Note Of Caution

As discussed at the beginning of this chapter, reconfiguring individual identity as "intra-active" and relocating the risks to health to within the individual gives a rationale for the philosophy of self-management. However, in his presidential address at Yale University,

Brownell (1991) sounded a note of caution about over-emphasising individual personal responsibility and individual control over health.

Brownell described American culture as one that places immense emphasis on the power and responsibility of the individual. This description is mirrored in Ogden's views about the concept of personal responsibility for health being deeply ingrained in the individualism and self-reliance of the new Right in the USA. Brownlow postulated that whereas good health was seen as a means of attaining personal goals, it now also symbolises self-control, hard work, ambition and success in life. People expect and are expected to control their health, and this has moral implications. Those who have good health or remain well are judged as having positive qualities (strong and hard-working), in contrast to those who fall ill or have less than perfect health, who are judged as having negative qualities (passive and weak).

Those who fail to maintain or gain good health are likely to feel frightened, overwhelmed and vulnerable, and they may add to their own distress by making harsh judgements about themselves. The ensuing feelings of guilt and shame are likely to escalate their distress further. Moreover, they may be harshly judged and blamed by others, especially by what Brownlow termed the "self-righteous healthy". Exposure to people with health problems also makes healthy individuals feel more vulnerable and uncertain. This often leads to rationalisations or coping strategies that focus on the belief that the world is a just and fair place. As such "people get what they deserve and deserve what they get" (Lerner et al., 1976; Wortman & Lehman, 1985).

Other writers have also questioned whether, in contemporary Western culture, the point has been reached where it is not possible for an individual to become unwell without being at fault (Marantz, 1990). Marantz highlights the dangers of characterising episodes of illness as preventable, because this implies that the individual with that health problem becomes responsible for any recurrence. He argues that responsibility is attributed in this deterministic way because we all like to be able to explain why something has happened. However, calculating risk is meaningful only with respect to whole populations, and not to individuals, and were a risk factor to be correctly identified, it would not be an absolute cause of disorder. Marantz goes on to state that there is no known lifestyle (or self-management programme) which can ensure absence of health problems. For these reasons, he concludes that we should encourage people to modify known risk factors while, at the same time, "allowing them the luxury of getting sick without feeling guilty".

Brownlow argues that one of the reasons that people are so ready to attribute personal blame to others for disease is to be found in the paradoxical but coexisting beliefs about control. That is, we have control over our health yet at the same time are vulnerable to unpredictable factors. One resolution of this seeming paradox is overstating personal control and responsibility because it enables individuals to cope with the fear of having no or little control. Given the phenomenology of BD, in which an individual experiences marked and often unpredictable mood swings, it is vital to accept the limitations of personal responsibility and try to work within the realms of what can or cannot realistically be controlled or managed by any one individual.

The models described also have implications for health professionals. A collaborative working relationship between client and clinician requires the clinician to acknowledge and work with the clients' perceptions of their problems and an exploration of the clients' representation of the illness model. At the same time, clinicians should neither collude with inappropriate models nor be so rigid in their own theoretical stance that they cannot find common territory to form a working alliance. This is a challenge that many clinicians find frustrating. But, in reality, for the collaboration to be effective, the clinician and client must first develop a shared and accepted model of what is happening for that individual. Only when that negotiation is complete can they use this agreed (individualised) formulation to identify and prioritise the treatment or management interventions to be used. For many clinicians, this requires three things: a change in their style of interviewing and interaction, an acceptance of stress-vulnerability models of the disorder being treated, and an acceptance that health or well-being is not simply the absence of symptoms but is also the presence of a positive sense of self, and restoration or development of an appropriate quality of life for that individual.

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