relevance to Chinese
patients given the Chinese traditional perception
of a doctor as an authority figure. The importance
of attending to treatment alliance in BD is further underscored by research demonstrating that
a stronger alliance predicts fewer manic symptoms over time, fewer negative attitudes towards
mood stabilizing medications, and a lower sense
of stigma (Strauss and Johnson, 2006).
Several qualitative and quantitative studies in
non-Chinese populations have now shown that
experiences and perceptions of stigma are common in BD (Michalak et al, 2006; Meiser et al,
2007) and that perceived stigma can have profound implications for behaviours and outcomes
(Perlick et al, 2001). The present study revealed
that for New Zealand Chinese recovering from
BD, the connection with their families and the
wider Chinese community can be a ‘doubleedged sword’ as both the psychological support
and stigma associated with mental illness were
rooted in their community. The majority of the
participants regarded their families as a source of
support to aid their recovery from BD, and indeed,
other research has indicated that good social support is protective in the condition (Johnson et al,
1999). Connecting meaningfully with other people was important to many in this sample. On the
other hand, families or some members of the local
Chinese community were the source of interpersonal conflicts and stigma associated with mental illness. These findings are concordant with
other research comparing attitudes held towards
mental illness in the general public in Japan versus Australia (Griffiths et al, 2006), which found
higher rates of personal stigma and social distance
towards mental disorders in Japan, in comparison with Australia. As perceived stigma has been
shown to be related to reduced social functioning
in people with BD (Perlick et al, 2001) and to
other negative outcomes, such as reduced adherence with medications. Further exploration into
experiences of stigma in Chinese individuals living with BD is called for.
Conclusion
New Zealand Chinese are exposed to both Western
and Eastern influences. As a result, their responses
in relation to their illnesses become much more
complex. In order to decrease health expendi-
International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11
ture and improve the quality of health services,
it is important to develop our understanding of
how cultural factors impact on individuals’
self-management strategies. Firstly, the quality
of the relationships between health professionals and patients has to be addressed. Healthcare
workers need to receive cross-cultural training to
increase their understanding of problems faced
by their patients from diverse linguistic and cultural backgrounds. Secondly, current psychosocial
intervention programmes for BD such as psychoeducation, cognitive-behavioural therapy, and
family-focused therapy should take into account
traditional Chinese concepts, such as harmony,
balance and tolerance (Rizvi and Zaretsky, 2007;
Miklowitz et al, 2008). It is important to develop
these programmes within the appropriate cultural
framework, which requires the health service provider to understand, respect and be able to work
with people from different cultural backgrounds.
With regard to future research, an evaluation of
the effectiveness of self-management strategies
in improving psychological and social function is
recommended. Also, further research is needed to
explore the effects of acculturation on self-management skills of bipolar illness among Chinese
immigrants over an extended period of time.
This qualitative analysis is based on a relatively small sample and is not intended to be representative of the larger Chinese population in
New Zealand, particularly because New Zealand
Chinese form a heterogeneous group which has
a varied and geographically diverse immigration
history. For example, the immigrant Chinese population is composed of both native and foreignborn individuals coming from mainland China,
Taiwan, Hong Kong, Singapore and other areas.
Nevertheless, the use of a small sample from a
community setting allows researchers and mental
health practitioners to develop an in-depth understanding of the complex recovery experience of
New Zealand Chinese with BD. This qualitative
study does not seek to test hypothesis but generates new idea for further investigations. IJTR
Conflict of interest: none
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Key points
n This study considers how New Zealand Chinese with bipolar disorder
manage their condition, maintaining and regaining wellness through the use
of self-management techniques.
n The concepts of health and life, developed from traditional Chinese culture,
were found to be the fundamental elements influencing the coping patterns of New Zealand Chinese.
n The virtues of tolerance and endurance seemed to assist the Chinese
participants in enduring their suffering and developing a sense of
hope when facing the hardships associated with living with a chronic,
recurrent illness.
n The connection with their families and the wider Chinese community can be
a ‘double-edged sword’.
n There was a clear relationship between New Zealand Chinese patients’
connection with their health professionals and their attitudes towards their treatment.
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COMMENTARy
With a prevalence of 1 to 2%
(Merikangas et al, 2007), there
are approximately 65 million
people in the world who are
living with bipolar disorder. The
World Health Organization lists
bipolar disorder in the top ten of
all illnesses, in terms of years of
life lived with disability (Murray
and Lopez, 1996). In the United
States, the costs associated
with bipolar disorder – aggregating across its treatment,
lost wages, and other economic indicators – is upwards of
$50 billion per year (Kleinman
et al, 2003). Despite how profoundly debilitating and costly
this illness is, we know little
about the optimal ‘recipe’ for
its treatment and for attaining
recovery. Data from a prospective study indicates that even
when people have access to
state-of-the-art care, most people with bipolar disorder spend
most of the time depressed
and with functional impairments (Post et al, 2003). By
any metric, bipolar disorder is
a public health problem that is
deserving of research attention,
particularly in terms of how we
can assist people in managing
life with this complex, chronic,
and fluctuating illness.
How do people manage the
medical, role-related, and emotional aspects of living with
608
bipolar disorder? Qualitative
research is well suited to
addressing such a question, as
exemplified by Wang et al in
this article. Combining the findings of Wang et al with those
of the few available studies
on the subjective experience of
self-management in bipolar disorder, several themes emerge
(Michalak et al, 2005; Russell
and Browne, 2005; Depp et al,
2008). First is the importance of
establishing routines, identifying early warning signs, making
plans to stay well – all of these
practices are consistent with
models for how psychotherapy
works to prevent recurrence
in bipolar disorder. This convergence of consumer-centered
and clinician viewpoints is comforting with regard to the utility of psychosocial treatments.
However, care must taken in
over-interpreting this agreement, as the samples used for
qualitative studies are often
from people who are actively
engaged in clinical care.
The second theme is that
there are some areas that
may not be addressed by routine clinical care, but that are
highly relevant to quality of
life. Spirituality is one example. Stigma, another example, has a powerful and direct
effect on self-esteem, as well
as indirect influence on quality
of life through raising barriers
to participation in care, the
workforce, and relationships.
Self-management programmes
for bipolar disorder should not
neglect the important and complex issue of stigma.
Third, bipolar disorder can be
an extremely isolating condition, as depressive symptoms,
the wake of manic episodes,
and stigma, all take their toll on
relationships. Support groups,
internet bulletin boards, and
other socialization resources
are thus a vital part of illness
management for many.
In this article, Wang et
al introduce to research on
self‑management in bipolar disorder another layer of complexity – the influence of culture.
Given that bipolar disorder is a
global illness, it is of paramount
importance that we begin to
understand how self‑management is influenced by
culture-based norms and practices so that we can tailor
treatment approaches to cultural values. Furthermore, it
may be that Eastern values
of equanimity, harmony, and
balance, such as described in
Wang et al’s article, supply
new ingredients to the recipe
for self-care for all people with
bipolar disorder. The more we
can listen to and learn from
these individual experiences
of living with this illness, the
more tools we can use to chip
away at the disability produced
by bipolar disorder.
Colin Depp, Ph.D.
Department of Psychiatry
University of California San Diego
La Jolla, California, USA
[email protected]
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International Journal of Therapy and Rehabilitation, November 2009, Vol 16, No 11