All Summer in a Day by Ray Bradbury No one in the class .docx

All Summer in a Day
by Ray Bradbury
No one in the class could remember a 3me when there
wasn't rain.
“Ready?"
"Ready."
"Now?"
"Soon."
"Do the scien:sts really know? Will it happen today, will
it?"
"Look, look; see for yourself!"
The children pressed to each other like so many roses, so
many weeds, intermixed, peering out for a look at the hidden
sun.
It rained.
It had been raining for seven years; thousand upon
thousands of days compounded and filled from one end to the
other with rain, with the drum and gush of water, with the
sweet crystal fall of showers and the concussion of storms so
heavy they were :dal waves come over the islands. A thousand
forests had been crushed under the rain and grown up a
thousand :mes to be crushed again. And this was the way life
was forever on the planet Venus, and this was the schoolroom
of the children of the rocket men and women who had come to
a raining world to set up civiliza:on and live out their lives.

"It's stopping, it's stopping!"
"Yes, yes!"
Margot stood apart from these children who could never
remember a :me when there wasn't rain and rain and rain.
They were all nine years old, and if there had been a day, seven
years ago, when the sun came out for an hour and showed its
face to the stunned world, they could not recall. Some:mes, at
night, she heard them s:r, in remembrance, and she knew they
were dreaming and remembering and old or a yellow crayon or
a coin large enough to buy the world with. She knew they
thought they remembered a warmness, like a blushing in the
face, in the body, in the arms and legs and trembling hands.
But then they always awoke to the taQng drum, the endless
shaking down of clear bead necklaces upon the roof, the walk,
the gardens, the forests, and their dreams were gone.
All day yesterday they had read in class about the sun.
About how like a lemon it was, and how hot. And they had
wriRen small stories or essays or poems about it:
I think the sun is a flower,
That blooms for just one hour.
That was Margot's poem, read in a quiet voice in the s:ll
classroom while the rain was
falling outside.
"Aw, you didn't write that!" protested one of the boys.
"I did," said Margot. "I did."
"William!" said the teacher.
But that was yesterday. Now the rain was slackening, and
the children were crushed in the great thick windows.
"Where's teacher?"

"She'll be back."
"She'd beRer hurry, we'll miss it!"
They turned on themselves, like a feverish wheel, all
tumbling spokes.
Margot stood alone. She was a very frail girl who looked as
if she had been lost in the rain for years and the rain had
washed out the blue from her eyes and the red from her mouth
and the yellow from her hair. She was an old photograph
dusted from an album, whitened away, and if she spoke at all
her voice would be a ghost. Now she stood, separate, staring at
the rain and the loud wet world beyond the huge glass.
"What're you looking at?" said William.
Margot said nothing.
":Speak when you're spoken to." He gave her a shove. But
she did not move; rather she let herself by moved only by him
and nothing else.
They edged away from her, they would not look at her. She
felt them go away. And this was because she would play no
games with them in the echoing tunnels of the underground
city. If they tagged her and ran, she stood blinking aVer them
and did not follow. When the class sang songs about happiness
and life and games her lips barely moved. Only when they sang
about the sun and the summer did her lips move as she
watched the drenched windows.
And then, of course, the biggest crime of all was that she
had come here only five years ago from Earth, and she
remembered the sun and the way the sun was and the sky was
when she was four in Ohio. And they, they had been on Venus
all their lives, and they had been only two years old when last
the sun came out and had long since forgoRen the color and

heat of it and the way it really was. But Margot remembered.
"It's like a penny," she said once, eyes closed.
"No it's not!" the children cried.
"It's like a fire," she said, "in the stove."
"You're lying, you don't remember!" cried the children.
But she remembered and stood quietly apart from all of
them and watched the paRerning windows. And once, a month
ago, she had refused to shower in the school shower rooms,
had clutched her hands to her ears and over her head,
screaming the water mustn't touch her head. So aVer that,
dimly, dimly, she sensed it, she was different and they knew her
difference and kept away.
There was talk that her father and mother were taking her
back to earth next year; it seemed vital to her that they do so,
though it would mean the loss of thousands of dollars to her
family. And so, the children hated her for all these reasons of
big and liRle consequence. They hated her pale snow face, her
wai:ng silence, her thinness, and her possible future.
"Get away!" The boy gave her another push. "What're you
wai:ng for?"
Then, for the first :me, she turned and looked at him. And
what she was wai:ng for was in her eyes.
"Well, don't wait around here!" cried the boy savagely.
"You won't see nothing!"
Her lips moved.
"Nothing!" he cried. "It was all a joke, wasn't it?" He

turned to the other children. "Nothing's happening today. Is
it?"
They all blinked at him and then, understanding, laughed
and shook their heads. "Nothing, nothing!"
"Oh, but," Margot whispered, her eyes helpless. "But this
is the day, the scien:sts predict, they say, they know, the sun. . .
."
"All a joke!" said the boy, and seized her roughly. "Hey,
everyone, let's put her in a closet before teacher comes!"
"No," said Margot, falling back.
They surged about her, caught her up and bore her,
protes:ng, and then pleading, and then crying, back into a
tunnel, a room, a closet, where they slammed and locked the
door. They stood looking at the door and saw it tremble from
her bea:ng and throwing herself against it. They heard her
muffled cries. Then, smiling, they turned and went out and
back down the tunnel, just as the teacher arrived.
"Ready, children?" she glanced at her watch.
"Yes!" said everyone.
"Are we all here?"
"Yes!"
The rain slackened s:ll more.
They crowded to the huge door.
The rain stopped.
It was as if, in the midst of a film, concerning an avalanche,
a tornado, a hurricane, a volcanic erup:on, something had,
first, gone wrong with the sound apparatus, thus muffling and
finally cuQng off all noise, all of the blasts and repercussions
and thunders, and then, second, ripped the film from the

projector and inserted in its place a peaceful tropical slide
which did not move or tremor. The world ground to a stands:ll.
The silence was so immense and unbelievable that you felt your
ears had been stuffed or you had lost your hearing altogether.
The children put their hands to their ears. They stood apart.
The door slid back and the smell of the silent, wai:ng world
came in to them.
The sun came out.
It was the color of flaming bronze and it was very large.
And the sky around it was a blazing blue :le color. And the
jungle burned with sunlight as the children, released from their
spell, rushed out, yelling, into the spring:me.
"Now don't go too far," called the teacher aVer them.
"You've only two hours, you know. You wouldn't want to get
caught out!"
But they were running and turning their faces up to the sky
and feeling the sun on their cheeks like a warm iron; they were
taking off their jackets and leQng the sun burn their arms.
"Oh, it's beRer than the sun lamps, isn't it?"
"Much, much beRer!"
They stopped running and stood in the great jungle that
covered Venus, that grew and never stopped growing,
tumultuously, even as you watched it. It was a nest of octopi,
clustering up great arms of flesh-like weed, wavering, flowering
this brief spring. It was the color of rubber and ash, this jungle,
from the many years without sun. It was the color of stones
and white cheeses and ink, and it was the color of the moon.
The children lay out, laughing, on the jungle maRress, and
heard it sigh and squeak under them, resilient and alive. They

ran among the trees, they slipped and fell, they pushed each
other, they played hide-and-seek and tag, but most of all
they squinted at the sun un:l the tears ran down their faces,
they put their hands up to that yellowness and that amazing
blueness and they breathed of the fresh, fresh air and listened
and listened to the silence which suspended them in a blessed
sea of no sound and no mo:on. They looked at everything and
savored everything. Then, wildly, like animals escaped from
their caves, they ran and ran in shou:ng circles. They ran for an
hour and did not stop running.
And then—
In the midst of their running one of the girls wailed.
Everyone stopped.
The girl, standing in the open, held out her hand.
"Oh, look, look," she said, trembling.
They came slowly to look at her opened palm.
In the center of it, cupped and huge, was a single raindrop.
She began to cry, looking at it.
They glanced quietly at the sky.
"Oh. Oh."
A few cold drops fell on their noses and their cheeks and
their mouths. The sun faded behind a s:r of mist. A wind blew
cool around them. They turned and started to walk back
toward the underground house, their hands at their sides, their
smiles vanishing away.
A boom of thunder startled them and like leaves before a
new hurricane, they tumbled upon each other and ran.
Lightening struck ten miles away, five miles away, a mile, a
half
mile. The sky darkened into midnight in a flash.
They stood in the doorway of the underground for a

moment un:l it was raining hard. Then they closed the door
and heard the gigan:c sound of the rain falling in tons and
avalanches, everywhere and forever.
"Will it be seven more years?"
"Yes. Seven."
Then one of them gave a liRle cry.
"Margot!"
"What?"
"She's s:ll in the closet where we locked her."
"Margot."
They stood as if someone had driven them, like so many
stakes, into the floor. They looked at each other and then
looked away. They glanced out at the world that was raining
now and raining and raining steadily. They could not meet each
other's glances. Their faces were solemn and pale. They
looked at their hands and feet, their faces down.
"Margot.
One of the girls said, "Well . . .?"
No one moved.
"Go on," whispered the girl.
They walked slowly down the hall in the sound of the cold
rain. They turned through the doorway to the room in the
sound of the storm and thunder, lightening on their faces, blue
and terrible. They walked over to the closest door slowly and
stood by it.
Behind the closed door was only silence.
They unlocked the door, even more slowly, and let Margot

out.
Name:
Tamara Golson
Date:
11-18-19
Method Comparison Journal Exercise
Read the two research articles cited below and fill in what you
notice about their characteristics, similarities or differences in
the table below.
Qualitative Study:
Blixen, C., Perzynski, A. T., Bukah, A., Howland, M., &
Sajatovic, M. (2016). Patients’ perceptions of barriers to self-
managing bipolar disorder: A qualitative study. International
Journal of Social Psychology, 62(7), 635-644
Quantitative Study:
Boyers, G. B., & Rowe, L. S. (2018). Social support and
relationship satisfaction in bipolar disorder. Journal of Family
Psychology, 32(4), 538-543.
Characteristic
Qualitative
Quantitative
Research design
Sample size
Sampling method
Procedure

Measures and instruments
Data analysis technique
Results
Readability of report
Ethical considerations
Any other thoughts?
BRIEF REPORT
Social Support and Relationship Satisfaction in Bipolar
Disorder
Grace B. Boyers and Lorelei Simpson Rowe
Southern Methodist University
Social support is positively associated with individual well-
being, particularly if an intimate partner provides
that support. However, despite evidence that individuals with
bipolar disorder (BPD) are at high risk for
relationship discord and are especially vulnerable to low or

inadequate social support, little research has
explored the relationship between social support and
relationship quality among couples in which a partner has
BPD. The current study addresses this gap in the literature by
examining the association between social
support and relationship satisfaction in a weekly diary study.
Thirty-eight opposite-sex couples who were
married or living together for at least one year and in which one
partner met diagnostic criteria for BPD
completed up to 26 weekly diaries measuring social support and
relationship satisfaction, as well as psychiatric
symptoms. Results revealed that greater social support on
average was associated with higher average
relationship satisfaction for individuals with BPD and their
partners, and that more support than usual in any
given week was associated with higher relationship satisfaction
that week. The converse was also true, with
greater-than-average relationship satisfaction and more
satisfaction than usual associated with greater social
support. The results emphasize the week-to-week variability of
social support and relationship satisfaction and
the probable reciprocal relationship between support and
satisfaction among couples in which a partner has
BPD. Thus, social support may be important for maintaining
relationship satisfaction and vice versa, even after
controlling for concurrent mood symptoms.
Keywords: bipolar disorder, marriage, social support,
longitudinal, relationship satisfaction
Bipolar disorder (BPD) is a severe and chronic illness charac-
terized by extreme mood shifts (American Psychiatric
Association,
2000) and impairment in occupational and social functioning,
even
between affective episodes (Fagiolini et al., 2005; Judd &

Akiskal,
2003). Individuals with BPD are less likely to marry or live
with
a romantic partner, and those who do are at higher risk for
relationship distress and dissolution compared to individuals
with
other psychiatric disorders and those without mental illness
(Co-
ryell et al., 1993; Judd & Akiskal, 2003; Whisman, 2007). Rela-
tionship dysfunction has been attributed to a number of factors,
including patient mood symptoms (e.g., Lam, Donaldson,
Brown,
& Malliaris, 2005), caregiver burden (Reinares et al., 2006),
and
deficits in psychosocial functioning (Coryell et al., 1993).
Partners
of individuals with BPD are also at risk for social, occupational,
and financial distress, and symptoms of depression and anxiety
(Lam et al., 2005). The high risk for individual and couple
distress
has led to calls to investigate factors that may buffer the
negative
effects of illness and improve functioning among individuals
with
BPD and their partners (Reinares et al., 2006).
One potential buffering factor is social support. Multiple
studies
with nonclinical samples have demonstrated a positive
association
between social support and individual well-being (for a review,
see
Cohen & Wills, 1985), particularly when an intimate partner is
the
support provider (e.g., Beach, Martin, Blum, & Roman, 1993).

This effect has been documented with both self-report and ob-
served data, concurrently and over time (e.g., Cutrona & Suhr,
1994; Sullivan, Pasch, Johnson, & Bradbury, 2010). Moreover,
social support appears to buffer the effects of individual and
couple-level stress on individual and relationship functioning
(Bodenmann, 1995) and facilitate caring and intimacy (Cohen &
Wills, 1985). This research is consistent with the intimacy
process
model (Reis & Patrick, 1996), which suggests that intimacy de-
velops through exchanges that convey validation and
understand-
ing, especially in response to expressions of vulnerability. In
contrast, inadequate or miscarried social support attempts are
associated with declines in relationship quality over time (e.g.,
Brock & Lawrence, 2009).
For individuals with BPD, lack of social support (in either the
quality or the number of supportive relationships) is associated
with lower medication compliance and greater stress (e.g., Kul-
hara, Basu, Mattoo, Sharan, & Chopra, 1999). In contrast, the
Grace B. Boyers and Lorelei Simpson Rowe, Department of
Psychology,
Southern Methodist University.
The analyses presented in this study were conducted in
fulfillment of
Grace B. Boyers’s master’s thesis and have not previously been
published.
Previous versions of the analyses presented in this study were
presented
as a poster at the Annual Conference of the Association for
Behavioral and
Cognitive Therapies in November 2015 and as a paper at the
Annual

Conference of the Southwestern Psychological Association in
April 2016.
Other analyses using this data set were presented in Rowe and
Miller
Morris (2012).
Correspondence concerning this article should be addressed to
Lo-
relei Simpson Rowe, Department of Psychology, Southern
Methodist
University, P.O. Box 750442, Dallas, TX 75275-0442. E-mail:
[email protected]
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Journal of Family Psychology © 2018 American Psychological
Association
2018, Vol. 32, No. 4, 538–543 0893-3200/18/$12.00
http://dx.doi.org/10.1037/fam0000400
538
mailto:[email protected]
http://dx.doi.org/10.1037/fam0000400
presence of support predicts longer time between recurrence of
affective episodes (Cohen, Hammen, Henry, & Daley, 2004;
John-
son, Lundström, Åberg-Wistedt, & Mathé, 2003) and quicker
recovery from mood episodes (Johnson, Winett, Meyer, Green-

house, & Miller, 1999). However, no known research has
directly
studied the association between social support and relationship
satisfaction within the context of BPD. This is particularly
impor-
tant because, although individuals with BPD have a high need
for
social support, they often do not receive it (Coryell et al.,
1993).
Likewise, their partners receive less social support than partners
of
individuals without mental illness; this has been attributed to
limited social activities as well as lower support from the
partner
with BPD (Dore & Romans, 2001). In the current study, we
examine the association between social support and relationship
satisfaction among individuals with BPD and their intimate
part-
ners using an intensive longitudinal diary method. This method
permits evaluation of fluctuation of variables over time,
whereas
the existing, predominantly cross-sectional research does not.
That
is, we can assess the overall association between relationship
satisfaction and social support as well as the association
between
fluctuations in each variable.
Second, we focus on each participant’s report of emotional
support they received from their partner (e.g., expressions of
care
and understanding). We focus on perceived social support
because
associations between one partner’s report of support provision
and
the other’s report of support receipt are often weak (Haber,

Cohen,
Lucas, & Baltes, 2007), reflecting the subjective nature of
social
support and variability in support provision skill (Howland &
Simpson, 2010). That is, one partner may engage in actions in-
tended to be supportive that the other partner does not perceive
as
helpful, which can decrease relationship satisfaction (Bolger &
Amarel, 2007). We also focus on emotional support,
specifically,
because it is more universally acceptable than instrumental
support
(i.e., active assistance; Cutrona & Suhr, 1992).
We examined weekly reports of partner provision of social
support from individuals with BPD and their partners,
hypothesiz-
ing that (a) individuals with BPD would report receiving more
support than would their partners. We also tested the hypotheses
that (b) support would be positively associated with relationship
satisfaction on average and (c) support in any given week would
be
positively associated with relationship satisfaction in that week.
Finally, because there is reason to believe that social support
and
relationship satisfaction build upon each other in a reciprocal
fashion (Dunkel-Schetter & Skokan, 1990), we tested the
converse
hypotheses that (d) relationship satisfaction would be associated
with support on average and (e) satisfaction in any given week
would be positively associated with support in that week. We
controlled for patient and partner depressive symptoms and
patient
manic symptoms because own and partner symptoms correlate
with relationship satisfaction and social support (Lam et al.,
2005;

Lee et al., 2011; Whisman, Uebelacker, & Weinstock, 2004).
Method
Participants
Thirty-eight individuals with a lifetime diagnosis of bipolar I
(90%) or bipolar II (10%) disorder and their opposite sex
partners
participated in a 6-month weekly diary study. In 71% of cases,
the
individual with bipolar disorder (hereafter referred to as the pa-
tient) was female. Participants ranged in age from 25 to 64
years,
with a mean age of 44 years (SD � 10) for patients and 46 years
(SD � 11) for partners. The sample was predominantly non-
Hispanic White (92% of patients, 84% of partners), with the
remainder identifying as Hispanic of any race (5% of patients
and
8% of partners) or other (3% of patients, 8% of partners).
Partic-
ipants had 15 years of education on average (SD � 3 years) and
50% of patients and 76% of partners were employed, with a
median household income of $4,500 per month. All couples had
been living together for at least 1 year, with an average
relationship
length of 12 years (SD � 10), and 84% were married. In 76% of
couples, at least one partner had a biological child (children’s
age
ranged from 1 to 41 years), with a mean of 2.86 children (SD �
1.66) among couples who had children.
Procedure
The study was conducted in a large southwestern city in the

United States. All procedures were approved by the local
institu-
tional review board. Couples were recruited through Internet
and
newspaper advertisements and presentations to local mental
health
consumer organizations. To participate, one partner had to meet
Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM–IV; American Psychiatric Association, 2000)
crite-
ria for bipolar I or II disorder, and the other partner could not
meet
criteria for a bipolar spectrum disorder or a primary psychotic
disorder. The couple had to be married and/or cohabiting for at
least one year, and partners had to be between the ages of 25
and
64 years, have completed a tenth-grade education or higher, and
be
able to read and understand English.
After providing informed consent, participants completed a bat-
tery of questionnaires and clinical interviews (including those
to
confirm diagnostic eligibility) at a laboratory assessment. At
the
end of the assessment, participants completed the first weekly
diary, described below, and received instructions for completing
and returning weekly diaries for the next 6 months. Participants
received $125 each ($250 per couple) in compensation for com-
pleting the initial laboratory session and $5 for each completed
diary. They were asked to complete the weekly diaries indepen-
dently from their partner and return them in self-addressed,
stamped envelopes. To encourage timely completion of diaries,
participants received payment only if the post date of the diary
was
within 3 days of the due date; only data from these diaries were

included in analyses. Participants completed an average of 20
weekly diaries (range � 2–26, SD � 8), with 74% completing at
least 20, 8% completing 10–20, 9% completing 5–10, and 8%
completing 4 or fewer.
Measures
Diagnosis and symptoms. The Structured Clinical Interview
for DSM–IV Axis I disorders, research version, patient edition
(SCID-I/P; First, Spitzer, Gibbon, & Williams, 2002) was used
to
confirm diagnostic eligibility. The SCID was administered by
clinical psychology doctoral students under the supervision of
the
primary investigator. Patients and their partners completed the
SCID-I/P independently with different interviewers. The SCID-
I/P
is a reliable and well-validated diagnostic tool (e.g., First,
Spitzer,
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539RELATIONSHIP SATISFACTION IN BPD
Gibbon, & Williams, 2002). Interrater agreement within this
study
was calculated by rescoring 30% of all interviews (n � 23);
current mood episode (� � .89), and mood diagnosis (� � .83)

had
acceptable agreement.
Patient and partner weekly depressive symptoms were assessed
with the Patient Health Questionnaire (PHQ-9; Kroenke,
Spitzer,
& Williams, 2001), a nine-item measure of DSM–IV depressive
symptoms experienced in the past week. Symptoms were rated
on
a scale ranging from 0, not at all, to 3, nearly every day, with
total
scores ranging from 0 to 27. The PHQ-9 is well validated and
reliable, with good specificity and sensitivity to change
(Kroenke
et al., 2001). Coefficient alpha for the first diary was .91 for
patients and .88 for partners. First-week diary scores were
corre-
lated with Hamilton Rating Scale for Depression (Hamilton,
1960)
scores obtained at the laboratory assessment, r � .67 for
patients,
.77 for partners, ps � .001.
Patient weekly manic symptoms were measured using the Alt-
man Self Rating Scale for Mania (ASRM; Altman, Hedeker,
Peterson, & Davis, 1997), a five-item measure of manic
symptoms
in which participants rate symptoms on a scale ranging from 0
to
4; total scores can range from 0 to 20. The ASRM is correlated
with clinician-rated measures of mania and has good reliability
and
specificity (Altman et al., 1997). Coefficient alpha for ASRM
scores in the first diary was .89. First-week diary scores were
correlated with the Young Mania Rating Scale (Young, Biggs,
Ziegler, & Meyer, 1978) scores obtained at the laboratory

assess-
ment, r � .77, p � .001.
Relationship satisfaction. Weekly relationship satisfaction
was measured by a single item, “All things considered, how
happy
have you felt in your relationship in the last week?” on a nine-
point
scale ranging from 0, very unhappy, to 8, perfectly happy. First-
week satisfaction scores were positively correlated with self-
reported relationship satisfaction at the laboratory assessment
us-
ing the Dyadic Adjustment Scale (Spanier, 1976), r � .46 for
patients and .39 for partners, ps � .05. Previous studies have
documented the validity of single-item measures of constructs
such as relationship closeness (Aron, Aron, & Smollan, 1992),
life
satisfaction (Antonucci, Lansford, & Akiyama, 2001), and well-
being (Pavot & Diener, 1993).
Social support. Participants reported on weekly support using
a single item, “My partner has provided emotional support for
me,” on a scale ranging from 0, not at all, to 8, very much.
Social
support from the first diary week was correlated with reports of
overall social support from the partner on the Social Provisions
Scale (Cutrona & Russell, 1987), obtained at the laboratory as-
sessment, r � .40 for patients and .57 for partners, ps � .05.
Although social support and relationship satisfaction are
correlated
and some older measures of relationship satisfaction have
included
items about social support (Fincham & Bradbury, 1987), more
recent research shows that they are related, but distinct,
constructs
(e.g., Funk & Rogge, 2007).

Data Analytic Plan
Multilevel models with distinguishable dyads (patient vs. part-
ner) across up to 26 weeks of diaries (diary completed at the
laboratory assessment plus 25 additional diaries) were used to
test
the hypotheses. Data that were missing at random, such as
skipped
individual items in multi-item scales (.01% of the PHQ-9 items
and .002% of the ASRM items), were imputed using EM
imputa-
tion procedures. Missing single items measuring relationship
sat-
isfaction and social support were not imputed (8.1% of the rela-
tionship satisfaction items, 0.2% of the social support items)
because it was impossible to know whether the item was
missing
at random or on purpose.
Models were estimated in SAS PROC MIXED (SAS Institute,
Cary, NC) using restricted maximum likelihood. The intraclass
correlation (as calculated for a dual-intercept empty-means
model)
for relationship satisfaction was .51 for patients and .39 for
part-
ners, indicating that 51% and 39% of the variance in
relationship
satisfaction was due to between-person mean differences in pa-
tients and partners, respectively, with the remaining variance
oc-
curring at the within-person level. The intraclass correlation for
social support was .56 for patients and .53 for partners,
indicating
that approximately half of the variance in social support was

due
to between-person mean differences. Thus, examination of
within-
person means for both relationship satisfaction and social
support
was justified.
We used modified Actor-Partner Interdependence Models
(Kenny, 1996), including separate fixed and random intercepts
for
patients and partners (Atkins, 2005), as shown in the equation
for
relationship satisfaction below. Independent variables were
disag-
gregated into Level 2 person-mean (PM) and Level 1 within-
person (WP) components (Singer & Willett, 2003). Person-mean
variables were grand-mean centered by partner, and WP
variables
were centered at each individual’s mean score. We included
both
actor and partner effects for weekly depressive symptoms but
only
the actor effect of manic symptoms for patients and the partner
effect for partners because partners, by definition, had very low
levels of manic symptoms. The autoregressive coefficient for
the
dependent variable (i.e., the individual’s score from the
previous
week) was included in all models to control for the possibility
that
the association between present week satisfaction and support
was
due to the effect of past week values. Patient sex was not
included
in the analyses reported below because it did not moderate
effects

(analyses including sex as a moderator are available from the
authors upon request).
Relationship satisfactionti � (patient)��00 � �01(PM social
supporti)
� �02(PM actor PHQ-9i) � �03(PM partner PHQ-9i)
� �04(PM actor ASRMi) � �10(WP social supportti)
� �20(WP actor PHQ-9ti) � �30(WP partner PHQ-9ti)
� �40(WP actor ASRMti) � �50(previous week satisfactionti)
� ε0i� � (partner)��100 � �101(PM social supporti)
� �102(PM actor PHQ-9i) � �103(PM partner PHQ-9i)
��104(PM partner ASRMi) � �110(WP social supportti)
� �120(WP actor PHQ-9ti) � �130(WP partner PHQ-9ti)
� �140(WP partner ASRMti) � �150(previous week
satisfactionti)
� ε10i�
Results
Participants reported moderate levels of relationship
satisfaction
(patients: M � 4.71, SD � 2.34; partners: M � 4.76, SD �
2.17)
and emotional support (patients: M � 5.04, SD � 2.17;
partners:
M � 4.26, SD � 2.26) on average over the course of the study.

T
hi
s
do
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en
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A
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A
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oc
ia
tio
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or
on
e
of
its
al
lie
d
pu
bl
is
he

rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al

us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
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em
in
at

ed
br
oa
dl
y.
540 BOYERS AND SIMPSON ROWE
Patients had moderate symptoms of depression (M � 7.10, SD
�
6.78) and mild symptoms of mania (M � 2.23, SD � 3.55) on
average, whereas partners had mild symptoms of depression (M
�
1.85, SD � 3.12).
As expected, a test of the difference of the intercept coefficients
using an empty-means model revealed that partners reported
less
emotional support than patients, t(37.7) � �2.96, p � .005 (Hy-
pothesis 1). Next, we tested the hypotheses that support on
average
would be positively associated with relationship satisfaction on
average (Hypothesis 2) and that support in any given week
would
be associated with concurrent relationship satisfaction in that
week
(Hypothesis 3). We regressed weekly satisfaction onto person-
mean and within-person support, controlling for past week satis-
faction and person-mean and within-person psychiatric
symptoms.
As hypothesized, person-mean support was positively associated

with average relationship satisfaction for patients, b � .51, SE
�
.09, p � .001, and partners, b � .35, SE � .10, p � .002, and
within-person support was positively associated with within-
person relationship satisfaction for patients, b � .32, SE � .04,
p � .001, and partners, b � .33, SE � .04, p � .001 (see Table
1).
Finally, we tested the converse hypotheses that satisfaction
would be positively associated with support, on average
(Hypoth-
esis 4), and that satisfaction in any given week would be
associated
with concurrent support (Hypothesis 5), controlling for past
week
support and person-mean and within-person psychiatric symp-
toms. As expected, person-mean relationship satisfaction was
pos-
itively associated with average support for patients, b � .58, SE
�
.11, p � .001, and partners, b � .34, SE � .14, p � .02, and
within-person relationship satisfaction was positively associated
with within-person support for patients, b � .24, SE � .04, p �
.001, and partners, b � .23, SE � .03, p � .001 (see Table 2).
Discussion
As expected, partners received less social support than patients,
suggesting that partners of individuals with BPD may be at risk
for
inadequate social support in their relationships. Also as
hypothe-
sized, average social support was positively associated with
aver-
age relationship satisfaction, and greater-than-average support

within any given week was associated with greater-than-average
relationship satisfaction that week, controlling for patient and
partner mood symptoms and previous week relationship
satisfac-
tion. The converse hypotheses, with support as the dependent
variable and person-mean and within-person relationship
satisfac-
tion as the independent variables, were also supported. These
results are consistent with the literature (e.g., Cutrona & Suhr,
1994; Sullivan et al., 2010) and expand the existing body of
knowledge by demonstrating a reciprocal association between
support and satisfaction. This pattern is consistent with the inti-
macy process model (Reis & Patrick, 1996), in which support in
times of vulnerability enhances intimacy, increasing the
likelihood
of future expressions of vulnerability.
Our results also highlight the important relationship between
social support and relationship satisfaction among couples in
which a partner has BPD, over and above the well-documented
effects of patient and partner mood symptoms on relationship
functioning (e.g., Lam et al., 2005). Indeed, our results
emphasize
the need to go beyond the focus on patient symptoms and func-
tioning alone in understanding BPD and to include broader rela-
tionship outcomes. Specifically, although individuals with BPD
and their partners are at high risk for relationship distress and
dissolution (Coryell et al., 1993; Whisman, 2007), the current
study shows that at least some couples coping with BPD are
able
to sustain high levels of satisfaction. However, the association
between social support and relationship satisfaction may also
indicate that low levels of either variable may have reciprocal
effects, leading to declines in the other. In addition, the lower
levels of support reported by partners may reflect an imbalance
in

support provision that could contribute to eventual relationship
distress and caregiver burden (Brock & Lawrence, 2009; Lam et
al., 2005). Alternatively, it may be that individuals with BPD
simply need more support than their partners and the results
reflect
the differential need.
Table 1
Predicting Relationship Satisfaction by Patient and Partner
Social Support
Variable Patient B (SE) Partner B (SE)
Intercept 3.29�� (.21) 3.42�� (.22)
Weekly emotional support,
person-mean .51�� (.09) .35�� (.10)
Weekly emotional support,
within-person .32�� (.04) .33�� (.04)
Control variables
Previous week satisfaction .29�� (.03) .29�� (.03)
Own PHQ-9, person-mean �.09�� (.03) .04 (.06)
Own PHQ-9, within-person �.07�� (.02) �.15�� (.03)
Own ASRM, person-mean �.03 (.07) —
Own ASRM, within-person .03 (.02) —
Partner PHQ-9, person-mean �.003 (.06) �.05 (.03)
Partner PHQ-9, within-person �.02 (.04) .001 (.02)
Partner ASRM, person-mean — .004 (.08)
Partner ASRM, within-person — .05� (.02)
Note. PHQ-9 � Patient Health Questionnaire; ASRM � Altman
Self-
Rating Scale for Depression.
� p � .05. �� p � .01. �� p �.001.

Table 2
Predicting Social Support by Patient and Partner
Relationship Satisfaction
Variable Patient B (SE) Partner B (SE)
Intercept 3.88�� (.25) 3.23�� (.23)
Weekly relationship satisfaction,
person-mean .58�� (.11) .34� (.14)
Weekly relationship satisfaction,
within-person .24�� (.04) .23�� (.03)
Control variables
Social support the previous week .23�� (.04) .26�� (.04)
Own PHQ-9, person-mean .03 (.04) �.01 (.07)
Own PHQ-9, within-person �.002 (.02) �.12�� (.03)
Own ASRM, person-mean .02 (.09) —
Own ASRM, within-person .03 (.09) —
Partner PHQ-9, person-mean .02 (.07) �.06 (.04)
Partner PHQ-9, within-person �.07� (.03) �.04�� (.02)
Partner ASRM, person-mean — .15 (.09)
Partner ASRM, within-person — .03 (.02)
Note. PHQ-9 � Patient Health Questionnaire; ASRM � Altman
Self-
Rating Scale for Depression.
� p � .05. �� p � .01. �� p � .001.
T
hi
s
do

cu
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A
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ca
l
A
ss
oc
ia
tio
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or
on
e
of
its
al
lie
d
pu
bl
is
he
rs
.
T
hi

s
ar
tic
le
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th

e
in
di
vi
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al
us
er
an
d
is
no
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to
be
di
ss
em
in
at
ed
br
oa
dl

y.
Limitations
The primary limitation in the current study is the use of single-
item measures of relationship satisfaction and social support.
Single-item measures limit the information that can be obtained
about multifaceted constructs; future studies of social support in
couples with BPD using more comprehensive measures of both
variables are important to replicate our findings. In addition,
the
sample was relatively small and is not likely to be
representative of
all couples in which a partner has BPD. Indeed, the low levels
of
mood symptoms, on average, suggest that this may be a
relatively
high-functioning sample, although many patients in the study
experienced weeks in which depressive and/or manic symptoms
were quite high. Finally, the majority of participants were
White,
so the results may not generalize to a more diverse sample.
Implications and Future Directions
Social support from an intimate partner is highly beneficial
(e.g.,
Cutrona & Suhr, 1994) as long as support is provided with some
degree of skill and balanced, with neither partner experiencing
too
much burden of support provision or feeling inadequate as a

result
of needing support (Bolger & Amarel, 2007; Brock & Lawrence,
2009). Our findings extend the literature on social support to
individuals with BPD and their partners. Unfortunately, couples
in
this population may be less skilled in support provision and ac-
ceptance than couples without severe mental illness, given the
high
rates of relationship dysfunction in BPD (Coryell et al., 1993;
Judd
& Akiskal, 2003; Whisman, 2007). Future research will need to
explore the skill with which patients with BPD and their
partners
provide support to each other and factors that may interfere
with
support provision (e.g., severe mood episodes, substance abuse,
and stress). Experimental manipulation of support provision
through psychoeducation or instructions may also enhance our
understanding of the association between support and
relationship
satisfaction within this population. Such research has the
potential
to inform relationship and family-based interventions that may
benefit individuals with BPD and their loved ones.
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Received February 9, 2017
Revision received November 12, 2017
Accepted November 15, 2017 �
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http://dx.doi.org/10.1034/j.1399-5618.2003.00021.x
http://dx.doi.org/10.1034/j.1399-5618.2003.00021.x
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http://dx.doi.org/10.1177/0265407596132007
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http://dx.doi.org/10.1016/S0165-0327%2898%2900145-1

http://dx.doi.org/10.1111/j.1399-5618.2005.00240.x
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http://dx.doi.org/10.1097/NMD.0b013e3182043b73
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http://dx.doi.org/10.1192/bjp.133.5.429Social Support and
Relationship Satisfaction in Bipolar
DisorderMethodParticipantsProcedureMeasuresDiagnosis and
symptomsRelationship satisfactionSocial supportData Analytic
PlanResultsDiscussionLimitationsImplications and Future
DirectionsReferences
International Journal of
Social Psychiatry
2016, Vol. 62(7) 635 –644
© The Author(s) 2016
Reprints and permissions:
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DOI: 10.1177/0020764016666572
isp.sagepub.com
E CAMDEN SCHIZOPH
Introduction
Bipolar disorder (BD) is a chronic mental illness associ-
ated with reduced quality of life, decreased functioning,

high rates of suicide and high financial costs (Murray &
Lopez, 1997; Zaretsky, Rizvi, & Parikh, 2007). Prevalence
in the United States may be as high as 3.7% for BD spec-
trum disorders (American Psychiatric Association, 2002;
Hirschfeld, Calabrese, & Weissman, 2002). A cornerstone
of treatment for individuals with BD is mood stabilizing
medications such as lithium, anticonvulsants and atypical
antipsychotic medication (American Psychiatric
Association, 2002; Goodwin & Young, 2003; Yatham
et al., 2005); yet, roughly half of individuals with BD are
non-adherent with medication (Lingam & Scott, 2002;
Perlick, Rosenheck, Kaczynski, & Kozma, 2004; Sajatovic,
Valenstein, Blow, Ganoczy, & Ignacio. 2006, 2007).
Concurrent with the use of medications, Chronic Disease
Self-Management (CDSM) programs can empower
patients and improve health outcomes by emphasizing the
central role of the individual in managing their mental and
physical health while collaborating with health-care pro-
fessionals and systems (Janney, Bauer, & Kilbourne, 2014;
Lorig, 2015; Lorig, Ritter, Pifer, & Werner, 2015).
Evidence-based skills shown to be effective in BD and
amenable to chronic disease self-management include the
following: psychoeducation, monitoring moods, social
functioning, sleep hygiene, setting goals and relapse plans
and adopting healthy lifestyle plans (Janney, Bauer, &
Kilbourne, 2014). However, self-management is challeng-
ing for many individuals with BD; there are numerous bar-
riers that can impede progress and success.
Few studies have specifically addressed patients’ per-
ceptions of barriers to self-management of BD; most have
focused on risk factors for poor adherence (Lingam &
Scott, 2002; Perlick et al., 2004; Sajatovic et al., 2006,
2007). In this qualitative analysis, perceived barriers to

Patients’ perceptions of barriers to
self-managing bipolar disorder:
A qualitative study
Carol Blixen1,2, Adam T Perzynski2, Ashley Bukach1,
Molly Howland3 and Martha Sajatovic4,5
Abstract
Background: Self-management of bipolar disorder (BD) is
challenging for many individuals.
Material: Interviews were used to assess perceived barriers to
disease self-management among 21 high-risk patients
with BD. Content analysis, with an emphasis on dominant
themes, was used to analyze the data.
Results: Three major domains of barriers emerged: individual
barriers (psychological, knowledge, behavioral and physical
health); family/community-level barriers (lack of support and
resources); and provider/healthcare system (inadequate
communication and access to care).
Conclusion: Care approaches providing social and peer support,
optimizing communication with providers and
integrating medical and psychiatric care may improve self-
management of BD in this vulnerable population.
Keywords
Bipolar disorder, barriers, self-management
1 Department of Psychiatry, Case Western Reserve University,
Cleveland, OH, USA
2 Center for Health Care Research and Policy, MetroHealth
Medical
Center, Case Western Reserve University, Cleveland, OH, USA
3 School of Medicine, Case Western Reserve University,
Cleveland, OH,

USA
4 Department of Psychiatry, Neurology, and Biostatistics &
Epidemiology, School of Medicine, Case Western Reserve
University,
Cleveland, OH, USA
5 Neurological Institute, University Hospitals Case Medical
Center,
Cleveland, OH, USA
Corresponding author:
Carol Blixen, Department of Psychiatry, Case Western Reserve
University, Cleveland, OH 44106, USA.
Email: [email protected]
666572 ISP0010.1177/0020764016666572International Journal
of Social PsychiatryBlixen et al.
research-article2016
Original Article
mailto:[email protected]
http://crossmark.crossref.org/dialog/?doi=10.1177%2F00207640
16666572&domain=pdf&date_stamp=2016-09-19
636 International Journal of Social Psychiatry 62(7)
self-management among high-risk patients with BD were
assessed as part of a large, on-going US National Institutes
of Mental Health (NIMH)-funded, randomized controlled
trial (RCT). This RCT is testing a novel customized adher-
ence enhancement (CAE) intervention intended to pro-
mote BD medication adherence versus an educational
control (EDU) intervention in poorly adherent individuals
with BD. Our findings can enrich our understanding of the

processes that impact the outcomes of this RCT and may
help clinicians and researchers integrate the consideration
of these factors into effective care delivery practices.
Methods
Sample and setting
Participants (n = 21) from the RCT were recruited at base-
line for the present analysis. For qualitative research, this
sample size is within the recommended number of 5–25
individuals who have all experienced the same phenomena
(Polkinghorne, 1989). Non-adherence was assessed by the
Tablets Routine Questionnaire (TRQ) as the percentage of
days with missed doses in the past week for each pre-
scribed foundational oral medication for the treatment of
BD. For individuals who were on one or more founda-
tional medication, an average was calculated in order to
gather information on the full BD treatment regimen.
Higher TRQ scores are a reflection of worse medication
adherence (Scott & Pope, 2002). In addition, a sampling
grid designed to ensure variability in gender, age, race/eth-
nicity and randomization group was used in the recruit-
ment of the medication non-adherent participants. The
study was conducted in the Department of Psychiatry of a
Midwestern urban hospital in the United States and was
approved by the local Institutional Review Board. All par-
ticipants provided written informed consent.
The mean age of the sample was 47.29 (standard devia-
tion (SD) = 11.06) years, 15 (71.4%) were women and the
mean level of education was 12.10 (SD = 2.31) years. Only
3 (14.3%) were married, and 18 (85.7%) were disabled or
unemployed. In all, 13 (61.9%), identified themselves as
African-American, 5 (23.8%) as Caucasian, 1 (4.8%) as
Hispanic and 3 (14.3%) as others. In all, 17 (81.0%) had

type I BD, and 3 (14.3%) had type II BD. The average age
of onset was 22.05 (SD = 10.31) years, and the average
number of psychiatric hospitalizations was 4.15
(SD = 3.47). We have limited data on comorbid physical
health conditions for the 21 participants in this qualitative
study. This type of information was not collected until
approximately 6 months after the study had started, when
many of them had completed their participation. However,
comorbidities reported for the whole sample in the RCT
(n = 160) revealed the leading conditions to be hyperten-
sion 59 (45.7%), arthritis 73 (45.6%) and high cholesterol
39 (38.0%).
Study design
In this cross-sectional qualitative study, a thematic analyti-
cal approach was used to develop a deeper understanding
of the perceived barriers to optimal self-management of
BD (Strauss, 1987). In this approach, researchers move
their analysis from a broad reading of the data toward dis-
covering patterns and developing themes.
Qualitative data collection and analysis
Individual face-to-face semi-structured interviews, con-
ducted as part of the baseline assessment in the RCT, were
used to collect narrative data on self-management barriers.
The goal of using this type of interview was to explore a
topic more openly and to allow interviewees to express
their opinions and ideas in their own words. Semi-
structured interviews are an appropriate strategy for learn-
ing the vocabulary, and discovering the thinking patterns,
of the target audience as well as for discovering unantici-
pated findings and exploring hidden meanings (Marshall
& Rossman, 2006). Therefore, respondents were given as
much latitude as possible to describe the strategies they

used to manage their chronic disease. A topic guide was
used to focus the discussion on main topics and specific
topic-related questions. For example, under the topic, ‘bar-
riers to managing BD’, the following question was asked:
‘What sort of things get in the way, or prevent you from
managing/taking care of your BD?’ Follow-up questions
such as ‘Would you explain further’, and ‘Would you give
me an example?’ were used to facilitate respondent com-
munication. Interviews, which lasted approximately an
hour, were audiotaped and transcribed verbatim.
In qualitative research, data collection, coding and anal-
ysis occur simultaneously. Emerging insights can be incor-
porated into later stages of data generation, enhancing the
comprehensiveness of the results (Strauss, 1987). We used
a thematic content analysis approach to data analysis,
encompassing open, axial and sequential coding and the
constant comparative method to generate constructs
(themes) and elaborate the relationship among constructs
(Strauss, 1987). A coding dictionary that included mutu-
ally exclusive code definitions was then constructed.
Coding structure was reviewed after a preliminary analysis
of a sub-sample of transcripts, and the dictionary was
refined through comparison, categorization and discussion
of each code’s properties and dimensions (Strauss, 1987).
Significant statements and themes attached to the codes
enabled identification/characterization of perceived barri-
ers to self-management of BD. Reduction of data in this
manner enabled us to write a composite description that
represented the essence of the phenomenon (perceptions
of ‘how’ and ‘why’) individuals with BD have problems
with self-managing. To ensure qualitative rigor throughout
the inquiry process, an audit trail was developed which

Blixen et al. 637
documented all research discussions, meetings and activi-
ties. In addition, two qualitatively trained investigators
(C.B., A.P.) independently coded each transcript to ensure
consistency and transparency of the coding; discrepancies
were resolved by discussion.
Results
Analysis of the data generated three major domains of bar-
riers to disease self-management among patients with BD:
(1) personal-level barriers, (2) family- and community-
level barriers and (3) provider- and health-care system–
level barriers.
Personal-level barriers
In Table 1, themes and illustrative quotations emerging
from the discussion of individual-level barriers to self-
management are shown. We classified these themes into
the four categories that reflected the personal barriers that
our respondents faced in trying to self-manage their BD:
(1) psychological, (2) knowledge, (3) behavioral and (4)
physical health.
Psychological barriers
Stigma and isolation. As noted in Table 1, having BD was
stigmatizing, causing respondents to feel perceived as dif-
ferent from others, resulting in a loss of self and social
isolation:
I feel different from other people. Sometime I feel God gave
me a bad hand. If I can’t think like most people, or you
know, do stuff like other people, it gets to me. (Respondent

#2004)
I like to play chess, but I don’t go nowhere to play chess.
Normally, I sit with the pieces by myself. (Respondent #2012)
Taking medications for BD was also perceived as stigma-
tizing because everyone would then know they had a men-
tal illness:
It took a long time for me to take the medicine because I
didn’t want to be classified as having a mental illness because
I thought I’d be ostracized … If my friends knew that I was
taking medicine because I was bipolar, they’ll say I am crazy.
(Respondent #2006)
Knowledge barriers
Diagnosis and causes. There was a paucity of knowledge
about BD, ranging from the diagnosis itself to causes of
the disease:
I had a long time problem trying to understand it because I
thought bipolar was two people in one and this evil side and
this good side would come in and out. (Respondent #2006)
… I still don’t understand what constitutes it. To understand it
is the first issue. And since I don’t understand what symptoms
are, I gotta first know ‘em before I can say I’m aware of ‘em.
(Respondent #2052)
While some described the cause of their BD as a ‘chemical
imbalance of the brain’ or ‘genetic’, many other causes
were cited which ranged from traumatic childhoods:
I’ve had a few tragedies, you know, coming up in childhood
and stuff, but I don’t know if that had something to do with it.

(Respondent #2009)
To being born of alcoholic parents as well as their own
alcohol and drug use:
I thought because me being a child alcoholic that has
something to do with my parents drinking when I was born.
(Respondent #2006)
Table 1. Personal-level barriers to disease self-management
among poorly adherent patients with bipolar disorder (BD) (n =
21).
Themes and categories Illustrative quotations from respondents
Psychological barriers
Stigma and isolation
‘It’s kinda weird. People look at you differently. When you say,
well, I have bipolar disorder, it’s like
you’re crazy or something. Stay away from her’. (Respondent
#2015)
‘… I isolate a lot. I try to stay away from people; basically just
stay in my room. I just lock my doors
and stay in the house all the time’. (Respondent #2052)
Knowledge barriers
Diagnosis and causes
‘I have no understanding of Bipolar Disorder. Once I understand
what it is that I have and why
I’m what I am, then maybe I’ll understand why I sometimes
respond or do things the way I do’.
(Respondent #2052)
‘I would like to know what causes it, but I don’t. I just figured I
was just born like this’. (Respondent

#2012)
Behavioral barriers
Attitudes and lifestyle
issues
‘I don’t like being controlled by my medication, and being so
dependent upon it. I just try to do it on
my own. I don’t want to be stuck on medicine all the rest of my
life’. (Respondent #2009)
‘Bipolar is a serious disease because I make irrational, crazy
decisions, mainly when I’m manic. Then I
have to face the consequences’. (Respondent #2003)
Physical health barriers ‘But being bipolar and dealing with
having HIV is sort of like a tough issue because I’m dealing
with
two things!’ (Respondent #2005)
It has something to do with my brain, you know. I know I did
a lot of damage to myself. … drugs and alcohol play a part in
damaging my brain. (Respondent #2005)
Most respondents described their symptoms of BD as
mood swings, manic behavior and/or depression, but one
respondent described his symptoms as something called
the HALT:
But then when I get home, sometime I get real lonely and get
that H-A-L- T–where you get hungry, angry, lonely and tired.
… it’s like I’m shutting down, and I don’t know when I’m
coming out of it. (Respondent #2015)

Behavioral barriers
Attitudes. All the respondents agreed that BD was a very
serious illness:
It’s basically one of those illnesses, like cancer or AIDS or
something like that. So, it’s very serious, like heart attacks or
those illnesses that can take your life. (Respondent #2020)
However, negative or ambivalent attitudes about medica-
tions prescribed for their BD posed barriers to self-man-
agement. These included complaints about side effects,
which ranged from dry mouth, inability to concentrate,
drowsiness, weight gain to out-of-body experiences:
… it’s almost like an out-of-body experience. Like even just
looking into the world, like walking down the street, it would
seem so far away. And it would seem like it took extra effort
to pick up my legs and to move … it was a very uncomfortable
and edgy feeling. And I couldn’t handle it. (Respondent
#2016)
Frustration with keeping up a medication routine and skip-
ping medications on days when they were feeling good
were also common attitudes:
A lot of times I stop taking my medication, because I get tired
of just the routine of taking medication. I’ll just get up one
morning and just say ‘I ain’t taking it’. Then a few days go by
where I haven’t took it and then I just start lookin for some
drugs. (Respondent #2012)
Sometimes you feel you don’t need to take it maybe because
you feel fine or something, so the good days could be skip
days. (Respondent #2005)

For some, being in a relationship meant that they avoided
taking medications, while others felt that they didn’t need
to take them:
If I start a relationship, I stop taking medication because I
don’t want them to know what I got (BD). (Respondent #2007)
I don’t see myself being one of those people who need it
(medication). So, I have a messed up way of thinking.
(Respondent #2020)
Lifestyle issues. One of the major barriers to self-manage-
ment was making irrational decisions which led to a spiral
of negative consequences and despair:
I make irrational decisions mainly when I’m manic. I make
crazy, bad decisions, and then I have consequences. I got
arrested because I had warrants on me from 2012 for being
argumentative and irritable in public places. And when the
cops approached me, I would be yelling and screaming. And
then I got jail for eight days and lost my job … (Respondent
#2013)
One respondent described her sudden decision to move out
of state with her three children because she looked on-line
and saw
… these big beautiful houses they have in Georgia, that you
can get for less price that you can get here. The problem was
I didn’t have enough money and no support. I didn’t have a
car and everybody would tell me not to go to Georgia without
having transportation. But I went anyway, sold everything
and dragged my three kids with me, uprooted them. I was
manic, I was excited and then I came back to reality, and
moved back here, and became very depressed after that.

(Respondent #2015)
Limited finances, lack of transportation and drug and alcohol
use were also cited as barriers to self-management of BD:
I have no social activities. I have no money to socialize, even
Bingo costs money. (Respondent #2002)
I have a lot of problems going to get meds and seeing my
doctor. A lot of times I don’t have bus fare. (Respondent
#2012)
I’m a recovering addict, and I sometimes have my back slides.
I’m somebody who experimented with a lot of things and just
got it down to just two, smoking marijuana or doing cocaine
or crack. I’m weaning myself – slowly but surely. (Respondent
#205)
Physical health barriers
As noted in Table 1 and below, respondents also cited
comorbid physical illnesses as barriers to management of
their mental illness:
… I have diabetes, chronic arthritis, and chronic asthma. I
have a history of pulmonary embolisms and deep vein
thrombosis. Did I miss any? Oh, I also have high blood
pressure and asthma. (Respondent #2093)
Blixen et al. 639
I was diagnosed with diabetes type one thirteen years ago. I
take insulin and that interacts with bipolar and causes mood
swings too. It’s even more dangerous to have type one

interacting with bipolar than type two because you go from
low to high very quickly. (Respondent #2013)
In summary, respondents in the study cited many personal
barriers to self-management of BD which included per-
ceived stigma and isolation, lack of knowledge about the
disease itself and their own negative attitudes toward med-
ications which ranged from denial of their need for them to
feelings of being controlled and dependent. Other personal
barriers included their own chaotic lifestyles and comorbid
physical diseases which also complicated management of
their BD.
Family- and community-level barriers
Table 2 shows themes, descriptive codes and illustrative
quotations emerging from the discussion of family- and
community-level barriers. Two key barrier categories were
as follows: (1) limited understanding of BD and (2) limited
community resources.
Limited understanding of BD
Lack of support. In addition to their feeling isolated and
alone, respondents felt an overwhelming lack of sup-
port from family and the community in which they
lived:
Well, they try, but they don’t really know. They think they
know and a lot of them just don’t think there’s anything wrong
with me. Like the lady I stay with, she try to understand, but
she really don’t understand. (Respondent #2012)
Well my husband, he has a mental illness too. Schizophrenic
… paranoia. I mean, he might understand but he basically
don’t like to talk about certain things anyways, so I don’t

know if he understands. (Respondent #2005)
Estrangement. Having BD sometimes led to estrangement
from family:
Yep, that’s what my family does, they avoid me. And they say
it’s because I live on the west side, and they live all the way
out on the east side. They got a car. I don’t. I compare my
situation to my friends and their relationship with their
families and I’m like well, her cousins come over and visit
her. You know, it’s like no matter where I live if you’re
concerned, then show it! (Respondent #2007)
I don’t have family in the United States. It’s just me. The last
few years really, my communications with them went from
bad to worse. (Respondent #2013)
Stressful relationships. Friction, misunderstandings and
sometimes abuse added additional barriers to self-manag-
ing their BD:
And like even with your family, you can tend to get more
stressed, get angry at each other and get frustrated …
(Respondent #2005)
I live with my boyfriend and it’s been an on and off twenty
year abusive relationship. And as my mind gets a little bit
clearer, he’s not liking it. He’s so used to keeping me, like in
his control, you know. He’s been physical with me and with
my dog, cause when he goes at me, my dog goes at him. And
he don’t like that. I’ve put him in prison before for domestic
violence. (Respondent #2016)
Negative attitudes about medications for BD
Because of misinformation and beliefs about BD, family

members and even community support groups often gave
respondents incorrect advice about taking medications for
their BD:
My family is always telling me ‘I don’t think you need to take
the medication, I think you need to call the doctor’.
(Respondent #2011)
… and people telling me ‘Girl you don’t need that medicine,
just all you need to do is cut the stress in your life, you don’t
need the medicine. You looked zooted out. You know, I can
tell you’re on medicine’. And that makes me say ‘Okay, I
don’t need it no more’. But I know I do. (Respondent #2007)
Table 2. Family and community barriers to disease self-
management among poorly adherent patients with bipolar
disorder (BD)
(n = 21).
Limited understanding
of BD
‘My father thinks I should just get over it, that it’s just in my
head. Like I’m making it out to be more
than what it is. My father just don’t get it and I don’t think he
ever will. He’s just set in his ways and
he thinks I’m just stupid and just do these things. (Respondent
#2016)
‘You have people that tell you, “Oh you don’t need that
(medications), you just need God.” But you
know, I know I need them. I know that I need it, that’s the one
thing I know’. (Respondent #2008)
Limited community

resources
‘Right now I stay with a friend. I’m homeless. I been tryin to
get some help with subsidized housing,
but I can’t seem to get no help, unless I stay at this shelter, S.G.
And I know if I go down to S.G. and
stay, I’ll wind up usin drugs, cause it’s a lot of drugs down
there’. (Respondent #2012)
I used to go to this one AA meeting, and they were saying no
drugs or alcohol whatsoever and they tried to implicate that
you shouldn’t even take mental health drug and stuff because
they felt that the effect of them got you high, which is not true.
(Respondent #2006)
Limited community resources
Unstable living situations, homelessness and limited
income often led to living in shelters where self-managing
BD was especially difficult and led to a spiral of despair:
I stay with a friend, but she don’t want me there, because she
wants an intimate relationship. And I don’t want an intimate
relationship with her. So, basically, I don’t have a home.
(Respondent #2012)
The problem is a lot of housing programs I do not qualify for,
because I’m not a permanent resident or an American citizen
for the last seven years, which is a requirement. So I have to
go back down to the shelter. It’s been very hard for me to
accept it. And that’s triggering my depression. (Respondent
#2013)

When you have a limited income, it’s hard to find housing.
It’s hard to find programs where you can go to be able to get
some type of help. They don’t give you any avenues of
resources. They’ll tell you ‘well, go down to the welfare
building’. Welfare building cannot help you … it’s even more
frustrating when you get down there and you have to deal
with the social workers, supervisors, the people down there,
the people waiting in the lobby. It’s crazy and it’s another
thing, more stress added on to you. (Respondent #2011)
In summary, family and community issues such as lack of
social support, limited understanding of BD, misinforma-
tion about medication, stressful relationships and limited
income and housing options posed what respondents per-
ceived as insurmountable barriers to self-management of
BD.
Provider- and health-care system–level barriers
Table 3 shows themes, descriptive codes and illustrative
quotations emerging from the discussion of provider- and
health-care system–level barriers. Two key categories of
barriers emerged from the data: (1) patient/provider rela-
tionships and (2) access to care.
Patient/provider relationships
Ineffective communication. For respondents, the major bar-
rier to having a good patient/provider relationship was the
inability of their provider to communicate with them.
Many times respondents didn’t understand what their pro-
viders told them during visits because of the use of unfa-
miliar words or medical jargon:
I’m developmentally delayed, and I don’t comprehend things

as well as most people. If you don’t break it down to something
in basically layman’s terms that I can understand, I’m not
gonna understand what they say … (Respondent #2020)
The emphasis on medication-prescribing during the visit,
instead of listening, was also seen as a barrier to effective
communication:
I’m looking at her and she’s looking at me and it’s making me
feel like I’m really crazy or I don’t know what I’m saying. It’s
hard to get them to understand and they just give you you
pills, and bye bye! I don’t want your drugs. I just want you to
hear me, what I’m telling you! (Respondent #2004)
Another reported aspect of poor provider communication
skills was provider body language that made them feel as
though they were ‘just another patient’:
She really didn’t say much. She kinda just sat there… no
rapport whatsoever. It wasn’t that I didn’t understand what
she was saying, but her body language! A lot of times people
don’t realize your body language will speak louder than what
your verbal words say. When I see that your body language is
speaking to me, as if you’re like, ‘oK’ here we go with another
hard luck person with a hundred problems. (Respondent
#2011)
Access to care
Appointment issues. As noted in Table 3, getting an appoint-
ment with a mental health provider was a long and frustrat-
ing process, and infrequent scheduled appointments left
too much time for respondents to remember what they
wanted to report or talk about:
I’ve seen him maybe twice over the last six months. By the

time I get around to seeing him, I can’t remember. But I know
there’s something important I want to talk to him about, but
we’re already on another issue, then I can’t frame what the
question’s gonna be or why I’m asking the question.
(Respondent #2052)
Turnover in providers. Most of the respondents received
their care from resident physician trainees who often
rotated off the service after a period of time. Turnover in
providers left respondents feeling frustrated and often pre-
vented the formation of a therapeutic relationship. For
those who had made progress in managing their BD, the
loss of the provider was especially discouraging:
… at L.S. you never can tell who you’re gonna get. It’s like a
box of chocolates … I could have somebody one week and
somebody the next week. … I always want the same person.
I’ll wait three months to get an appointment, and then that
person is no longer there. So, there’s a turnover. And I don’t
get to build up a relationship. (Respondent #2093)
Blixen et al. 641
Well I wish she had stayed. She left there and went over to B.
She was, as far as I’m concerned, the very best therapist that I
had. I was making leaps and bounds with her and being able
to be myself, which is rare. I have a new one. His name’s Q.I.
They canceled the last meeting. I’m tryin to get back on track
to where I see him. (Respondent #2052)
In summary, respondents cited ineffective communication
with their provider as a major barrier to forming a thera-
peutic relationship. Communication problems were com-
pounded by difficulties getting an appointment and the

subsequent rapid turnover in providers.
Discussion
In this well-characterized sample of poorly adherent peo-
ple with BD, qualitative analysis identified a number of
barriers to self-management that have important implica-
tions as to how best to help and empower high-risk indi-
viduals. First, participants with BD identified barriers to
self-management that spanned individual, family/commu-
nity and provider/healthcare system domains. This is con-
sistent with McLeroy, Bibeau, Steckler, and Glanz’s (1988)
social ecological model of health behavior. This model
posits that behavior, actions and events are influenced by
individual, interpersonal, organizational, community and
policy factors.
Second, the internalized stigma associated with having
a mental illness was clearly articulated by some partici-
pants. Internalized stigma, or self-stigma, occurs when
individuals accept society’s assessment and incorporate it
into their sense of self (Corrigan, Kerr, & Knudsen, 2005;
Ellison, Mason, & Scior, 2013; Latalova et al., 2013). In a
meta-analysis of internalized stigma in people living with
mental illness, Livingston and Boyd (2010) found a
striking negative relationship between internalized stigma
and psychosocial variables (hope, self-esteem and empow-
erment), medication adherence and a positive relationship
with psychiatric symptom severity. In addition to internal-
ized stigma, or perhaps because of it, isolation and a loss of
self were common themes among participants. Charmaz
(1983) describes this loss of self as a form of suffering felt
by those living with a chronic illness who ‘observe their
former self-images crumbling away without the simultane-
ous development of equally valued ones’. This author con-

cludes that this loss of self results in ‘restricted lives, social
isolation, and feeling that one’s illness has become a major
source of identity’.
Third, while social support is known to be helpful for
chronic illness self-management (Gallant, 2003; Strom &
Egede, 2012), in this study, there appeared to be a marked
absence of social support from families and communities.
This included negative attitudes toward psychotropic med-
ications and limited resources such as income and housing
resources. Medication adherence in BD treatment has been
shown to be related to a number of factors, among them
psychosocial support, number of comorbid illnesses and
attitudes toward medications (Lingam & Scott, 2002;
Perlick et al., 2004; Sajatovic et al., 2007).
Fourth, communication is crucial to building a thera-
peutic clinician–patient relationship and delivering high-
quality care (Arora, 2003; Fong Ha & Longnecker, 2010;
Roter, 1983; Stewart, 1995); yet, there were those respond-
ents who felt that they couldn’t understand what their pro-
vider said, or they were viewed impersonally, ‘as just
another patient’. Ineffective provider communication and
resultant dissatisfaction are not unique to the participants
in our study, and patient surveys have consistently shown
a desire for better communication with their clinicians
(Duffy et al., 2004).
Table 3. Provider and health-care system–level barriers to
disease self-management among poorly adherent patients with
bipolar
disorder (n = 21).
Patient/provider

relationships
‘That’s fine and well, but it would be nice if I understood what
is all goin on, so I can at least
appreciate the visit, half hour though it may be … I: … then I
can at least understand or know which
direction I’m goin, or at least I’ll have a workin knowledge of
why you’re asking the questions you
are asking me, or whatever. When I see my therapist again, I’m
gonna ask him to explain to me what
the hell bipolar is – nobody ever told me’. (Respondent #2052)
‘The same questions every time. It’s just a standard group of
questions. Do I hear voices? Can I read
other people’s minds? Sometime I want to tell what’s goin on.
Like, if my brother, sister dies, my
past. I’ll get upset about that and I want to vent. I wanna get
that out. It’s like, I go in just to get a
prescription for meds’. (Respondent #2093)
Access to care ‘It’s been over a year. They state you have to
have a referral. Well, if that’s the case I’m still waiting
almost two years for that same referral for someone to call me.
Hey look, what does it take? Me to
hurt myself or someone else or to really have a bad, you know,
reaction for myself, in order to get
some help. I need to speak to somebody. I got a lot of issues’.
(Respondent #2089)
‘… but every six months they give you a new one (therapist)
anyway. So you don’t really have a
chance to have a close relationship. So, personally I try not to
discuss anything with them that I feel is
very personal to me’. (Respondent #2006)

An additional finding from this qualitative analysis was
that reported comorbid physical illnesses complicated self-
management of BD. Physical illnesses are more prevalent
in people with serious mental illness (SMI) than in the
general population (DeHertet al., 2011), but there is a sig-
nificant lack of awareness of the physical health and
health-care access problems for people with SMI. Mental
health treatments in the United States are often delivered
separately from clinical settings for primary, or other,
medical specialty care. Most of the respondents in this
study received their psychiatric care from Community
Mental Health Centers (CMHCs) which generally provide
an array of mental health services; however, care is often
not integrated with primary care or other specialty care. In
addition, medical settings may be poorly equipped to
assess and manage individuals with more severe psychiat-
ric symptoms. A recent systematic review of mortality in
mental disorders (Walker, McGhee, & Druss, 2015) noted
that approximately two-thirds of deaths in people with
mental disorders are due to causes like heart disease and
diabetes. Care of chronic medical conditions in those with
mental illness requires an approach that promotes healthy
behaviors and coordinates care between mental health and
medical systems.
It is possible that changing elements in the health-care
climate, such as the addition of primary care services to
CMHC infrastructures, increased use of electronic health
records that facilitate communication between primary and
specialty care providers, and between providers and
patients, may help to minimize the barriers to physical and
mental health–integrated care delivery. Furthermore, many
experts believe that the increased presence of medical
homes, a model that seeks to facilitate partnerships among
the patient, his or her primary care physician and the

patient’s family can solve many of the problems related to
concurrent care of people with both physical and mental
illnesses (Bodenheimer & Pham, 2010). Another element
to incorporate into the health-care system may be the use of
peer educators. Peer support, provided by individuals who
have a SMI such as BD, can teach and model self-manage-
ment, help normalize the illness experience, promote hope
for recovery and increase feelings of empowerment and
self-esteem (Repper & Carter, 2011; Schon, 2015). Peers
may also help in reducing the feelings of stigma associated
with BD, provide social support for individuals who feel
isolated and improve outcomes. Indeed, a recent evaluation
of peer support services for individuals with SMI (Chinman,
et al., 2014) found that compared with professional staff,
peers were better able to reduce inpatient use and improve
a range of recovery outcomes.
Although our findings on overall barriers to disease
self-management among patients with BD have implica-
tions for informing care, there are some limitations.
Patients with BD who receive care in other treatment set-
tings, or those who have less severe or disabling illness,
may have different experiences in managing this chronic
illness and different types of encounters with providers
and health-care systems. At the same time, the focus on
poorly adherent patients facilitated an understanding on
barriers to self-management among those who are most in
need for intervention. The small convenience sample and
the conduct of the study in a single urban area in the United
States may limit transferability of the study findings. In
addition, our inability to obtain only limited information
on comorbid physical health conditions for our 21 partici-
pants may indicate that this randomly chosen sample may
not be representative of the entire data set. These limita-
tions are offset, to some extent, by the use of rigorous

qualitative research methods described in this study . The
self-report method is direct, versatile and yields informa-
tion that would be difficult, if not impossible, to gather by
other means.
Conclusion
Our findings indicate that poorly adherent patients with
BD had internalized the sense of stigma associated with
having a mental illness. Additionally, they had inadequate
knowledge about the causes and management of their
mental disorder, little or no social support from family and
community, stressful relationships, family estrangement,
multiple comorbid conditions, alcohol and substance
abuse, and chaotic lifestyles. All these factors posed innu-
merable barriers to self-management for the study respond-
ents. Care approaches that provide social and peer support,
locate resources, optimize communication with providers
and integrate medical and psychiatric care may improve
self-management and reduce health complications in this
vulnerable population.
Additional areas of future research should further
explore the topic of adherence enhancement in individuals
with BD as it relates to specific barriers. Our qualitative
data illustrate that adherence barriers are not uniform, and
it is likely that a one-size-fits-all approach will not satisfy
the needs of many with this chronic mental illness.
Targeted, or personalized, approaches that address specific
challenges to adherence are likely to yield benefits that can
help diverse individuals in a variety of settings.
Conflict of interest
The author(s) declared the following potential conflicts of inter-
est with respect to the research, authorship, and/or publication

of
this article: Dr Sajatovic has research grants from Pfizer,
Merck,
Janssen, Reuter Foundation, Woodruff Foundation, Reinberger
Foundation, National Institute of Health (NIH) and the Centers
for Disease Control and Prevention (CDC). Dr Sajatovic is a
con-
sultant to Bracket, Prophase, Otsuka, Pfizer and Sunovion and
has received royalties from Springer Press, Johns Hopkins
University Press, Oxford Press, UpToDate and Lexicomp. None
of the other authors declare conflict of interest.
Blixen et al. 643
Funding
The author(s) disclosed receipt of the following financial
support
for the research, authorship, and/or publication of this article:
Research reported in this publication was supported by the
National Institute of Mental Health of the National Institutes of
Health under award no. R01MH093321. Support was also
received from the Clinical and Translational Science of
Cleveland, UL1TR000439, from the National Center for
Advancing Translational Sciences (NCATS) component of the
National Institutes of Health and NIH Roadmap for Medical
Research. The content is solely the responsibility of the authors
and does not necessarily represent the official views of the
National Institutes of Health.
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