Conclusions

This chapter highlights the development of the self-management approach to BD. As conceptualisations about the individual have changed, so have ideas about the location of health risks (Ogden, 1995). The contemporary view is that health risks reside within the individual, who has personal control and responsibility for his or her health. The rise of self-efficacy and personal responsibility models have had an impact at the national (expert patients), service (collaborative clinician-client approaches to treatment) and community (user-led self-management programmes) levels. The philosophy is well accepted, and the future of such approaches appears to be ensured. Furthermore, the idea of user-led programmes fits well into the general 'stepped-care' model of multidimensional approaches to the clinical treatment of BD. However, self-management is not for the faint-hearted. The difficulties of understanding and coping with a disorder such as BD should not be underestimated. However, as strongly expressed by one of the participants in Pollack's (1996) study, "It is a lot easier for me to take control of my life than to have someone run it for me."

The notion of self-management and empowerment is also implicit in professionally led therapies such as CBT. What was a chasm between those who treat mental disorders and those who have a disorder is reduced, and the therapist and the person with BD work together to understand and manage the problems that arise. This divide has been further reduced as people with BD are beginning to make a special contribution through the development of user-led self-management programmes.

Efforts to self-manage a disorder such as BD, where the expected health change is valued, are certainly worthwhile. However, there are risks inherent in the tendency to overstate personal control over health. Biology, like random events and factors, limits the degree to which health is under the control of the individual. It is vitally important that the limits on self-control and personal responsibility are recognised. One obvious consequence of setting unattainable standards is that many people will be blamed by themselves or others for their assumed failings, further undermining self-esteem. Nothing will more undermine individuals' confidence (self-efficacy) than to receive messages from care professionals and the wider society that they have failed as people when, or if, they become unwell.

The theme that runs through the shifting ideas about individual identity, the recovery model, and government policy is that an individual with a long-term disorder is someone with knowledge and expertise to contribute to the management of that disorder and the services provided. People with BD are no longer passive recipients of care but have personal control over their own health care and are a central component of health-care delivery for other people with BD. However, with control goes responsibility, and it is also important to set realistic limits—individuals need to be aware of what they can control and what is beyond their sphere of influence, so that we do not promise more than any of us is capable of delivering.

Letting Go, Moving On

Letting Go, Moving On

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