Background: Informal caregivers provide unpaid support to a family member, which has been shown to more positively affect their relatives’ health outcomes than equivalent paid caregivers. The provision of this support, however, comes at a cost to the carers’ health and wellbeing through meeting the demands of the caring role. Efforts have been made to alleviate these consequences through various forms of interventions aimed to enable the carers to meet these demands. The reported success of these interventions is varied in regards to their effectiveness; an argument supported by literature review papers on the subject that questions the methodologies and evaluations of these interventions. Rationale: There is a need to explore the ways to enhance the health and wellbeing of informal carers by means of a robust design and evaluation. This thesis reports a study, the aim of which is to provide information about how to reduce the negative effects of the carer role whilst enhancing the positive effects using an intervention developed using lived experience. Method: The self-care intervention was developed and piloted with those caring for a relative with bipolar disorder. This was achieved in three stages: (i) qualitative interviews with carers to explore and understand the role, (ii) developing the intervention informed by qualitative findings, and finally by (iii) piloting the intervention. Effectiveness of the intervention was determined using health and wellbeing outcomes, the results of which were compared to a control group who did not take part in the intervention. Results: A positive potential for psychoeducational, cognitive behavioural and mindfulness techniques in enhancing the health and wellbeing of those caring for a relative diagnosed with bipolar disorder was found. From the exploration of lived experience, “Being Bound” was elicited from the data representing the conflict between the detrimental effects of providing care and being unable to take respite or reprieve through guilt and anxiety. Conclusion: Professionals who work with family members, individually or as part of a family unit, should consider the benefits of targeted information for carers. Provision of information is not enough to engage the carer in the process of understanding their relative’s behaviours, but requires a process of interaction and personalisation. In contributing to existing research, the use of hermeneutic phenomenology provided new insight in to the experiences of those providing care. The outcome of the intervention pilot shows positive potential for the use of interventions beyond psychoeducation alone and the use of a self-care approach.

The study aimed to test how progress on achievement and power goals, and perceptions of power, fluctuate with mania symptoms in Bipolar Disorder (BD), testing the Dominance Behavioural System (DBS) model. The DBS includes biological, psychological, and behavioural components that serve the goal of control over social and material resources needed for survival and reproduction (Johnson, Leedom, & Muhtadie, 2012c). Daily diary methodology was employed, with 29 individuals meeting the Diagnostic and Statistical Manual-Fourth Edition (DSM-IV) criteria for BD I or II as verified by the Structured Clinical Interview [SCID-I-RV] (First, Spitzer, Gibbon & Williams, 2002). Baseline measures of dominance motivation and ambitious goal setting were taken. Over fourteen days, participants reported daily on their goal progress, symptoms of mania, power, and anger. It was hypothesised there would be a positive relationship between symptoms of mania and dominance motivation. It was also hypothesised that for power but not achievement goals, ii) goal progress would be associated with perceptions of power, iii) symptoms of mania, and iv) that goal frustration would be associated with anger. Pearson’s correlations and multilevel modelling analyses found largely null results with the exception of a positive relationship between progress towards power goals and perceptions of power. Thus, the results did not provide support for the DBS model predictions for relationships between power goals and manic symptoms. Future studies could utilise further measures of dominance motivation and power, and study goal pursuit over a more protracted duration, including comparisons between BD, depressed groups, and healthy controls.

This dissertation is a contribution to the contemporary field of phenomenological psychopathology, or the phenomenological study of psychiatric disorders. The work proceeds with two major aims. The first is to show how a phenomenological approach can clarify and illuminate the nature of psychopathology—specifically those conditions typically labeled as major depressive disorder and bipolar disorder. The second is to show how engaging with psychopathological conditions can challenge and undermine many phenomenological presuppositions, especially phenomenology’s status as a transcendental philosophy and its corresponding anti-naturalistic outlook. In the opening chapter, I articulate the three layers of the subject matter of phenomenological research—what I refer to as “existentials,” “modes,” and “prejudices.” As I argue, while each layer contributes to what we might call the “structure” of human existence, they do not do so in the same way, or to the same degree. Because phenomenological psychopathology—and applied phenomenology in general—aims to characterize how the structure of human existence can change and alter, it is paramount that these layers be adequately delineated and defined before investigating these changes. In chapters two through five, I conduct hermeneutic and phenomenological investigations of psychopathological phenomena typically labeled as major depressive disorder or bipolar disorder. These investigations address the affective aspects of depression and mania, and the embodied aspects of depression. In addition to clearly articulating the nature of these phenomena, I show how certain psychopathological conditions involve changes in the deepest or most fundamental layer of human existence—what I refer to as existentials. As I argue, many of the classical phenomenologists (including Husserl and Heidegger) believed that these structural features were necessary, unchanging, and universal. However, this presupposition is challenged through the examination of psychopathological and neuropathological conditions, undermining the status of phenomenology as a transcendental philosophy. While this challenge to classical phenomenology is only sketched in the early chapters, in chapters six and seven I develop it in more detail in order to achieve two distinct ends. In chapter six I argue that psychopathology and neuropathology not only challenge phenomenology’s status as a transcendental philosophy, but also supply a key to developing a phenomenological naturalism (which I contrast with a naturalized phenomenology). Phenomenological naturalism, as I articulate it, is a position in which phenomenology is not subsumed by the metaphysical and methodological framework of the natural sciences, but nonetheless maintains the capacity to investigate how the natural world stands independent of human subjectivity (and how events in the natural world can bring about changes in the most fundamental structures of human existence). In the seventh chapter I argue that a phenomenology in which existentials are contingent and variable rather than necessary and unchanging allows phenomenologists to contribute to new dimensional approaches to psychiatric classification. Rather than begin from distinct categories of disorder, these approaches begin from distinct core features of human existence. These features, referred to as either dimensions or constructs, can vary in degree and are studied in both normal and pathological forms.

Magister Artium (Social Work) - MA(SW) / Caregivers of people with psychiatric illnesses experience challenges, which contribute significantly to their burden of care and can result in health and mental health problems. The researcher was interested in the lived experiences of caregivers, which resulted in the following research questions: What are the lived experiences of caregivers caring for a co-morbid bi-polar and substance-abuse patient, and what context and situations contribute to the problems? The goal of this research was to explore the experiences of family members caring for relatives admitted in a psychiatric hospital, and the contexts in which these occurred. The objectives were to explore and describe the lived experiences of family members caring for a relative with a co-morbid diagnosis of bi-polar and substance abuse, as well as the situations or contexts in which these experiences occur. These objectives were followed by the last objective of the research, which was to make recommendations to the multi-disciplinary teams (MDTs) on services for family members caring for such a relative. A qualitative, phenomenological research approach was used for this study with explorative and descriptive research designs. The population for the study comprised families in the Western Cape caring for female relatives admitted to a psychiatric hospital with co-morbid bipolar and substance use disorder. The researcher purposively selected relatives of female in-patients admitted in a female admission ward. Families were chosen whose members were admitted for more than three months. In-depth phenomenological interviews were done with six participants until data saturation was reached. Phenomenological data analysis, focusing on the textural (lived experience) and structural (context in which it was experienced), were followed after data collection. Findings comprised a composite description of the phenomena of both textural and structural description. The findings of this research resulted in conclusions and recommendations for MDTs and social work on interventions for family members caring for a family member with this mental condition. Findings from this study conclude what was found in the literature regarding challenges in the system leads to caregivers feeling burdened with their mentally ill relative, and that resources and support are lacking in communities. This led to recommendations aiming at MDTs, government and social workers working in institutions, to align with community social workers in order to strengthen working relationships with the aim of providing the necessary support services to families caring for mentally ill relatives. Future research suggestions are also aimed at supporting families caring for patients with a mental illness for which reasons for re-admissions will be assessed and evaluated.

Bipolar disorder (BPD) is associated with negative health outcomes and high relapse rates and group psychoeducation (PE) is recognised as an effective intervention when used in conjunction with pharmacological treatment. Unhealthy beliefs and attitudes have not been measured or related to outcomes in group PE and the mechanism for how PE exerts its effect are unidentified. Aims: (a). An adapted group psychoeducation intervention will change (improve) unhealthy personal beliefs about illness and attitudes towards medication when compared to a treatment as usual group. (b). Changes in unhealthy personal beliefs and attitudes will be maintained overtime (a 12 month follow up period). (c). People who subsequently relapse compared to those who do not relapse, will have less improvement in their unhealthy personal beliefs about illness and attitudes towards medication from PE. (d). An evaluation of the efficacy of psychoeducation in a systematic review for bipolar disorder in preventing relapse and other outcomes will identify factors that relate to clinical outcomes. Methods: A 10 session PE intervention was adapted and 38 participants with bipolar disorder I or II (using DSM-IV criteria) were recruited from a Specialist Affective Disorders Service. A waiting list assessment time was used as a parallel group control and a longitudinal study took place over a 12 month follow up period in all participants once they had received the intervention. A mirror image study reviewed case notes to identify relapse 12 month pre versus post intervention. Assessments measuring, beliefs and attitudes, mood symptoms and satisfaction where carried out, 8 weeks prior to intervention (waiting list), pre intervention, and 6 and 12 months post intervention. Results Summary: The waiting list control comparison showed significant improvement in attitudes measured by the Personal Beliefs about Illness Questionnaire (PBIQ) and Drug attitude Inventory (DAI) and symptoms and functioning. Beliefs on all domains of the PBIQ improved significantly (p<0.001) as did attitudes toward medication (p<0.001) there were also small but significant improvements in mood symptoms. In all participants (n=38) improvements were maintained over the 12 month follow up period. Nine people relapsed in the 12 months after the intervention compared with 22 before (p<0.002) and relapsers improved significantly less than non-relapsers following PE on the PBIQ (p=0.012) and the DAI (p=0.046). Conclusions: A group PE intervention reduced unhealthy personal beliefs and attitudes, both manic and depressive relapse and improved functioning. Improvements are maintained over time except adherence which remained unchanged. The amount of improvement in the PBIQ and DAI is related to relapse with non relapsers improving more than relapsers. The systematic review provides reasonable evidence that psychoeducation is at least modestly effective in preventing relapse in bipolar disorder, with the strongest evidence for reducing overall and manic relapse.

This thesis explores the experience of parenting with severe mental illness, using qualitative methodologies. It is presented in three parts: a literature review, a report of the empirical research, and a critical reflection of the process undertaken. The literature review provides both a systematic review of qualitative studies exploring the experience of parenting with a severe mental illness (SMI), and a meta-synthesis of the findings from the included studies. The findings demonstrated six overarching themes that were central to the parents' experience. The themes were interlinked and often conflictual in nature and a model of the relationship between the themes is provided. The synthesis revealed how the additional and conflicting pressures faced by parents with SMI can interact with their symptoms to affect parenting behaviours and decisions about engagement with services. The model of themes elicited by the synthesis provides a broad conceptual framework in which parenting with SMI can be considered across the age range of children, parental symptoms and parenting roles. The empirical research provides a specific focus on the views and experiences of parents with Bipolar Disorder (BD). Interpretative Phenomenological Analysis was used to explore the lived experience of parenting with BD, to provide insight into the parents' perspective and the influence that this may have on outcomes for parents as well as their children. The analysis resulted in six overarching themes, each of which consisted of a number of sub-themes. There were important interactions between the themes and these are illustrated for the reader. It was found that the parents identified a number of challenges in being a parent with BD and experienced feelings of inadequacy, guilt and worry relating to the impact that their illness had on their children and family. Strategies for managing these feelings and limiting the impact of BD could have an inadvertent negative effect on their own well-being, and that of their child. Learning to accept their diagnosis and developing strategies for managing their symptoms were crucial for positive parenting, although the changing needs of their children often presented new challenges. Contextual factors, including the stigma associated with mental illness, could also either mediate or exacerbate the challenge of parenting with BD. The clinical implications of these findings are discussed. The critical reflection provides a consideration of qualitative methodologies and a personal reflection on the qualitative process in relation to the empirical research. It details the critical debates around qualitative methodology, the application of qualitative methodologies, and the challenges this presented for the researcher. The report was written on completion of the investigation and reflects the process by which, as a novice, the author was able to develop an understanding of qualitative methodology and carry out an insightful piece of research.

Bipolar disorder is characterised by intense fluctuations in mood, including the experience of severe episodes of depression, mania and hypomania. The experience of bipolar disorder can also be associated with biases in various cognitive processes, including rumination in response to positive and negative mood states and tendencies to make dysfunctional self-appraisals. Preliminary research has also suggested that bipolar disorder may be associated with deficits in the recall of specifically detailed autobiographical memories. The lack of specificity in the recall of autobiographical memories, known as the 'overgeneral' recall bias, refers to tendencies to generate generalised memory representations as the memory recall process is terminated prior to the activation of specifically detailed memories. This overgeneral recall of autobiographical memories can also contribute to ruminative thought patterns, impair the generation of effective solutions to problems, and is associated with poor illness outcomes. The overgeneral bias has been extensively researched within major depressive disorder and suicidality, but has been comparatively under-researched in bipolar disorder and in vulnerable individuals. A series of eight studies were designed to: (i) investigate the cross-sectional associations across measures of positive and negative rumination and self-appraisal with the vulnerability to hypomania, and investigate the associations of these cognitive styles with prospective mood symptoms in an at-risk sample; (ii) investigate the cognitive vulnerability to hypomania in relation to rumination, problem-solving and autobiographical memory specificity; (iii) conduct a preliminary investigation into the associations between goal-related memory processes and extreme goal-pursuit in relation to hypomania vulnerability; (iv) investigate whether the vulnerability to hypomania and future bipolar disorders is associated with similar patterns of overgeneral memory recall on a standardised cue memory task; and (v) investigate the patterns of autobiographical memory specificity within a remitted bipolar sample. The heightened vulnerability to future bipolar disorders was associated with tendencies to engage in both positive and negative forms of ruminative thought processes, and with poorer psychosocial problem-solving, however, this relationship with problem-solving was not independent of current mood symptoms. The results of two studies indicated that the heightened vulnerability to hypomania was associated with an overgeneral memory bias across two different assessments of memory specificity, in direct contrast to previous research. Individuals diagnosed with bipolar disorder also reported more extreme overgenerality during memory recall than a sample of age and gender-matched healthy controls, but were able to recall some specifically detailed negative memories in short response latencies compared to non-bipolar control participants. The research presented within this thesis supports the notion of a continuum of increasing overgenerality in the bipolar disorder spectrum, inclusive of at-risk individuals to people formally diagnosed with bipolar disorder. Although bipolar disorder appears to be associated with a trait-based overgeneral memory bias, bipolar individuals appear to have ready access to some specific negative memories even during remission from symptoms. The clinical implications of this research, methodological considerations in the assessment of memory specificity, and directions for further investigations into the nature of autobiographical memory recall in bipolar spectrum disorders are discussed.

This thesis investigated the experiences of children who have a parent with a mental illness, using qualitative methods. It is divided into three separate sections, the first two written as standalone journal papers. Paper 1 is a systematic review and synthesis of qualitative studies exploring children's experiences of having a parent with a mental illness. The review used specific databases, a search of qualitative journals and a general internet search to identify relevant studies, and the subsequent application of inclusion/exclusion criteria and a quality appraisal assessment. 14 studies meeting inclusion and quality criteria were identified exploring the experiences of 163 children and young people aged between 5 and 22 years, from a range of countries, with a variety of parental mental health diagnoses. The review then involved synthesising the findings of these studies to generate five overarching themes which were found to influence children's experiences. Children who had some knowledge and understanding of their parent's mental illness were more likely to use effective coping strategies, have a more positive relationship with their parent, and experience fewer negative effects on them as a child. Paper 2 is an original research study which explored the experiences of children who have a parent with bipolar disorder, to see how this might impact on the child's emotional wellbeing. This qualitative study used 'In My Shoes', a computer assisted interview tool, to explore the experiences of ten children from England aged between 4 and 10 years. Subsequent comparison with their parent's accounts enabled greater insight into family life. Child and parent interview data was analysed using thematic and content analyses. The four main themes that emerged from the child interviews were: knowledge and awareness of bipolar disorder; perception of parents; managing family life with a 'bipolar' parent; and living in a family with bipolar disorder. The study concluded that further research was needed to understand children's perspectives, which should be taken into account when developing appropriate services and interventions to support children and parents with mental illness, including bipolar disorder. Finally the third section of the thesis was a critical appraisal of the literature review, research study and research process as a whole, including methodological reflections, implications for future research and clinical practice, and the researcher's personal reflections in undertaking the research. The findings were deemed vitally important for the future of families in which a parent has bipolar disorder.

There is generally a lack of studies examining prevalence and phenomenology of bipolar disorder in Africa. In literature, a unipolar manic course of illness in particular is reported to be rare. The purpose of this study was to investigate and describe the course of illness and clinical features in a cross-section of patients diagnosed with bipolar disorder attending public hospitals in Limpopo Province, South Africa and to determine the rate of a unipolar manic course in this sample of patients. This was a descriptive, cross-sectional study of patients presenting with a history of mania between October 2009 and April 2010, to three hospitals in Limpopo Province. A purposeful sample of 103 patients was recruited and interviewed using the Affective Disorders Evaluation. This study confirms that a unipolar manic course is indeed much more common than rates suggested in present day literature with57% of the study sample only ever experiencing manic episodes. The study also confirms the debilitating nature of bipolar disorder with more than two-thirds being unemployed in spite of a quarter of the study subjects having a tertiary education. The high rates of attempted suicide, history of violence and history of drug abuse all furthermore points to the devastating effects bipolar disorder has on individuals and their families. Treatment choice appeared to be a combination of a mood-stabilising agent in combination with an anti-psychotic. It was found that two-thirds of study subjects had consulted with faith- or traditional healers. Significant gender differences appeared in that females were more likely to suffer from comorbid anxiety disorders, have a history of sexual trauma, and be HIV positive whilst men were more likely to have a forensic- and substance-abuse history, experience hallucinations and receive clozapine. Patients presenting with a unipolar manic course of illness, as described in this thesis, may contribute to the search for an etiologically homogeneous sub-group which presents unique phenotype for genetic research and the search for genetic markers in mental illness. A unipolar manic course therefore needs to be considered as a specifier in diagnostic systems in order to heighten the awareness of such a course of illness in bipolar disorder, with a view to future research. / Thesis (MD)--University of Pretoria, 2012. / Psychiatry / unrestricted

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