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RESILIENCE PROCESS IN BIPOLAR DISORDER FROM THE VIEWS OF PATIENTS AND HEALTH PROFESSIONALS

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Bipolar disorder (BD) is associated with negative social, family, and occupational functioning and quality of life outcomes, with the impairment in these areas evident even after symptomatic recovery (Angst et al., 2003; Hirschfeld, Lewis, & Vornik, 2003; Merikangas et al., 2011). Because of the asso-ciated role impairment, high risk of suicide, comor-bidity with other lifetime DSM-IV-TR disorders, and severe symptoms of BD, it has a high socioeconomic and public health burden (Hirschfeld et al., 2003; Merikangas et al., 2011; Woods, 2000). Therefore, most research has focused on the clear negative as-pects of BD (Galvez, Thommi, & Ghaemi, 2011). Nev-ertheless, a paradigm shift in the conceptualization

of mental health should occur to facilitate progres-sion toward a positive and salutogenic approach that complements and balances the traditional literature striving mainly to alleviate negative symptoms and restore functioning (Fava & Tomba, 2009). Accord-ingly, researchers and clinicians should also pro-mote the acquisition and the experience of positive factors, such as resilience factors, which will help in the lasting recovery of individuals with BD.

Some autobiographical reports indicate the po-tential to experience wellness, manage mental health, and live a fulfilling life with BD (Mansell, Pow-ell, Pedley, Thomas, & Jones, 2010; Russell & Browne, 2005). For example, Mansell et al. (2010) found that the key factors associated with positive outcomes and personal recovery in BD include an understanding of bipolar experiences, lifestyle fun-damentals (stable sleep, diet, and routine in

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ROCESO DE RESILIENCIA EN EL TRASTORNO BIPOLAR DESDE LA

PERSPECTIVA DE PACIENTES y PROFESIONALES DE LA SALuD

Ainara Echezarraga

1

, Carlota Las Hayas

1

, Esther Calvete

1

,

Ana María González-Pinto

2,3

& Steven Jones

4

Abstract

Research about resilience in bipolar disorders (BD) is scarce, or lacking in reference to qualitative studies.A qualitative phenomenological study was performed to understand the intrapersonal process of resilience as experienced by patients in remission from BD and from the perspectives of clinicians experts in BD. A total of 15 participants in remission from BD (mean age = 42.88 and SD = 11.99) par-ticipated in individual interviews or in a focus group. Six mental health clinicians attended two focus groups. Data were transcribed for thematic analysis. All participants reported a meaningful experience of resilience during the remission journey from BD, identifying seven main themes. Although data were retrospective and sensitive to memory bias, findings are relevant for interventions in BD.

Key words:Bipolar disorder, mental health, resilience, qualitative, health promotion.

Resumen

La investigación en resiliencia en el trastorno bipolar (TB) es escasa, o ausente respecto a estu-dios cualitativos. Se realizó un estudio cualitativo fenomenológico para comprender el proceso in-trapersonal de la resiliencia desde la perspectiva de pacientes en remisión del TB y de clínicos expertos en el TB. Quince participantes en remisión del TB (edad media = 42.88, SD = 11.99) partic-iparon en entrevistas individuales o en un grupo focal. Seis clínicos atendieron dos grupos focales. Los datos fueron transcritos para su análisis temático. Todos reportaron la experiencia de la resilien-cia en el TB, identificando siete temas principales.A pesar del carácter retrospectivo de los datos y su sensibilidad a sesgos de recuerdo, los resultados son relevantes para intervenciones en el TB.

Palabras clave:Trastorno bipolar, salud mental, resiliencia, cualitativo, promoción de la salud. Recibido: 25-10-17 | Aceptado: 24-06-18

1University of Deusto, Spain. 2University Hospital Santiago

Apos-tol, Spain. 3CIBERSAM. 4Lancaster University, United Kingdom.

E-Mail: a.echezarraga@deusto.es

REVISTA ARGENTINA DE CLÍNICA PSICOLÓGICA XXVIII p.p. 794-807 © 2019 Fundación AIGLÉ.

RESILIENCE PROCESS IN BIPOLAR DISORDER FROM THE VIEWS

OF PATIENTS AND HEALTH PROFESSIONALS

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sonal/occupational activities), social support, and companionship (openness and involvement with/from others). Similarly, Todd, Jones, and Lob-ban (2012) acknowledged the process of recovery from BD in their qualitative study; they described it as a process that requires taking responsibility for one’s own wellness, self-management based on cur-rent skills, and overcoming obstacles to recovery, without implying the absence of symptoms (Todd et al., 2012). Recovery in mental health cannot be ex-plained solely by psychopathology, psychosocial functioning, or symptomatic dimensions but also by personal changes in the attitudes, values, goals, and skills by which people can live fulfilling lives despite experiencingy mental health symptoms and vulner-abilities (Agrest & Druetta, 2011; Andresen, Oades, & Caputi, 2003; Anthony, 1993; Davidson et al., 2001; Whitley and Drake, 2010; Slade, Amering, & Oades, 2008). This approach of recovery is, at pre-sent, established in mental health policies and guidelines (e.g., Department of Health, 2011; Presi-dent's New Freedom Commission on Mental Health, 2003). Along this line, BD has been associated with positive psychological features, including creativity, enthusiasm, sensitivity/empathy, social extrover-sion, and occupational or educational productivity, suggesting that preserving and enhancing these as-pects may improve outcomes in BD (Galvez et al., 2011; Lobban, Taylor, Murray, & Jones, 2012; Murray & Johnson, 2010; Weich et al., 2012; Taylor, Fletcher, & Lobban, 2015).

Resilience was defined by Wathen et al. (2012) as the “dynamic process in which psychological, social, environmental, and biological factors interact to en-able an individual at any stage of life to develop, maintain, or regain his/her mental health despite ex-posure to adversity” (p. 10). According to Reivich and Shatté (2002) and Pesce, Assis, Santos, and Oliveira (2004), resilience could be acquired, built, and taught at any moment in life, but its qualities could be dependent on the context (Luthar, Cicchetti, & Becker, 2000; Rutter, 1987; 1999) and the individ-ual’s lifespan (Fletcher & Fletcher, 2005); therefore, an individual is not ensured to be resilient in all cir-cumstances. It contributes to the promotion and maintenance of mental health and quality of life, in general (Grotberg, 2003), and is important in over-coming challenges associated with mental disorders, such as depression, eating disorders, and schizophrenia (Dowrick, Kokanovic, Hegarty, Grif-fiths, & Gunn, 2008; Las Hayas et al., 2014; Torgals-bøen, 2011). For example, in a 15-year follow-up study of people with schizophrenia (Torgalsbøen, 2011), resilience was positively associated with later psychosocial functioning and negatively with nega-tive symptoms. Consistent with this, Las Hayas et al. (2014) found higher levels of resilience in individuals who had recovered from eating disorders than in in-dividuals currently diagnosed with one. Another

qualitative study found the presence of resilient qualities in participants in remission from six differ-ent mdiffer-ental disorders, including BD (Edward, Welch, & Chater, 2009).

To our knowledge, only three studies have specif-ically looked at resilience in BD. Choi et al. (2015), from their quantitative study with participants diag-nosed with BD (n = 62), concluded that resilience en-hancement may make important contributions in improving treatment outcomes. In another study, Echezarraga, Las Hayas, González-Pinto, and Jones (2017a) developed a questionnaire to assess re-silience dimensions and reported that rere-silience scores were higher for people who had recovered from BD in comparison with people not recovered from it. Later, in a longitudinal study, Echezarraga, Calvete, González-Pinto, and Las Hayas (2017b) found that resilience dimensions were positively re-lated with mental health indicators in BD and that they were mutually related between each other, ex-cept for the turning point resilience dimension. The turning point, which consists of determination and commitment directed to change the stressful and painful situation caused by this condition in order to overcome it (Echezarraga et al., 2017a), was nega-tively associated with some positive indicators of mental health at baseline (Echezarraga et al., 2017b). The authors proposed that, according to the litera-ture on resilience, a turning point occurs when a per-son experiences a stressful and painful experience (Garmezy, 1991; Rutter, 2013), occurs when a person questions whether his/her lifestyle requires a change, and might act as a trigger to activate the re-silience process. Experiencing a turning point does not guarantee the achievement of positive mental health outcomes. In the same study, the self-confi-dence resilience dimension predicted an improve-ment in personal recovery at follow-up and, at the same time, an improvement of self-confidence me-diated the predictive relationship between interper-sonal support and self-care at baseline and perinterper-sonal recovery at follow-up. These findings suggest that some resilience factors promote changes in other re-silience factors.

The above findings provide preliminary evidence of the beneficial role of resilience in recovery from BD. Identifying the process of resilience and the spe-cific resilience qualitites that lead to positive adap-tation in specific types of patients (e.g., BD) could help clinicians plan individualized resilience inter-ventions to strengthen these resilience qualities (Wright, Masten, & Narayan, 2013). The interpreta-tion of some of the findings could be improved by means of qualitative studies that include the per-spectives of patients with BD and professionals in its treatment. Nevertheless, a critical review of the re-search literature indicates that positive accounts of living with BD remain largely absent (Russell & Browne, 2005; Wright et al., 2013). Moreover,

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qual-itative research exploring resilience experiences in people with BD is lacking.

Aims of This Study

This study aims to explore the views of BD pa-tients and experienced clinicians on the resilience process experienced by people living with BD. The perspective of experienced clinicians is also relevant because during therapy they have multiple opportu-nities to observe resilience in their clients diagnosed with BD. Thus, this study explores the extent to which different information sources (patients and clinicians) might yield different results. Additionally, a variety of methods have been used to increase the credibility of the results (Williamson, 2005): method triangulation, using individual interviews and focus groups to explore the same phenomenon, as used in in other qualitative studies across the health field (Las Hayas et al., 2016; Morden, Jinks, Ong, Porcheret, & Dziedzic, 2014; Taylor et al., 2015; Weich et al., 2012); the member check procedure, in which preliminary thematic analyses are presented to participants to verify, add information or contra-dict the interpreted results; and objectivity, in which data collection, data analysis, and findings are veri-fied independently and with hindsight among the analysis team.

THE STUDY

Design

This is a qualitative phenomenological re-search study (Van Manem, 2014) to understand the intrapersonal process of resilience as experi-enced by patients in remission from BD and by mental health experts in BD (Cunningham, Fel-land, Ginsburg, & Pham, 2011; Dew, 2007). A phe-nomenological research design was selected because the main aim is to describe the structure and understand the event of resilience from the subjective point of view of participants without relying on theory, deduction, or assumptions from other disciplines. Data were transcribed for anal-ysis, and thematic analysis as proposed by Braun and Clarke (2006) was performed.

Participants

The samples were intentionally selected (Mayan, 2001) to collect first-person resilience experiences. Samples were selected based on the following inclu-sion criteria:

BD Sample: Participants were in remission from bipolar I or II disorder, between 18 and 65 years old, fluent in Spanish, and able to give informed and vol-untary consent. The patients were excluded if they met the DSM-IV-TR (American Psychiatric Associa-tion, 2000) criteria for substance abuse disorder within the previous four weeks and/or had low

scores in resilience. The condition of being in sion from BD was understood from the clinical remis-sion approach (i.e., normal or minimal severity and symptomatology), which was met via clinicians’ re-ports and self-rere-ports (see below the detailed pro-cedure for data collection). The criterion for eligibility to be in remission from BD was included because it acted as a guarantee that the patients had adapted positively to the disorder (Zautra, 2009).

Clinician sample: Participants had more than two years of experience in treating patients with BD and were able to give informed and voluntary consent.

Both samples were recruited from two public mental health centres and one public hospital (psy-chiatry service) from Basque Country. Letters were sent to 27 clinicians experienced in the treatment of BD to collaborate in the study. From these, six men-tal health experts agreed to participate in the focus groups and also helped in the recruitment of former patients in remission from BD. Clinicians, based on their clinical expertise and the medical histories of their patients, selected a representative sample and approached a number of current who met patients meeting study criteria via postal mail (the total num-ber was not reported). Fifteen people in remission from BD (mean age = 42.88 and SD = 11.99) who met the study criteria agreed to participate, signed a con-sent form, and gave their contact details to the re-search team. Once the patients agreed to participate, the severity of their BD was assessed though the Spanish version (Vieta et al., 2002) of the Clinical Global Impression Scale for Bipolar Disorder Modified (CGI-BP-M; Spearing, Post, Leverich, Brandt, & Nolen, 1997) as completed by their clini-cians (a score between normal and minimal was re-quired to retain the participants) and through the self-report Spanish version (Vázquez et al., 2010) of the Bipolar Spectrum Diagnostic Scale (BSDS) (a cut-off score < 13 was required to retain the partici-pants) (Ghaemi et al., 2005). In addition, patients self-completed the Spanish version (Las Hayas et al., 2014) of the Resilience Scale-25 (RS-25) to ensure they did not have a low resilience level (a score above 116 was required to retain participants) (Wag-nild & young, 1993).

All the patients that agreed to participate met the inclusion criteria of the study and were randomly as-signed to take part in individual interviews (n = 9) or a focus group (n = 6). The sample in the individual interviews included five women and four men in re-mission from BD (mean age = 42 years old, SD = 14.98). The sample in the focus group consisted of six women in remission (mean age = 44.17 years old, SD = 6.31). A clinical description of participants is displayed in Table 1.

Six mental health clinicians agreed to attend two focus groups (n = 4 and 2). This sample consisted of two women and four men with more than 20 years of expertise in BD treatment.

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Data Collection

Data were collected over 9 months between 2014-2015.

Individual interviews and focus groups. Individ-ual interviews and focus groups were semi-struc-tured. The guide of semi-structured questions was developed based on a previous literature revision about resilience in mental health (Bloor, Frankland, Thomas, & Robson, 2001; Willgerodt, 2003). The in-terviews and focus groups took place either in a pub-lic hospital or in a private room at the university of (Redacted). Each interview and focus group lasted approximately two hours. The same facilitator led all the sessions, which were audiotaped (with partici-pants’ consent) and transcribed verbatim (names of participants were changed to ensure anonymity), and researcher’ field notes from the interviews and focus groups were gathered (Barbour, 2005).

At the beginning of the interviews and focus groups, the interviewers first provided a general, in-troductory definition of psychological resilience to patients and clinicians: “Resilience refers to a pro-cess of changes in behaviors, cognitions, and atti-tudes that drive people to overcome or adapt to adversity.” See supplementary information appendix for detailed information about the content of the semi-structured interviews and focus groups.

Ethical Considerations

The study was given ethical approval (April 2014) by the Clinical Research of Basque Country’s Ethics Committee (Spain). Personal data of the participants was protected following the indications of the 15/1999 Organic Law 13th December. Once partici-pants agreed to take part in the study, the study was again explained to them and they signed informed consent. Participants were allowed to leave the in-terview or the group or to withdraw their participa-tion without any explanaparticipa-tion.

Data Analyses

A qualitative phenomenological research design (Van Manem, 2014) was employed, using the the-matic analysis proposed by Braun and Clarke (2006). This analysis consists on identifying the simplest sig-nificant units in the transcribed text and grouping them by common significant characteristics to form themes and subthemes that describe the studied field (Cachon-Perez, Álvaro-López, & Palacios-Ceña, 2013). Afterwards, an inductive analysis was used to discover themes and subthemes from the narratives of participants (Bradley, Curry, & Devers, 2007). Fol-lowing this design, themes were developed itera-tively until a main theme was identified. Theoretical saturation was reached for every phase of the study, as issues and themes became recurrent and new in-terviews of focus groups provided little or no addi-tional information (Guest, Bunce, & Johnson, 2006). Divergences between patients and clinicians on their

views about resilience were noted and analysed ac-cordingly in the results. SPSS Statistics 20 was used to compute descriptive statistics.

Methodological Rigor

To ensure the confirmability, credibility, and au-thenticity of results, a reflexive exploration of the analysis of how subjective and intersubjective ele-ments influenced our research was discussed at regular meetings with our research team (Nicholls, 2009). Team members come from different training backgrounds (psychiatry, clinical psychology, and public health research) to facilitate the plurality in the interpretation of the research results. Addition-ally, credibility was maintained using triangulation methods and proofs of participants’ narratives that refer to and support the findings (member checks). To maintain dependability, a detailed description of the sample and data collection methods has been provided (Nicholls, 2009). Finally, the quality recommendations for qualitative studies published by Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed (Tong, Sainsbury, & Craig, 2007).

RESULTS

Emerging Themes

Participants affirmed having experienced the pro-cess of resilience after the brief and general defini-tion of resilience was given to them. As reported by participants, resilience attributes are related to each other and develop without a specific sequence. Par-ticipants declared that resilience could exist along-side BD symptoms and that it played an important role in their recovery journeys, meaning both clinical (symptom remission) and personal recovery (as de-fined by Anthony, 1993).

The experience of resilience to BD is described below and represented graphically in Figure 1. If not otherwise specified, data presented reflects views shared by both clinicians and patients.

Theme 1: Resilience as a dynamic process.All pa-tients affirmed having experienced resilience at some point after the onset of their BD. In contrast, clinicians affirmed having observed resilience only in some patients. Resilience was described as a slowly-progressing, dynamic, and non-linear process that emerges when an additional inner strength is needed to face adverse situations. Once resilience was displayed, it played a protective role against fu-ture adversities related to BD:

Well, I think that it is a slow process, which skips back and forth...it is not a process that goes at the same rate all the time, but rather, it is bumpy…The mobilization of resources aimed at my resilience increased dramati-cally…until the pace began to drop...as it is

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not so necessary, you don't deploy it [re-silience]. (Helen, female patient in remission from BD, in an interview)

Theme 2: Antecedent conditions for resilience. The following conditions create the basis for experi-encing the process of resilience:

Minimum level of mental health.The participants agreed that for resilience to emerge, a patient has to be going through a period in his/her life that is free from any psychotic symptoms or of other severe psy-chopathologies, such as drug dependence, to allow him/her to interpret his/her current situation from a less-biased view.

Maybe they [people who do not develop re-silience] have more serious problems...maybe [they are in] a very bad state [of mental health]. (Mia, female patient in remission from BD, in a focus group)

Acceptance and awareness of BD.Both patients and clinicians felt that acceptance of diagnosis and recognition of negative features of mania and de-pression were important for resilience. However, both also affirmed that patients found it more diffi-cult to negatively judge (hypo) manic episodes than depressive episodes:

There comes a time when, if they [patients] become aware, this helps them to endure the treatment; the problem is that they do not ac-cept the disorder, and when they undergo this process is when they make a sudden change. (David, male psychiatrist, in a focus group) Theme 3: Turning point.Participants reported the experience of a turning point in the course of resilience, a moment in which they felt committed to move steadily, firmly, and determinedly out of their present adversities. Several subthemes were identified.

Refusal of suffering.Participants described a re-fusal to remain immersed in BD-related adversities and the need to get over them:

I had to reflect, analyse why my life was like a boat at the mercy of the waves...and I realized that I could not go on like this, because so much instability was hurting me so much...and from the moment when you be-come aware that you cannot go on like that, you begin to emerge from it [BD] a little. (Miriam, female patient in remission from BD, in a focus group)

Sometimes, the rejection of the adverse situation was motivated by a sense of responsibility for the wellbeing of relatives.

There comes a time when you see the people you love the most suffering, when the respon-sibility is too much, because you don't want to go back—not just that you can't put your-self in that situation, but you can't put the people who are closest to you in that situa-tion. (Helen, female patient in remission from

BD, in an interview)

Participants stressed the importance of not adopting the role of victim, which implies a passive attitude and feeling of powerlessness about recov-ering from BD.

People who do not break free [of the disorder don’t do so] because in the end, instead of seeing the goal of breaking free, they say, “well, here I am,” and they don't see why they have to evolve to the next step. (Andrea, fe-male patient in remission from BD, in a focus group)

Hope for getting better.Participants stressed the importance of experiencing hope that a more posi-tive life is possible:

Remembering happy moments of my child-hood, in order to relive them, I say, if I have experienced this, why can I not re-awaken it? In other words, I draw on those memories. That is, you must remember that moment to reflect on it and feel it again. And that gives you the strength [to fight against the disor-der]. (Sofia, female patient in remission from BD, in a focus group)

Determination for change. Despite the chal-lenges, patients affirmed that resilience was linked to persisting with positive efforts towards wellness:

Where does that motivation for change come from? Bah! Sometimes it's rage! For example, I don't feel at all like...I'm a little low...and I say, this cannot be! I cannot go on like this! I'm going to put on my shoes and I'm going [to run] without giving it another thought. (Daniel, male patient in remission from BD, in an interview)

Theme 4: Making use of resilience resources or attributes. Once patients felt they were making progress, several key attributes and strategies came into play and interacted. For some people, certain re-silience attributes were developed from scratch, while for others, the attributes were resources that the person already had but were dormant. Several resilience resources were identified.

Self-awareness and redefinition.Participants re-ported that they had analysed their strengths, weak-nesses, goals, and hobbies in order to know themselves better. They agreed that introspection was essential to understanding how and why they had certain reactions to different situations. This al-lowed them to redefine their identities separately from the illness.

Seeing what we really are, that is the most im-portant thing, what am I, who am I, and what am I like…That's why it's important to know what is inherent to your personality and what is due to the BD. (Andrea, female patient in remission from BD, in a focus group)

Reconsideration of the direction of life. Partic-ipants identified the act of re-planning their lives

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to do what was meaningful to them and reengage with life.

until you have a crisis, you do not consider what to do with your life. (Jorge, male psychi-atrist, in a focus group)

I had to stop to reflect, to analyse my life and rebuild my future from the bottom up, with what I had, [seeing] what resources I have, setting a goal [in terms of] what I want to do, [and in terms of] what I want to be as a per-son. (Mia, female patient in remission from BD, in a focus group)

Self-management of BD.Participants reported the need to learn about the disorder; thus, all pa-tients had read books on the clinical features of BD (e.g. symptoms, consequences, and self-manage-ment strategies for BD), and some of them went to psychoeducational groups and individual therapies. All had tried to understand in depth how BD affects them as individuals, including consideration of their past bipolar experiences. All participants agreed that this information was helpful for critical examination of available resources for handling BD and for re-searching alternative resources when more appro-priate ones were not available.

I have sought enough information: I read quite a few books on psychology, then books more focused on BD to see how to combat it and all that…And I related the methods in those books with the way I was and what I was going through and so on…It's a little, I'd say, it is like comparing the information that you obtain, contrasting it with your past and with that, you make your own particular man-ual. (Alex, male patient in remission from BD, in an interview).

This knowledge is also helpful in the attempt to anticipate and identify BD symptoms and early warn-ing signals or stimuli that trigger symptoms.

you learn to realize when you're going wrong and you get back on the track with the strate-gies that you're acquiring; knowing it [BD] makes you manage it better. (Julia, female pa-tient in remission from BD, in a focus group) They [patients] interpret the symptoms cor-rectly and begin to set limits to stop the phase. (Megan, female psychiatrist, in a focus group)

Adherence to drug therapy was highlighted by all participants as a resilience attribute because they felt empowered to manage BD by participating ac-tively in the pharmacological therapy agreed upon by psychiatrist and patient.

[I'm] compliant [about the medication] but not submissive...you should trust the one who is guiding you [in the medication], and if you don't trust them, you should tell them. you're smart enough to know that what they are say-ing is valid for you but other times, no, you

ac-cept what you believe [benefits you]. (Sofia, female patient in remission from BD, in a focus group)

Lifestyle balance.During the resilience process, having good mental health is a priority. In this sense, having a balanced lifestyle, involving healthy habits, discipline, and trying to achieve harmony between personal, familiar/social, and work/study spheres, is fundamental. Participants highlighted the impor-tance of living one day at a time and moving forward on a daily basis, which in turn has a positive effect by improving perceptions of self-worth.

I believe that an orderly life is essential. That is, an orderly life, physical exercise, the envi-ronment, the family envienvi-ronment, the social environment you have, which, of course, may or may not favour you. (Eva, female patient in remission from BD, in an interview)

Positive personality qualities.Participants de-scribed a variety of positive personality characteris-tics that emerge during the resilience process, particularly initiative, perseverance, willpower, ex-troversion, good social skills, sense of humour, and creativity.

I've been an extrovert, with a lot of social skills, I had a great sense of humour...yes, I think I'm a positive person...I was self-confi-dent, I knew that I could make it, that I was worthy, then, that's why I still went on trying. (Ana, female patient in remission from BD, in an interview)

At least I was brave, I always had enough courage…I've always had a lot of willpower. (Paul, male patient in remission from BD, in an interview)

Interpersonal support. Both informal external support from family, friends, and colleagues and for-mal external support from mental health clinicians and mental health associations were considered beneficial during the resilience experience. Interper-sonal support was described by patients as having at least one person who loved them unconditionally and with whom they trusted sharing their experi-ences. Participants also described the benefit of hav-ing people who can detect in advance when patients start to show signals of instability and warn patients before it develops fully.

The BD association has been very good, too; we have taken many self-esteem courses which have done us good…The two psychol-ogists have also been there helping us a lot and telling us things that we didn't know…In fact, I have felt the most support in the hos-pital…My husband was always with me, be-cause when I took Haloperidol, I couldn't breathe because of the side effects, and he would tell me “now breathe, come, now, come on, now” and he would cry, and those are the moments when you realize the

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diffi-cult times that we have gone through to-gether and we have got ahead. (Maria, female patient in remission from BD, in an interview) yes, yes, all that stuff of them loving me and giving me a hug and telling me “Don't worry, you're going to be OK, because you've been through this before and you got out OK, this time too, why not this time?”…For example, my kids tell me that I am the best mother in the world. (Laura, female patient in remission from BD, in an interview)

DISCUSSION

This qualitative study explored the experience of resilience in BD from the perspectives of patients in remission from BD as well as from the clinicians’ points of view. All of the participants reported having experienced resilience and all clinicians reported ob-serving it in some of their patients. This finding is consistent with studies that reported that resilience was present in people with other mental disorders (Dowrick et al., 2008; Torgalsbøen, 2011; Choi et al., 2015), including BD (Edward et al., 2009).

In this study, all participants affirmed that re-silience played an important role in the recovery process. This is in line with studies in other mental health problems that support the role of resilience as a promoter of mental health and quality of life (Choi et al., 2015; Dowrick et al., 2008; Torgals-bøen, 2011). This is also consistent with the find-ings of the quantitative study by Echezarraga et al. (2017b), which found that the self-confidence re-silience domain directly predicts improvement in personal recovery over time and that the interper-sonal support and self-care dimensions of re-silience indirectly predict improvement in personal recovery through the mediation of self-confidence in BD (Echezarraga et al., 2017b).

The definitions of resilience given by partici-pants in this study are in agreement with the defi-nitions of resilience given by several experts in the resilience field (Grotberg, 1995; 2003; Reivich & Shatté, 2002; Wathen et al., 2012). The participants described resilience as a dynamic process in which a variety of conditions and strategies interact, al-lowing them to regain mental health and personal recovery. However, as identified by the American Psychological Association (2010), all participants noted that experiencing resilience does not exclude pain or suffering.

Findings of this study help to clarify the meaning and functions of turning points. The turning point is described as taking decisive action and being deter-mined and committed to the struggle for change in a patient’s suffering (Garmezy, 1991; Rutter, 2013). Turning points seem to emerge when a patient ex-periences severe suffering and emotional difficulties.

This is consistent with previous findings that turning points are negatively associated with positive men-tal health outcomes in BD (Echezarraga et al., 2017b). Thus, the explanation of the turning point theme of resilience in BD falls in line with previous literature. Moreover, the current study details other antecedents of turning points. Participants in this study highlighted the importance of acceptance of the disorder and awareness of how it negatively af-fects them. Most patients had received some treat-ment, either in the form of psychoeducation, individual psychotherapy, or support groups; we in-terpret that any of these treatments could have helped in the acceptance and awareness of bipolar-ity (Gaudiano & Herbert, 2006).

Some of the resilience attributes reported after a turning point in this study are comparable to the di-mensions of resilience that other studies have re-ported, though the majority of these studies were carried out in non-clinical contexts. For example, Wolin and Wolin (2010) affirmed that acknowledg-ment of one’s own strengths and limitations and self-analysis were resilience dimensions; these were described in this study under the self-awareness sub-theme. In the study by Echezarraga et al. (2017b), the self-confidence domain of resilience, which includes characteristics related to self-awareness (self-re-liance and self-respectful attitudes), was positively related with well-being and personal recovery and negatively with deficits in psychosocial functioning at baseline. In addition, self-confidence positively predicts personal recovery at follow-up in BD (Echezarraga et al., 2017b). Other resilience at-tributes found in this study, such as the redefinition of personality and the idea of differentiating oneself from illness, were not found in previous literature on resilience, although they are consistent with the self-confidence domain reported by Echezarraga et al. (2017a), suggesting that those attributes could be specific to the resilience process in BD. In addition, the pursuit of a meaningful life (Wagnild & young, 1993; Werner, 1995), making realistic plans, and tak-ing steps to carry them out (Fletcher & Sarkar, 2015) were important features of resilience from existing research that were also described in this study, under the reconsideration of life direction subtheme.

Some components of the self-management of BD subtheme, such as problem-solving, management of strong feelings and impulses, its relationship with drug therapy, (Werner, 1995; Fletcher & Sarkar, 2015, Perry, Tarrier, Morriss, McCarthy, & Limb, 1999), personal agency (Rutter, 2013), and being ready to learn (Friedli, 2009), were also found in other studies of resilience. By contrast, other as-pects of this subtheme, such as the importance of detecting early warning signals and the importance of treatment compliance, have not been labelled as resilience attributes in previous studies, although they were identified as relevant for wellbeing,

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per-sonal recovery, and quality of life in BD. For exam-ple, despite suffering the negative consecuences of a hypomanic episode (which may progress to a more severe manic episode), the patients indicated that they find themselves struggling with adher-ence to drug therapy because they feel that many times, this treatment prevents them from being their true selves (perceived as more extrovert, op-timistic, and creative). Nevertheless, the patients who recovered highlighted the relevance of finding a balance, to the best extent possible, between negative consequences and personal positive qual-ities by means of active and empowered manage-ment and participation in their pharmacological therapy. Thus, the self-management of BD, a re-silience dimension in this study, plays an important role in wellbeing, personal recovery, and quality of life (Echezarraga et al., 2017b).

Lifestyle balance as a resilience resource in BD is described as having healthy habits and has been re-lated to disease prevention and health promotion in mental health in other studies (Mrazek & Haggerty, 1994). The importance of having a balance between the personal, familiar/social, and work/study areas of life is referenced by Everly, McCormack, and Strouse (2012) as one of the seven characteristics of highly resilient people. Likewise, Echezarraga et al. (2017b) found that a healthy lifestyle indirectly pre-dicts an increase in personal recovery in BD at fol-low-up via mediation of the self-confidence resilience domain.

The main positive personality qualities found in this study, such as perseverance and social and com-munication skills, also appear in the wider research literature about resilience (Wagnild & young, 1993; Werner, 1995). Optimism, defined by Everly et al. (2012) as a resilience quality, and creativity are in-cluded within the positive personality qualities sub-theme in this study, despite the paradoxical roles they represent in BD (Johnson et al., 2012; Wolin & Wolin, 2010). Although neither the clinicians nor some of the patients were completely sure whether the resilient qualities of sense of humour and cre-ativity were a result of personality or of BD, a psychi-atrist suggested that these features, especially creativity, could become hazardous, as they may lead to manic episodes.

Finally, interpersonal support has also been proposed as an external resilience factor or psy-chosocial resilience factor in several studies (Gar-cía del Castillo, Gar(Gar-cía del Castillo-López, López-Sánchez, & Dias, 2016; Garmezy & Masten, 1986; Werner, 1995; Fletcher & Sarkar, 2015). In fact, interpersonal support has been shown to in-directly predict personal recovery in BD through the mediation of the self-confidence domain of re-silience (Echezarraga et al., 2017b). Most of the participants in this study affirmed the importance of having at least one person with whom they

es-tablished a permanent, close bond. under the in-terpersonal support subtheme, participants also pointed out the importance of a formal support network, such as psychiatrists, psychologists, sup-port groups, and mental health associations. A possible explanation for the high importance placed on formal support networks could be that our study sample consisted mainly of patients of a mental health service or clinicians. This could be a reason why formal support is not addressed as a resilience resource in studies whose participants come from the general population.

LIMITATIONS

This study has some limitations that provide new venues for future research. One limitation is related to the restrictions in the inclusion criteria. For example, patients were included only if they were in remission from BD and came from a limited number of mental health centers. We included the criterion of being in remission from the BD to act as a guarantee that the patients had adapted pos-itively to the disorder, increasing the chances that they could have experienced resilience. Exploring whether the features of resilience in this study are also observed in participants recruited from differ-ent sources and with higher levels of subsyndro-mal symptoms would therefore be of interest. For example, according to the results of the present study, we hypothesize that (a) patients who are less familiar with the characteristics and conse-quences of bipolar mood episodes and drug ther-apy may need more attention and support to increase their acceptance and awareness of BD so that they could bounce back and have the determi-nation to change and redirect their lifestyle and self-manage their BD, (b) the odds for the emer-gence of resilience may be increased with less-se-vere psychopathology and higher mental health stability, (c) the resilience process could probably be easily developed in patients with BD when they receive better psychosocial and health support, as well as interventions aiming to foster personal pos-itive resilience qualities, such as initiative, social skills, and creativity.

A second limitation is that participating clinicians were all psychiatrists, and the participation of health professionals from other backgrounds is also worth considering. A third limitation is the small size of the samples of participants, particularly in the focus groups. Finally, the starting points of the researchers (such as their backgrounds) might have influenced findings, but this subjectivity was explicitly dis-cussed between the members of the analysis team, facilitating the identification and correction of poten-tially misleading assumptions and enabling more re-flexivity (Mauthner & Doucet 2003).

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CONCLUSIONS

This study balances the previous focus on nega-tive characteristics that created a biased picture of BD by presenting a phenomenon, such as resilience, that is experienced favourably by people with BD. Resilience was described as a dynamic process in-volving the interaction of a variety of strategies and attributes, such as self-awareness and redefinition, to regain mental health and move towards personal recovery. The evidence from this research is consis-tent with other studies of resilience and mental health, and adds new findings for the concept of re-silience within the BD diagnostic group. Further, these findings help to better understand findings from previous quantitative studies in the field of re-silience. This research reports a graphical represen-tation of the phenomenon of resilience in BD, offering insight into the main resilience themes in people with BD that enable them to maintain or re-gain their mental health. In addition, this study de-scribes the experience of resilience not only from the point of view of patients but also from that of clini-cians. Realizing that people with BD can be resilient, especially when they are diagnosed early and treated appropriately, is important (Perry et al., 1999). Therefore, this research would provide new insights for health care professionals. A better un-derstanding of the resilience process and its implied domains is crucial to the development of better as-sessment and intervention processes aimed at im-proving personal recovery in mental health. Clinicians may benefit from this information to im-prove psychological treatment in this diagnostic group by targeting interventions focused on re-silience in great detail.

Conflict of interest:The Author(s) declare(s) that there is no con-flict of interest.

Acknowledgements:We especially would like to thank the parti-cipants who shared their stories with us. Additionally, we appre-ciate the help of the following psychiatrists in the clinicians sample recruitment: Luis Pacheco, Begoña Mendibil, Purificación García, Maria Echeveste, Enrique Aragüés, Ángel Segura, and Pablo Malo.

Funding:This research was funded by the pre-doctoral grant “Re-search Training Grants Programme” from the university of Deusto (Bilbao, Spain) to the first author (Ainara Echezarraga). The fun-ding source was not involved in the study design, collection, analysis and interpretation of the data, in the writing of the report or in the decision to submit the article for publication.

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APPENDIX

Supplementary information: Guideline for the interviews and focus groups

Patients in the interviews and focus group and clinicians in the focus group were provided an in-troductory generic definition of resilience. Next, the participants were interviewed about resilience in BD following, as a guideline, similar semi-struc-tured questions for a) both individual interviews and the focus group with patients who had remis-sion from BD (“Do you recognize having gone through a process of resilience during your BD?”, “If so, how would you describe your resilience pro-cess with BD?”, “How did resilience originate in you?” ,“What qualities, behaviors, and resources were put in practice to overcome the adversity of having BD?”, “Which changes and qualities do you think makes you different from those who don’t achieve your level of recovery?”, “What advice would you give to a person to overcome BD?”, and

“Did resilience play an essential role in your remis-sion from BD?”) and b) the focus group with clini-cians (“Do you agree that people in recovery have gone through a resilience process to face BD?”, “How would you describe a typical person with BD who is experiencing resilience?”, “How do you think resilience is originated in those people?”, and “What qualities, behaviors, and resources (regard-ing resilience) were put in practice to overcome the adversity of having BD?”).

In addition, the patients participating in the focus group were also presented with the preliminary re-sults from the individual interviews and were then asked whether they considered the results valid in order to determine their perceptions of whether the data interpretations were correct or needed revision. Similarly, the clinicians were presented the results from patients (individual interviews and the focus group), and they were asked if they considered the resilience model of BD correct, to validate and com-plete the draft model.

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Table 1. Clinical Data to Describe Participating Patients

Individual Interviews

% Focus Groups % All patients %

N = 9 N= 6 N= 15

Female 5 55.60 6 100 11 73.30

Education level

Primary education 2 22.20 0 0 2 13.30

Secondary education 2 22.20 0 0 2 13.30

university degree 4 44.40 4 66.70 8 53.30

Post-degree education 1 11.10 2 33.30 3 20

Marital status

Married/living together 3 33.30 4 66.70 7 46.70

With partner 1 11.10 0 0 1 6.70

Single 4 44.40 2 33.30 6 40.00

Divorced/separated 1 11.10 0 0 1 6.70

Employment situation

unemployed 7 77.80 3 50 10 66.70

Employed 2 22.20 3 50 5 33.30

Prescribed drug therapy 9 100 6 100 15 100

a (Mood stabilizers) only 2 22.20 1 16.70 3 20

b (Antipsychotics) only 0 0 0 0 0 0

c (Anticonvulsants) only 0 0 1 16.70 1 6.70

d (Antidepressants) only 0 0 0 0 0 0

a + b 1 11.10 4 66.70 5 33.30

b + c 2 22.20 0 0 2 13.30

a + b + c 3 33.30 0 0 3 20

a + c + d 1 11.10 0 0 1 6.70

Received psychological therapy 8 88.90 4 66.70 12 80

Mean

SD Mean SD Mean SD

(n = 9) (n = 6) (n = 15)

Age 42.00 14.98 44.17 6.31 42.88 11.99

Age at BD onset 24.22 11.70 26.17 6.49 25 9.71

CGI-BP overall 1.67 1.00 1.00 0.00 1.47 .83

BSDS 3.56 2.65 1.50 1.38 2.73 2.40

RS-25 137.00 18.60 139.00 15.80 137.80 16.97

Note. CGI-BP-M: Clinical Global Impression Scale for Bipolar Disorder, Modified, thresholds: 1 (normal), 2 (minimum), 3 (mild) 4 (moderate), 5 (mar-ked), 6 (severe), and 7 (extreme); BSDS: Bipolar Spectrum Diagnostic Scale, the cut-off score of 13 points indicates a positive predictive value when screening BD; RS-25: Resilience Scale-25, thresholds: a) scores >145 (moderately-high to high resilience), b) scores 116-144 (moderately-low to mode-rate resilience), and c) scores ? 115 (very low resilience).

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