Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Sagar, Nathalie
Doctor of Philosophy - PhD
University of British Columbia
Bipolar disorder (BD) is a potentially severe and recurrent mental illness that impacts not only the individual but also their social and familial systems (Miklowitz, 2008). It is one of the most genetically mediated mental illnesses, and research has illustrated an expansive list of adverse outcomes for children of individuals with BD (Post & Levrich, 2007). Thus, the children of individuals with BD are dually vulnerable. Despite this, little research has explored the lives of those who experience intergenerational BD. This study sought to explore these experiences to provide nuance and context to the existing literature and ‘misery statistics’ about intergenerational BD. Five adults with a BD diagnosis, who are the genetic children of an individual with BD, shared their stories. Each participant’s interview was re-storied, and a cross-narrative analysis was conducted. Cross-narrative analysis identified that participants used the narrative structure of a ‘journey’ to make sense of their experiences. Four key themes were identified: communion (isolation), agency (powerlessness), identity (confusion), and ‘be the best that you can.’ The findings highlight both the advantages and the hardships associated with intergenerational BD. Identifying and exploring where the existing variability lies within these experiences contributes to an emerging understanding of how to support best those living within family systems with a family member(s) living with BD
i “IT DOESN’T HAVE TO BE ONE THING OR THE OTHER”: STORIES OF SECOND-GENERATION BIPOLAR DISORDER by NATHALIE SAGAR M.A. The University of British Columbia, 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School And Applied Child Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (VANCOUVER) July 2024 © Nathalie Sagar, 2024 ii The following individuals certify that they have read and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance the dissertation entitled: “It Doesn’t Have to Be One Thing or The Other”: Stories of Second-Generation Bipolar Disorder submitted by Nathalie Sagar in partial fulfilment of the requirements for the degree of Doctor of Philosophy in School And Applied Child Psychology Examining Committee: Dr. William McKee, Professor Emeritus, Department of Educational and Counselling Psychology, UBC Co-supervisor Dr. Sandra Mathison, Professor, Department of Educational and Counselling Psychology, UBC Co-supervisor Dr. Erin Michalak, Professor, Department of Psychiatry, UBC Supervisory Committee Member Dr. George Belliveau, Professor, Department of Language and Literacy Education, UBC University Examiner Dr. Grant Charles, Associate Professor, School of Social Work, UBC University Examiner Dr. Andrea Reupert, Professor, School of Educational Psychology and Counselling, Monash University External Examiner Additional Supervisory Committee Members: Dr. Thomas Schanding, Professor, Department of Educational and Counselling Psychology, UBC Supervisory Committee Member iii ABSTRACT Bipolar disorder (BD) is a potentially severe and recurrent mental illness that impacts not only the individual but also their social and familial systems (Miklowitz, 2008). It is one of the most genetically mediated mental illnesses, and research has illustrated an expansive list of adverse outcomes for children of individuals with BD (Post & Levrich, 2007). Thus, the children of individuals with BD are dually vulnerable. Despite this, little research has explored the lives of those who experience intergenerational BD. This study sought to explore these experiences to provide nuance and context to the existing literature and ‘misery statistics’ about intergenerational BD. Five adults with a BD diagnosis, who are the genetic children of an individual with BD, shared their stories. Each participant’s interview was re-storied, and a cross-narrative analysis was conducted. Cross-narrative analysis identified that participants used the narrative structure of a ‘journey’ to make sense of their experiences. Four key themes were identified: communion (isolation), agency (powerlessness), identity (confusion), and ‘be the best that you can.’ The findings highlight both the advantages and the hardships associated with intergenerational BD. Identifying and exploring where the existing variability lies within these experiences contributes to an emerging understanding of how to support best those living within family systems with a family member(s) living with BD. iv LAY SUMMARY This study aims to provide a nuanced and rich understanding of individuals living with intergenerational bipolar disorder (BD), meaning those who have a BD diagnosis and who also have a biological parent with the same diagnosis. Narrative inquiry was used to learn the stories of each individual to help shed light on how they experienced, communicated about, and made sense of their shared diagnosis. Cross-narrative analysis found that participants used the narrative structure of a ‘journey’ to make sense of their experiences. Participants also explored themes of agency, communion, identity and ‘be the best that you can.’ Within each theme, participants expressed both advantages and hardships due to their intergenerational experiences, highlighting their navigation through shades of gray. With the information gleaned from this study, we can intentionally support families experiencing intergenerational BD as our understanding emerges beyond the existing ‘misery statistics.’ v PREFACE This dissertation is an original, unpublished work written by Nathalie Sagar under the co-supervision and input of Dr. William McKee and Dr. Sandra Mathison. Nathalie Sagar conducted all of the interviews, transcription, and writing. Data collection for this project was approved by the University of British Columbia’s Research Ethics Board (certificate no. H21-02617). vi TABLE OF CONTENTS ABSTRACT ................................................................................................................................... iii LAY SUMMARY .......................................................................................................................... iv PREFACE ....................................................................................................................................... v TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... xi LIST OF FIGURES ...................................................................................................................... xii ACKNOWLEDGEMENTS ......................................................................................................... xiii CHAPTER ONE: INTRODUCTION ............................................................................................. 1 Bipolar Disorder and the Family System .................................................................................... 2 Narrative Inquiry as an Approach ............................................................................................... 3 Research Purpose and Question .................................................................................................. 4 CHAPTER TWO: LITERATURE REVIEW ................................................................................. 6 Bipolar Disorders ........................................................................................................................ 6 Etiology ................................................................................................................................... 9 Theoretical Foundation ............................................................................................................. 12 Application of FST ............................................................................................................... 14 Family Stories. .................................................................................................................. 15 Family Roles. .................................................................................................................... 15 Understanding Lived Experiences of BD ................................................................................. 16 vii Individual Accounts of Living With BD .............................................................................. 17 BD as a Family Experience ................................................................................................... 18 Family Support for BD. .................................................................................................... 19 Experiences as a Child of an Individual with BD. ............................................................ 21 Experience as an Individual with Intergenerational BD. .................................................. 28 Experiences as a Parent Living with BD. ......................................................................... 29 Persistent Gaps .......................................................................................................................... 30 The Power of Narratives ........................................................................................................... 31 Present Study ............................................................................................................................ 33 CHAPTER THREE: METHODOLOGY ..................................................................................... 34 Narrative Inquiry ....................................................................................................................... 35 Appropriateness of Methodology ......................................................................................... 37 Ontology and Epistemology ................................................................................................. 37 Role of the Researcher .......................................................................................................... 38 Description of Participants ........................................................................................................ 40 Criteria for the Selection of Participants ............................................................................... 41 Measures and Tools .................................................................................................................. 42 Past Clinical Experiences ...................................................................................................... 43 Life Graph ............................................................................................................................. 44 Researcher Journaling ........................................................................................................... 45 viii Description of Procedures ......................................................................................................... 45 Recruitment of Participants ................................................................................................... 46 Initial Meetings ..................................................................................................................... 47 Data Collection ..................................................................................................................... 48 Member Checks. ............................................................................................................... 50 Data Analysis ............................................................................................................................ 51 Individual Narratives ............................................................................................................ 52 Cross Narrative Analysis ...................................................................................................... 55 Considerations of Accessibility, Safety, and Trustworthiness .................................................. 55 Ethical Considerations .......................................................................................................... 56 Procedural Ethics. ............................................................................................................. 56 Situational Ethics. ............................................................................................................. 56 Relational Ethics. .............................................................................................................. 59 Exit Ethics. ........................................................................................................................ 61 Trustworthiness ..................................................................................................................... 61 My Research Journey ................................................................................................................ 63 Procedural and Data Analysis Summary .................................................................................. 66 CHAPTER 4: PRESENTATION OF RESEARCH FINDINGS .................................................. 67 Individual Narratives ................................................................................................................ 67 Alissa's Story: "You Can Always Be Well Again." .............................................................. 68 ix Charlotte's Story: "So Much Makes Sense Now." ................................................................ 80 Ella's Story: "I Think I Got the Best Possible Outcomes for Intergenerational Bipolar." .... 93 Evelyn's Story: "It's Like a Hike… … Every Step Is Painful… and Then You Get to the Top, and You're Like, That's What I Did!" ......................................................................... 103 Frank's Story: "It's Like Doing the Opposite of What Your Parents Do." .......................... 121 Cross Narrative Analysis ........................................................................................................ 134 Narrative Elements .............................................................................................................. 135 The Journey. .................................................................................................................... 136 Balance. ........................................................................................................................... 140 Storyteller’s Landscape ................................................................................................... 141 Summary of Narrative Elements. .................................................................................... 145 Major Themes ..................................................................................................................... 146 Communion (Isolation). .................................................................................................. 146 Agency (Powerlessness). ................................................................................................ 149 Identity (Confusion). ....................................................................................................... 151 ‘Be the Best That You Can.’ ........................................................................................... 156 Summary Of Themes ...................................................................................................... 158 Motifs .................................................................................................................................. 158 Cycles. ............................................................................................................................. 158 Secrets. ............................................................................................................................ 160 x Grief. ............................................................................................................................... 162 Summary of Findings .............................................................................................................. 163 CHAPTER FIVE: DISCUSSION OF THE FINDINGS ............................................................ 164 Brief Overview ........................................................................................................................ 164 Discussion of the Findings in the Context of the Existing Literature ..................................... 164 Second-Generation Experiences of Intergenerational BD .................................................. 165 Clinical Experiences. ...................................................................................................... 165 Experiences with Agency, Communion, and Identity. ................................................... 167 Narrative Sensemaking. .................................................................................................. 170 Relational Experiences of Intergenerational BD ................................................................ 171 Familial Patterns of Communication. ............................................................................. 176 Implications For Future Research ........................................................................................... 179 Implications For Practice ........................................................................................................ 182 Conclusion .............................................................................................................................. 184 REFERENCES ........................................................................................................................... 186 APPENDIX A ............................................................................................................................. 216 APPENDIX B ............................................................................................................................. 217 APPENDIX C ............................................................................................................................. 220 APPENDIX D ............................................................................................................................. 221 xi LIST OF TABLES Table 1 Definitions of the Core Concepts of FST FST ................................................................ 13 Table 2 Demographic Information ................................................................................................ 41 Table 4 Summary of the Findings Across Narratives ................................................................. 134 Table 5 Participant Turning Points ............................................................................................. 137 Table 6 Findings as they Pertain to the Core Concepts of FST .................................................. 173 xii LIST OF FIGURES Figure 1 The Story Teller Journey .............................................................................................. 135 xiii ACKNOWLEDGEMENTS I want to express my deepest gratitude to all those who have contributed to completing this dissertation. First and foremost, I am immensely thankful to the participants of this study who shared parts of themselves with me. This research could not have occurred without your vulnerability and insights. I am immensely grateful to my supervisors Dr. William McKee and Dr. Sandra Mathison for their invaluable compassion, guidance, and encouragement throughout the research process. To my committee members, your expertise and support has been instrumental at every stage of the research process. I would also like to extend my heartfelt appreciation to my friends, family, and colleagues for their unwavering encouragement and support. For your words of encouragement, constant source of love and grounding, and for reminding me that there's life beyond academia, thank you. Kyle, your unwavering love, patience, and encouragement carried me across this finish line. Thank you for helping me see that I am a part of the club. This dissertation is a testament to the collective efforts of all those mentioned above, and I am sincerely thankful for every contribution. This research was supported by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship Award. 1 CHAPTER ONE: INTRODUCTION My interest in intergenerational bipolar disorder (BD) emerges from my personal experiences within a family system entangled with multiple generations of BD. Although I do not live with BD, many loved ones do, and I have seen firsthand some of the hardships and advantages that living with BD can facilitate. Being within academia, when loved ones have struggled, I instinctively turn to research for direction. In doing so, I have often faced what Lobban et al. (2012) describe as ‘bipolar misery statistics.’ In my own experience, I have found much of the research reads like a laundry list of negative characteristics and outcomes. In times of need, I have found that this contributed to my sense of overwhelmedness, anxiety, and, at times, feelings of defeat. The extant literature regarding BD has primarily used post-positivistic research to examine the etiology, associated risk factors, and optimal treatment. Although this research is important, the focus has led to an uneven representation of life with BD. I embarked upon this research journey in hopes of adding nuance and expanding our understanding of intergenerational BD. In line with Helmink et al.’s (2023) call for a paradigm shift to better support the children of parents with BD, I wanted to provide a voice for these individuals, with the hope it could facilitate the creation and implementation of meaningful, mindful, and empathic practices when supporting family systems experiencing intergenerational BD. When writing this dissertation, I struggled to find coherence in using previous research to support understanding participant stories. Simultaneously, I was mindful of my potential participation in emphasizing the adverse outcomes associated with BD. Throughout the writing, I strove to accurately represent the review of the extant literature. The subsequent sections provide 2 an overview of the extant literature about BD and its impact on individuals and their families. Whenever possible, I included research highlighting both the negative and positive outcomes associated with BD; however, as it may become clear, the research on the latter is limited. Lobban et al. (2012) are the first researchers to directly explore the positive experiences as defined by firsthand accounts, and much is left to be understood to facilitate a more balanced understanding of the lives and experiences of living with BD. Bipolar Disorder and the Family System BD is a potentially severe and recurrent condition that is estimated to be one of the most prevalent severe mental illnesses (Clemente et al., 2015). It is thought to be one of the most genetically mediated mental illnesses (Post & Levrich, 2007), with a positive family history being reported as the most robust predictor for the development of BD (Lau et al., 2018). An expansive list of adverse outcomes or 'misery statistics' has been derived not only for the individuals living with BD but also for their children. These findings suggest that these children are themselves at risk and, therefore, may benefit from targeted support. Despite the extensive body of literature examining the risks associated with being the child of an individual with BD across several dimensions, including psychological, social, and educational adversity (Karimzadeh et al., 2017; Nurnberger et al., 2011; Rasic et al., 2013; Schluter-Muller, 2020; Stapp et al., 2020; Uher et al., 2023; Vandeleur et al., 2012), relatively little research has attempted to gain an in-depth understanding of these individuals’ experiences. Previous literature provides a fledgling understanding of the lived experiences of individuals with BD and provides an understanding of the intergenerational impact in broad strokes. However, there is a lack of research providing a deep understanding of how BD may impact the family as a system and, specifically, the lived experiences of children with a parent with BD. 3 Having a shared diagnosis may influence the family system and could contribute to various factors, positively or negatively. For example, it may influence how early childhood experiences are viewed, family communication about BD, shifts in roles within the family, feelings of stigma, age of diagnosis, feelings of hopefulness or hopelessness, knowledge of BD, and knowledge of treatment options. These experiences could then indirectly and directly influence the functional impairment associated with their diagnosis. Theories of family functioning, including Family Systems Theory (FST; Bowen, 1978) can provide a framework to understand the experience of intergenerational BD. FST views all living family members as a part of a fluid and changing emotional system. Within FST, each family member's thoughts, feelings, and actions are believed to be interrelated. For example, a family member may react to the needs, emotions, or expectations of another through conscious and unconscious communication (Bowen, 1978). This provides a framework for understanding how a parent's BD diagnosis may impact all family members. Narrative Inquiry as an Approach Most of the current academic landscape centers around risk and resilience factors, leaving significant inquiry into the lives of those experiencing intergenerational BD largely unexplored. The present study uses narrative inquiry to understand better the experiences, stories, and sense made by people experiencing intergenerational BD. Specifically, using narrative inquiry, first-person narratives were co-constructed, analyzed, and represented. In doing so, the aim was to learn the ways in which participants have made sense of their lives as individuals living with intergenerational BD (Connelly & Clandinin, 1990) and to re-present the shared and unique stories of how intergenerational BD is experienced and understood. 4 Narrative inquiry entails working closely with the participant(s) to naturally and intuitively construct a meaningful story of the participant's experiences (Riessman, 2008). As this study aimed to understand the sense made in people’s experience of intergenerational BD, providing the participants with the space to create meaning through narrative allowed me to answer my research questions. Finally, narrative inquiry allows for contradiction and ambiguity (Riessman, 2008), allowing me to capture the complexities within the sense of those experiencing intergenerational BD. Research Purpose and Question To date, little research has explored the experience of intergenerational mental illness. Due to BD's complex genetic and environmental etiology, it presents itself as an optimal diagnosis through which we can explore stories of intergenerational mental health. Bodies of research have examined the experiences of mental illness of individuals as parents, children, or individuals. However, I have yet to find a study connecting these embedded identities, specifically, the complex phenomenon of being both an individual living with BD and a child of an individual living with BD. The purpose of this study was to contribute to developing a richer, more informed, and more nuanced understanding of the lives of children of individuals with BD and their experiences within their family system and, specifically, examining the adult child's experience in the context of having a family history of and shared BD diagnosis. Through examining retrospective accounts of adult children, the research questions used as a framework to guide this study are: (1) how do second-generation diagnosed individuals experience intergenerational BD? (2) how is intergenerational BD communicated and relationally experienced within families? 5 Researchers acknowledge that BD impacts not only the individual but also their familial and social networks (Miklowitz, 2008); however, there is a lack of interpretive studies that shed light on the complex lived experiences of these family systems. Fostering an understanding of the complexities of the lives of those experiencing intergenerational BD allows for a richer and more nuanced understanding to complement the well-documented risk factors. This, in turn, informs future methods of supporting the family systems of those living with BD. Further, in using narrative inquiry, I invited participants to share how they have made sense of their experiences beyond the 'misery statistics.' 6 CHAPTER TWO: LITERATURE REVIEW Bipolar disorder (BD) is a prevalent and potentially impairing condition. It can be associated with difficulties optimizing medication to manage episodes, which can lead to high rates of relapse and hospitalization (Gitlin et al., 1995). Echoing these difficulties, Judd and Akiskal (2003) found that the functional impairment associated with BD ranks as the sixth leading cause of disability worldwide. Despite these significant adverse impacts, BD is also known to be coupled with creativity (Jamison, 1993; Ye, 2022) and adaptability (Martin, 2007). Further, Lobban et al. (2012) found many individuals with BD reported feeling as though their “disorder” had direct positive effects on their everyday experiences. Specifically, participants reported feeling a broad range and depth of emotions and experiences and increased human connectedness due to their diagnosis. However, this is said to be the first study that directly explored the positive experiences of BD as defined by firsthand accounts (Lobban et al., 2012), and much is left to be understood. This chapter outlines the general symptoms, age of onset, course, and treatment for BD. Then, the etiology is outlined, including hypothesized pathways that can account for both the intergenerational and environmental role of developing BD. Next, the focus shifts to the experiences of those impacted by BD, including individual accounts and BD as a family experience. Finally, this chapter reviews what is already known about the lives of those living with intergenerational BD and gaps in the current literature. This research is discussed within the context of its implications for the present study, its purpose, and its significance. Bipolar Disorders BD is characterized by recurrent experiences of manic (or hypomanic, depending on the severity) and depressive episodes (Carvalho et al., 2020). Manic and hypomanic episodes are 7 conceptualized as having a wide range of manifestations, including a highly elevated mood, overconfidence, grandiosity, talkativeness, irritability, and a decreased need for sleep. A manic episode is defined as being more intense than a hypomanic episode, with the possibility of psychotic symptoms, such as delusions or hallucinations. Research estimates that these more severe symptoms occur in up to 75% of manic episodes (Carvalho et al., 2020). Four subtypes of BD are encompassed under the umbrella term outlined within the American Psychiatric Association’s (2022) Diagnostic and Statistical Manual, fifth edition, text revision (DSM-V TR). Recurrent manic and depressive episodes define BD type I (BD-I). Recurrent hypomanic and depressive episodes define BD type II (BD-II). Cyclothymic disorder is classified as two years, where periods of hypomanic and depressive symptoms that do not meet the criteria for an episode are experienced. Further, the DSM-V TR outlines the criteria for other specified BD and related disorders and unspecified BD and related disorders. Both these diagnoses encompass symptoms related to BD-I or BD-II, where the diagnostic criteria for the disorders are not met. Finally, the DSM-V TR outlines substance or medication-induced BD and BD related or due to another medical condition (American Psychiatric Association, 2022). For this dissertation, I will focus on BD-I and BD-II, as they are associated with a strong hereditary link and are genetically correlated (Mullins et al., 2020). Continued debate exists around whether BD-I and BD-II are distinct disorders or the same disorder on a continuum of severity (Guzman-Parra et al., 2021). Historically, due to the increased severity of manic episodes experienced by those living with BD-I, it has been viewed as a more severe form of BD-II. The increased severity of manic episodes is associated with more hospitalizations and more severe impairment in cognitive functioning (Guzman-Parra et al., 2020). However, recent research suggests a shift from viewing BD-I as distinctly more severe 8 than BD-II. New research has found that BD-II is associated with increased comorbidity of a variety of diagnoses (Karanti et al., 2019; Vinberg al., 2008), lower functioning (Vinberg et al., 2008), and lower quality of life (Albert et al., 2008). Although these results have not been consistently demonstrated (Karanti et al., 2019), these findings suggest the differences between BD-I and BD-II are complex and cannot simply be conceptualized as BD-I being a more severe form of BD-II. The onset of BD is estimated to range from age 17 to age 20 (Carvalho et al., 2020; Merikangas et al., 2014; Perlis et al., 2004). A meta-analysis conducted by Joslyn et al. (2016) found an earlier onset of BD was typically associated with a poorer prognosis, increased delay to effective treatment, increased comorbidity, and increased severity of depressive episodes. BD is a lifelong diagnosis; research suggests that over 95% of people with BD will experience recurrent episodes throughout their adult life (Goodwin & Jamison, 1990), and around 50% will experience more than ten mood episodes across their lifespan (Magalhães et al., 2012). Typically, the onset of BD begins with a depressive episode, resulting in an initial (mis)diagnosis of depressive disorder (Zimmerman et al., 2008), particularly among those experiencing BD-II, as it is associated with hypomania and a greater quantity of depressive episodes (American Psychiatric Association, 2022). It has been consistently estimated that the delay between initial symptom onset and an accurate diagnosis is up to ten years (Fritz et al., 2017; Hirschfeld & Vornik, 2003; Lish et al., 1994). This challenge persists despite Goodwin and Jamison (1990) describing high rates of misdiagnosis, underdiagnosis, and a misunderstanding of those with BD over three decades ago. Misdiagnosis poses a significant risk factor to those experiencing BD. Specifically, misdiagnosis and missed diagnoses contribute to some of the adverse outcomes associated with BD, including increased severity and quantity of 9 depressive episodes (Post et al., 2010), in addition to increased rates of unemployment and mortality (Leboyer & Kupfer, 2010). Mortality itself poses a tangible risk to those experiencing BD, as it has been suggested that 25-50% of those with BD attempt suicide at least once in their life, and 10-19% die as a result of suicide (Chen & Dilsaver, 1996; Jamison, 2001). Vast bodies of literature have examined the optimal treatment methods for BD. Historically, lithium was the standard medication prescribed. There has been a more recent shift in the past 25 years to anticonvulsant medicines as an alternative (Geddes et al., 2004). A meta-analysis conducted by Geddes et al. (2004) found that lithium is an effective medical treatment in preventing relapse in BD; as such, it has been defined as the ‘gold standard’ medication for long-term treatment of BD (Goodwin et al., 2016). Similarly, the Canadian Network for Mood and Anxiety Treatments and the International Society for Bipolar Disorders highlight lithium as a first-line treatment for bipolar depression and divalproex (an anticonvulsant) as a first-line of maintenance therapy for BD-I in their treatment guidelines (Yatham et al., 2018). Despite the demonstrated efficacy of psychotropic medication to treat symptoms of BD, research estimates that about half of those with BD are nonadherent with their prescribed medications over a year (Jawad et al., 2018). Research has proposed various factors estimated to affect treatment adherence, including knowledge of BD and medication options (Bowskill et al., 2007; Sajatovic & Jenkins, 2007) and family attitudes (Scott et al., 2012), among others. Etiology Episodes of BD are a result of the cumulative effects of a complex interplay of various risk factors, including genes, neurobiology, psychosocial stressors, and psychological vulnerabilities across development (Aldinger & Schulze, 2016; Miklowitz & Cicchetti, 2006). It has been well documented that there is a hereditary link to BD, with Post and Levrich (2007) 10 positing that BD is one of the most genetically mediated mental illnesses. Further, research suggests a high genetic correlation between BD-I and BD-II (Mullins et al., 2020). Evidence of genetic transmission has been demonstrated through twin, family, and adoption studies (Smoller & Finn, 2003). Specifically, Smoller and Finn (2003) found a 59-87% heritability of BD and that first-degree relatives of those with BD are at ‘very high risk’ of BD themselves. Echoing these results, research has estimated that with a bilinear positive family history of affective disorders and at least one parent with BD, there is approximately a 70% chance the children of these parents would develop unipolar depression or BD in their lifetime (Gershon et al., 1982; Lapalme et al., 1997). Although both BD-I and BD-II have strong genetic links, research suggests BD-I may have a higher genetic correlation when compared to BD-II (Mullins et al., 2020). Despite the apparent role of genetics in the development of BD, it is necessary also to acknowledge the role of the environment. Due to the profound impact that BD can have on one’s ability to perform daily tasks (Miklowitz, 2011) and its potential link to increased experiences of family stressors (Metz & Jungbauer, 2019), it is evident that BD impacts not only the individual but also the immediate and extended family (Miklowitz, 2008). As such, the emotional and behavioural experiences of individuals with BD affect their social and familial network, including their parents, siblings, partners, and children. Thus, if a child is raised in a home with a parent with BD, it can be challenging to disentangle the role of genetics from the cumulative effects of environmental factors that the parent’s symptoms may exacerbate. In seeking an understanding of both the genetic and environmental links to intergenerational psychopathology, Goodman and Gotlib (1999) that outlined four pathways of risk for child psychopathology. The first pathway for risk is the parental psychopathology during 11 the prenatal period. Second, is the genetic risk and the interaction between the genetic risk and the previously described parental psychopathology. This is further evidenced by Lau et al.’s (2018) hypothesis that parental behaviours due to psychopathology may exacerbate normative stressors throughout development, particularly during the period of their child’s adolescence. Third, Goodman and Gotlib (1999) describe a pathway of exposure to psychosocial stressors. Consistent with this stage, childhood adversity, life events, and high familial expressed emotion and family discord have been found to exacerbate genetic vulnerabilities associated with BD (Miklowitz & Johnson, 2006; Post & Levrich, 2007). When a parent has BD, families may experience more interpersonal difficulties (Barron et al., 2014). This can include decreased family cohesion and increased family conflict, which may, in turn, lead to increased family stressors. These adverse life events have been associated with depressive symptoms and the onset of depressive disorders among children with a parent with BD (Hillegers et al., 2004). The fourth pathway described is parenting quality and attachment (Goodman & Gotlib, 1999), suggesting that a parent experiencing psychopathology may struggle to engage in optimal parenting or may have deficiencies in specific parenting skills. This highlights how BD may influence a family system. Vance et al. (2008) found parents with BD rated themselves as being more negative in interacting with their children than controls or parents with unipolar depression. This suggests that children with a parent with BD may be at higher risk of experiencing adverse parenting outcomes when compared to children of parents with other psychopathologies. These findings are synthesized by Aldinger and Schulze’s (2016) narrative review of the extant literature in the development and clinical course of BD. They concluded that although more research is necessary to further untangle the role of individual factors, it is clear that environmental factors, life events, and trauma have significant influence on both the onset and 12 clinical course of BD (Aldinger & Schulze, 2016). The variety of pathways illustrate the nuance and variety of elements that can contribute to the risk and protective factors for children of a parent with BD. The inclusion of psychosocial stressors, trauma, and attachment highlights the importance of understanding the lived experiences of those with BD, and provides a framework for understanding BD as a family experience. Theoretical Foundation As evidenced by Goodman and Gotlib’s (1999) work, BD can be conceptualized as a family experience. Family systems theory (FST) (Bowen et al., 1978) provides a theoretical framework for understanding the context of how one family member’s mental health diagnoses may affect others within the family. This theory was derived following a five-year study where Bowen et al. (1959) examined families with a family member living with schizophrenia. This initial data was used to generate FST and the general view of the family as a system operating over generations. FST generally sees competing forces within families, a desire for togetherness (attachment, cohesion, and companionship), and a simultaneous need for independence. Within FST, the family system is viewed as functional, implying the family works to achieve a task or a purpose (Bowen et al., 1959). For example, the family responds to the conditions of the environment and to meet the basic needs of family members. It views family members as interconnected and interdependent. Specifically, it is posited that the well-being of one family member can, through direct and indirect pathways, influence both the functioning and well-being of other family members (Abrams, 1999). Further, it is believed that the family system can work as both a protective measure for the family members and potentially be a catalyst for dysfunction (Bowen, 1978). See Table 1 for a description of the eight interconnected core concepts within FST. 13 Table 1 Definitions of the Core Concepts of FST FST Definitions of the Core Concepts Of FST Concept Definition Example related to intergenerational BD Family Projection A way in which parents automatically and unconsciously transfer their own emotional distress onto a child. Broadly parental projection can occur if a parent focusses on a child out of fear that something may be wrong with the child. A parent suspects that their child may be demonstrating symptoms of BD. The parent then looks for data to confirm this fear, for example seeing the child having a tantrum as confirmation that the child is demonstrating symptoms of BD. The parent then changes their treatment of the child to adjust to as if their fear is truly confirmed. The parent’s fears and perceptions shape and influence the child’s development and behaviour independent of if the fear is correct Multigenerational Transmission Process The unconscious and conscious transmission of patterns across generation. Bowen generally looked across three generations of a family. A first-generation person (grandmother) lives with BD and has difficulty following the birth of her first child (second generation). When her child is young, she learns to thrive while taking care of others (her mother and her siblings). This may lead to parentification of the child. When the child herself has children (the third generation), she becomes overly involved in the child’s life. Triangles Within two-person conflict humans naturally include a third to alleviate tension. Triangulation can be a healthy way of reducing conflict but also poses the risk of facilitating one of the members of the triangle feeling like an outsider. Two parents in conflict, turn their attention to their child. They alleviate their own unresolved tension through blaming the child as the problem. Differentiation of Self The degree to which a family member can separate their own emotional system from their intellectual system and keep their emotions and thinking separate. The ability to think rationally and logically even while upset. A family member with a poorly differentiated self finds themself overly dependent on the approval and acceptance of others and has difficulties seeing the actions, thoughts, and beliefs of others as different to their own. In conflict they may set aside their individual choices and preferences in attempts to achieve harmony within the family system. Emotional Cut-off Managing unresolved tension or emotional difficulties amongst family A child, after feeling overwhelmed by their relationship with their parent(s) distances 14 Concept Definition Example related to intergenerational BD members by cutting off emotional connection from their family system. themselves from them and only connects with them on holidays. They instead view their friends and workplace as their family. Their own children (third generation) now lack a relationship with their grandparents. Nuclear Family Emotion System The complex patterns that govern where problems express themselves within a family system. The four patterns are emotional distance, marital conflict, dysfunction in a spouse, and transmission of the problem to a child. In experiencing family tension, a parent externalizes their own anxiety onto their martial relationship. Instead of focusing on the true family tension, the couple instead focuses on what is wrong with the other. Societal Emotional Process and Regression The extension of the family emotional system into a larger social system A family experiencing oppression from outside society find themselves extremely stressed which impacts their ability to function as a healthy family unit. Sibling Position Each sibling position is thought to be associated with its own patterns, strengths, and weaknesses. The oldest child finds themselves in the position of caregiver for their ill parent, as eldest children are often naturally trained to take on more responsibility and leadership positions. This may lead to parentification or adultification of the child. Note. The concepts defined in this table are adapted from “The use of family theory in clinical practice” by M. Bowen, 1966, Comprehensive Psychiatry,7, pp. 345-374. Application of FST Using FST, one can predict that family members' behaviours, difficulties, beliefs, and attitudes impact and influence each other (Bowen, 1978). Therefore, having the same diagnosis as a parent may influence how a child experiences their shared diagnosis. One way this may occur is through parents projecting their anxiety onto a child at risk of developing BD, which in turn may affect the way they interact with their child. A family may also find themselves in multigenerational patterns of behaviours, caregiving roles, and fears specific to their experiences of intergenerational BD. These patterns may also shape how the family consciously and unconsciously communicates about BD through family stories (Bowen, 1978). 15 Family Stories. Family stories are accounts of personal experiences that impact the family, outline rules of interactions, reflect beliefs about relationships, and influence family values (Fiese & Winter, 2009). Family narratives clarify and justify patterns within the multigenerational transmission process (Manoogian et al., 2010) and provide younger generations with familial expectations of how they should behave (Stone, 2004). These narratives about shared experiences are said to have a lasting impact on the family members’ values, beliefs, attitudes, behaviours, and identity (Kellas, 2018; Kellas et al., 2015). Specific to health, family narratives direct family members toward choices, routines, and “how things are done” (Manoogian et al., 2010, p. 42). Bowen posits that the history of a family and how the history is communicated creates a template for future generations’ values, thoughts, and experiences (Nichols, 2010). Despite this, Flood-Grady and Kellas (2019) explored sensemaking, socialization, and stigma through family stories of mental illness, asserting that research on family socialization about mental illness is nearly non-existent in the academic landscape. Using communicated narrative sensemaking theory, they examined how narratives of mental illness were ‘inherited’ by communication between family members, particularly inheriting stories of struggle and caution. Although the family narratives of mental illness were primarily of negative valence, participants reported learning positive lessons and promoting understanding (Flood-Grady & Kellas, 2019). These findings further highlight the power of family members in shaping how an individual would make sense of their BD diagnosis. Family Roles. Miklowitz (2004) asserts that the family environment plays a central role as a moderator of the course of severe mental illness, including BD. Specifically, it provides a framework to understand how a family might react or organize itself around a member’s mental 16 illness (Miklowitz, 2004). One way this might occur is through the roles each family member enacts. Within a family system, each family member may play a specific role. These roles can sometimes be functional to maintain balance within the family system; however, if they are rigid, it can lead to dysfunction (Minuchin, 1985). Within families where a parent experiences mental health problems, research has demonstrated that the child may often be placed in the role of parentification (Van Loon et al., 2015). Parentification is a term coined by Boszormenyi-Nagy and Spark (1965), which describes when a child steps in to assume the caretaking role of a parent within the family system. This may include attending to the emotional needs of the parent or siblings, acting as a peacemaker between family members, or providing instrumental duties (such as household chores) (Minuchin et al., 1967). Parentification is a phenomenon that has been identified in focus groups of children of parents living with mental illness (Maybery et al., 2005). Generally, research has documented that parentification of a child can lead to an increased risk of psychopathology for the child, including internalizing problems and intergenerational familial patterns of these roles being enacted (Van Loon et al., 2015). However, emerging research suggests that with the appropriate boundaries and support systems, parentification may lead to some child strengths, such as increased self-esteem and resilience (Masiran et al., 2023). Understanding Lived Experiences of BD Past research helps to provide context and understanding of some of the findings regarding BD and its associated risks that I have previously outlined. Specifically, interpretive research can help to facilitate a more nuanced understanding of the lives of those with diagnoses of BD. Research has explored the accounts and experiences of individuals living with BD and their familial networks. Within this section, I describe the phenomenon of intergenerational BD, within which I identify and propose an understanding through the lens of embedded identities 17 (individual with BD, child of an individual with BD). Due to BD’s complex genetic and environmental etiology, it presents itself as an optimal diagnosis in which to explore stories of intergenerational mental health. This understanding could then be applied more broadly to other psychopathologies. Individual Accounts of Living With BD Much of the extant interpretive literature examines individuals' perceptions and experiences, and many studies identify the challenges and barriers faced. For example, Lim et al.'s (2004) phenomenological study explored individuals' experiences of what it is like for them to have BD. These accounts highlighted difficulties experienced by the participants, including feeling helpless, unable to change or mitigate their illness, and difficulties with experiencing stability and normalcy. Similarly, Crowe and colleagues (2012) conducted interpretive research with participants to explore the impact of BD, finding the core theme was a feeling of loss of control. Participants highlighted feeling misunderstood by their family members, experiencing stigma, and feeling a loss of autonomy (Crowe et al., 2012). Michalak and colleagues (2005) found that several psychosocial factors can impact the quality of life of individuals with BD, including stigma, spirituality, social support, and identity. Beyond the psychological risks associated with BD, research has found negative stigma and social reactions are of significant impairment to individuals with BD. Specifically, stigma impacts the quality of life, feelings of distress, and the level of disability associated with BD (Michalak et al., 2011). Self-stigma, confusion, contradiction, and self-doubt are common to the experience of those living with BD (Brohan et al., 2011; Inder et al., 2008). These feelings, feeling defined by one's diagnosis in tandem with self-stigma, have been posited to be related to treatment adherence (Berk et al., 2004; Shoemaker & de Olivera, 2008). 18 These findings illuminate some of the lived experiences of those with BD and factors that might exacerbate and ameliorate their symptoms. Consistent throughout the literature is the impact of stigma on quality of life and treatment adherence. Further, feelings of loss of control, autonomy, and normalcy were echoed across studies. Regarding protective factors, a sense of identity and self and the role of familial and social networks in providing support and understanding are common threads. It is possible that having a family history of BD may influence some of these factors; however, to date, we have yet to develop an understanding of the individual's experience in the context of having a family history and shared BD diagnosis. BD as a Family Experience Having a parent with BD may shift the family dynamic within the family system as family members shift to support each other as symptoms fluctuate. For example, a family member may be required to act as a caregiver for the parent with BD when symptoms worsen within the system. Van der Voort et al. (2007) defined caregivers as unpaid professionals, including family or friends, who care for and support individuals with mental illnesses. Caregiving is associated with feelings of burden, symptoms of anxiety and depression, and poor health outcomes (Perlick et al., 2005). A meta-synthesis conducted by Dam and Hall (2016) found that children with a parent with psychopathology generally reported feeling an increased sense of responsibility in providing some sort of caregiving role. Metz and Jungbauer (2019) found that children with a parent experiencing psychopathology reported a sense of responsibility for their parents and siblings. Applied to BD, the children of individuals with BD may be in a position where the caregiving role is thrust upon them. 19 Further, caregiver burden may impact a child’s secondary caregivers or the ‘well’ parent. This may, in turn, impact their availability to provide emotional support to the child. Research is currently needed to understand this potential relationship better. Family Support for BD. Despite the research supporting the use of medication to prevent relapses within BD, there is also evidence to support the use of psychotherapeutic treatments for BD in tandem with medication. Specifically, psychoeducational interventions can, increase treatment adherence, and facilitate positive outcomes (Miklowitz et al., 2003). Further, Miller and colleagues (2010) found that within families where a high level of parental impairment was reported, including the family through family therapy or family psychoeducation resulted in a significant improvement in the course of the parents’ BD symptoms. Colom’s (2011) review of randomized control studies found that psychoeducation, in tandem with medication, may give the person with BD a greater understanding of their illness. Individuals, therefore, can recognize signs of relapse and develop effective coping strategies. This then was associated with decreased relapse rates and overall improvements in social functioning. However, Colom cautions that these results have not been consistently replicated and, therefore, should be interpreted with caution. Considering the family context, this review also found that family psychoeducation increased treatment adherence (Colom, 2011), suggesting the utility of engaging the family system in treating BD. Miklowitz et al. (2003) highlight the importance of providing psychoeducation for those living with BD and their family members. Echoing these results, Nadkarni and Fristad (2010) examined the effects of a group psychoeducation treatment for families with a parent with BD. Psychoeducational interventions were posited as potential preventative interventions for children with a parent with BD, as they can help to improve resiliency and coping skills, as well as 20 enhance family dynamics (Nadkarni & Fristad, 2010). Thus, family psychoeducation may not only have positive impacts on the parents with BD themselves but may also serve as a protective factor for the children. Despite the potential utility of including the family, Zalewski et al. (2017) highlight the discrepancy between parent and child mental health. Specifically, there is an absence of evidence-based interventions for individuals with BD that address their needs as parents and the needs of their children. Contrarily, child mental health consistently involves parents and acknowledges the importance and role of the family unit (Lock, 2017). Despite involving parents, supports for children do not always account for co-occurring mental illness within the family system. Research estimates that 79% of children served by mental health services are living with a parent who also had a diagnosis of a mental illness (Naughton et al., 2017), and that the intergenerational experiences of mental illness shaped their experiences within their family system. Specifically, children from families with co-occurring mental illnesses show lower improvement on overall functioning when compared to their same aged peers (Frederick et al., 2019). These findings illustrate the importance of considering the entire family system, and mental health needs across generations when support both children and adults. Further, it highlights the importance of further understanding co-occurring, or intergenerational experiences of mental illness. Although previous research has clearly demonstrated the genetic and environmental role played in BD, as well as the familial impact of having a parent with BD, I have yet to find research that has examined the broader impact of intergenerational BD or the concept of having the same diagnosis as a parent. Due to BD's complex genetic and environmental etiology, it presents itself as an optimal diagnosis through which we can explore stories of intergenerational 21 mental health; yet the concept of intergenerational BD remains largely unexplored. Emerging research alludes to the idea that individuals experiencing intergenerational BD may have unique experiences. For example, Reichart et al. (2007) found that individuals experiencing intergenerational BD (meaning they themselves and one of their parents had a BD diagnosis) reported increased rejection by their parents when compared to children without their own BD diagnoses. Despite this, no study to date has examined the broader experience of intergenerational BD. Experiences as a Child of an Individual with BD. Within the web of intergenerational BD, one of the relational experiences is as a child. Some of the risk factors associated with being a child of an individual with BD are outlined in the etiology section of this paper. This section aims to provide context and nuance to these statistics. The findings of various studies that collected qualitative data highlight a variety of impacts, including impact on their well-being, relationships, and stigma. There are a variety of ways in which having a parent with BD may impact the daily experiences of a child. Within this, the understanding of and experience of the lives may differ whether the child is asked in vivo or to reflect on their childhood as an adult retroactively. A limited number of studies explore the impact of BD on a family system, but rather focus on parental psychopathology more broadly. Thus, the following subsection reviews literature that explores the experiences of children of parents experiencing serious illness and mental illness more broadly. Potential periods of separation from a parent during hospitalization are one way in which the daily life of children with a parent with BD may be impacted. Research estimates around one-quarter of those diagnosed with BD will be hospitalized due to symptoms of mania or depression (Peters et al., 2016). Research examining the experiences of children with a parent 22 with severe illness (not just mental illness) has demonstrated that the resulting periods of separation pose an additional stressor for the child (Melcher et al., 2015; Pfeffer et al., 2009; Phillips, 2014). Attachment theory helps us understand that separation can lead to disrupted attachment, which is traumatic in and of itself (Ainsworth et al., 2015). Ainsworth’s original research on attachment disruptions found separation from a primary caregiver when the child is between six months and four years of age is most traumatic. Thus, young children of a parent who experiences a psychiatric hospitalization may be at greater risk of the long-term effects of this attachment disruption. Despite the demonstrated attachment disruption associated with parental hospitalization, Garley and Gallop’s (1997) focus groups found that parental hospitalization may, at times, be experienced positively by children. Specifically, they found that some children reported that hospitalization brought relief, as it facilitated parental safety and a shift of caregiving to a more available adult. This highlights some of the nuance in the experiences of children, the potential contrasting experiences of attachment loss, and increased safety that may be a part of parental hospitalization. Overall, Yamamoto and Keogh’s (2018) meta-synthesis challenges these findings, reporting that the hospital itself as a setting poses a potential exacerbating factor for children, as it is an unfamiliar setting, which may be frightening and suggests a worsening of their parent’s illness. Further, Faugli et al. (2020) highlight the role of a parent in safeguarding and regulating a child’s emotions during times of adversity and the challenges a child may face if their parent is too ill to support them through navigating the associated difficulties. Thus, the child may not only experience fear related to the hospital itself but may also lose their availability to a caring adult to co-regulate with them. 23 Another way in which parental mental illness may affect the child is through a shift in caregiver roles or dynamics within the family system when the parent is symptomatic. Interviews have demonstrated adultification or parentification, where the child takes on a caregiving role for their parent within the family system (Handley et al., 2001; Meadus & Johnson, 2000). Parentification itself is a nuanced concept, with an integrated review by Masiran et al. (2023) concluding that in the proper contexts and with the appropriate support, parentification may lead to positive outcomes, such as increases in the child’s self-esteem and resilience. The child's desire for increased understanding and the need for psychoeducation and accurate information is also present across studies (Faugli et al., 2020; Riebschleger, 2004; Stallard et al., 2004). Mental health literacy and psychoeducation have been identified as important areas to support the children’s ability to cope and respond to their parent’s mental illness (Bee et al., 2013). Specifically, research has demonstrated that a lack of information can make it hard for children to make sense of what is happening when their parent is ill and can lead to feelings of fear (including fear of getting the illness themselves), confusion, and feeling they are to blame (Handley et al., 2001). Thus, providing children with accurate and developmentally appropriate information may help to address potential misconceptions such as self-blame. Similarly, research interviewing children within a Canadian context illustrated that most of the children were not well informed about the parent’s mental illness and that it was not discussed (Mordoch, 2010). This lack of knowledge led to the children having difficulty understanding their parents’ illness, which led to exacerbated fears, particularly around parental hospitalization. These findings generally echoed the existing literature and highlighted the importance of a trusted and empathetic adult communicating and sharing accurate information with children of parents experiencing mental illness (Mordoch, 2010). 24 In considering the experiences of young children, Backer et al. (2017) examined the experience of children (aged 4-12) of individuals with BD. They found that most children possessed some knowledge of their parents’ diagnoses and saw both positives and negatives of their experiences, and all the participants spoke very highly of their relationships with their parents. Similarly, Pölkki et al. (2004) interviewed six children aged 9 to 11 of parents experiencing mental illness. Their interviews found that the children reported not being well informed about their parents’ illness and expressed a desire to learn more. The children reported fears and worries about their parent’s well-being and disliked visits to the hospital. Although not explicitly shared, the researchers inferred through the body language of the children in interviews that they were nervous and confused when discussing their parent’s mental illness. Despite these areas of vulnerability, the interviews highlighted that the children felt safe within their homes and felt social and familial support. This research highlights that at a young age, children of a parent with BD already possessed some knowledge of their parent’s diagnosis. It also highlighted that they can notice and experience some of the effects of their parent’s diagnosis, thus demonstrating the children’s awareness of some of how their parent’s diagnosis may have an impact on their daily lives. Retrospective Accounts of Children. Another way research has sought to provide a voice for children is by asking adult children for their retroactive accounts of childhood. Metz and Jungbauer (2019) interviewed adult children to reflect on their parent’s psychopathology in their childhood. This is the only study I could find that examines the children’s experiences with regard to their own mental health and well-being. Consistent with previous research, these researchers found that as children, the participants were exposed to various stressors, including 25 struggling to understand their parent’s behaviour and feeling a sense of responsibility for their parent(s) and siblings (Metz & Jungbauer, 2019). Having a parent with a BD diagnosis may have lasting impacts on one’s own mental health, future relationships, and perceptions of stigma through direct and indirect impacts. Metz and Jungbauer (2019) found that many children with a parent experiencing mental illness expressed a desire for increased professional support to support their own well-being. They reported that many of the participants held their parents’ mental health as a ‘family secret’ and experienced a sense of relief and sense-making through sharing their stories. Pölkki et al. (2004) analyzed written samples of 17 adult children in response to the prompt “How my life changed after a member of my family became mentally ill” for a writing competition. Their analysis of these stories found that parental mental illness often led to a shift in roles and responsibilities of family members, as the child felt they had lost the unwell parent as a caregiver. The written accounts also described the onset of the parent’s illness as being dramatic and changing their life completely. The adult children also described feeling as though their parents’ illness was a secret and reflected that they were not allowed to tell people. Despite these hardships, all of the adult children estimated that they could cope reasonably well. Similarly, Knuttsin-Medin et al. (2008) found that adult children of parents experiencing mental illness reported negative experiences as being due to a lack of information and support from psychiatric services. Specifically, the children desired more information and more contact with professionals. Despite the aforementioned existing literature base, persistent gaps remain. Gladstone et al. (2006) provide a critique of the existing landscape of the ‘misery statistics’ of children experiencing parental mental health and argue for a broader and more nuanced understanding of 26 children as complex persons who have competencies in addition to their developmental vulnerabilities. Specifically, they critique the focus on “risk factors,” asserting that “being identified as ‘at-risk’ is a powerful label, which children of parents with mental illness cannot evade” (Gladstone et al., 2006, p. 2542), highlighting the contrasting, yet under-reported, research that these children remain healthy, resilient, and socially accomplished. Gladstone and colleagues (2006) argue that these children are “invisible” in the existing literature, and their perspectives and nuanced identities are overlooked. Therefore, they argue, little is known about what it is truly like to be a child of a parent experiencing mental illness. Similarly, a systematic review of studies examining parental BD conducted by Stapp and colleagues (2021) highlighted a dearth of research into child perceptions of the family environment, asserting that the child’s perspective is rarely obtained. In sum, despite decades of research, children of parents living with BD still may not have their voices fully represented in the academic landscape. Reichart et al. (2007) claim to have done the first study that examines the perceptions of children raised in a family with a parent experiencing BD. Their study highlights some of the strengths of having a parent with BD. Researchers interviewed adult children of a parent experiencing BD and adult children of individuals without psychopathology. Their results indicated that, generally, the children themselves did not experience their parent with BD as more dysfunctional when compared to children with parents who were not experiencing psychopathology, particularly when their mothers were the parent experiencing BD. Specifically, individuals with mothers living with BD reported perceiving their mothers as more emotionally warm, less overprotective, and less rejecting when compared to the general population. They did find that those with a father with BD found their father to be significantly more rejecting and less emotionally warm when compared to their other parent. This study provides a continued 27 understanding of adult children’s perceptions of individuals experiencing BD. Further, Reichart et al. (2007) noted that 10% of the participants had a BD diagnosis, although their experiences with intergenerational BD were not explicitly addressed in their study. Thus, understanding the individual’s experience in the context of having a family history and shared BD diagnosis was unexplored. Harris (2016) interviewed eight adult women about their relationships with their fathers who had BD. Harris identified the following as key themes across interviews: awareness of their father’s diagnosis, the main symptoms noticed, the immediate and lasting impact of said symptoms, family conflict, coping, changing relationships with their father, and information they reported wishing they had known. Harris found these women’s experiences had a lasting impact on their sense of self, as many of them internalized their father’s emotions as related to their experience of BD. Further, Harris found that many women reported feeling as though they appeased their fathers, acted as caretakers and that their father’s diagnosis had an impact on their future romantic relationships. This potentially can lead to a multigenerational pattern of relationships between parents and children, as outlined in FST (Bowen, 1978). Harris herself highlights the dearth of literature with a focus on the experiences of a child with a parent with BD and reports being the first ‘qualitative’ study examining the relationship between women with fathers living with BD. To my knowledge, this has yet to change. In considering the role of stigma on the children and families of those with BD, one can see how the parent’s knowledge and stigma and associated impact on treatment adherence (Berk et al., 2004; Shoemaker & de Olivera, 2008) may directly impact families. It is also possible that children of individuals with BD may dually experience this stigma as they may see it directed towards their parents and themselves. This is alluded to by the meta-synthesis of 22 studies 28 conducted by Dam and Hall (2016) who found that children of parents with psychopathology reported feeling stigma and a sense of responsibility to keep their parent’s diagnoses a secret. Michalak et al. (2011) found an area related to internalized stigma amongst those with BD was intergenerational silence. Inversely, it could be that within families where BD is experienced intergenerationally, open conversations and trickle-down psychoeducation around BD may serve as protective factors for the children. These findings suggest stigma may be an optimal area to explore further to inform possible interventions and supports. Further, these findings highlight the importance of family communication and family stories and how they can impact the children of those living with BD. Experience as an Individual with Intergenerational BD. Despite the existing literature that has examined the role of an individual with BD and a parent with a child with BD as separate identities, no study has explicitly connected the two roles and conceptualized someone as an individual experiencing intergenerational BD. Although potentially associated with stressors, some benefits may come with experiencing intergenerational BD. For example, typically, BD initially presents with symptoms of depression that are typically indistinguishable from symptoms of major depressive disorder (Malhi et al., 2017). For an individual who is at high risk of developing BD due to either genetic or environmental factors, this may indicate that they are at risk for developing BD, and a BD diagnosis becomes possible. Therefore, within families experiencing intergenerational BD, it could potentially facilitate a faster diagnosis and appropriate treatment, which may, in turn, lead to more positive outcomes for the individual experiencing second-generation BD. Research has found that individuals experiencing the possibility of intergenerational BD may feel a lack of control over their own mental well-being. For example, in Crowe et al. (2012) 29 study of the experiences of those with BD, some participants with BD reported feeling as though they could have never controlled or avoided BD due to its hereditary nature. Specifically, one participant noted that they felt they could not have controlled it, as two of their family members had a BD diagnosis (Crowe et al., 2012). These feelings may impact the individual and their motivation to seek support and treatment and contribute to their decisions around childbearing. More research is necessary to help us better understand the lived experiences of individuals experiencing intergenerational BD and potential protective, risk, and unique factors within this context. Experiences as a Parent Living with BD. Although not all individuals experiencing BD will themselves become parents, it is an additional factor that may profoundly impact the life experiences of individuals with BD. Being both a parent, a child, and an individual adds additional layers to the dimensions of experiences of individuals experiencing intergenerational BD. Specifically, being a potential conduit to a subsequent generation of individuals experiencing BD may impact their decision to have children, experience in pregnancy, parenting practices, and experiences of attachment with their children. Thus, the potential for intergenerational BD impacts individuals with BD and their partners as they determine whether to have children. Dore and Romans (2001) found that 44% of partners of individuals with BD reported that the heritability of BD influenced their decision to have children. Similarly, Dolman et al. (2016) found that women living with BD experienced reported fear of passing BD onto their child, fear of becoming ill, fear of being a bad parent, and anticipated stigma as significant factors in their decisions around parenthood. Harries and colleagues (2023) conducted a systematic review that they assert is the first to synthesize qualitative data about parenting and severe mental illness comprehensively. This 30 review found that in addition to some of the persistent areas of difficulty associated with being a parent living with a severe mental illness (feelings of loss of control, overwhelmedness, and fear), parenting was also described as being a source of comfort, pride, hope, motivation, and solace. Parents who reported feeling hopeful and optimistic about the future, in turn, also had a commitment to treatment for their diagnoses. Parenting can be a source of pride, hopefulness for the future, and motivation for parents living with serious mental illness (Harries et al., 2023). Previous literature has further explored the role of parenthood for individuals with BD (Lawrence, 2011; Venkatraman & Ackerson, 2009; Wilson & Crowe, 2009), although it is not the area of focus for this study. This emerging body of research provides an understanding of the impact of intergenerational mental illness on individuals considering and experiencing parenthood, providing some context and nuance to the aforementioned ‘laundry list’ of risk factors that have primarily dominated the literature base about BD. Despite this, persistent gaps remain, specifically a dearth of research that seeks to understand the experiences of having the same diagnosis as a parent. Persistent Gaps BD and its associated difficulties have been estimated to be the sixth leading cause of disability worldwide (Judd & Akiskal, 2003). As such, fastidious research has been conducted into its treatment, etiology, and associated risk factors. Although undoubtedly important, this research focus has led to an uneven representation of BD (Lobban et al., 2012). Research has acknowledged that BD impacts not only the individual but also their familial and social networks (Miklowitz, 2008); however, presently, there is a lack of critical and interpretive studies that can shed light on the lived experiences of these individuals. 31 Emerging research has shifted to seek a broader understanding of the experiences of individuals living with intergenerational mental health. Much of the focus has been examining its impact on the children’s siloed roles, including the distinct role of a child, a parent, or an individual. This research provides insight and context to help ameliorate our understanding of individuals with BD, their children, and their broader familial and social network; however, a research gap persists in understanding the lived experience of intergenerational BD—specifically, the potential impact of having a shared diagnosis with a parent. The Power of Narratives Narratives are powerful tools for generating empathy and communicating with others. It has been argued that narratives are more effective than facts or statistics in generating belief and understanding (Witten, 1993). It is argued amongst narrative researchers that narratives are (1) how human experiences are made meaningful, (2) universal across cultures, and (3) important in our society such that we become competent at storytelling at a very young age (Polkinghorne, 1991). Narratives occur individually, in a social context, and exist in an imagined past, present, and future (Clandinin & Connelly, 2000), with time being a universal and essential concept in our life stories (Bruner, 1991). Further, through stories, individuals learn cultural and family norms, values, beliefs, attitudes, and behaviours (Kellas, 2018; Kellas et al., 2015). The human desire to impose a plot to make sense of events was evidenced incidentally by a study conducted by Michotte (1946). Initially attempting to research visual perception, this study had participants watch short videos of coloured rectangles in motion. Participants were asked to describe what they saw. They found that participants often provided stories with plots and meaning attributed to the events (Michotte, 1946). Similarly, Heider and Simmel (1944) found that participants recounted complex narratives with common themes paralleling human 32 life when asked to describe what they saw after watching a video of shapes in motion. Relatedly, in our lives, humans use narratives to display events’ significance to one another (Polkinghorne, 1988) and to make sense of our experiences. Family storytelling is posited to be an essential aspect of socialization. Specifically, an across-generation experience facilitates family storytelling and family narratives. Family stories are accounts of personal experiences that impact the family, outline rules of interactions, reflect beliefs about relationships, and influence family values (Fiese & Winter, 2009). Family narratives are believed to clarify and justify patterns of interaction across generations (Manoogian et al., 2010) and provide younger generations with familial expectations of how they should behave (Stone, 2004). These narratives about shared experiences are said to have a lasting impact on the family members’ values, beliefs, attitudes, behaviours, and identities (Kellas, 2018; Kellas et al., 2015). Specific to health, family narratives direct family members toward choices, routines, and “how things are done” (Manoogian et al., 2010, p.42). Specifically, in exploring the stories of ‘health legacies’ (intergenerational experiences of a hereditary illness), Manoogian et al. (2010) found that family storytelling shaped how individual family members understood and managed their illness. These findings highlight the power of stories both for the individual and within their family system. Narrative inquiry allowed me to embrace the power of narrative and address the persistent gaps in the literature. This methodology has been previously used to provide insight into the sense made by individuals with BD (for example, the work of Metz & Jungbauer, 2019; Murphy et al., 2018; Patrick et al., 2019b). Narrative inquiry allows for rich data collection and has been proposed as an alternative to the dominating ‘sterile’ methods of post-positivistic data 33 collection (Lieblich et al., 1998). A core belief of narrative inquiry is that humans unconsciously lead storied lives, and those narratives are the primary way in which our lives and experiences are made meaningful (Polkinghorne, 1988). In examining narratives, one can make the unconscious imposition of a narrative conscious and evaluate the impact of said narratives. This study contributes to the emerging literature base of more deeply understanding the lives of those with BD by inviting individuals to try to retrospectively story their lives and learn how they have made sense and meaning of their past experiences. Present Study In sum, previous literature has asked: what is it like to be a child of an individual with BD, what is it like to be an individual living with BD, and what is it like to be a parent with BD; but to date no study has examined the broader experience of intergenerational BD. Further, it has neglected to explore how different roles related to intergenerational BD may intersect and impact one another. It is crucial to diverge from the ‘misery statistics’ and seek a candid and socially valid description of how those who experience intergenerational BD make sense of their experiences. This study uses narrative inquiry to address these persistent gaps. 34 CHAPTER THREE: METHODOLOGY There exists a persistent gap in understanding the lived experiences of those experiencing intergenerational bipolar disorder (BD)—specifically, individuals who have the same diagnosis as a parent. Although there is an abundance of research and data that has highlighted the risks associated with being a child of an individual with BD, what is missing is a systematic and rich representation of the child’s full experiences. This study addresses this gap by providing individuals experiencing intergenerational BD the space to tell their stories, describe their experiences, and contribute detailed descriptions to the literature base. Specifically, the present study aims to understand how individuals make sense of their experience of intergenerational BD. Narrative inquiry helps to generate knowledge and answer the following research questions: (1) how do second-generation diagnosed individuals experience intergenerational BD? (2) how is intergenerational BD communicated and relationally experienced within families? The central focus of the research is on the stories relayed by each participant who contributes to the research project. I interviewed each participant several times to gather their individual stories. For each participant, I organized their accounts into a storied form (Polkinghorne, 1988), the details of which are further detailed in the sections below. Once I had an organized and meaningful story for each participant, I analyzed the participant’s narratives to identify common themes. The following sections of this chapter will further describe narrative inquiry, the specific methodological approach used to facilitate the representation of the participants’ understanding and sense made of their experience. I will then outline the details of my recruitment procedures, methods of engagements, and procedures used to gather and analyze participant’s stories in a 35 meaningful and ethical manner. Finally, I will explore my positionality, including my place in the research, the central role I will play throughout this research, and the cautions and procedures I undertook to support not only the integrity of the data and its interpretation and representation but also care for myself while conducting this research. Narrative Inquiry Narrative inquiry is rooted in the belief that narratives are how human experiences are made meaningful. As such, storying is argued to be universal across cultures and apparent from a very young age (Polkinghorne, 1991). Narrative inquiry as a research approach has its roots in social constructivism and considers the individual within their social environment (Lieblich et al., 1998). This approach to researching the individual lives of individuals allows examination of the unique ways in which individuals interact and make sense of their social worlds (Bruner, 1991). In privileging the participant’s positionality and subjectivity (Riessman, 2000), I endeavoured to facilitate an understanding of the meaning made by those experiencing intergenerational BD by asking participants to share their insights, perspectives, and stories, more specifically, the meaning made through telling their stories of the realization that they share a diagnosis with a parent. The meaning of events is part of an overarching narrative (Polkinghorne, 1988), and our lives are a sequence of “nows” that we make sense of through emplotment. Emplotment is taking these individual “nows” and shepherding them towards a conclusion or ending, resulting in a whole, complex story (Ricoeur, 1980). Narrative structuring provides part-whole organization, similar to gestalt psychology (Polkinghorne, 1991), and through this process, we can make sense of our experiences as humans. 36 We adapt plots from cultural stories and myths to make sense of the events in our lives (Ricoeur, 1980). However, emplotment is not the imposition of a pre-existing plot onto a random set of events. It is, instead, an attempt to give meaning to events by identifying them as parts of a plot, identifying themes, and examining how these components come together into one story that facilitates integrated self-understanding. In other words, everything experienced by individuals is made meaningful by relating time and sequence into a story (Crossley, 2000). In narrative inquiry, the goal is to facilitate emplotment and re-storying (the integration and organization of events described by participants into meaningful stories) by mapping the shared experiences onto the structure of a traditional narrative, including time, plot, and scene (Connelly & Clandinin, 1990). The scene is conceptualized as where the story’s action occurs; this may be a physical setting and/or a cultural and social context. Plot and time are intertwined, as time is necessary to plot, and will imply a story’s beginning, middle, and end (Connelly & Clandinin, 1990). The result is meaningful narratives co-constructed by the researcher and each participant. As the researcher, I facilitated the emplotment and re-storying. As such, the researcher’s interpretation is central to the representation of the stories of each participant. Narrative inquiry allows us to understand not only an individual’s experience, the sense they have made of their experiences, and the plot they may have imposed (consciously or not) to facilitate this sense-making but also the social, cultural, and institutional narratives that are within or have shaped their experiences (Riessman, 2000). It allows us to understand the experience as understood and experienced by the individuals, as it privileges positionality and subjectivity (Riessman, 2000). Expanding on this, Clandinin and Connelly (2000) propose three dimensions of narrative inquiry: personal and social (interaction), time (past, present, and future), and situation or place (Clandinin & Connelly, 2000). This highlights the relational component of 37 narratives. Specifically, it speaks of the relation between the person and their world, their past, present, and future, the individual and space, the person and their cultural structure, familial narratives, and the relation between the participant and the researcher. Therefore, one can understand personal experiences and the social and historical context in which these experiences occurred (Riessman, 2000). Appropriateness of Methodology Within narrative inquiry, the purpose is to work with the participant to construct a meaningful and purposeful story – one that encompasses the experiences the participant has lived in a manner that is natural and intuitive to them (Riessman, 2008). Another tenet of narrative inquiry is validating how the participant constructs meaning and its value when creating their narrative (Marshall & Rossman, 2016). This facilitates narrative inquiry’s usefulness when working with voices that are not always heard and represented. This allowed me to contribute context and nuance to the previously described ‘misery statistics.’ Finally, narrative inquiry allows for contradiction and ambiguity (Riessman, 2008); this allowed me to understand the complexities associated with being an individual experiencing intergenerational BD and a shared diagnosis with a parent. Ontology and Epistemology This study approached reality from a perspective of bounded relativism. Within this, it is acknowledged that multiple realities exist across groups but that a shared reality exists within a bounded group (such as cultural or moral groups) (Moon & Blackman, 2014). This study approached knowledge from a social constructivist perspective. Within social constructivism, the underlying belief is that meaning and knowledge are made by the participants through interactions, living, and experiencing, and it is not something that is simply found nor merely a 38 subjective experience (Burr, 2006). From a social-constructionist epistemology, this research project was iterative and interactive (Riessman, 2008), and so as I collected and interpreted data, I reflected on my research questions and literature review to help (re)frame my thinking, interpretations, and derived meaning. I was flexible, and procedures evolved as necessary to meet the needs of participants and myself throughout the study. For example, I met with one participant, Charlotte (pseudonym), months after our first meeting to facilitate a conversation after she had a meeting with her biological father. Finally, in line with narrative research, bounded relativism, and social constructivism, this study privileges pluralism, relativism, and subjectivity, grounded in the belief that there is no absolute truth or correct interpretation of a text (Lieblich et al., 1998). Within narrative inquiry, the participants and researchers both play vital roles, as the participants’ stories and the re-storying of them by the researcher are at the heart of the research. As such, it is essential to acknowledge the potential diversity in beliefs, interactions, and life experiences that all individuals involved in the study bring with them. Role of the Researcher Bruner (1991) emphasizes the importance and role of the background knowledge, beliefs, and biases of both the participant and researcher, which can impact the stories told and stories heard. When I wrote my research proposal, I was very aware of the researcher’s role in narrative inquiry. Within this methodology, the researchers are not passive, objective, or seen simply as scribes (Connelly & Clandinin, 2001) but rather construct a story collaboratively and mutually with the participants. During the interviews, the participants share experiences and stories as they occur, and the researcher re-stories them through analysis. Thus, before beginning the research process, I needed to reflect on my positionality and how I might shape the narratives captured 39 within this study. As I conducted the research, I became aware of how much my past experiences, beliefs, and biases played an active role in the research. I admit that I had underestimated the significance of my positionality, and it was only when I was amidst conducting the interviews that I became aware of and humbled by how much of myself would be drawn upon in this research. Before beginning this research, I knew that my experience as a child of an individual with BD was an important consideration. I felt prepared to tap into this. My experiences inspired and invigorated my passion for researching this area. I felt I had done the work in my sense-making and support for myself to dive into this work and create meaningful and personally enjoyable research to contribute to the literature. With this lens, I noticed within myself a desire to step away from the ‘misery statistics’ and improve how we communicate with children about intergenerational mental illness. At the onset of conducting this study, I possessed hopes that may influence my approach and analysis of the data. I hoped to hear of the strengths experienced by those living with intergenerational BD. For example, I had written in my research proposal that I hope to hear that psychoeducation around BD and its treatment that the participants witnessed as a child helped them to identify, cope with, and effectively manage their BD symptoms. I expected to hear reference to some feelings of anxiety or worry when participants initially experienced the onset of their own BD, particularly knowing the 'misery statistics’ and stigma that currently exists towards BD. I expected to hear rich and nuanced descriptions of events to enrich the 'laundry list' of statistics that currently dominate the academic space around living with BD. Finally, I documented a hope that through these interviews, I would be able to empower, provide a voice for, and facilitate sense-making for the participants. In acknowledging the lens that I bring to this 40 research and continually reflecting and journaling, I hoped to create a synergy between privileging the voice of participants and my experience in co-creating their narratives. Although I do not personally have a BD diagnosis, many close to me do. Due to this, I anticipated experiencing projection or countertransference among some of the participants in this study. For example, there were times, in interviews, when participants shared events, concepts, or attitudes that particularly resonated with me. In these moments, I could intuitively attune to and validate the participants' emotions. I was also mindful that sometimes, given similarities, one can lean towards making assumptions about the other's experiences. I was mindful of working to manage my own assumptions. Specifically, I was mindful that despite potential similarities, I did not inherently wholly or completely understand any participant’s experiences. Further descriptions of how my positionality was woven throughout this research study are described in the My Research Journey section at the end of this chapter. Description of Participants I was fortunate to have five participants willing to share their stories with me. They each selected a pseudonym for this research. See Table 2 for the demographic information collected about these participants. I met with each of these participants on three occasions for data collection. I met with each participant over Zoom, except Evelyn, whom I met on the UBC campus. Across participants, there was a diversity in age at interview, age at diagnosis, and the parent diagnosed with BD. Interestingly, each of the participant’s parents had been diagnosed with BD-II, and the majority of participants themselves were also diagnosed with BD-II. Preceding each participant’s narrative is a brief description of the participants to help provide additional context and understanding of each individual. 41 Participant sample sizes within narrative inquiry are often kept small as interviews are in-depth and result in considerable data (Lieblich, Tuval-Mashiach & Zilber, 1998). Further, analysis of stories seeks primarily to collect and present individual cases of experience, explanation, and meaning, and secondarily to consider generalities across stories (Polkinghorne, 1995). Therefore, five participants allowed for a range of experiences and a robust number of interviews to generate amble qualitative data to analyze the experiences of intergenerational BD. Further, this sample size is consistent with other narrative inquiry dissertations, for example, the work of Brunanski (2009), Richardson (2019), and Weins (2005). Table 2 Demographic Information Demographic Information Alissa Charlotte Evelyn Ella Frank Age at Interview 25 44 27 36 54 Age at Diagnosis 21 44 22 36 24 Type of BD BD-I BD-II BD-II BD-II BD-II Parent with BD Father Father Mother Mother Mother Parent Age at Diagnosis Early 20s Late 20s Around 30 Early 30s Early 30s Parental Type of BD BD-II BD-II BD-II BD-II BD-II Criteria for the Selection of Participants Each of the participants met the following predetermined criteria: (1) the participant was 19 years of age or older, (2) the participant had a formal diagnosis of type I or type II BD, and (3) the participant reported being the genetic child of an adult with BD who was diagnosed with 42 BD prior to the participant. Further, each of my five participants was actively engaged in the process and interested in sharing their stories. For several reasons, I conducted this study with adult participants, whom I asked to reflect on their childhood and youth rather than with children and youth. Firstly, as adults, the participants may have had more time to make sense of their experiences and may be more comfortable in sharing their experiences of their own and their parent’s mental illness. Further, the adults may have had experience with their parent and their mental illness across many developmental stages, allowing them to reflect on many components of their experience and what components they have felt are most salient to them. Finally, the onset of BD is typically not until early adulthood (Johnson et al., 2000); therefore, it was likely that participants who meet the eligibility criteria would be adults themselves. Participants were required to be diagnosed with either BD type I (BD-I) or BD type II (BD-II), as both are associated with a hereditary link. Although each type is associated with different levels of severity and impairment (individuals living with BD-I often experience more severe manic episodes, and individuals living with BD-II often experience more severe and frequent depressive episodes), participants with either diagnosis were eligible to participate in the study. Measures and Tools In order to collect descriptive information about the participants, at the time of recruitment and screening, each participant engaged in a screening interview and completed a standardized assessment, the MINI international neuropsychiatric interview (MINI; Lecrubier et al., 1997) to learn more about their clinical experiences. Further, before our first semi-structured interview, I asked each participant to create a life graph (Söderström, 2019) to facilitate our 43 conversations. Finally, I, the primary researcher, continually engaged in reflexive journaling throughout the research process. Each of these tools is further described below. Past Clinical Experiences At the first meeting with participants, I conducted the MINI to confirm participant diagnoses of BD, as this was an inclusionary criterion of the study. The MINI (Lecrubier et al., 1997) is a structured diagnostic interview designed to efficiently diagnose major psychiatric disorders in the DSM-5 (American Psychiatric Association, 2013). It has acceptable test re-test reliability (kappa ranging from 0.76 and 0.93) and very high inter-rater reliability (kappa ranging from 0.88 to 1.0). Although I am not formally trained in administering the MINI, I have had formal training in the administration, scoring, and interpretation of standardized assessments and semi-structured interviews. Prior to administering the MINI, I reviewed the administration guidelines, and throughout administration I applied my previous training and clinical skills. The MINI includes a question about suicidality (Lecrubier et al., 1997). The research protocol provided a condition that if, in this interview, the participant(s) indicated that they had had thoughts of suicide in the past two weeks, they would be flagged. A risk assessment (further outlined in the considerations of risk section) would then be conducted. I (the primary researcher) planned to conduct a clinical check-in with flagged participants before the in-depth interview to assess their risk further and provide support. This would also have allowed me to mitigate the risks of potentially participating in the study. On the MINI, all participants reported meeting the criteria for a manic or hypomanic episode in the past, affirming their reported BD diagnoses. Interestingly, all participant’s ratings indicated some symptoms of an anxiety disorder, including generalized anxiety or a panic disorder. This is consistent with past research that indicates that many of those living with BD 44 also experience comorbid anxiety (Boylan et al., 2004). Many participant’s reports also indicated that they may also met the criteria for other diagnoses, including alcohol dependence, panic disorders, and post-traumatic stress disorder. No participants reported active or recent (in the last two weeks) suicidality on the MINI; therefore, no risk assessments or follow-up was deemed necessary. Life Graph I asked each participant to create a life graph to facilitate participant engagement in the subsequent interview. A life graph is a methodological tool that can help to facilitate recalling major life events (Söderström, 2019). Participants are asked to document and think through key events or ‘turning points’ throughout their lives from birth until the present day in a manner similar to creating a timeline. Söderström (2019) describes that using visuals such as life graphs can help balance the power dynamic between the participant and interviewer within interpretive research. Finally, it has been suggested that creating a visual may elicit a deeper recollection of the participant’s perspective (Söderström, 2019). Life graphs can be created with different focuses; for this study, I asked participants to create a life graph emphasizing their experiences of intergenerational BD. I asked participants to plot the event on a scale of negative five to positive five to indicate the event as a low or high point of their life. This was done before the initial data collection interview and was intended to serve as a memory device to cue their recall of key events before the interview and facilitate conversation during the interview. All but one participant (Frank) created a form of a life graph. Generally, the life graph was a helpful tool that worked as intended in my meetings with participants. 45 Researcher Journaling As outlined by Tracy (2010) a core component to high quality interpretive research is the sincerity of the study, which includes self-reflexivity, vulnerability, and honesty. Thus, it was important to document my own reactions, observations, reflections throughout the study. Prior to beginning the study, I journaled about my own positionality, biases, hopes, and goals for the research and included these reflections in my research proposal. While engaging in data collection, I set aside an hour after each participant interview to journal my reactions and reflections. These journal transcriptions were used to memo moments and support me in attending to my own voice, as described by McCormack (2000), when I co-constructed participant narratives. This process is further described in the data-analysis section of this chapter. Finally, as I conducted the data analysis, the journal entries were used to continually explore my own emotional reactions to the participant narratives, my positionality, and to memo decisions made. In sum, researcher journaling was a tool used throughout the study to support both the sincerity of the study as defined by Tracy (2010) in addition to supporting the analysis and interpretation of the data. Description of Procedures This study occurred in six broad stages: (1) first meeting - recruitment, screening, and descriptive data collection (2) second meeting– initial rapport building (3) semi-structured interviews - primary data collection (4) data analysis and re-storying of individual stories (5) member check and (6) analysis across stories. Each stage of the study is further discussed in detail below. 46 Recruitment of Participants Throughout this study, I collaborated with the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD), an organization through the University of British Columbia that supports collaborative research and knowledge translation specific to BD (CREST.BD, 2021). CREST.BD has a following on their website, blog, and social media. I consulted with CREST.BD about the accessibility of the recruitment materials to facilitate the participation of a diverse sample of participants. Upon obtaining ethics approval from the University of British Columbia, I released two blog posts on the CREST.BD website, which facilitated my recruitment. Specifically, On June 24th, 2021, I released a blog post on CREST.BD, which announced the upcoming study, introduced myself and the research. On February 1st, 2022, a second blog post was published, which announced the official recruitment. Individuals subscribed to the CREST.BD newsletter were also alerted to this post through the email newsletter. This post outlined the description of the study, the eligibility criteria, and my contact information; following this initial post, eleven potential participants connected with me via email, seven met the inclusion criteria for participation. Three interested parties then declined to participate or halted communication before scheduling an initial meeting. The remaining four participated in the study. I initially aimed to have five to ten participants for my dissertation. This was determined as it would allow for a range of substantial contributions, a feasible number of interviews, and an amount of qualitative data to integrate within a doctoral dissertation. Lieblich et al. (1998) highlight that participant group sizes within narrative inquiry are often kept small because interviews are in-depth, and considerable amounts of data can be gathered in each interview. 47 Having five to ten participants is consistent with the range observed in studies conducted using narrative inquiry within this population; specifically, it is consistent with the number of participants interviewed in studies by Patrick et al. (2019b) and Murphy et al. (2018). Having only recruited four eligible participants, I contacted local support groups for those living with BD to help advertise the study recruitment. On June 10th, 2022, I connected with the Pathways Serious Mental Illness Society, who shared the blog post with their members. One person responded to this post, which led to the recruitment of my fifth participant for the study, Frank. No other interested support groups or potential participants contacted me. Initial Meetings I conducted interviews in an iterative way to pilot procedures, better understand myself and my possible barriers in interviewing (Marshall & Rossman, 2016), and adapt my procedures to benefit the participants as needed. This allowed me to refine my interview questions, follow up probes, and engage in ongoing reflexivity. In meeting with Alissa, I sought her feedback on the process and journaled about what I noticed and how I might refine future interviews. The intention was to make adjustments that would enhance the final study's quality, transparency, and rigour. Alissa provided little feedback about the interview process and experienced it positively. Therefore, few changes were made to the general procedures. Following Seidman's (1991) recommendation, participants were interviewed three times to allow them to overcome hesitancy to share personal information: I met with each participant once for initial screening, once for a brief rapport-building interview, and twice more for primary data collection. The specific details of these meetings are described below. All five individuals participated in an initial interview to ensure they met eligibility criteria, to collect descriptive information, and to review informed consent. In this meeting, 48 informed consent, including potential participation risks, was explained orally and provided in writing. Participants were asked to personally evaluate their mental well-being and negotiate if they felt they were able and willing to continue to participate in the study presently. I also asked participants to identify potential sources of support they could connect with throughout the study if needed. Informed consent was obtained from all participants, and once deemed eligible for the study the MINI (Lecrubier et al., 1997) was administered to collect descriptive information about participants and their clinical experiences. Polkinghorne (2007) outlines the importance of rapport for engaging in narrative inquiry. Therefore, I had a distinct initial meeting focusing on building connection and rapport with the participant. This interview aimed to review the purpose of the study, review confidentiality and consent, and develop an initial rapport with participants. These meetings were relatively brief, all of them being under an hour. Before the subsequent data collection interview, participants were asked to create a life graph. As such, I described life graphs in this initial meeting and gave participants a sample life graph (my own) and a blank template. The template can be found in Appendix A. All but one participant (Frank) created a form of a life graph. I invited participants to bring with them any artifacts, such as letters, photos, objects, or notes that are meaningful to them that they wanted to bring or share at the time of data collection. One participant (Alissa) brought a photo and journal entry; another (Ella) brought entries from her online blog. Other participants did not share artifacts. Data Collection The primary data source for the study was the audio and video-recorded interviews with each participant. After the rapport-building meeting, I met with each participant twice to conduct the semi-structured interview, which varied in length from one hour to two hours. Additional 49 sources of data were: (1) the descriptive information provided in the screening procedures, (2) the life graphs of each participant, (3) any artifacts provided by participants, and (4) transcriptions of my journal entries throughout the study. I intentionally began subsequent interviews by revisiting rapport and connection to maintain rapport. Following each interview, I set aside one hour to journal my reactions, observations, reflections, and feelings in reaction to the interview. Participants engaged in two semi-structured interviews where they were asked to share their stories of experiencing intergenerational BD. These meetings were intentionally distinct to help facilitate rapport and participant comfort in sharing deeply personal information (Seidman, 1991). I began the meeting by orienting the participants to the purpose of the study. If the participant brought a life graph, I had them share their life graph. For some participants, reviewing their life graphs took the entirety of the initial data collection meeting. For others, their review of their life graph was briefer and was used to facilitate conversation about other topics relevant to the research question (see Appendix B for the orienting statement and interview questions). The purpose of these interviews was to co-construct a detailed account of the participants' stories as individuals experiencing intergenerational BD and how intergenerational BD was communicated about and relationally experienced in their families. The life graph was intended to help facilitate connections across the temporal aspect of narratives (past, present, future). The life graph provided an opportunity to probe the connections through and across time with the participants. For example, how past events may influence events in the present or future, how past events continue to reverberate in the participant’s present and future life, and how events can impact a predicted or desired future. Further, the life graph was intended to facilitate the 50 identification of peripeteia(s), their solution(s), and the connections between these events, problems, and changes. The life graph helped facilitate these conversations with many of the participants. Throughout the interviews, I was mindful to give the participants the time and space to have a voice, share their experiences, and gain authority in our conversation (Connelly & Clandinin, 1990). Therefore, I consciously employed empathic listening, allowed the participant to lead, and used encouragers or probes to allow participants to share their experiences at their own pace and will. Being mindful of the fact that when people talk about their lives, it is not necessarily in a planful way but is often in a meaningful way, I followed each participant’s lead and allowed them to share in a way that was meaningful to them. Member Checks. Acknowledging that the reconstructed narratives are not an exact reproduction of what the participants have stated and are instead a creation and interaction between the participants and me (Polkinghorne, 2007), I solicited feedback from participants on their individual narratives. This process was an effort to enhance the credibility of the narratives and also to maintain trust and rapport with the participants. Due to some of the potential risks associated with member checking (such as re-traumatization from hearing their stories and feeling isolated or misunderstood), the participants were first consulted to confirm if they would like to participate in validation, to which all agreed. Once I had re-storied each individual narrative, I asked each participant to review the narrative before I continued with my analysis. Participants were asked if they felt the story resonated with them, if they felt I had missed anything, and if they would like to set up a time to discuss further. All participants were given two weeks to respond. A follow-up email was sent to two participants one month after initial contact, having not received feedback from them. Two 51 participants, Ella and Evelyn, did not provide feedback on their narratives. The other participants responded positively, providing updates about their lives and offering only minor changes, such as minor changes to the wording of quotes and offering more detail. Some participants seemed to have an emotional reaction to reading their story. For example, Frank shared, “I am honoured that I am included in your work. Thank you for this opportunity. As I read what you wrote… and then your insights and inserts… I appreciated even more your work… thank you… your comments are making me reflect, which is a good thing.” Alissa shared, “It was very touching and accurate, and I love how you incorporate your own thoughts and feelings along the way.” All participants who provided feedback expressed an interest in reading the completed dissertation upon completion. Data Analysis Data analysis was an iterative and multistep process that began in the initial interviews and continued into my cross-narrative analysis. Through this process, many simultaneous and interwoven steps occurred. Broadly, the data analysis occurred in two overarching phases: (1) re-storying and co-creating the individual narratives and (2) analyzing across narratives for common themes. As the researcher, the onus was on me to demonstrate skill, judgment, and integration of events and organize the participants' accounts into coherent stories that follow a set structure (Polkinghorne, 1988). Across phases, I continually reflected on my research question and literature review to help frame my thinking, interpretations, and derived meaning. I reflected on narrative elements and processes such as the problem, resolution, themes, and archetypal characters as they pertained to each narrative. Finally, I consistently consulted with my supervisory committee to help explore my decision-making and solicit feedback. 52 Individual Narratives In interviews, I gathered each participant’s events, stories, and memories; these stories and descriptions of events acted as the field texts I explored for my data analysis (Clandinin & Connelly, 2000). I worked with both transcriptions of the interviews and re-watching or listening to the interviews to re-immerse myself in the data. Additional data sources include the transcriptions of my journal entries, life graphs, and artifacts. These were also integrated into the co-creation of the story as relevant. I began data analysis by transcribing each interview and watching the interview back a second time to ensure the transcript was transcribed correctly. I then reread each transcript multiple times, coding for the following: (1) descriptions of personal experiences, (2) descriptions of interactions, (3) characters, (4) settings, and (5) indicators of temporality. I then documented this information in the format of Ollerenshaw and Creswell's (2002) adaptation from Clandinin and Connelly (2000). See Appendix C for this table. Ollerenshaw and Creswell’s (2002) re-storying strategy lends itself well to broad, holistic sketches of experiences, but privileges personal experiences and interactions with other ‘characters’ and the context of these interactions. The narrative structure is, therefore, experience-oriented and holistic and considers the narrative structure to be an interaction between personal and social interactions. I rewatched each interview and reviewed each transcript, attending to my own experiences as the researcher and my positionality, in line with the three voices outlined by Lieblich et al. (1998), the voice of the participant (the narrator), the theoretical framework, and my voice. I identified moments in the interviews where something unexpected happened or stood out to me and coded my reactions as an interviewer. For example, I asked myself how I 53 responded emotionally and intellectually to the participant (McCormack, 2000). I then wove these observations into the transcripts. I printed each transcript and cut up the excerpts, allowing me to manipulate the data physically. The purpose of this was twofold. I could manually organize the transcripts chronologically, allowing me to understand the temporality of each story better. Second, I could attend to the language used by each participant more easily by documenting word groupings, words used together, and words used repeatedly. Less formally, I could manipulate excerpts of the transcripts, looking for themes and key ideas, sometimes using lines to create poems with the participants’ words. I simultaneously engaged in a more traditional coding of the transcripts in NVivo. This facilitated looking across narratives. I coded for themes, characters, settings, quotes, and narrative elements as I identified them. I asked myself why the story was being told, how it was being told, and what brought the story to a close (if it did have a close) (McCormack, 2000). Here, I also coded elements I noticed in my manual organization of the narratives, such as repeated word use. After immersing myself in each narrative, I re-storied the interviews. This was also an iterative process, where I sought the support of my supervisors. I strove to maintain the integrity of what was shared while organizing interviews into a meaningful story structure. The re-storied narratives were primarily structured chronologically; in doing so, some of the jaggedness or inconclusion of participant lives is belied. I decided to use chronological time for its straightforwardness and to highlight the resolutions within participants’ stories to maintain the integrity of their tone, including expressions of optimism, hopefulness, and their own reported sense of closure. 54 I wrote the narratives primarily in the third person, with myself as the limited narrator, rather than an ‘omniscient’ narrator who is privy to the thoughts and ideas of the characters. The separation of the narrator and the protagonist permits the narrator to engage in reflexivity as they observe, reflect, and comment on what is being presented (Linde, 1993). Thus, writing in the third person and maintaining my position as a narrator allowed me to include relationships between what participants shared, my reactions, and my interpretations without presupposing access to the entire world of the participants. As I became aware of how my positionality was intertwined in the co-constructed narratives and how my interpretation influenced the outcomes, it was important to maintain my voice within the stories. In the third person, you do not see directly through the protagonists’ eyes, nor do you suppose that you know their true thoughts. In using this voice, I was able to acknowledge that I do not have a completely accurate understanding of the participant’s true or complete thoughts, allowing the potential for narrative secrets. I maintained my stance as a limited narrator to acknowledge that any retelling of a story is partial, incomplete, and tentative (Finlay, 2012) and that no interpretative account can ever fully capture or represent a lived experience (Greene, 2007). Thus, my interpretation of the co-constructed story is exactly that, my interpretation; therefore, I maintained my position as the narrator, including my reflections and observations throughout the interviews. Despite primarily engaging in the third person, whenever possible, I included verbatim language from participants. This was done to provide space for their voices, demonstrating how they talked about their experiences and to support their agency in storytelling. Further, it was done to invite the reader to “think and feel from the participant perspectives, in their words” (Oliver, 1998, p. 249). I also, at times, used the first person to describe my own reactions to the 55 interviews. This was done to illustrate my experiences and practice mutual vulnerability, as described by Finlay (2022). Both of the uses of the first person were in an effort to evoke an ‘experience-near’ response in the reader, where they are able to witness and read the stories with a reflective, empathic, and attentive stance (Finlay, 2012). Cross Narrative Analysis Once the individual interviews were re-storied and participant feedback integrated, the complete narratives were compared and analyzed. Following steps similar to the individual story analysis, I coded the stories in NVivo and engaged in multiple readings to re-immerse myself in the individual stories. In line with the principles for the analysis of narratives described by Polkinghorne (1995), I conducted a paradigmatic analysis of participant stories. Specifically, I looked across narratives for concepts related to previous research, including overarching narratives, common formula stories, and elements from family systems theory (Bowen, 1978), while also inductively identifying common themes and motifs across stories. These commonalities were then used to inform broader theories or conclusions about the participants' stories. Throughout this process, I consulted with my research supervisors. Considerations of Accessibility, Safety, and Trustworthiness When I initially proposed this research project, I identified various areas of consideration, including possible challenges and barriers, to ensure an ethical and trustworthy research outcome. Specifically, given the subjective and intimate nature of the data, and the power dynamics within a research experience, it was imperative that I consider both the accessibility of my study and the safety of the participants and myself. These anticipated risks and the predetermined attempts to circumnavigate them are further described in this section. 56 Ethical Considerations Tracy (2010) outlines eight criteria for excellent interpretive research. These criteria were created to provide a framework to facilitate the production of high-quality interpretive research and evaluate it in a meaningful and appropriate way. These criteria allow the core value of critical and interpretive research to be created so that critical and interpretive research can be appropriately and fairly judged and evaluated. These criteria are the worthiness of the topic, the rigour of research, sincerity, credibility, significance, ethics, and meaningful coherence of this study (Tracy, 2010). In the following paragraphs, I address these and have interwoven additional considerations of the accessibility of my study and potential risk to participants. Procedural Ethics. Procedural ethics are ethical actions dictated as universally necessary (Tracy, 2010). In line with procedural ethics, I sought approval from the ethics review board before implementing this study. Further, prior to the implementation of the study, informed consent was reviewed with each participant. I explained that participation is voluntary and that participants have the right and capacity to terminate their participation at any time. Further, I emphasized to the participants the nature of the research and the potential consequences of participating in the research. I ensured participants' privacy and confidentiality by storing their consent forms securely, using pseudonyms in all documentation, and writing following informed consent. Situational Ethics. Situational ethics is the practice of identifying areas of consideration that result from the study's specific circumstances (Tracy, 2010). In anticipation of working with a potentially vulnerable population who may have had previous negative experiences with those in positions of power, I planned to continually reflect on the power dynamics and try to create a partnership with participants. This is particularly important in narrative inquiry as, for example, 57 Clandinin (2016) highlights that in narrative inquiry, the researcher intentionally creates a relationship with their participants and puts their lives alongside each other. Considerations of Risk. Throughout this study, I asked participants to share intimate and personal accounts of their experiences with intergenerational BD. Sharing about potentially sensitive topics at length may have been highly distressing for the participants. As such, it was possible that the interviews themselves would be retraumatizing and/or place the participants at risk. Throughout the interviews, I actively engaged my previous training in counselling to employ empathetic listening and attune to the participant. I was also mindful of my relationship with each participant and negotiated boundaries where I could support the participants but not slip into a counselling role. At times, I found this challenging. Two participants, Ella and Evelyn, drew comparisons between our meetings and therapy, citing their comfort and method of sharing. I hope that this is illustrative of the warm environment shared. Participants were given the right to withdraw from the study or discontinue the interviews at any time; however, none elected to do so. For the interviews conducted virtually, I asked participants to provide the address of where they would be during the interview so that, if necessary, their predetermined supports could be sent to them. In-person interviews occurred on the UBC campus in a publicly accessible room that allowed for privacy. A predetermined protocol was set in the case that a participant expresses distress or thoughts of suicide at any time throughout the research process. This protocol, adapted from the suicide risk assessment guide created by Perlman et al. (2011), can be found in Appendix D. Before participating in the study, participants were asked to identify personal resources they could access should they need them. For example, participants identified their supports including their doctors, therapists, and close family members. I (the primary researcher) am formally 58 trained in suicide risk assessment and am knowledgeable about the warning signs and symptoms of mental distress. I was able and prepared to assess and determine the support needed for participants throughout each interview. Further, prior to the implementation of this study, I developed a protocol to implement if participant safety risk was identified. These predetermined procedures provided myself with a sense of security and preparedness, although I did not need to use them. I was also mindful of my own emotional safety throughout the research process. I had initially detailed ways in which I would limit interviews to protect myself. For example, limiting the number of interviews and intended time for transcription per day. Due to unforeseen circumstances throughout the research process (further described in My Research Journey section), greater precautions were required. Specifically, I consciously took a step back from this research for several months as I found the interviews and research data particularly challenging to work with. I debriefed with trusted advisors and colleagues through this decision-making process. This was a challenging yet necessary step to ensure my emotional safety throughout the research process. Finally, as participants shared personal information that is included in their stories, it was important that I considered ways I would maintain their confidentiality. Although all participants selected pseudonyms, it was a potential risk that in sharing sufficient details about their past and present lives, a reader might deduce who the participant was. In co-creating participant narratives, I was mindful to remove sufficient details such that participants could not be identified by their stories. This was done, for example, by removing specific details shared by participants, such as specific professions, workplaces, or current places of residence. 59 Relational Ethics. Relational ethics outlines an ethical self-consciousness in which researchers consider their actions, character, and potential impact on others (Tracy, 2010). I addressed this by seeking to ensure the mutual respect, dignity, and connectedness between myself and the participants. This was particularly important as I worked closely with the participants and engaged with them in the sense-making of their lived experiences. I prioritized rapport and facilitating a trusting relationship with participants. To facilitate connection and shared experience with the participants, I participated in some of the procedures for this study, including creating a life graph and documenting my own story of my experience with intergenerational BD. Further, I continually reflected and journaled to manage any possible countertransference between the participants and myself, wherein my own personal experiences, emotional reactions, and/or projections, might have influenced how I responded to the participants in both the interviews and in the co-creation of their stories. Considerations for Inclusive Research. To support the dignity of the participants, I considered the inclusivity and accessibility of my data collection and procedures, particularly as BD can be associated with significant impairment (Akiskal, 2003), including moderate impacts on verbal learning and memory (Kurtz & Gerraty, 2009) and possible impairment within executive functions (Robinson et al., 2006) and attention (Burdick et al., 2006). There were several ways in which I planned initially to create an inclusive research study. For example, when engaging in recruitment, I collaborated with the CREST.BD team to ensure that recruitment materials were provided in accessible and plain language. In my data collection interviews for participants who brought life graphs and artifacts, I used them as tools to facilitate the participant’s memory. Further, I was continually mindful that participants may have trouble recalling past life events, particularly those that may have occurred during episodes of depression 60 or (hypo)mania. As this was something that I had anticipated, when it did occur in interviews, I could approach lapses in memory with compassion, understanding, and patience. As the focus of this dissertation privileges the participant's perspective, I was open and available to explore the stories as recalled by participants and was flexible in the amount of detail, variety, and stories provided by individual participants. All stories and events the participants shared were considered valid and important, regardless of the depth, detail, and length of events shared. As a result, I had some participants whose interviews lasted two hours, while others were just under an hour, depending on the amount of detail shared. Further, the life graphs of the participants were welcomed to be as detailed or sparse as they would like and were able. My priority was to provide a non-judgemental and safe space for participants to share at their own pace and to the best of their ability. I had procedures built in, such that at the time of the interview, if a participant were experiencing difficulties recalling their experiences to the degree that was causing them distress, they would be given the option to discontinue the interview and either reconvene at another date or withdraw from the study; however, I did not encounter this in my data collection. I provided participants with the choice of meeting virtually over Zoom or in person with social distancing and other COVID-19 safety precautions in place. Four of the participants elected to meet virtually, and one in person. As the researcher, I worked to create a warm and safe environment that was conducive to trust, rapport, and emotional safety. I was mindful of my body language, physical environment, and tone. For the participants I met virtually, I also ensured they were in a comfortable and safe environment before beginning the interviews. In my restorying of participant narratives I was mindful to use inclusive language. I reflected on my linguistic choices and how they might be interpreted both by participants and the 61 readers of my dissertation. For example, I reflected on the use of person-first language and identity first language. I made the decision to write using person-first language, however I did not alter the language used by participants when I included verbatim quotes. Exit Ethics. Exit ethics are considerations that continue beyond data collection and how I not only end my relationships with the participants but share the results (Tracy, 2010). I intended to address this by clarifying to participants the length of their involvement and how I planned to follow up with them for member checks. In writing the narratives, I was mindful of creating outcomes that were not only accurate but also honourable and respectful. I was also mindful of the nuance in my writing and avoided writing that could easily be misread, misused, or misappropriated. Further, I consciously reflected on whether my research was “doing more harm than good” by monitoring the reactions and emotions felt by participants in interviews (Tracy, 2010). Trustworthiness Riessman (2008) highlights that there is no prescribed or all-encompassing way that data from narrative inquiry can be validated or proven reliable. Bruner (1991) argues that truth is judged by the narrative's appearance of being true or real rather than its actual verifiability. Echoing this, Connelly and Clandinin (1990) believe that adequacy and plausibility are critical components of narrative truth. These are all considerations that I reflected on throughout this study. For example, I understood that language is not neutral (Bruner, 1985; Wittgenstein, 1968), and there may have been misconceptions, misunderstandings, or missed meanings in rendering the stories as told by participants. I attempted to mitigate this risk through member checks by asking participants if the re-storied narratives resonated with them, and if they felt 62 their stories were accurately represented. When soliciting participant feedback, I also welcomed participant reflections, including reactions to reading the re-storied narratives. In hearing these reflections, I was able to explore if participants felt the narratives were meaningful, understandable, bolstering the trustworthiness of the results. Kermode (1980) highlights the risk of narrative secrets or stories that are not told. I attempted to mitigate this as much as possible by building rapport and attempting to establish a trusting relationship with participants, as well as offering them multiple opportunities to build comfort in meeting and sharing with me (Wittgenstein, 1968); however, there are likely parts of each of the participant's experiences that they did not share with me. At times, with some participants, I did sense there were 'narrative secrets' or parts of their story that were not shared. I was mindful of this in co-constructing their narrative while integrating and analyzing the information they chose to share. It may be challenging for individuals to create a chronology of connected themes and events (Connelly & Clandinin, 1990). Individuals may find listing events without connecting themes or making sense of a plot a more manageable task, and it was, therefore, my responsibility as the researcher to re-story what was shared in this way. To support me in doing this, I asked participants to complete a life graph prior to the primary data collection; four participants completed these life graphs, which facilitated an enriched interview. There is a complicated relationship between narrative time and memory, as individuals may revise and edit the remembered to lead to congruence between identities in the present. Human life often has a narrative but can comprise many distinct stories. These stories may be sequential and congruent, but others may co-exist, even if contradictory. Despite this, it is essential to note that the stories are not a factual retelling of events but an articulation told from a 63 point of view (Riessman, 2008). As highlighted by Tavris and Aronson (2008), memory is a "self-serving historian" (p. 76); as humans, we adjust our memories to create a coherent story to make meaning of past events and actions. Further, narratives are at risk of smoothing, where one constructs a narrative where everything works out in the end (Spence, 1986) and as humans, we tend to revise the plot of our narratives to integrate new events or create unity within ourselves (Polkinghorne, 1988). This social constructivist view grounded my research: I was not on a quest to find a singular truth. I re-storied the interview data to highlight the nuances of the narratives and give the reader the opportunity to make sense of the findings. As much as possible, I triangulated the findings through multiple data sources, including interviews, artifacts, life graphs, and participant feedback from the member checks. These were all means to ensure the trustworthiness of these research findings. My Research Journey The process of completing my dissertation was expectedly gruelling; as Charlotte wrote to me in an email exchange when I apologized for the delay in my restorying of her narrative: “Writing a dissertation sounds like hell!” This dissertation also required a piece of me, a vulnerability that I had not expected and was not used to. In writing this dissertation, I feel I have interwoven pieces of myself and have illuminated my own sense-making and narratives in a manner similar to what I asked of participants. As previously described, while conducting this research, it became evident how much my positionality was interwoven into this work. As such, I intentionally maintained my voice as a narrator and included my reflections within each narrative. As I authentically engaged in this process of co-creating the stories, I reflected on my history, my connections drawn, my 64 observations and reactions to things shared, and my experiences in the interview processes. This was maintained in the narrative to help enrich the co-constructed story. In the individual narratives, I have intentionally maintained my voice in the narratives, as read in italics. When I proposed this study, however tepidly, I felt prepared to explore my own experiences within a family system with intergenerational BD. What I was not prepared for was the events that occurred within my personal life outside of my family as I began data collection. While I was in the midst of my data collection, a loved one began to experience symptoms of hypomania. In my journal entries after my initial meetings, I drew parallels between participant's experiences and what I witnessed unravelling in my personal life. Unlike my experiences within my family, with which I felt I had processed, understood, and had some sense of closure, I felt I was drowning in the simultaneous chaos of my personal life. For better or worse, I continued to spin the plates and navigated the interviews with participants. I genuinely could empathize with their struggles in many ways, as I had in the past and was, at the time, experiencing eerily similar events with a loved one. Looking back, I wonder how I may have approached them differently with the understanding, closure, and sense-making I have now. Like many participants, I heard their stories from the middle of my own rather than from the end. I reflected that I could physically feel my own experiences weighing me down as I tried to transcribe and attune to each participant's experiences. It was only after several months of data collection and analysis that I admitted to my primary research supervisor that I felt utterly overwhelmed and activated while trying to transcribe and analyze the interviews. I felt embarrassed, ashamed, and like I was spilling over. I wrote in my journal that I felt like a bowl of soup. I was a mess. My primary research supervisor was kind and patient with me and suggested I create a safety plan for myself. After several 65 meetings, we decided that I would take an intentional pause from transcribing and analyzing my interviews, a pause from the research. I had a few false starts where I attempted to re-engage with my research but needed more time to feel ready to do so safely. It was not until almost exactly one year after my first interview that I felt grounded and that I had had the space to process and make sense of my own experiences that I was ready and able to re-engage in the research. Initially, when analyzing the narratives, my supervisors noticed a clinical coolness in my writing. After weeks, I realized my coolness was because I did not want to connect with my emotional experiences during these interviews. It felt scary to connect with my vulnerability. I reflected on Finlay’s (2012) description of her challenges connecting with the writing process. Specifically, Finlay describes challenges navigating her own identity as a novice writer and her challenges reconnecting with ‘then’ (the challenging time in which her data was collected). It relieved me that I was not alone, nor was I failing, in experiencing these challenges. With my system's support, I was able to reconnect with myself ‘then.’ I rewatched my interviews, looking not only at the participants but also at myself. I considered what the interviews brought up for me and how my positionality can help to facilitate richness in these stories. The stories created as a part of this research are, therefore, not only a part of each participant, but also, a part of me. It was inevitable that the stories I interpreted from the participants would be within the context of my lens, biases, and assumptions. As McLeod (1997) wrote, "Telling a story is a performance, shaped by the response of the audience" (p.15). As the audience, I was shaping the performance, and it was vital to be mindful of how I was doing so. I had been prepared, in some ways, to acknowledge this role but quickly became overwhelmed by unforeseen circumstances. I consistently journaled, reflected, and practiced compassion with myself as I completed this 66 dissertation on a supportive timeline. The resulting narratives include pieces of my genuine self within them. Procedural and Data Analysis Summary In sum, I worked with five participants whom I met with on multiple occasions. Throughout these meetings, I worked to facilitate rapport and trust and learn the stories of these individuals. These interviews were recorded and transcribed. Using the transcriptions, the life graphs, the details of artifacts (if relevant) and my own journal entries, I re-storied and co-created a cohesive narrative for each participant. The significance of my own positionality was unanticipated but honoured. Participants were asked to check their individual stories to ensure they felt that their stories were represented accurately. Once each story was co-created, I examined across narratives to look for common themes, motifs, and narrative elements. Throughout this iterative research process, I connected with my research supervisors often to allow for debriefing to ensure that analyses were grounded in the data (Marshall & Rossman, 2016). 67 CHAPTER 4: PRESENTATION OF RESEARCH FINDINGS The following chapter presents the research findings of this study. First, I will present the individual narratives co-created by the research participant and me through our data collection. I will then explore the findings across narratives. Individual Narratives This section will present the individual narratives for each participant. Preceding each narrative is a brief introduction to the participant and our meetings together. In creating these stories, I worked to use numerous direct quotations from the interviews to provide a voice to the participants. The title of each story is a quotation that reflects the overarching idea that emerged in the analysis of the interview data. Further, I included quotations as subtitles, which are underlined. Throughout the narratives, sections written in italics are my voice and positionality. Portions of text that are in bold relate to one of the overarching themes: agency (powerlessness), communion (agency), identity (confusion), and ‘be the best that you can.’ These overarching themes are further discussed in the cross-narrative analysis. Finally, in order to facilitate the flow of each story, the individual narratives do not follow APA formatting. For example, one may notice that the headings do not follow APA formatting. The stories are presented in the order in which the interviews were completed. The following narratives are a distillation of my understanding of each participant’s experience. We are looking through a peephole, capturing only a snippet of the stories, wisdom, reflection, and compassion they shared with me in our interviews. 68 Alissa's Story: "You Can Always Be Well Again." Alissa was my first dissertation participant. She, like me, is a graduate student in her mid-twenties. She describes herself as a 'well-functioning weirdo,' one who never felt like she had fit into a box or category. Our rapport was established easily. After our first meeting, Alissa emailed me, saying she hoped she did not talk my ears off. I laughed, noting how it had not felt that way at all. My meetings with Alissa felt connecting and grounding. Time had passed quickly; conversation flowed naturally. As with all participants, Alissa and I met on several occasions. During these meetings, she shared with me her experiences with intergenerational bipolar disorder (BD) and how she is currently navigating her diagnosis and symptoms. We shared our favourite resources, books, and movies. She was reflective, open, and vulnerable, with a quiet confidence. "Are you sure he's not a thief?" Alissa describes herself as having had a peaceful and happy childhood. She has an older sister, but as she was fifteen years older than Alissa, they did not share much time together in their childhood home. "My sister, we never grew up together... and so… I didn't really talk that much to her because she was... living her own life in the capital, and I was in the countryside with my mother and sometimes my father when he was there." Alissa lovingly describes her mother as "superwoman" who did everything for the family. "I was very close to my mother because she was the only one I had at that time." In contrast to her descriptions of her mother, Alissa's descriptions of her father are in relative terms. She describes times when she liked him more or less, and times she felt more or less close. Alissa's descriptions of her father are entangled in her own experiences. 69 Despite her self-described traditional and happy childhood, at times, Alissa had an underlying sense of unease. "I could sense that there was something being… kept as a secret from me… there was something hidden." She wondered if her father was 'bad'; she could tell something was being kept from her, but she was unsure what. At the time, Alissa had a children's book about a thief; in the book, the thief was a 'nice' man, but he did 'bad' things. Alissa wondered if that was the secret that was being kept from her. "I could just sense that there was something off... and I also just didn't know what else to do about it…so I just kept asking [my mother] … I remember asking her at least four times, are you sure he's not a thief?" Alissa's mother repeatedly assured her that her father was not a thief, yet Alissa still sensed that something was being kept from her. "My mother just told me that he was out sailing because we had a sailing boat... and um... when he wasn't at home, he was just out sailing, so when I hadn't seen him for a couple of weeks, he was just out sailing," What Alissa was attuned to was that at this time her father was not out sailing, he was in the midst of a manic episode, the first of her lifetime. Although Alissa and I laughed while she shared this story, I felt an undertone of sadness. I imagined how scary it would feel to have a sense that something was off and not be able to articulate or understand what it was. I think about how, in my childhood, summers passed I had not seen my own father for several weeks. Instead of sailing, he was working. After about six months, Alissa's father seemed to have returned, and the nagging feeling that something was not quite right lifted. This return marked the beginning of a nearly decade-long period of stability and calmness. Alissa's father experienced a manic episode three more times throughout her childhood when she was 13, 16, and 19. "Ok, here we go again." "We managed it before; we can do it now." Each time, it seemed to worsen. The onset always occurred swiftly, and it repeatedly was as 70 though Alissa had wholly lost her father in the span of a week. As Alissa was a teenager during these episodes, it was harder to hide her father's diagnosis and symptoms from her. When she was 13, she learned that he had been diagnosed with BD. That same year, in biology class, Alissa learned that some mental illnesses, including BD, have a genetic component. Alissa recalls feeling worried that she might inherit her father's illness. "Shit …I really hope. I have not inherited that…That looks tough." Her mother reassured her, "No," "That won't happen to you," "You will be fine." As Alissa shared her experiences of her father's manic episodes, I could sense the tension rising. Alissa leaned in; her pacing quickened. Her father's episodes led to her and her mother seeking refuge with friends, visiting her father in the hospital, and struggling to understand who this unrecognizable man, whom she called father, was. When describing visiting him in the hospital, Alissa shares, "I thought, woah, he is not himself. Then I saw the others [in the hospital]. This is not a proper place to be treated. People are just kept here so they don't kill each other or kill themselves." Despite her young age, the weight of her father's manic episodes felt heavy on Alissa. "It kind of felt like a big burden and a secret that I had to, like, keep up appearances." She describes a time when she ran into her father on the street while she was with friends, "it was very awkward…. because you could see it on him… my friends were like... is that your father…? and I was like yeah?" Alissa and her mother stuck together and supported each other through these times. Alissa recalls sharing with her mother, "…. you know, somehow, I … I… hate Dad, but on the other hand, I know I don't hate him, but do you know what I mean? And [her mother] was like… yeah, I know what you mean, yes of course, I also don't hate him, but sometimes I hate his actions..." 71 In these repeating times of crisis, Alissa acted as an advisor to her mother and a caregiver to her father. At the time, she did not feel like she was taking on more than she could handle. "I was just doing what anybody would do in this circumstance," Alissa recalls reassuring her mother. "I never complained, I did not mind, it was the only right thing to do, I did it natural." Alissa pauses again. Her eyes look down. "Looking back, it could have been exhausting for a kid. Maybe a child shouldn't have experienced these things. But I survived, and I don't feel like I have many scars." I ask Alissa about her sister's role in the family, noting to myself that she has not had much of a presence in her stories. Alissa pauses thoughtfully and remarks, "It's something I've never really thought about." She and her sister have never experienced her father's diagnosis together. "Was he jolly manic in that episode? Or angry manic?" The experiences vary. They have not discussed it much. Between his episodes were moments of calm: "We were like this… nuclear family again..." Alissa recalls, laughing, that after her father's second manic episode, she thought it was funny that she liked him more now than before. He was more present and grounded; things were more harmonious. ‘He was really there and really present probably also because he wanted somehow to make up for it, but he was also more calm and grounded and like…. true…. it just felt much better." Through these periods of calm, Alissa and her family lived their belief that "things can always get better," "everything is temporary," and that "you can always be well again." Despite this sense of optimism, the underlying sense of unease is lurking. If everything was temporary, it might only be a matter of time until her father was again taken from her. "You might know that my father also has a diagnosis, but I am not like him, and you should not assume that." 72 Alissa was 19 when she experienced her first hypomanic episode, simultaneous to her father's fourth of her lifetime. "[I was] not sleeping, drinking a lot, partying a lot, meeting a lot of guys that …pfft… yeah… and um, working a lot, like I had five different jobs, and I worked more than 80 hours a week..." While in this state, Alissa journaled constantly. Journaling was, and still is her lifeline. It is how she makes sense of the sometimes-nonsensical world around her. While in a manic state, Alissa wrote feverishly, and at times, it felt like she physically could not stop writing. Alissa describes a scene of her riding the local transit back and forth, continuously missing her stop, as by the time she had gotten to her destination, she was not done journaling. The journal helped in the moment, but reading them back is painful, so Alissa generally does not read back her entries. While describing this part of her life, the tension rises; it is palpable in the air. "I kept on saying I have everything under control." Alissa, during this time, acquired tickets for various driving violations and was physically injured and exhausted from working multiple jobs, partying, and drinking excessively. Upon reflection, she asserts she should have been hospitalized. Unlike her father's typical pattern of six-month manic episodes, this one for him did not seem to end. Six months passed, then another, then another. In this period, he lost 40 kilos and thousands of Kroners, broke multiple ribs, and was hospitalized four times. When others suggested that Alissa might be going through a hard time, she recalls comparing herself to her father and thinking, well, I am not drinking as much, spending as much, or sleeping as poorly. This comparison shielded Alissa from her hypomania, as she felt she was functioning well, particularly compared to her father. During this period, a psychiatrist suggested to Alissa that she might have BD herself, but Alissa dismissed him. "You might know that my father also has a diagnosis, but I am not like him, and you should not assume that." 73 After about nine months, Alissa herself seemed to have transitioned out of her hypomanic state, but her father, on the other hand, seemed stuck. Despite having some contact, to Alissa and her mother, it felt as though they had almost wholly lost him: "We were just waiting for the time we would hear that… he had… committed suicide... or… he was dead or something…. um…. and that was like…. really tough..." While Alissa described this period of her life, I felt the familiar feeling of helplessness, guilt, and grief that comes with caring for and loving someone who is mentally unwell. I notice myself holding my breath. I take an intentional, audible, grounding breath. We continue. In direct contrast to the feeling of loss, during these difficult years, Alissa and her father became closer than ever through their shared understanding of each other. She describes, pausing often, her eyes welled with tears, "He opened up… much more… he told me things… um… that I had never heard before… and…. um… we talked a bit about it and I… I… tried to be there for him... to listen and... understand and …that was when he told me that... from his perspective, it seemed as if I was the only one in the whole world who would actually understand..." Alissa tried to be there for him as a daughter, a caregiver, and a support. She visited him often when he was in the hospital—listened to him, understood him, lent him money. He felt conflicted about receiving this care from her. "This is not good. This is not how it's supposed to be; I am the father," she recalls him saying. She reflects now, "It was the only right thing to do." There was no doubt in my mind that Alissa could convey her compassion and care for her father through this time. He told her that he wanted to die but that he did not want her to be alone. He gave her a necklace so that if he happened to die by suicide and it was out of his control, she would 74 have something to remember him by. She tearfully shares that they had come to an agreement. If it happens, it happens. If it happens, she will not be alone because she has the necklace. Alissa still has the necklace with her everywhere she goes. She doesn’t wear it, but she keeps it close. This agreement gave Alissa some sense of closure despite the ongoing turbulence around her. "It was a bit of an ending from my perspective." She reminds herself of the family motto: "It doesn't have to be like this forever. There is a way out. There must be. You can always be well again." Several months later, 18 months into this continuous manic episode, it was as though a switch suddenly flipped. Suddenly, her father was well again. Alissa reflects on conversations about her father's diagnosis after their manic episodes. She began the sentence, "Since then we talked…" and trailed off. She pauses, thinks for a beat, and continues, "We didn't really talk about it, actually." In the moment, everything felt dramatic and painful. Now, talking about it brings up the associated feelings of pain. This sensation is familiar to me. While working on my dissertation, cutting up excerpts of Alissa's transcript, and organizing them on my mother's living room floor, my mother and I engage in sheepish conversations about our familial experiences with BD. There is an awkwardness to it. An undertone of pain, an unspoken consensus to avoid facing it head-on. We are through it now; why re-engage ourselves in the pain? Similarly, Alissa reflects that with her parents, she feels there are many things to discuss, but the conversations have not yet occurred. "I actually feel like life is easy again…" Alissa found the COVID-19 pandemic healing, informative, and helpful. It helped her to slow down, attune to her body, realize and accept that her erratic behaviour was not a phase. "Ok, now you are just exactly repeating your father's pattern. Why don't you take the advice you gave him?" "You have seen what happens if you do not." "You have to get this under 75 control." "Otherwise, I might end up like my father." "I do not want it to ruin my life when I am 40. If I even make it to 40." She sought a diagnosis and felt held and heard by the clinicians who supported her. "I am very grateful for the way the system took me in." Alissa had always felt like she did not fit socially into one box, but when seeking psychiatric support for a second time, she found a box that fit. "When I saw the description of bipolar, I was thinking, shit, this is like a description of me... This is too good to be true. I am angry with this. Why is this category so well-fitting? I think, like, I've always like felt I didn't really fit into a box or category when I was growing up… I was always a weirdo, but a very well-functioning weirdo, so I didn't feel anything bad about that … but then when there was all of a sudden, a category where I just fit perfectly in… that got me a bit nervous." She reflects on her family's belief that you are not just one thing. "You are so much more than one label. We are so much more." Alissa is more than her diagnosis; her diagnosis is simply a category that can help her identify and access support. Her identity is fluid and changeable. "Just because I have been manic a couple of times doesn't mean that I will always be like that." "Things can change, and you can always be well again." Alissa reflects on how this belief is a survival mechanism, a coping strategy, and a source of hope for her and her family. Upon receiving her diagnosis, Alissa initially felt nervous to tell her parents. She told her mother first. Initially, Alissa's mother was surprised and hesitant; she had concerns about Alissa being on medication. Alissa might just be sensitive, not someone with BD. A couple of days later, her mother called her back and expressed her support for Alissa. She was happy that Alissa was taking her diagnosis seriously because if she was "unlucky," she could end up like her father. 76 Alissa also felt scared to tell her father, worried he might feel guilty, that it was his fault, haunted by what he might have done differently to shield her from it. To Alissa's surprise, her father responded well to the news of her diagnosis. Together, they reflected on how, with her knowledge and diagnosis, she could take action instead of pretending it was nothing. BD is not something that just goes away. "But this comes back again and again." "My dad had such long periods of stability. But we know it's just temporary." When you pretend it is nothing, it will most likely escalate into something you cannot control. With awareness and attunement, they can escape the cycles of their previous manic episodes. Alissa has yet to tell her sister about her diagnosis. When we discuss this for the first time in our interviews, she hesitates, and a sense of caution lingers in the air. She pauses, "huh…" Alissa acts in a caregiver role to both of her parents more than most of her friends, her boyfriend, or her sister. She feels on the same level as her parents. Her sister may have a more typical child role. Alissa wonders if it might have something to do with the responsibility she took in times of crisis. Her sister goes to their parents for advice. At times, her sister even comes to Alissa for advice. Alissa notes that that is potentially illustrative of her caregiver role within the family. Following her diagnosis, Alissa heeded her parents' caution about medication and did not start it right away. She experienced another hypomanic episode and then another since noticing a pattern where she becomes hypomanic in the summer. It was not until the summer of 2021, when Alissa began medication that she experienced a summer without some symptoms of hypomania in six years. Since starting medication, Alissa has managed her symptoms well. When discussing the present, Alissa shares, "I actually feel like life is easy again… and it's so nice because it was such a struggle for such a long time. It is so nice that I feel like I am back to before." 77 "It doesn't have to follow you like an evil shadow." In our third meeting, the energy is visibly brighter. There was a sense of freshness between Alissa and me. It may have been the spring light shining through the window or our increased comfort. We are meeting over Zoom in entirely different time zones, and the sunlight shines on both faces. Alissa has moved to a new country and has established her own life. She has reenrolled in school, has many friends she feels are similar to her, and has a supportive boyfriend. We discussed how, before our last meeting, Alissa had just returned from visiting him. Travel, particularly when it affects her sleep, can sometimes act as a trigger to her feeling slightly off-kilter. Alissa is now attuned to her bodily cues of when she might need to slow down and take care of herself. She feels in tune with the sun, rising with it each morning, the specific time shifting with the seasons. In the summer, the sun rises earlier, and so does Alissa. She laughs, sharing that winters are much more comfortable as she sleeps in later. Alissa does not want to feel limited by her diagnosis. "It doesn't have to follow you like an evil shadow." She sees BD as a tool to help her access the appropriate services and supports. She reflects on how it feels easier to move on, and as though these episodes were experiences of the past. Alissa is optimistic yet still maintains an awareness of potential challenges to come. "I think maybe there will be some big major life events sooner or later that will again affect me but the good thing is.. now like I know that I have [BD] and I can take it into account, I can be like more mindful about it." Alissa hopes to have a family of her own one day and reflects on how she may have to approach pregnancy and the early years of motherhood mindfully due to her diagnosis. "I hope a lot to be pregnant and have my own child. I'm also a bit nervous about it, both for my own sake but also 78 for my child's sake. But on the other hand, I have thought a lot about it. I still think I have had a nice life. Despite having [a BD diagnosis]." “I think I’ve been quite fortunate by having a father with the same diagnosis. I have seen it, um… expressed in a person…. And it makes me more capable of recognizing it in myself.” It is beneficial that they can talk about it from time to time, even if "the conversations aren't smooth" or if it is uncomfortable. Alissa has a friend who also has a BD diagnosis and who does not have any family members with BD. She reflects on how isolating that might feel and how challenging it would be not to have a reference or know what is typical. She and her father share a closeness, a bond, and an understanding. "He can also sense or see that I actually really understand what he has been going through and what he's experiencing." Seeing symptoms expressed in her father makes her better able to identify them within herself. She has seen what happens when you do not follow the advice of professionals, which has motivated her to seek help and adhere to her treatment. Alissa's experience of being a relative of someone with BD shapes how she interacts with those in her life. Her first-hand experiences with her father have led her to try to shield her boyfriend from her symptoms. She laughs, stating that she is doing a pretty good job, perhaps too good. Alissa's boyfriend is very supportive, and he hopes that she will let him in further. "It's really difficult for me…to like… receive help and like ask for help, but I… practiced a bit, and the more I do it, it becomes easier and easier, and it's... it's working out well (laughs)... when you ask for help, it works." Alissa is many things. A daughter, a partner, a sister, a friend. A student, a self-described weirdo, an athlete. She is someone living with and managing their BD. She is optimistic and hopeful for 79 the future. She is still learning and evolving, aware of the uncertainties to come, but is in control. "I can still be myself and have bipolar at the same time. I do not have to change myself. I can manage these problems I am experiencing and still be me." 80 Charlotte's Story: "So Much Makes Sense Now." Charlotte had just recently been diagnosed with BD in the months leading up to our meeting. There was a sense of freshness, clarity, and excitement in her willingness to share. She spoke quickly, hurriedly almost, with a newfound sense of understanding. Simultaneously, there was a feeling like we were still within the third act of Charlotte's story like she was telling it from the middle. It seemed to me that Charlotte might still be making sense of and reworking her past with the new lens that she has. She paused often at the end of her sentences, although checking with me if she got it right. Right? Her uncertainty contagious, I found myself doubting myself as an interviewer. In our second meeting, Charlotte shared that she found it hard to 'go down memory lane.' She finds that there is a fine line between being nostalgic and wallowing, which is overwhelming emotionally. She has kept journals but does not reread them. Instead, she usually burns them. With this perspective, I suddenly became aware of how challenging these meetings might have been for Charlotte. It also helped me to understand this sense I had that we may have been dancing on the surface of the feelings. I myself struggled to process if I was perhaps colluding in Charlotte's avoidance or was meeting her where she was at and sharing what she felt comfortable and able to; my journal entries from after all of our meetings documents this struggle. I contemplate the catharsis of burning journals. "Out of the frying pan into the fire." Charlotte grew up just she and her mother. She had no siblings, her mother was not close with her extended family, and she never knew her father. "[My mother] would say, if you want to look for him, I will always support you and help you, but then I didn't feel like she really meant that… you know? I don't know, it just didn't feel like a legitimate offer and I never really 81 knew where to start without this idea of like hurting her feelings." At age 42, after feeling unsure, atypical, and alone, Charlotte used a biotech company to DNA connect with her paternal relatives. Filling test tubes with spit for a write-up to facilitate understanding of who she is, where she comes from, and how she got here, unsure if she would be connected with anyone. Months later, Charlotte received a Facebook message from one of her first cousins, whom she connected with via DNA. The message informed Charlotte that her father was alive and that she had two half-siblings. The message included links to each of their Facebook profiles. Charlotte scrolled through the eerily familiar yet unknown faces and felt a sense of grounding. "It just feels like I've always known him. But I just met him, so that's a really interesting thing; there's just this sense of familiarity with him… Because we're very similar…." "So much makes sense now." Charlotte grew up in a childhood of extreme poverty. She and her mother lived in a small town, then seemingly abruptly moved to Toronto when she was nine. "We lived in this one-bedroom basement apartment; we had moved to Toronto…. and… because she was like in love with this guy who was married, and she decided that a small town wasn't big enough for me." Charlotte describes her childhood as challenging as she navigates what she describes as a codependent and enmeshed relationship with her mother. Charlotte's mother struggled with anxiety and depression, and as a child, Charlotte felt she accommodated her mother often. "In hindsight… it was just always really scared me when my mom would cry?... And so… I was always trying to make things so that… you know she wouldn't be upset… even though in hindsight it had nothing to do with me…um... and so… you know when you're little and you don't have anything to compare it to you just become... … adapted to that, right?" Charlotte cared for her mother emotionally, as she felt she was her primary source of support. 82 Charlotte does not mention friends or extended family when describing her childhood. She tells a story of decorating the Christmas tree by herself at age 11 while her mother cried in the bathroom. "To be fair to her, she raised me alone." Charlotte spent her childhood caring for her mom, alone. Despite describing a childhood marked with hardship, Charlotte holds space for multiple truths when describing her relationship with her mother. She sees their relationship as having been unhealthy, enmeshed, and codependent, yet names how her mother was able to be there for her, reflecting that "it doesn't have to be one thing or another." Charlotte empathizes with her mother's challenging upbringing, and despite her anger and frustration towards her mother, she sees her as having done her best given her circumstances. "I can have compassion for her now and still be angry." She reflects on the role her mother's upbringing likely had on her as a parent. "The trauma legacy that gets passed on and on and all those echoes of alcoholism and dysfunction that…. Get passed, and then… You know my mother was a cycle breaker, she really was… and then I feel like I continue to be a cycle breaker because it's not a one-generation thing." Charlotte experienced the onset of incremental changes across generations, the cycle starting to slow. Her mother's shifts are steps in the right direction. Her mother was able to understand, listen to, and validate Charlotte's experience of anxiety, "she was good at that one." "We talked about feelings in our house. That is something we did well. It gave me a lot of emotional intelligence." Her mother was attuned to Charlotte’s experiences of anxiety, and when Charlotte had her first panic attack at age 14, her mother connected her with a therapist. "She definitely tried to get me that resource." Anxiety and depression were treatable, expected, and 83 the norm. Charlotte could carry these skills with her as she sought help and resources throughout her life. Despite these shifts, Charlotte’s mother’s symptoms of anxiety and depression continued to lead to an unhealthy dynamic between the two of them. Charlotte describes her vulnerability coming out of her childhood, struggling to differentiate herself from her mother. "It was a normal thing, but she was just devastated because she didn't have anybody else like… It wasn't a healthy kind of reliance in my mind that she had on me because it… was just me and her, and she had no other … real relationships besides me, and then when I did what I was supposed to do… and started to become a self-actualized adult she... couldn't handle it." Charlotte went "out of the frying pan, into the fire," leaving her mother's house and acting "crazy for a while," "act first, think later." Finding herself in one abusive relationship, and then another. She reflects on how her early relationships made "a lot of things seem… normal that weren't?" As Charlotte shares, she seems confident, together, and as though she has worked through much of what she has told me. She references some of the revelations she has had in therapy and how these shifts have changed how she shows up in relationships today. Despite this, Charlotte seems to be rushing through this part of her narrative. She describes the first 30 years of her life to me in only 15 minutes. Leaving room for only 'mhms," "mms," and "ahhs" from my end of the Zoom call. I check in with her to see if there is anything else she would like to share at the end of our first meeting; she responds "I think I got it all out." "What was happening to me was not at all normal." Throughout Charlotte's early adulthood, she struggled with impulsive and risky behaviour. "It's sort of a blurry time period in my mind?" Reflecting, Charlotte struggles to identify what 84 parts of her challenges were caused by situational factors, her trauma history, and what might have been early symptoms of BD. Charlotte found ways to create a life where her ups and downs were masked or helpful. "You know, in that stage of life, it didn't seem abnormal... it was just… and maybe it was abnormal, but… hard to know." Working fast-paced jobs, such as serving, chronic spending, traveling, partying, and risky behavior, including substance use, "seemed very normal at the time because of the crowd that I was running with." Despite describing this feeling of normalcy, Charlotte still sought help; using her mother's wisdom, Charlotte could seek support, advocate for herself, and problem-solve. In her mid-twenties, Charlotte had a series of positive shifts. "I decided to get my life together, and I kind of did." She joined Al-Anon, which helped her identify negative patterns in her relationships, the influence of her childhood, and the importance of her needs and boundaries. She started taking courses at university, decided to get out of debt, broke up with her abusive partner, and moved back in with her mom. "I needed to sort of re-ground, and it was really challenging to move back in with her, but... it being it was… it was necessary, and it helped." Things were relatively stable for Charlotte for a few years; normal, and she finished her degree. Despite Charlotte's hard work and efforts to manage her symptoms, the cycle "repeated over and over and over and over and over again." Charlotte felt a sense of normalcy in her behaviour; she simultaneously expressed a feeling of something, a lurking feeling, that something was wrong. A sense that she was "going through the motions," her memories "blurry" and disorganized. She "pushed it down," "squished it down," and "just kept working and working and working." Charlotte felt like she was "spinning plates," performing a balancing act to 85 keep everything afloat. Her periods of hypomania allowed her to make up for the depressions, the two-week rapid cycling keeping her afloat, "spinning plates" for years to come. "I didn't think it was a problem until it was." In her late 20s, Charlotte worked in Australia selling popcorn at a circus. "I was always… pretty good at pretending I was fine", but she was struggling. I picture Charlotte amidst a circus, putting on her own show of normalcy. "That's when things started to become unmanageable… when I was unable to function basically," "I wasn't able to keep the plates spinning." Charlotte had the emotional intelligence, self-awareness, and knowledge of support that her mother imparted to her for anxiety and depression. She sought help, was (mis)diagnosed with depression, and prescribed an antidepressant. "I'll do anything because I don't want to feel like this anymore," Charlotte thought. She filled the prescription and took her first dose immediately before even leaving the pharmacy. She was following the advice of the medical professionals, but things only seemed to worsen. "I think it triggered me into like a… manic or mixed state... and it took me... I want to say three or four weeks to come out of that?" "The cycling continues..." Charlotte reflects on her 20s with her new knowledge of her BD diagnosis. "When I look back on it, I wonder, right? Some of the behaviours certainly line up with the profile when I look back with that lens." She pauses and looks down as if taking a moment to honour this new knowledge. "Grief for my former self not having the care... that was required… and not being able to advocate or articulate what was really going on and how it was not okay…" Charlotte 86 continued to trial different medications. Some provided relief, but none gave long-term reprieve of symptoms. In Charlotte's early 30s, adulthood quickly took shape around her. She came home from travelling, got a job in her chosen field, was rapidly promoted, moved to the East Coast, got a dog, and bought a car and a house. Despite the normalcy of these milestones, these decisions were abrupt and impulsive. "You know, all these great things happen, but it was in this total like... my head was like mush… like I remember buying my house and feeling so out of control, the details like I didn't really know what's happening." Soon after, she met her husband and got married. "I found out on the third day of our honeymoon that I was pregnant…so... that... was… not… ideal (laughs), but babies have their own timeline." Navigating pregnancy, delivery, and early infancy was very challenging for Charlotte. She was physically very ill much of her pregnancy. "I was miserable; I was depressed." Her delivery was traumatic, and post-partum, Charlotte experienced her worst depressive episode to date. "I just remember being in like the darkest possible place after the birth of my child, and the anxiety was so overwhelming…" "I was such a wreck, but everyone kept telling me, oh, it's normal to feel this way, it's normal, it's normal, but what was happening to me was not at all normal, but I couldn't articulate it because I…. I have nothing to compare it to, right? I'm just saying that it wasn't normal, wasn't normal, but I probably should have been hospitalized… Like I was in… such bad shape… and… I wrote here bordering on psychosis..." I hear the echoes and the confusion around normalcy. Why aren't things going as they are supposed to? Why aren't the normal things working? "And through all this time, I have no family support really." 87 Six months after the birth of her daughter, Charlotte went back on medication. "But I was even afraid to tell my husband that I went back on medication like I felt like it was a failure…. To need it… Um, but once I went back on it, I remember feeling, like, oh my gosh, I actually love my baby now… Because before that I didn't, I didn't feel, like I felt like this intense need to protect her?... But, I didn't feel love for her the way that you know I do now and the way I did once I was... better." There was a moment of stability, a sense of relief from the medication, a pause in the waves. But then, again, the cycle continues "and it built and built and built." Charlotte's mental health deteriorated once again. Charlotte, determined to get better, continued to advocate for and seek help. She sought out and received life-changing therapy, continued to try different medication combinations, requested a medication review with her psychiatrist, and even tried experimental treatments, such as micro-dosing psychedelics. However, nothing seemed to be working. Charlotte blamed herself, "I thought it was this moral failing that I couldn't find a medication that worked for me." "Now we know what we're dealing with." In 2019, when Charlotte's psychiatrist first suggested that she might have BD, Charlotte responded: "Oh, it can't be that." "Oh, but I come from a long line of anxiety and depression." "I don't have [BD] because I don't know anybody in my family that has that." Charlotte's maternal family suffered from anxiety and depression, not BD. "That is the only story that I know... my grandmother had mental health issues; my mom has mental health issues… That's the danger of a single story, right? So... my family has mental health problems, right, and they said, this is what they are [anxiety and depression]." Her mother had the language to 88 communicate with Charlotte about anxiety and depression. The world seemed more accepting of those diagnoses as well. "I think there's a lot of understanding around depression… and anxiety... but [BD] is not as well understood, and they just seem like… really crazy… you know, based on the, you know perceptions, and the imagery that were given in the media." Charlotte had been struggling but did not feel "really crazy." Growing up, Charlotte's mom used the words' manic' and 'bipolar' as slurs. The media depicted those living with BD as being crazy, always going off their medications. The extreme portrayals were all she knew. "In January of 2022 is when I connected with [my dad], and some of the first questions I asked were around health, and he said 'I'm manic depressive' and I was just like ohhh…. (laughs)…. So much makes sense now." As Charlotte revisited her life with the lens of BD, looking for its common expression through cycles of highs and lows, everything suddenly made sense. "I didn't think it was bad; it was just me, but in retrospect..." "It was such a mess, like a big tangled jumble of electrical wires and so…. Slowly I’m starting to unravel them, and so, this last six months has been like this really significant… unravelling of the mess." Charlotte had spent her life seeking treatment for anxiety and depression, the diagnoses that fit with her maternal legacy, but nothing seemed to have helped long-term. Equipped with the information from her father, Charlotte connected with her psychiatrist and was promptly diagnosed with BD. "There was definitely a sense of relief. Because it, it was… so much made sense… that was all that I kept telling people: 'So much makes sense now, so much makes sense." 89 "Because you want to be the best that you can." My last meeting with Charlotte occurred just after her father’s first in-person visit. “It was just like… you know when you have a really good friend and you don't see them for a number of years, and then you see them and pick up where you left off, and you just move forward, like no time has gone by that… feels like that, except I have never met them." She excitedly shares about having a lobster dinner with him, comparing notes over glasses of wine. "I said at one point in the conversation, I was like wow nature versus nurture and he's like yeah I think nature is winning out here" Charlotte agrees "There was just so many similarities." Charlotte is her father’s daughter. "I find it very grounding." "He's there for me in a way my mother isn't able to… from not understanding… from not having it." Charlotte is continuing to grow her affirming relationship with her father and is excited to continue to get to know him. He is showing up in ways that only he can. Charlotte and her mother have continued to grow apart. Charlotte feels disappointed in how her mother has responded to her diagnosis. "I wanted support, and I got pushback." Charlotte articulates her disappointment in not currently having support from her mother. She reflects on how her father can fulfill this need for the time being, although "ideally, the need would be met from both sides." Charlotte speaks about her mother with empathy and frustration, reflecting that both can be true. Charlotte's frustration emphasizes a potential hope for her mother to do better, to continue to make steps to break the cycles, and to support Charlotte the way she hopes for. When Charlotte describes her relationship with her own daughter, she is reflective and mindful; her desire to do differently by her daughter, to continue to take steps to being a cycle breaker, is palpable. “[Children] are wonderful teachers, because…um they make you want to be… a 90 better person.” With her newfound knowledge, she is working to seek appropriate treatment to be the best version of herself. "It's a constant analysis of honesty and humility. Right?... because you want to be the best that you can." Charlotte describes conversations she has had with her daughter about mental health and the normalcy of therapy. She recalls telling her daughter, "We're not really meant to do life alone. We need support." I think of the contrast between Charlotte's isolated childhood and the support she has built into her daughter's life. Charlotte is mindful of the patterns of her childhood and how she hopes to be different, sharing conversations she has had with her daughter: "It's not your responsibility. You're not responsible for our happiness. We're grownups." Charlotte considers her daughter's mind as she reflects on her potential motivations for behaviours. "It's nice when she's caring, but she's not our caretaker." Charlotte continues the incremental changes her mother initiated to continue to slow the cycles, the intergenerational familial patterns, to a stop. "I just. I just hope that I haven't done too much damage to her in the last seven years, like being undiagnosed that...um… I really tried." A sense of sadness lingers, a grief for the past self, who was not yet diagnosed. Who was trying with all the tools she had in her toolbox but was working with the wrong framework. "Now we know what we are dealing with." With this new knowledge, she can tackle her BD appropriately. "No wonder I felt that way." After decades of advocating, seeking help, and trying different medications and treatments that did not provide symptom relief and, at times, even seemed to make things worse, Charlotte now has the understanding and tools to access the appropriate support. "I thought it was this moral 91 failing that I couldn't find a medication that worked for me, and now it's like, no wonder I felt that way." "I wonder, sometimes, like, what would have happened, how long would I have gone on um… improperly medicated…. If I hadn't found that piece of the puzzle…" Despite this sense of relief, understanding, and things clicking, Charlotte is still working towards coming to terms with her diagnosis. Other than her father, Charlotte had never met someone with BD; she only understood it through the lens of how the media portrayed it. Her mother has not been a source of support for her, and her reactions have only been hurtful to Charlotte. Charlotte also reflects on her experience of receiving the diagnosis. "Relief, grief, and then you know some… anxiety and like…. You know, ‘What is this?’ and ‘Am I really unwell?’ you know, like, am I…Because of the way it's portrayed… " 'There's also an element of grief because of the lost time… right?" I find myself wondering how Charlotte will continue to grow in her journey with BD. I have a feeling as though I have met with her from within the third act, her journey not quite complete. We have just passed the climax, the reveal that unlocks and reshapes our understanding of past events, but the denouement has not yet occurred. On the horizon, Charlotte speaks with a sense of optimism and excitement. She describes the new research coming out about BD. Her interest in exploring understanding it as a whole-body experience. Her hope to continue to build a community and connect with others with BD. She is realistic that there is "always going to be an element of management," but excitedly comments on how "now we know what we are dealing with." With this new knowledge, she can tackle her BD appropriately. Charlotte shares how she is always trying to be better. 92 Charlotte has told her friends about her diagnosis, and they have shown up for her supportively. Reminding her, "This doesn't define you." She has been accepted by those around her and supported by many. She is still learning, exploring, and unpacking, with a fresh and more accurate understanding of herself, her symptoms, and how to treat them. After decades of feeling alone and like she does not quite fit into the box or "these slots that you fit into," Charlotte not only has an answer, but she also has someone who understands, is supportive, and has a positive outlook on BD. "[My father] shared a bunch of information about, you know, medications that have worked and things that haven't." She has someone to help her not feel so alone in this journey. 93 Ella's Story: "I Think I Got the Best Possible Outcomes for Intergenerational Bipolar." Ella is my age, lived in the same city as me, and speaks with a familiar vernacular; in many ways, we could have easily been friends. We connected over shared interests and the familiarity of being raised simultaneously in similar environments. Despite these similarities and inherent feelings of rapport, there was a formality to our meetings. I asked each participant to prepare a life graph; Ella made a PowerPoint presentation instead. She spent our second meeting talking me through her slides and clicking the embedded links to her Tumblr posts. She was organized and prepared, confident and self-assured. Sometimes, I would ask follow-up questions, and she would suggest we put a pin in them and return to them after she had finished her presentation. Ella was in the driver's seat. In our third meeting, without a presentation, moments of vulnerability slipped through. Our conversations flowed more naturally. At the end of our last meeting, Ella apologized for "treating [me] like [her] therapist." I had a newfound appreciation for Ella's vulnerability and the potential discomfort and novelty of sharing this way. "Everyone in my family is mentally ill." Ella grew up in British Columbia with her parents and a sibling who is close to her in age. "Everyone in my family is mentally ill," Ella jokes as she describes her family tree. Ella's mother was diagnosed with BD in her 20s, and she suspects her father likely would meet the criteria for depression, but to her knowledge, he has never sought a diagnosis. Her paternal grandparents have a legacy of acute mental health difficulties. Despite this pertinent legacy, Ella reflects on how, while growing up, the knowledge felt unspoken, "there was never any real discussion." "I always kind of knew [my mom had BD]. I wasn't supposed to tell my friends about it or my friends' moms." Ella's mom had disclosed her diagnosis to the parent of one of Ella's friends. After the disclosure, she noticed that the friend began acting strange and withdrew from them. 94 To avoid this happening again, Ella's mother learned to keep her diagnosis to herself. "My mom was definitely pretty quiet about it." Despite the secrecy associated with her mother's diagnosis, there was also a sense of normalcy. Ella's mother had always had BD; it was just a fact about her. "It just wasn't a big thing… I don't think I was really aware… or I was maybe too self-centered to really think about it." Ella expresses compassion and empathy towards her mother, "huge credit to my mom, who was depressed, but was still there and still present." Despite the lack of shared family activities, Ella's mother took them to school and their extracurriculars and provided practical support. She was doing her best. Although Ella's mother had managed her hypomanic episodes before Ella was born, she continues to struggle with symptoms of depression to this day. "I have never seen my mom in a hypomanic episode. She leaned towards depression." Ella identifies primarily as having been raised by a depressed parent rather than one living with BD. "Being raised by a depressed parent who wasn't fully there definitely affected me negatively." "My mom wasn't there, or didn't notice things, or wasn't very emotionally involved." Ella's descriptions of her father contrast her compassion and empathy towards her mother. On multiple occasions, Ella refers to her father's involvement throughout her childhood as "doing jack shit." Her tone softens when she describes him now, "My dad is very much not an emotional person, um.. but he's kind of slowly softening up and… I'm like the point of contact for my dad." Ella does not have many positive memories from her childhood. Between slides, Ella asked herself, "What did you do together as a family?" "What did you do on weekends?" and responded assertively, "fuck if I know!" 95 Ella describes herself as a quiet kid who read a lot, was always very sensitive, and cried at home and school. Ella's parents struggled to support her emotions. "I was very materially cared for, I wasn't emotionally abused, but was I a bit emotionally neglected? Yes. The depression and bipolar was a part of it." Ella describes being sent to her room often to calm down. Her emotional outbursts are too much for her parents to support. Ella learned to keep her feelings to herself. In elementary school, she was bullied, and when she started to experience symptoms of depression in high school, she kept it to herself. "I didn't tell [my parents] I was unhappy. They didn't know the extent of what was happening." "I never relied on my family for emotional support, ever." While Ella shares, I think of my own family; at times, there was a sense that feelings were not safe. Feelings are scary. Feelings are what wind up getting you hospitalized. Feelings are things that are best kept to yourself. "No one noticed something was off." When Ella was in her first year of university, her parents divorced. She was not surprised. "I was never like, Mom, why the fuck are you leaving Dad. I knew why she was leaving Dad. It was pretty brutal." Ella attended a local university and still lived in her childhood home, but her older sibling had already moved out. As a result of the divorce, her mother moved out, leaving Ella and her father to live in her childhood home. Ella describes her father as a "courteous roommate" who was often out camping, sailing, or working on his computer. She was not doing well and did not feel supported by him. "I don't know what the fuck I did. I was not doing great. I didn't talk to my family." Ella felt invisible and isolated in her everyday life while struggling with her mental health. When describing her first hypomanic episode that occurred in the fourth year of her undergraduate degree, Ella asserts, "No one noticed something was off." Ella's 96 symptoms and difficulties were invisible; she continued to spend a lot of time alone in her room. "I didn't know what to do." Throughout her adolescence and early adulthood, the website Tumblr was a setting where Ella got the emotional support and sense of community she felt she was lacking in her daily life. "I don't really remember a lot of my interactions with my mom or my dad at this point, to be honest." "I just didn't talk about it with anybody. I made posts on my Tumblr." Ella clicks the embedded links in her PowerPoint presentation to blog posts she had written that highlighted her distress at the time. They read, "I haven't been able to feel much of anything at all lately." "I just want to stay in bed and never leave my house again." Looking back on the posts, Ella comments, "So I really wasn't doing too hot," "and then it got worse," and "those years were really, really bad." Ella did not feel emotionally supported by her family, so she sought refuge and found community online through Tumblr. Here, Ella could be vulnerable, express her negative emotions, and feel heard and supported. She made many close friends, many of whom she is still close with. Ella wrote about her personal experiences and shared her creative writing, specifically fanfiction, where she explored a fantasy alternate universe. The community and support Ella received through Tumblr and the sense of confidence she gained through her writing "saved [her] life." Although a generally challenging time, Ella's undergraduate degree was checkered with positive experiences. Some of Ella's writing became quite popular on Tumblr, and her community spread. She started working at the school's radio station, meeting new people and stretching herself socially. In the third year of her degree, she went on an exchange to the Netherlands, a nod to her 97 Dutch lineage. The exchange was challenging, but Ella's online community supported her. Ella reflects that her mother began to support her through this time. She and Ella video-called often so Ella could see their family dog. "I remember, at least at that point, [my mom] was really there supporting me." With this support, Ella enjoyed her exchange. Upon returning home, Ella became an English as a second language teacher. Slowly, her self-confidence grew. Stretching herself and branching out in these ways is something that Ella is proud of to this day. "My mom saw me." In the final semester of her undergraduate degree, Ella's parents sold her childhood home, and her father moved to a city suburb. Ella took this opportunity to move in with her mother, who lived closer to the university's campus. "I think it was really, really good I moved in with my mom and having that new environment." Ella and her mother grew closer and got to know each other as adults. Upon finishing her degree, Ella felt lost. She had been struggling with her mental health for years and felt frustrated and powerless due to the cycles of her mood. Her first summer after finishing her degree, Ella experienced one of her worst depressive episodes to date. Living together allowed her mom to support her through this challenging time. As Ella's mental health deteriorated, her mother was able to see that she was struggling. "I think she had kind of known for a while. But it wasn't until I was there like crying on the floor." Ella's mother, who had her own first-hand experiences with depressive episodes, was attuned to the fact that Ella required support; she stepped in. "My mom saw me. Saw what I was like and got me to the doctor." After years of feeling like her struggles were invisible, Ella was seen and connected with the appropriate supports. "My mom was like, Ella, I think you need to go to a doctor, and I was like, I think I do too." 98 "I knew I was mentally ill for a while before I was diagnosed. There was a part of me that was like, my mom is bipolar, so it makes sense I might have some mental illness." Despite this awareness, it had not occurred to Ella that she might have BD. Her depressive episodes and symptoms of anxiety are what stood out to her. One year after moving in with her mother, Ella went to see her mother’s doctor, "she knows my mom's entire history, and she talked to me and was like… you have bipolar [disorder]." Ella was diagnosed through the knowledge of her mother's history. She was able to identify her more subtle hypomanic episodes before they spiralled into something worse. Ella reflects on how her mother's support allowed her to be "diagnosed correctly and before [she] spiralled too far." The diagnosis came with a sense of relief, as it also came with knowledge of treatment methods and an opportunity to shift from the repeating cycles Ella had been experiencing for years. Simultaneously, the BD diagnosis felt like a blow, "I went home and screamed into a pillow." "There is something wrong with me. This is what is wrong with me." "This is something I have to deal with for the rest of my life." Ella immediately posted on Tumblr, receiving support from her online community. She was also able to get support from her mom. "My mom was super supportive. Helped me a ton." "My mom worked very hard to be stable, to make sure she was on the right medications, change her lifestyle accordingly, so she was in a position to help me, get me diagnosed, get me meds, keep going, even though I was depressed." Ella's mother can show up for her in ways her own mother could not. "My mom was diagnosed [with BD] in her late 20s. My Oma just didn't believe it, which I think caused a lot of stress and strain in their relationship." Despite being a medical doctor, Ella's Oma struggled to understand her daughter's BD diagnosis, "why aren't you just happy?" In contrast, Ella describes 99 her mother as understanding her emotional experiences, "my mom gets it too; she's never invalidated my emotions, ever." The diagnosis brought Ella and her mother closer together and opened up conversations about both of their diagnoses. "It was like, oh, we have this in common." Ella's mother was able to support her despite her potential emotional reactions navigating Ella's diagnosis. "I knew immediately how much guilt she was holding because bipolar gets passed on genetically, so I think she felt a lot of guilt that her child now has to live the same struggle she does… to an extent." Ella's mother was able to hold space for Ella, maintaining her role as the parent and providing the emotional support, love, and care Ella needed at the time. "She was really instrumental in getting me out of the house, making sure I was getting on meds and all that kind of stuff." Ella reflects on all of the support her mother was able to provide for her leading up to and after her diagnosis and how the knowledge of her mom's symptoms helped her get diagnosed early and receive the appropriate treatments. Ella "didn't have to play the med game," her doctor had a 'cheat sheet' from her mom's history and was able to use that to optimize her medication quickly. "If your parents are mentally ill and have those meds, get those meds too." Ella reflects, "I think I got the best possible outcomes for intergenerational bipolar [disorder]." "We are walking the balance beam right now." It has been four relatively stable years since Ella's diagnosis. With symptom relief, Ella has been able to work, go out with friends, and feel "what being an adult in your 20s should be like." "That all felt really good." Ella went back to school and found it much easier to manage this time around. "It was amazing being in school where I wasn't…depressed or anxious all the 100 time. It was an incredible experience, and like, once again, like, it was another one of those confidence boosters." Ella has navigated the COVID-19 pandemic and breakups, experiencing some highs and lows. However, with the support of her system, including her mother, therapist, and psychiatrist, Ella found these periods relatively manageable. Ella is currently in therapy, "a game changer," and on medication. She has a job in her chosen field. She thinks of herself, including her diagnosis, positively: "I know that I am a creative person, an intelligent person. I see some things slightly differently; part of that is because of bipolar." She sees mental illness as "a piece of me that can be a core part of my identity, but not something to be ashamed of, or define me." This year, Ella moved out of her mom's house but stayed nearby so they could continue to support each other. Ella experienced her "best summer ever" and is proud of herself for all the growth associated with moving out independently. She continues to explore what she wants for her future but in a way no different from other women her age. She is dating, considering career choices, and spending time with friends. Ella is mindful of how she can make choices to support her symptom management but is not defined or limited by her diagnosis. Ella is aware of how she might need to work to support her mental health in the future. "We are walking the balance beam right now." "In some ways, I need to play it safe in order to ensure my mental health. It could be dangerous." Ella feels good but worries about "negative things on the horizon." She worries about how episodes might "derail her career." She saw that her mother struggled to work full-time throughout her life, "when I was diagnosed, I thought, oh, am I going to be like my mom? And not be able to hold down a career?" Ella reflects on how 101 seeking various supports and finding a work environment that sees and treats her as a “valuable human” will help her continue to work through whatever episodes may come. Ella reflects that she has never had a strong desire to have children in the future. "I'm like 100% no kids for like at least the next eight years… I would say 100% sure about that, and then maybe when I'm older, more established in life, like… Totally depends on the partner. Maybe?" Ella also reflects on how having children might be more challenging for her than others because of her diagnosis. "There are like some things that would be a very bad idea for me to do… um.. or much more difficult for me to do. One of those is having kids." She explores how she would have to be mindful of her medication, of sleepless nights, and of the potential for postpartum depression. "I could do that, but… it will be a lot harder for me than it would be for other people." Almost as an afterthought, she adds, "Slash, will the kid end up having bipolar too?" before she trails off onto the next subject. Ella's mother continues to be a source of support for her. "If you had asked me five years ago, I wasn't close with my mom. I'm seeing my mom every day now. I have that relationship with my mom now." "I still don't rely on my family for emotional support of any type really…" she then pauses and reflects, "I do [rely on] my mom a little more now." When their beloved family dog Teddy passed away, it was hard on both of them. "My mom and I really leaned on each other emotionally. No one understood what Teddy did for us emotionally. I was really taking care of my mom." Before then, Ella's mom managed her feelings more privately. "She doesn't always open up with how she is feeling as well." "At this point, I am helping my mom more; up until that point, she had been quite independent. Didn't ask much of me." Since Teddy's passing, Ella has been checking in on her mom more, ensuring she is okay, and keeping her company. "That was something I really took upon myself." "She seems to be 102 better now." Ella and her mother are both "fighting to be happy," and it seems to be working. Ella is in the driver's seat and is in control of her future. Ella and her mother are still closer than ever. "I definitely got like the… best possible, I think I got the best possible outcomes of intergenerational bipolar [disorder] because my mom worked very, very hard to be stable…" and now Ella is doing the same. 103 Evelyn's Story: "It's Like a Hike… … Every Step Is Painful… and Then You Get to the Top, and You're Like, That's What I Did!" Evelyn was the only participant that I met with in person, only months after her diagnosis. Our meetings were long; our second was almost two hours, yet time passed quickly. Evelyn is a librarian; she loves information and learning. We excitedly shared our favourite resources and commiserated about graduate school. Evelyn had just started taking voice acting classes and listening back to the recordings; this became quite apparent. Her voice is expressive, her storytelling gripping as she weaves in voices for the different characters of her life. She was cheerful, earnest, and genuine. Evelyn often shared as if she had read my mind, spontaneously answering the follow-up question that was at the tip of my tongue. It may be because we could connect in person or because of our shared experiences; we quickly established rapport. Our interviews flowed conversationally, and I found myself validating Evelyn's experiences with ease, as I could relate to many of them. Listening back to our interview over a year later, I noticed the language Evelyn used that I have since borrowed to describe my own emotional experiences. The impact she has had on me is long-lasting. Evelyn was consistently reflective, stepping back to comprehend her reflections or how she might sound to me. She was vulnerable even in sharing what the experience of meeting with me had been like. Sharing that after our first meeting, she wondered, "What did I just say?". She wondered if she had come off judgemental or as though she had blamed others. I did not think so at all. A friend asked her how it was, and she responded, "emotionally draining; it was a lot." I appreciated her candidness in sharing her experience of meeting with me. At the end of our third meeting, she laughed as she shared that, in some ways, she had found our meetings and the 104 associated sensemaking, unpacking, and prodding at her memories had been more helpful than some of the counsellors she had seen. This invigorated me and provided me comfort that her feelings of being emotionally drained may not have been futile. She articulated that in our meetings, she noticed a recurring theme of loneliness. After sharing her story, she felt she could now see where that feeling stemmed from and how it weaves throughout her life—another piece of her puzzle of self-understanding and support. "Emotions are bad… my mom is too emotional." Evelyn's father worked with the Canadian military; thus, her family moved often. At times, moves were positive, bringing them back to the familiar, closer to their family and friends. Other times, these moves were challenging as they were stretched further from these supports. Evelyn was born into a challenging situation. Just before her birth, in 1985, her parents had moved away from Manitoba, where their family and support were, to a town in Ontario. Shortly after, Evelyn's maternal grandmother passed away. Evelyn's mother struggled with postpartum depression following Evelyn's birth and did not have a support system around her. Her mental health deteriorated, and she was eventually hospitalized. In 1986, with Evelyn, a newborn, her family moved back to Manitoba. This began five years of some stability surrounded by friends and family until Evelyn's family moved again for her father's work, to a new city in Ontario. Neither Evelyn nor her mother wanted to leave Manitoba. Evelyn was lonely in the location. "A theme through much of my life is a feeling of loneliness; as a child, I always wished I had a sibling. I was alone a lot." Her brother was born when she was eight, and she recalls it being the best day of her life. He was born prematurely and thus began a familial pattern of Evelyn acting in a caregiver role and her brother 105 receiving extra care. Evelyn's mother again experienced significant postpartum depression. Evelyn, despite her young age, was ready to step in. "I wanted to take care of [my brother]". This same year, Evelyn and her family uprooted again, this time to go to Quebec. Evelyn's family still lives there, and her mother still hates it. Evelyn lovingly describes her brother as being smart, witty, and funny. She reflects that not many people get to see that side of him due to what she presumes to be his social anxiety. He is supportive and understanding. "He's not one for words, but he will sit with me, be present, and give me a hug. "That is how he shows his care." He lives at home with his parents, continuing a pattern where Evelyn feels he gets more support from them, "How come my brother gets the support, and I have to do everything?" She laughs as she reflects that both she and her brother each think that the other is the favourite child. When Evelyn and her parents fight, her brother is a "spectator." "He's like the United Nations; he doesn't get involved in conflicts." As he continued to grow, Evelyn reflects that she became "like a second parent to him." Evelyn is still protective of her brother; she is mindful of how her personality might overshadow him and tries to monitor how much air space she takes up when they are together. "Since I was a kid, I was a caretaker. My mom was always sick. My dad was away a lot. I was either fending for myself or making sure my mom was okay." Getting her mother better was the family's focus. "Emotions were not allowed, not functional." "I'd try to express how I feel, and [my mom] would be dismissive of our feelings." "Emotions are bad… my mom is too emotional." Evelyn describes her father as being the opposite of her mother. If Evelyn's mother and her family were "all emotion," her father is "no emotion." Evelyn describes her father as the family rock. He was not expressive or comfortable talking about feelings or being vulnerable, but he was stable. Evelyn, too, learned not to try not to show her emotions. 106 Growing up, Evelyn's mother's symptoms dominated a lot of the space within the household. "I just remember her crying all the time or sleeping all the time, for days on end," Evelyn recalls having a feeling that her mom was letting her down and was not there for her. Her mother's hypomania presented as anger and irritability. "You never knew when she would go off." "It was a shit show for years." Behind the scenes, Evelyn did not cause problems at home; she quietly did what was asked of her. She was top of her class in elementary school and was bullied, but she had friends. She was under the radar. "Why is my mom here?" Before Evelyn's mother was diagnosed with BD, she was hospitalized several times. Evelyn recalls being in elementary school, getting picked up to visit her mother at the hospital while her friends played on the playground. She knew her mother was "sick" but did not understand why she was in the hospital. She recalls being at the hospital at a young age, seeing people crying, yelling, being restrained, and thinking to herself, "Why is my mom here?" "This is where feelings go?" Evelyn noticed the bars on the windows. Oblivious to why someone might be hospitalized, she wondered out loud, jokingly, "Why are there bars on the window? What? Is someone going to jump out?" Her parents responded in hushed tones, "Yes!" Evelyn was only more frightened and confused. Evelyn reflects on how these experiences continue to affect her today. Her initial visits to the hospital and associated feelings of fear, exacerbated by the portrayal in movies and TV, have left Evelyn feeling terrified of the potential of being hospitalized. She recalls times she was feeling suicidal but avoided seeking help as she was scared that she might hospitalized against her will. "I wanted to get help, but I was like God! Don't commit me!" "I know what they're going to do when you get there. They're going to throw you in a room and lock you up." Evelyn 107 acknowledges that this might not accurately represent what might happen when you seek help, yet the mental representations of what could happen continue to haunt her. Evelyn was nine when her mother was diagnosed with BD. The hospitalizations stopped, but as her mother began her trial and error to find the proper medications, her rage continued. Evelyn knew of her mom's diagnosis, but there were no open conversations about it. She was told that her mother was manic-depressive, but she did not know what that meant. No one sat her down or explained it to her. Looking back, Evelyn wonders if understanding BD and more about mental health, in general, might have helped her. To have it communicated that it was okay to have feelings, okay to be scared, or okay to feel bad. Having open conversations about mental health might have helped it all not feel so scary. Evelyn's mother's diagnosis led to a trickling of other family members realizing they also had BD. Her maternal aunt was next to realize that she, too, had BD. Evelyn and her mother suspect that her maternal uncle also had BD, although he was never diagnosed. Evelyn's teenage cousin was also diagnosed around this time. He had been struggling with the law and excess drinking. Evelyn wonders if he was diagnosed so young as his challenges were more extreme, more pronounced. Tragically, he died shortly after, at age 20, in a drunk driving accident. "They do say like the statistics of people who are bipolar are more likely to die… not just from suicide but from recklessness..." Evelyn was 14 at the time. Evelyn wonders if her cousin might have turned his life around had he had more time. "I survived that; I don't even know how". As a teenager, Evelyn began to grow into her sense of self. She sought autonomy by getting jobs, dating, and trying different styles. During this period, Evelyn and her mother did not 108 get along; "we hated each other," "we used to get into screaming matches." "We were like two lions going at it. Sometimes it was physical… it sounds worse than it was." "I remember this rage and volatility. Her smashing things, trashing the kitchen, throwing pots and pans at my dad, being physically abusive". When she and her mother would fight, her mother would threaten to kick her out; Evelyn recalls thinking, "Okay, great, you're going to kick me out for expressing some slight dissatisfaction." Evelyn could not wait until she graduated high school and could move out on her own. Looking back, Evelyn reflects that her mother might have "just been hypomanic" much of this time, noting that her mother was still struggling during this period of her life. Evelyn holds compassion for her mom, "I still love my mom, she's my mom, there are good things, it was just … a lot." Evelyn's difficulties started to trickle into her school. She had anxiety and felt sick, but her feelings were dismissed as her "just wanting attention" or "just wanting to get out of class." She wasn't taken seriously; "they didn't understand." I am struck by Evelyn's repeated use of "just." Her mom was "just hypomanic". It was "just a lot," and her feelings were interpreted as "just wanting attention." Is Evelyn softening her mother's hypomania, undermining her difficulties in a way similar to what the adults around her did when she was a teenager? Evelyn was thrilled as she approached her last year of high school. She was ready to move on, move out, and get out of her volatile house. She was typically a straight-A student, but due to several circumstances, she ended up failing one class, which prevented her from being able to graduate. Evelyn felt alone and unsupported, as no one stepped in to advocate for her. "I had nobody to support me or fight for me." She felt her parents blamed her for failing and punished her. The adults around Evelyn told her it would not have happened if she had only tried harder. In sharp contrast, her parents had spent their lives fighting and advocating for her 109 brother, accommodating his learning differences and academic difficulties. This contrast continues to be a sore spot for Evelyn. "I just felt so let down". "I survived that; I don't even know how". Evelyn's inability to graduate sparked her first all-consuming depressive episode. She felt blamed, "you're bad," "it's your fault." Evelyn was used to being in a caregiver role and was now thrust into a position where she was unable to care for herself, let alone others. "You have to be okay to care for people – so I have to be okay." She felt she was letting everyone down and that it was her fault. A teacher in her adult education classroom noticed Evelyn's symptoms of depression and suggested she seek help. She went to a doctor at 17, "oh my god, am I bipolar?" "No!" they reassured her, “just depressed.” "Phewf!" Evelyn recalls thinking to herself, "I have issues, but at least I'm not bipolar; I'm not like my mom." This first depressive episode began an almost annual cycle that would continue for many years—beginning school, feeling good, crashing into a low, and dropping out. After four years of starting and stopping, Evelyn was finally able to graduate from CEGEP and began to feel optimistic again. She changed her life, moved to Montreal, and followed her dreams. She recalls feeling the happiest she had felt in years. Reflecting, she now wonders if she was hypomanic. Evelyn jokes about how hard it can be to question everything you have ever done. I wonder if this disavows previous feelings of joy and happiness. If worries of being hypomanic instead cloud them. Evelyn comments, "A part of me was always paranoid. Maybe I do have [BD]." I can relate to this. There are periods of my life where I have felt immense joy, a lightness, and then a pit in my stomach. Am I truly happy, or could I just be hypomanic? 110 "I felt like a ticking time bomb." Evelyn reflects on the denial that peppered her twenties. She did not want to admit to herself or others how much she was struggling; she wanted to be independent and did not want to worry her family. "Maybe I'm a little crazy, but I'm not that crazy," she thought. Nevertheless, the depression just kept happening "again and again," and Evelyn did not know why. It was not a "passing thing." "It's always been and always will be." She describes her 20s as being "many years of the same things happening, trying to go to school, depression, a relationship goes badly, ended. Another relationship, goes badly, ended." She struggled with chronic low mood, was crying all the time, and did not know what to do. She continued to internalize her low periods as being her fault. "There is something wrong with me. I'm lazy." "I felt like it was all my fault. I deserved it." "I can't cope. I don't know what to do. My life is going nowhere." She felt guilty and as though she was a burden to those around her. "I want to feel normal." Evelyn experienced her more subtle hypomania as a relief from her chronic depression. She often interpreted it as her being in a good mood or as a result of something going well. "I'm always jumping from one thing to the next, but that's my personality." "My risk-taking can be a good thing." Evelyn moved to many different cities and countries, changing degrees and majors and starting new jobs. She reflects now how it had been hard to move so much in her early life, and now it is something she seeks out. "Part of it is pursuing things; part of it is fleeing other things. Movement to escape things and myself." The moving helped to distract from Evelyn's mental health. She had the excitement of the move, and it was not until the dust settled that "you realize that your shit is still with you." Reflecting on her family, Evelyn remarks that 111 they set the stage, normalized things that are not normal, and made it easier to go for years without a diagnosis. At age 27, after many years of feeling as though her low mood would never end, Evelyn sought help. She asked her parents for help paying for a psychological assessment to help clarify if she, too, had BD. The assessment report concluded that Evelyn "had elements" of BD but "wasn't really bipolar." Evelyn again felt some sense of relief. On the other hand, she paused "...some features? What does that mean?" "How do I know if I am [bipolar] or not?" she recalls asking to clarify, "when you have a manic episode," they responded. "I felt like a ticking time bomb. I might be bipolar; I'm just waiting to go crazy. That's terrifying!" Looking back, Evelyn reflects on her confusion throughout this assessment. She recalls potentially underreporting her symptoms of hypomania, as she did not see them as being a problem. "Do you have grandiose thoughts?... I don't think I'm a god… but I do think everyone is incompetent but me, and I'm the only one who knows anything. Does that count?" "I don't gamble… but I would. I don't do drugs…because I know that might mess up my brain more. I wouldn't buy a boat… but I might get into significant debt." Evelyn's symptoms had been a relief from the depression, not something she thought to report as a problem. While waiting for "the other shoe to drop," Evelyn experienced some periods of "normalcy," which gave her hope that things could change. Following her assessment, she began therapy, which gave her the confidence to start graduate school. There, she found her “place,” her “people,” and her “purpose.” Evelyn found that school was grounding "because that was the first time...for most of that I felt normal-ish?" Her therapist believed in her 112 and helped Evelyn to experience periods of balance, periods where she could better manage. "I was on track." Evelyn then transitioned through a series of seemingly positive shifts. She finished her graduate degree and moved abroad at 29 to pursue her dream job. At 32, she moved to British Columbia, where she still lives. She got her current job, one of her favourites, and at 35, she felt that things were going great. Although she has experienced periods of depression, generally, "life was normal again, back on track." The onset of the COVID-19 pandemic was initially worrying, but Evelyn managed okay. She joined a local workout class, found community, ate healthy food, and exercised. She was still on track; she was, both figuratively and literally, climbing mountains. In the year following the onset of the COVID-19 pandemic, Evelyn experienced a debilitating depressive episode. She thought, "I haven't felt this bad since like the beginning… so like… and … the last couple of years before that were like really good…" She thought she had overcome her lows, but the cycle had repeated. In almost a Sisyphean turn of events, she was back at the bottom of the mountain. "Okay, maybe there's something more going on." Two significant events led to Evelyn seeking a diagnosis of BD once again. When her cousin tragically died by suicide in the fall of 2021, her family responded with surprise, "Oh, I never knew he was depressed." Evelyn understood his struggle; she wondered how long he struggled silently. She wonders if he, too, had BD. Evelyn was processing the grief of losing her cousin but also felt her chest tighten with a familiar sensation of anxiety. "I couldn't shake that feeling; 113 this will be you one day." "I was like, if I don't do something now, I'll end up in the hospital or worse..." That same year, Evelyn was at a party where a friend of a friend introduced himself and shared that he had BD. "He was so open about it; it really helped." "He's quirky but a relatively normal person. He has a job, has friends. Maybe we're not all… psycho". Interestingly, Evelyn recalls connecting with having BD, using we, although she at the time didn't have a diagnosis. This perhaps speaks to Evelyn's implicit understanding or fear that she might have had BD all along. Meeting this confident, high-functioning, and charming person made it feel like it could be okay to have BD. BD did not mean you had to be hospitalized or, worse off, dead. Equipped with the motivation to change, feel better, and a new sense of acceptance, Evelyn researched BD online. "When I started to read more stories online and people's stories, I was like … Oh… I don't know… well maybe. Oh shit… okay. Maybe I need to look into it some more." "Okay, maybe there's something more going on." In 2022, at age 36, Evelyn went to see another private psychologist. She felt equipped for whatever answer they gave her. She just hoped for an answer. "If I am [bipolar], I'm okay with that now. I have accepted that. I just want to get help and feel better. If I'm not, cool. I will go on antidepressants. I'll deal with it." She asked her parents to be raters as a part of the assessment. Initially, they were hesitant; they did not think Evelyn had BD. After Evelyn outlined what she had learned online and the cyclical nature of her symptoms, she recalled her mom responding, "Oh. My. God. Oh. Fuck. Oh my god! How did we not see it? You are!" Evelyn's assessment concluded that she had a "very clear" BD diagnosis. "I was like, very clear! It hasn't been very clear to anyone else! All the other therapists and doctors!" 114 Evelyn felt relief and grief, finally receiving an answer that could point her toward support. Grief for her past self, other versions of herself, and future self. "Grief for the loss of my pre-diagnosis life." "I grieve a lot for what I could have had. If I didn't have [BD], where would I be?" 'Yes, I can have great things despite it, but what could have been?" Evelyn started to feel angry that no one had previously made the connection when she was struggling through her 20s. She felt frustrated that her experiences had been dismissed in the past and that she was not listened to by those who were supposed to help. Evelyn pauses to reflect, kindly, that it takes time to see patterns, even though, looking back, it now seems “clear as day”; it is no one person's fault that the pattern was missed. She acknowledges how moving around made it hard to receive consistent care, and that might have played a role in her delay in diagnosis. She laughs at the irony that her moving was also likely influenced by her symptoms of the diagnosis she was missing. Evelyn felt comforted by the knowledge that this is quite typical. "That helps too, knowing how [delay in diagnosis] is common. I'm not the only one who was missed or fell through the cracks. A lot of us are missed. My mom was diagnosed at the same age [as me]." When Evelyn's mother initially sought support, she was told by doctors that she should just be happy. "You have a beautiful daughter; you have a husband; what are you complaining about?" It was not until several years after her initial hospitalization that she was diagnosed with BD. Almost immediately, Evelyn shared her diagnosis with her parents and her brother. Initially, her mom was very upset. Evelyn attributes this to her feelings of guilt. A feeling of worry that she gave BD to Evelyn. A worry that it was her fault that Evelyn was hurting. Her brother and father were quietly supportive, not being ones for words. Eventually, her mother came around. "I'm glad you're getting the help you need." 115 "The thing that put a big wedge between us originally is what is bringing us together." In the last decade, Evelyn's mother's mental health has significantly improved. "She has done so much work in her life to get better." After finding the right combination of medications, her mother was meticulous and never missed a dose. "Thank god for my mom's psychiatrist." Her mother continues to work with him to this day. Evelyn's whole family knows and loves him. Her mother has always been in therapy. She still struggles with low periods but has been very stable for about ten years. "Now she is a more pleasant functional person." "She is way better; I feel like a lot has changed." Simultaneously, Evelyn and her mother have reconciled, moved past the volatility of Evelyn's adolescence, and become very close. Growing up, Evelyn was often caught in the middle of her parents' arguments; now that she is close with her mother, she has noticed that she seems to butt heads with her father more. Evelyn wonders if her father feels ganged up on or threatened by her closeness with her mother. She recalls a fight with her dad where she expressed, "I'm allowed to have a relationship with both my parents. Don't you want me and mom to be close?" Following Evelyn's diagnosis, she and her mother are now closer than ever. "The thing that put a big wedge between us originally is what is bringing us together." “[My mom] gets it at least, when a lot of people can't, which is nice; this can feel very lonely and isolating." Her mother understands Evelyn's complex reaction to being diagnosed: her feelings of relief, paired with grief, regret, and impatience. How hard it can be, and how awful it can feel: feeling like a burden and uncertain about the future. "It has made us closer. It's made us closer in a way that I can't be with my dad or my brother. They don't have the same understanding." 116 Seeing where Evelyn's mom is now is a source of hope for Evelyn. "Knowing how she was before and seeing where she is now, it's like, okay, hopefully, I can get to that point myself." Evelyn continues to be a caregiver to those in her family, although she has actively tried to change this pattern. She laughs, remarking, "I still get sucked in sometimes." Evelyn reflects on the difficulties of setting boundaries that shift decade-old patterns. Living on the other side of the country, her brother helps more with the practical support for her parents, while she continues to do much of the emotional labour over video calls. Since her diagnosis, Evelyn has been able to get some closure her past. "This negative ball has followed me, and only recently, after I got my diagnosis, did I finally get [my family] to acknowledge how I felt back then. In high school." Evelyn names her feelings, expresses them, and lets them flow through her rather than her old pattern of bottling them up, pretending they are not there. Evelyn remarks proudly on how she has opened up conversations with her parents. "Even though we don't always communicate amazingly, we try." She reflects on how, since her diagnosis, she and her mother have had more open, deeper conversations. Evelyn is more open about her diagnosis and her difficulties and hopes that this will continue to set the scene for more open and healthy communication with her parents as time goes on. "I'm in a more accepting place now, recently, but there's still a little bit of that self-stigma." Equipped with her diagnosis, Evelyn knew what to do to get better. Her diagnosis helped her correct some of the self-blame she had experienced for 36 years. "Maybe it's not me, maybe it's not my fault," she later asserts a bit stronger, "mental [illness] is not my fault...and you don't have to suffer…" She felt relief; she had been seen and diagnosed and could now seek appropriate support. This period of her life has required an abundance of self-reflection and 117 monitoring. "It's my whole life now; I'm so sick of myself," she jokes. She is in a period of transformation, and she is experiencing it as being one of the most challenging periods of her life. She is seeing a psychiatrist, on medication, in group therapy, and is seeking further individual support. "I'm feeling more optimistic." Evelyn is still working through and making sense of her diagnosis. She explores her understanding of what it means to her to have BD. "You're not broken." she thinks of it as a chemical imbalance, "like needing an iron supplement." "It's not some deeply engrained personality flaw. I can stomach that a bit better." "I'm in a more accepting place now, recently, but there's still a little bit of that self-stigma." Simultaneously, she is parsing out what is BD, and what is a part of her. Evelyn has reflected that now, after her diagnosis, she finds herself questioning "everything [she has] ever done." She jokes, "Hopefully, that goes away at some point." Evelyn is grappling with what language to use to describe BD. She stops mid-sentence, "I don't like to call it a condition; I'm trying to find my terms that are appropriate." "Illness… I need a better word. I don't want to sound sick. Condition sounds like… she has a condition, don't talk to her." "I am bipolar… or I have bipolar… maybe I shouldn't say I am?" Evelyn reflects on how her history is shaping her ability to navigate her diagnosis with grace. "If no one in my family had it, and I was suddenly diagnosed at 36, it would have been more shocking. Or I'd be like oh my god, I'm crazy." "I knew a lot about bipolar before I was diagnosed; it is a weird difference in understanding." "Even though there is some stigma and some fear… negativity with the ups and downs, being exposed to it at a much younger age, it stigmatized but also normalized a bit. They're wrapped together." 118 "It doesn't have to be this shameful, dirty secret." Evelyn is actively fighting against her ingrained sense that she should keep her diagnosis to herself. "Seeing my own family members with it, it's definitely had that stigma effect… don't tell people; they're going to think you're bad." Consciously, Evelyn has shared her diagnosis with her close friends, and they have been supportive and understanding. "I was terrified that everyone would judge me, not want to be my friend, not let me babysit." She realized that those were her "own judgments projected." "It doesn't have to be this shameful, dirty secret." “Sharing has been helpful but scary. The more I tell, the more positive it is; it makes me more comfortable to share." Evelyn reflects on the role of the media. "I wish people weren't so influenced by what they see on TV." "In the media [representations of BD are] always high ups and downs, off your meds, dangerous." She describes a popular show with a character who has BD, "they portray him as this violent psycho who is trying to hurt his sister. By the end, he's just alone, it ruined his life, it's kind of sad. That's not the norm". The media tells stories of those who do not live happy lives or those “who meet tragic ends.” "I don't want that for my future." Evelyn expresses gratitude for the privilege of being able to invest in her mental health. "I'm lucky I can spend money on my mental health; a lot of people don't have that. What happens to them?" "Where is the federal government saying [mental health] is a priority." "It doesn't have to control me." Evelyn is still living in British Columbia, the longest time she has lived in one place since childhood. She loves her current job and has found many interests and hobbies she enjoys. Evelyn knows the importance of living a balanced life, eating well, and exercising. She enjoys walking along the ocean or in a park; it can help lift her spirits, even when feeling low. 119 Having been diagnosed only months ago, Evelyn is taking some time off work to focus on her mental health, to trial medications, focus on therapy, and take care of herself. Looking to her mom for an approximation of what she can expect, Evelyn comments, "I don't want to have to wait until my 40s to feel better. But it's a different situation. I've already done some of the work, and now I'm focusing on it. I'm optimistic." Evelyn is building an awareness of what can be triggers for her. Stress, time change, changes in seasons. With this building awareness and building of a support system, Evelyn is starting to feel in control of her symptoms, yet the uncertainty still lingers: "I can keep control somewhat, but what if I lose control?" "I don't want to grieve my future, but it will always be predicted by this now." Evelyn hopes to have a partner one day and to be able to let that partner in to care for her. "I'm tired of looking after everyone else. Which is probably a role I put myself into. Growing up this way. But can someone just ask me how I'm doing? Someone take care of me?" "I'm sick of like self-soothing… I just feel like I've been self-soothing since I was a little kid… because, like, if my dad was away, my mom wasn't doing well... it was just me." Evelyn worries that her diagnosis may make it harder for her to find a partner. Evelyn reflects that she carries some self-doubt and judgment; she worries that she is not lovable enough or good enough. Evelyn pauses, exploring her worries to name and celebrate her growth and progress. She feels some positive shifts in her life and reflects that progress, in all ways, can be hard to see at the moment and that it is not until you zoom out that you see the positive changes. "It's like a hike… … every step is painful...and then you get to the top, and you're like, that's what I did!" Like climbing a mountain, one step at a time, day to day, you might not notice the progress. Nevertheless, eventually, you get to the top, zoom out, and can see all of the progress 120 you have made. Those single degrees of change add up and eventually pay off. She expresses gratitude for her parents, "I feel very lucky that my parents are my parents." She has the tools and the support she needs to finish her climb. 121 Frank's Story: "It's Like Doing the Opposite of What Your Parents Do." Frank was dissimilar to the other participants in many ways. He was my only male participant, my oldest participant, and has had his diagnosis of BD decades longer than all of the others. He is the only participant who had been hospitalized as a result of his BD; the only participant who was diagnosed with BD before learning his parent also had a diagnosis. He is a professor and clinician in the field. I met with Frank months after my last meeting with a participant. Between meeting with Evelyn and Frank, I moved across the country for a residency in a new city. With that move, many chapters of my life that had been at the forefront during my other interviews had been closed. My perspective shifted. "I am fascinated by people's stories because in hearing people's stories... I hear clues around how to live a better life." Frank currently lives in British Columbia with his partner of nearly 20 years. He has a close group of friends whom he calls family, and he has spent the last ten years reconnecting with his siblings on his own terms. He has a successful career as a clinician and a professor in his chosen field. He has built an enviable life for himself. Yet, as Frank shares, I am struck by the feeling that he is distancing himself from his past. At times in our meetings, it felt as though Frank was withholding, monitoring himself, and not speaking freely. As if Frank had processed his childhood, packed it up in a box, and put it away. Many of Frank's experiences are far behind him. Across interviews, Frank was willing to look back in the rear-view mirror and describe to me what he saw, but he did not seem to turn around and face it head-on. I followed Frank's lead, respecting his comfort levels. As a result, I, too, felt I was looking at them from a distance. One thing was clear: Frank has differentiated himself from his family, from his parents, 122 from his past. Time has passed; physical distance made. The distance, perhaps protective, allowed him to build a better life. Throughout most of Frank's life, his relationship with his family was strained. He describes a childhood of profound loneliness, fear, and instability. Frank only briefly mentions his father, referring to him as an alcoholic and an absent father. Frank describes his mother tentatively. Her depression and the associated inconsistencies in parenting were challenging. "My mom was quite... um… depressed… when we were little." "I didn't see her as my mom for years." "My mother wasn't… she was there, but she didn't have the capacity to parent me." Immediately after graduating high school, given his first chance, Frank began distancing himself, physically and emotionally, from his family. "Goodbye! I'm out of here," he cheerfully recalls. "I was really disconnected from my family for many, many years; that's how I coped." "I stepped away from my family; I moved away." To this day, most of his siblings still live in the small community where they were raised; Frank, on the other hand, " just got further away, further away, further away." "It would have been hell [to have stayed]." Frank left the small community he grew up in to move to a larger city to study social work—the beginning of his career as a clinician and a professor. Frank's work and practice in the field were evident across interviews. At times, I notice Frank shifting into these roles, asking questions about me, asking me to define concepts, and sharing advice he gives his clients. Times we both slipped into clinical speak; perhaps with our clinician hats on, we were protected from the vulnerability of discussing our own experiences. 123 When discussing what led him to the field, Frank shares, "People fascinate me; people really fascinate me. So [studying social work] was one way for me that I would learn how to manage those stories and learn from those stories." "I am fascinated by people's stories because in hearing people's stories... I hear clues around how to live a better life." While Frank describes his career path, I think of the statistics and research about people in this field, the one that I, too, have chosen, and the correlation to mental illness in your families—studying and trying to understand the other in hopes of understanding yourself or your loved ones better. I reflect on my choice of topic for this dissertation. I have joked that I asked five strangers these questions instead of my family. Despite Frank's instinctual interest in the field, his path was tumultuous. In his 20s, when Frank was training as a social worker, he was exposed to immense learning about mental health and trauma. "You do a lot of self-reflection and self-analysis. That's when I started to really explore the impact of my family on my life and on my upbringing. That brought up a lot of abusive situations around a lack of parenting ability." Frank goes on, "So… when you're when you're raised in an in… dysfunctional environment, you don't really know it's dysfunctional…. until you get out… and then you reflect." "That was a lot to handle…. school, the pressure of school, self-reflection, becoming more and more aware of the abusive situations I was in as a child." In confronting his history, Frank's mental health began to unravel. “I needed to take care of myself because nobody else would.” Frank grew up in an extremely small community of about 2000 people, “all related,” he jokes. He describes his family as being isolated and poor. “We lived on a farm that wasn’t very productive, so my parents were always... um… we were very poor when I was little. There was a 124 lot of stress on my parents.” Frank is the youngest of six children born in eight years, “I’m the last.” Knowing Frank was raised with so many siblings, I imagined a boisterous, full house with close siblings piled on top of one another. In reality, Frank describes loneliness, fear, and instability. "The biggest time of impact of [my mother's] illness was when I was small." He describes the ages of three to six, "for me, that is when she was at her most unstable… her parenting was quite abusive and scary at times. Her being not medicated, being quite bipolar... was not… a good experience. It was actually quite an abusive experience." "Her parenting was quite inconsistent… her… reliability was not there, and she would do punishments that didn't really make sense." When Frank was four, his eight-year-old sister found their mother after she had attempted suicide. "[My sister] actually saved her life." I notice that Frank describes the horror of this event only as it relates to his sister. Only in how it has affected her, not how it affected him. Distancing himself from the experience. This led to Frank's mother's first hospitalization of his lifetime. Frank expresses a sense that his father let them down during this hospitalization. "My dad didn't even take care of us when she was hospitalized." All six children were divided amongst relatives to care for them while she was away. "My dad was an alcoholic. He didn't want to take accountability; he was an absent father". He softens his anger. "That was just the reality of his upbringing, right?" I am struck by the thought of how Frank must have felt so frightened and alone, separated not only from his caregivers and his home but also his siblings at such a young age. 125 Following her hospitalization, Frank's mother continued to struggle with her mental health, and Frank continued to support himself. "I did my own parenting; I raised myself in many ways." "I needed to take care of myself because nobody else would." Frank's mother was hospitalized again when he was 12. "I remember, um… the doctors asking me to come and soothe my mom because my mom wouldn't settle down even with medication. So, they would bring me in to calm my mom down, and I was like 12 years old, so that's just really mixed up." "Even when I went to the hospital, no one explained why; it was very weird," Frank recalls being brought to the hospital and seeing a sign that you had to be 16 years of age to enter. "And I was thinking, but I'm 12? I shouldn't be here." "I felt puzzlement, how come I am being allowed in?" I reflect on how illustrative this is of Frank caring for his mother and himself because no one else would. Despite the challenges of confronting his past, Frank managed his first year of university okay. The distance was helpful. When the university spring term ended, so did Frank's refuge from his family, and he returned home for the summer. "I went home for my summer… and then my…" Frank trails off, pauses, and laughs. "It's a crazy story that I have," he laughs again, "then my brother, who is a year and a half older than me, tried to kill my parents by burning my house down while we were there. And that was the onset of my own experiences of being bipolar." It was then that "things really blew apart." Briefly, we pause, digesting the information Frank has just shared. Frank’s brother’s attack on their parents triggered a period where Frank cycled between episodes of mania and depression "like a yo-yo, every two weeks." "My 20s were very, very unstable." After about five years of this, Frank, unable to bear it any longer, became quite 126 suicidal. At 24, Frank disclosed this to his therapist. "She thought I was high risk. I thought I was high risk." His therapist took him to the hospital, where he was admitted and held for two weeks. I imagine Frank in the hospital and the potential parallels between his mother's hospitalizations in his childhood. I wonder how Frank made sense of this experience, if he worried that he was becoming like his mother, and if he felt doomed to her fate of instability. I ask Frank if his hospitalization brought up any recollections or reflections about visiting his mother in the hospital as a child, "Totally no," he responds shortly. "I think for me … I took it as an opportunity to get my shit together." While in the hospital, Frank was offered an opportunity to be different from his mother. "I think for me … I took it as an opportunity to get my shit together, I really think so." During his stay, a psychiatrist diagnosed Frank with BD. Frank credits this psychiatrist for his treatment adherence and associated stability: "The way he was interacting with me, the way he was very honest with me. At one point he said that if I did not stay on medication, that I would die; because of my rapid cycling, because of my history, my mother and my dad. He said I wouldn't survive without medication. And so, I stayed on medication. I don't think I've ever not taken my medication since 1986. So, I've been really stable." Frank laughs, "he scared the shit out of me." While blunt, this psychiatrist was also candid and kind. He eventually became someone with whom Frank had a longstanding positive relationship. He supported Frank for 30 years. I think of the effect this corrective experience could have. To have someone you could trust. I wonder what this was like for Frank initially; was he skeptical? Unsure? Or was he keen for the care of others after a lifetime of caring for himself? 127 Frank describes starting medication as though he was feeling like he was waking up "…and for the very first time… the world sort of fell into place. It was like waking up. It was really like waking up." His diagnosis was teaching him to live a balanced life, offering him a way to be different from his mother. Initially, for the first decade or so, Frank recalls feeling like he was "walking on eggshells." Monitoring the self, medication, and stress levels with almost a hypervigilance. At this time, Frank experienced some worries: "fear that I would end up back in the hospital, or that I would end up dead, out of control, those types of worries." I find myself wondering, fear he might end up like his mother? This has dissipated for him over time. Now, Frank has been stable for nearly four decades. "Isn't that interesting, right? I've been very stable." Something shifts in Frank; a childlike playfulness spreads across his face with a smirk. He shares that, in some ways, his treatment adherence is an act of resistance, a way in which he can be different from his mother, an act of rebellion. "If I take medication, it's like doing the opposite of what your parents do." Frank asserts on many occasions how he is different from his mother. He began our first interview by sharing: "I think how my mom was diagnosed and how she responded to her diagnosis is quite different to how I responded to my diagnosis." Frank's mother felt she didn't need medication. "Look at how… unstable my mother is because she didn't take medication." Frank takes his unchangingly, almost as an act of rebellion. "If I take medication, it's like doing the opposite of what your parents do." Frank's mother stopped taking her medication when he was in high school after having been on it for only about four years. Frank shares that she decided to stop the medication because she liked 128 the "expressiveness" of her manic episodes and the associated creativity. "My mom is extraordinarily creative. She plays music, she drew, she did different types of sewing." During a manic episode, she was "bursting with creativity." Painting, drawing, playing the piano," “and then there were times where she wouldn't be doing music at all." "My grandmother was the same way." Frank suspects that his maternal grandmother also experienced BD. Frank sees this thread as connecting the three of them. "I was super creative as well," with an emphasis on the past tense. Frank has found that since his diagnosis and beginning medication, his creativity has reduced. "My mom played violin, guitar, piano, banjo, I played piano. But, I sold my piano." "I'd rather be less creative and alive than more creative and dead." Frank reflects, "At the beginning, it was really hard… but now it's more… there's so many years now, it is what it is." Frank sees this version of himself as his true self. “The way I look at it is… the medication allows my true self to come through. So, if I wasn't bipolar, I wouldn't need medication, and therefore, this is who I would be." Frank reflects on how he is more open about his diagnosis than his mother; Frank did not even know his mother had been diagnosed with BD until he shared with her his own diagnosis in his late 20s. "I knew my mom had been diagnosed with a psychiatric illness; she was probably clinically depressed, but it was only after my diagnosis and conversation with her that she really talked about her own bipolar [disorder]." Frank sought to understand his mother better, "I asked her to write about her experience... it may have been three or four pages, that's it. She wasn't really open to having a conversation about her mental health." "I think there were times when I tried to talk about it, but she wasn't open to having a conversation." 129 Shortly after Frank's hospitalization, he had an "opportunistic conversation" with his paternal uncle in an effort to learn more about his family history. Frank did not trust his parents but thought his uncle might be honest. Perhaps his uncle's distance from his family might help him be willing and able to share. Frank describes this conversation as pivotal, "it made me understand that my parents were human." "A lightbulb was struck by… they had their own problems." "I was also very angry, and I didn't want to… I didn't want to express my anger to my parents." "They don't need to hear my anger. I stepped away to be able to process and do my own grief around my childhood." "I think medication was helpful in maintaining a balance while I was processing all of that." Frank processed his childhood the way he was used to, without familial support. "I just got further away, further away, further away." In his late 20s, Frank came out to his family. "It was the height of the aids epidemic." "My parents were quite... you know… that wasn't necessarily what they 'wanted to hear,'" he says, using air quotes. "My father never really accepted my being gay… and there was a lot of tension; it was very tumultuous." "I think people… um, were more upset about my being gay than my being diagnosed bipolar… isn't that interesting?" Frank's father let him down once again. His familial relationships were now severed; he was alone. "I just got further away, further away, further away." Despite Frank's history of hardship and the lack of support from his family, he was determined to build a better life. Frank sought treatment with his own therapist, processed his upbringing, and continued to forge meaningful connections with those around him. Presently, Frank has many people in his life whom he can trust and rely on; he is no longer navigating life on his own. 130 When Frank was 28, he entered into a "life-changing relationship." "It was the first time I learned it was okay to trust somebody; it was okay to trust." I was imagining the undoing of his childhood trauma, the relief in this trust, when Frank continued, "But then he died." "He died when I was 31." I'm struck, he had someone he could trust, and then he lost him. I pause and sit in the grief, loss, and discomfort. This loss was significant for Frank. Shortly after, he experienced the only "wobble" in his mental health since his diagnosis. When Frank was in his 40s, he met his current partner. Together, they have created a local community, a support system, and four friends Frank refers to as family. In the last ten years, Frank has reconnected with his siblings; although they do not often talk about mental health, they do talk frequently. "I'm building the relationship on my terms, so that's helpful." "In fact, I'm sort of… I'm seen as the glue in my family now because I get along with all of my siblings, and all of my siblings get along with me." Frank has learned to trust others and found others he can trust. He is no longer alone. "My siblings became more important to me than before.” “When [my dad] died, I think things got better with my siblings, with my family.” “Once my dad died, my experience was that the rest of the family started to come around. So, I have a really good relationship with all of my siblings now, except for one.” When Frank’s mother passed away when he was in his 50s, he became even closer with his siblings. “My siblings became more important to me than before. So, I would say my relationship with my siblings has also become sort of important in my life.” “My family is pretty fragmented, but I choose to connect with them. I choose to build relationships with them.” 131 Despite increased importance, Frank distances himself in his descriptions of his siblings. He focuses on how events might have affected them but not him. "My siblings have their own strategies of coping," he lists them off, "I have one brother who is totally drug-addicted… quite… dysfunctional," "I have another brother who basically lives a very shallow life; he's not interested in feelings and emotions, he's not interested in psychology or understanding self." "I have a sister who is quite troubled. She is the one who found my mom when she tried to kill herself, and I think that's really impacted her. Her entire life. The whole sense of trauma." "I have another sister who is fundamentalist Christian, totally contradictory." "So, I think my siblings live their life without depth… because they can't." Frank and his siblings struggle to have open conversations about mental health, their coping or their upbringings. "We don't really talk about it, though as siblings, we just don't talk about [our mom's] mental health." "We don't talk about it. It's just not… we don't talk about the impact of my dad's alcoholism either." He and one sister are able to have conversations about mental health. "We will talk about how we were raised, and it wasn't stable, so she's been impacted." I notice how Frank emphasizes the impact on his sister, not mentioning how it might have affected him as well. Frank has attempted to have open conversations with his oldest brother, "when I had a conversation with him, he'd say, 'I don't remember my childhood." "That's a really normal response to severe trauma," Frank qualifies. Their ingrained secrecy and discomfort around discussing mental health is perhaps a result of their shared childhood environment. Growing up in a small community and in a period where mental health was associated with significant amounts of shame and taboo, Frank's mother's hospitalizations were kept a secret. "Because it's such a small community, we didn't want to talk about what was going on." "Nobody talks about it, but everybody knows about it." "There 132 was a lot of closed-door whispering going on." Reflecting back, Frank believes that having more open conversations with his family would have been helpful to him during this time. "I think having a conversation would have helped… because it was… just not talked about…. everyone knew, but you don't talk about it." Frank shares that as culture has shifted, stigma has reduced, and he has gotten older, he has gotten more comfortable discussing mental health. "Before it was very… hush hush, don't talk about it. After it was like… hush hush, don't talk about it… and as the years progressed, it was like… who the fuck cares?" In his work, Frank now provides parents with the support to navigate challenging conversations with their children, "parents are not trained to be parents about having difficult conversations." He facilitates for others what would have helped him when he was growing up; he is helping others to talk openly. "I'm a soul having a human journey, and this is a very interesting life." Looking back on his life, Frank shares his life philosophy with me; his method of sense-making and coping came to him when he was five. "I was about five years old when I came to the realization that all the bullshit going on with my parents has really nothing to do with me and the recognition that, oh, I'm here! I'm a soul having a human journey, you know I'm five years of age having a sense that my parents are the ones that were crazy and I wasn't… and that I needed to take care of myself because nobody else would." "I have a belief that I'm a soul having a human journey. So, I'm not a human with a soul. I'm a soul having a human journey." The protective distance is evident as Frank describes his experiences almost as a spectator: "I'm a soul having a human journey, and this is a very interesting life." 133 "So, I can have a brother that tried to kill my parents. I could be gay and all the issues around that. I was abused as a child. I was widowed when I was 30. I was diagnosed with BD. If you add up… that's a lot of shit to be happening (laughs). But if you… look at the central core of survival for me was… yeah, I'm a soul having a human journey, and this is a very interesting life." "What life gives me is what I'm needing to learn." Frank's life has taught him balance. It has taught him to be kind and respectful. It has taught him that he can trust and talk more openly. "I'm more interested in being kind and in being respectful, um, doing the best I can, because you know, at the end of the day. That's what my soul says, right? So, I'm being kind and being respectful and trying to be the best person you can be." Frank learned to take care of himself and did so quite well. He has a successful career as a clinician and a professor in his chosen field, where he can teach others the lessons he has learned. Frank shows up for his siblings, friends, students, and clients. He has forged trusting relationships and created a support system around himself. He no longer has to face things alone. "I'm a soul having a human journey, and this is a very interesting life." 134 Cross Narrative Analysis This section explores the role of narrative elements, major themes and motifs within participant stories. Table 4 summarizes these findings. Narrative elements include the common journey genre, turning points, seeking balance, and the role of the storyteller’s landscape. I will then explore the common themes identified across all of the stories. Finally, I will explore recurring motifs that were prominent within the stories and sense-making of the participants. Figure 1 illustrates these cross-narrative findings based on the research participant’s (the storyteller) journey. Table 3 Summary of the Findings Across Narratives Summary of the Findings Across Narratives Narrative Elements Themes Motifs Elements that intrinsically exist within narratives, including the genre, elements that facilitate plot, temporality, and space. Meaningful and recurring concepts that unify the data in relation to the research questions. Recurrent ideas/objects that underscore, reinforce, connect, and link themes and events. The Journey Genre Turning Points Balance Storyteller’s Landscape Agency (Powerlessness) Communion (Isolation) Identity (Confusion) ‘Be The Best That You Can’ Grief Secrets Cycles 135 Figure 1 The Story Teller Journey The Storyteller Journey Narrative Elements A number of narrative elements were identified in the co-created stories. These elements, including time, space, plot, and schemas, are inextricably embedded within one another, as all components are required for a meaningful narrative to be created. For the purpose of discussion, I will parse out each narrative element: the archetypical journey genre, turning points and a landscape constitutive of their experiences and meaning made, including societal and cultural 136 values, the family system, and the mental health system. Finally, within each story, participants used the schema of balance in both the ways their stories are told and as an explicit goal within the stories. The Journey. In examining the universality of narratives, Booker (2004) identified seven basic plots, or genres, that all stories fall under. Each plot has a specific story structure. One of these narrative structures is the journey (sometimes called the 'hero's journey' or 'the quest'). In the most basic form, a traditional journey is a goal-directed search (Schulz, 1981, as cited by Fresse, 2013). This may include a movement from one place to another as the protagonist searches for a specific place, object, or solution to a problem (Freese, 2013). In many journeys, the protagonist endures unfamiliar and dangerous situations as they face obstacles, conflicts, and villains. These obstacles present as potential turning points facilitating an eventual transformation where some resolution is made. The protagonist can then return to their original state with new knowledge and understanding. In the co-constructed narratives, participants described their journey toward goals of agency, communion, identity, and being the best that they can. Participants described obstacles such as feelings of powerlessness to their symptoms of BD, feelings of isolation, confusion, and hardship. These obstacles and goals will be further discussed as common themes. Participants identified hardships, including their parents and their symptomology, as challenges to overcome. Every obstacle faced and problem posed in the journey genre presents a potential turning point for the protagonist. Many turning points occurred within these participants' stories, facilitating their progress toward their goals. All participants described their diagnosis as one major turning point, a time of epiphany, which led to some sense of understanding and progress toward their goals. Table 5 below outlines the turning points as identified by each participant in the interview. 137 Table 4 Participant Turning Points Participant Turning Points Participant Turning Points Within the Chronology of Stories Alissa Onset of parent symptoms (experienced loss of parent) Onset of own symptoms (experienced loss of agency) COVID-19 pandemic (an opportunity to reflect) Diagnosis (regaining of agency) Self-acceptance and understanding (regaining of identity) Charlotte Seeking support through al-anon (attempts to gain agency and communion) Moving away and traveling (vacillation between gaining and loss of agency) Worsening symptoms, particularly after birth of daughter (experienced loss of agency and identity) Connecting with biological father (regaining identity and communion) Diagnosis and understanding of treatment methods (regaining of agency) Ella Negative experiences in elementary school (experienced isolation) Onset of own symptoms (loss of agency) Connecting with an online community (gaining communion) Moving in with mother (gaining communion) Diagnosis (regaining of agency) Self-acceptance and understanding. Experience ‘normalcy’ (regaining of identity) Evelyn Onset of parent symptoms, parental hospitalization (experienced loss of parent) Onset of own symptoms (loss of agency) Experiencing a sense of ‘normalcy’ (regaining identity and agency) Loss of cousin – motivation to seek diagnosis again (loss of loved one) Diagnosis and access to treatment methods (regaining of agency) Frank Parental hospitalization (experienced loss of parent) Moving away (attempts to gain agency and communion) Onset of own symptoms (loss of agency) Diagnosis and beginning medication (regaining of agency) Loss of partner (loss of agency) Loss of parents (in some ways regaining of communion) Note: Turning points experienced by more than one participant are shaded light gray. Universal turning points are shaded in dark gray. Themes are bolded. 138 As illustrated in the table, each journey had many turning points, but many related to participants' experiences of gaining and/or loss of agency, communion, and identity. For all participants, their diagnosis was a major turning point facilitating a regaining of agency as they accessed support. For example, when Charlotte connected with her father and subsequently understood she has BD, it was a turning point, allowing her to shift away from self-blame and better understand how to support herself. As she put it, "it all makes sense now." Similarly, for Evelyn, her diagnosis allowed her to shift away from self-blame and feelings of failure, her internalized villain, access appropriate supports and shift towards self-compassion. For Frank, his diagnosis was an opportunity to "get [his] shit together," and beginning medication was "like waking up." All participants' diagnoses were significant pivotal life events that led to shifts in their feelings of agency, transformation, and some sense of resolution. Participants integrated their parents' embedded journeys into their own, with the rippling experience of their parent's symptoms and the sense of having lost their parent to BD being a turning point described by many participants. Participants also explored their parents' current levels of agency over their diagnoses when describing their own. Evelyn and Ella's mothers were positive role models and templates for positive change. In contrast, for Frank and Alissa, their parents were understood as cautionary tales. These comparisons to parents are further described in the exploration of the theme of identity. Other shared turning points include the onset of the protagonists’ symptoms and an experienced loss of agency, moving away as an expression of the participant’s agency, and self-acceptance and understanding as participants renegotiated their identities to integrate their diagnosis. Participant’s turning points demonstrate their vacillation in their proximity towards their goals as they worked towards shifting patterns of experiences. For Charlotte and Evelyn, 139 who had just received their diagnosis, we met them in the midst of their story; their closure and restitution were not quite complete. Within the genre of ‘journey,’ many subtypes illustrate the obstacles faced and outcomes of the stories. For example, stories of escape have been described as stories where the protagonist breaks away from something (Freese, 2013), stories of endurance or survival, stories of returning to ‘normal’ (endeavour), and stories where one is transformed by their outcomes (enlightenment) (Llewellan-Beardsley et al., 2019). For Frank, with more time following his diagnosis, his journey is one of enlightenment, with greater closure, sense made, and transformation. For Ella and Alissa, who had had some time since their diagnosis, they were able to act as agents of change to manage their symptoms through an awareness of triggers, develop coping strategies and increase a sense of order and agency over their lives. A sense of resolution has occurred as they can implement their newfound knowledge to support themselves, illustrating a journey of endeavour. They expressed reflection, mindful optimism, self-acceptance, and understanding. Specifically, Alissa reflects that it “actually feels like life is easy again” and “it is so nice that I feel like I am back to before,” illustrating the sense of balance that had resumed in her life. Charlotte and Evelyn’s stories are more open-ended. Their goals are clear, and their tone is optimistic, yet they have not yet returned to their original or transformed states. Evelyn explicitly notes that she is in the midst of her transformation, working towards balance; she names her growth, progress, and optimism for her future. Charlotte continues striving to be the best version of herself and shift intergenerational parenting patterns and excitedly shares about her renewed sense of agency and understanding with her diagnosis. Both Charlotte and Evelyn expressed continually working towards self-acceptance and understanding and explored how 140 they are working towards these goals. Their journeys are those of endurance, as they have survived hardships and overcome many turning points but have not yet reached their goals. Narrativizing endurance through hardships as a means to a positive end allows the interpretation that those experiences occurred for a reason. Although participants continued to manage their symptoms and strive towards their goals, their diagnosis was a significant turning point. With diagnosis, participants unlocked new understanding and tools to support themselves, providing transformation, return to self, and regaining of agency. Balance. Balance is a fundamental schema used in storytelling (Polkinghorne, 2015). In storytelling, humans have a proclivity to seek balance and a meaningful resolution. Thus, as humans, we tend to tell stories with a plot that integrates events to create unity within ourselves, accommodate the past, and protect our possible futures (Polkinghorne, 1988). The genre of the journey itself contains balance, with the narrator overcoming obstacles towards a meaningful and 'balanced' resolution. For many participants, seeking 'balance' and 'stability' was an explicitly desired goal within participants' journeys. They sought agency to create this balance and have their life 'return to as it was" (as described as stories of endeavour.) In their journeys, the resolution included the management of symptoms, typically facilitated by self-awareness and increased agency, which potentially facilitated a personal transformation. Alissa, Ella, and Frank expressed feeling 'in control,' having conquered the beast of their previously unmanageable symptoms. Alissa shared: "I actually feel like life is easy again… and it's so nice because it was such a struggle for such a long time. It is so nice that I feel like I am back to before." Frank asserts that he has been "stable for decades" and is no longer plagued by worries about his stability. For him, the goal of balance 141 perhaps has been reached, while for other participants, it was something they were approaching but continually working towards. Participants were aware that there is "always an element of management." Thus, balance was an ongoing goal. As Ella stated, "We are walking the balance beam right now." Ella and Alissa explored how they are mindful to maintain their balance. Participants expressed knowledge of potential hardships to come but felt equipped as a result of their transformation and resolution to manage new hardships and maintain balance. Thus, participants continued to strive for balance when reflecting on their past, exploring their present selves, and describing their hopes for their futures. Storyteller’s Landscape. Within Ollerenshaw and Creswell’s (2002) description of the three-dimensional space approach to narrative inquiry, the storyteller’s landscape is essential in analyzing a story. In line with this, participant experiences are constitutive of the complex systems in which their stories are told. The storyteller’s landscape may include many variables, including geographical locations, societal and cultural values, temporal location, and the organizational systems that influence the protagonist. Within these participant stories, societal and cultural values, the mental health system, and the family system were repeatedly explored as important components of their metaphorical landscapes. Societal and Cultural Values. Many participants explored how the societal and cultural values of their landscapes played a role in their journeys with intergenerational BD. For Ella, the internet, specifically Tumblr, was a unique place that normalized mental health and helped her feel accepted and supported outside her family system. Tumblr facilitated Ella's sense of communion and identity as she navigated her journey, which facilitated her self-acceptance. In contrast, for Frank, his experiences of living in his hometown facilitated isolation and shame—a 142 feeling of mental health as 'taboo' and his familial pattern of secrecy. Frank also experienced marginalization from his communities due to his sexual orientation, which led to increased isolation, particularly from his family. Frank articulated how, as societal and cultural values shifted over time, so too has the acceptance of mental health diagnoses and experience of self-acceptance. He compared the community he lives in today to that of his mother; the changing times are a reason he gives for being more open about his diagnosis than she was. Similarly, Ella and Evelyn both reflect on how their mother's diagnoses were responded to differently due to cultural values and patterns of stigma at the time of their diagnoses. Despite participants' descriptions of a sense of increased sense of openness and acceptance within today's culture, many participants reflected on the pervasive negative perception of BD within the current media. Charlotte recalled, "Look at how it's portrayed in film and television… they're always crazy." For Charlotte and Evelyn, media depictions of BD contributed to their understanding and assumptions about living with BD. For Charlotte, the extreme portrayals led her to misunderstand her symptoms, and upon receiving her diagnosis, she recalls feeling anxious due to her limited exposure to BD outside of the media. She recalls thinking, "Am I really unwell? Because of how it's portrayed." Similarly, Evelyn recalls portrayals of BD in the media, showing stories contributing to her self-stigma. Thus, despite positive shifts towards acceptance and understanding in the present zeitgeist, there continue to be potentially harmful displays of BD in popular media that may influence the experiences of those living with BD. Overall, societal and cultural values shaped how participants experienced and made sense of their lives. Looking across generations, participants reflected on societal and cultural value 143 shifts and how they had experiences similar to and different from those of their parents. Further, Frank himself, having been diagnosed for decades, was able to reflect on the passage of time and aging and how that has influenced his sense-making. The participant stories are snapshots in time, told from the present perspective. These stories will continue to evolve as time passes, the participants continue to grow, and our culture continues to shift. The Family System. All stories explored the familial relationships of each participant and the conscious and unconscious interactions within families as they shaped their journeys. Participants described their roles within their family, familial patterns, and how their family systems adjusted to accommodate the family needs, for example, when a parent is hospitalized. All participants described a responsibility to care for themselves and others at some point in their journey. In these stories, the families function as a system. As children, many participants described taking on roles consistent with adultification or parentification to support their parents. Parentification is when a child sacrifices their own age-appropriate needs to care for their family, including their caretakers (Hooper, 2007). Participant stories highlight the functionality and the necessity of stepping into these roles as caregivers for their and their family's well-being. When reflecting on Alissa's support to her father, she says, "It was the only right thing to do; I did it natural." "I was just doing what anybody would do in this circumstance." For some participants, shifts occurred within the family dynamics following their diagnoses or when their parents' mental health stabilized. Evelyn experienced changes in her relationship with her mother as her mother's mental health stabilized. Similarly, Ella's mother could maintain a caregiver role and support her when struggling. Alissa reflected on how, as her father's mental health has stabilized, she felt she was able to return to her more "natural normal 144 daughter role." These shifts illustrate how changes in the family system may occur as the family's needs shift in tandem. Many participants reflected on how their roles within their family systems have lasting impacts on them. Evelyn shared that she has been caretaking in relationships since childhood: "I'm sick of self-soothing. I have since I was a kid." Evelyn felt isolated as her mother was ill, her father was away, and feeling like it was just her. She describes how this affects her seeking a romantic partner, wondering if she unconsciously finds relationships where she is again in a caregiver role. Similarly, Alissa described her role as a caregiver to her family members and her subsequent difficulty asking for help. A potential artifact of this self-reliance is that many participants did not explore the role of their partners across stories. Charlotte's husband did not play a significant role in her story. This may illustrate the lasting impact of childhood roles and patterns of self-reliance within the family system. The Mental Health System. The mental health system was also a part of these stories. All participants at the time of our meetings were on medication, accessing ongoing support and were recovering or had recovered within the mental health system. For some participants, such as Frank, the supports accessed were corrective experiences that led to long-lasting and positive experiences. Similarly, when Alissa sought support the second time, she felt supported and understood, sharing, “I was very grateful for the way the system took me in.” Further, the mental health system played a significant role in all participant journeys, as all described their diagnosis as being a major turning point towards agency, communion, identity, and being the best that they can. 145 However, not all interactions with the mental health system were positive. For many participants, feelings of frustration, dismissal, and being overlooked were present across stories. Alissa’s first interaction with a psychiatrist was negative as she felt they did not seek to understand her as an individual and only made assumptions because of her father’s diagnosis. Both Charlotte and Evelyn sought support on numerous occasions before being diagnosed with BD and experienced misdiagnoses and some prescribed medications as exacerbating their symptoms. Evelyn reflected that “being missed” and “falling through the cracks” are not uncommon experiences for those living with BD. This occurred despite Evelyn’s knowledge of her family history of BD. Similarly, Charlotte wondered how much longer she would have taken to be diagnosed had she not connected with her father and learnt of her own intergenerational experiences of BD. No participants’ stories included positive interactions with the medical system as children, as their parents sought support. Visits to the hospital were stressful, confusing, and scary, with lasting impacts. Evelyn felt haunted by these experiences when she required support as an adult and explored times in which it impacted her willingness to seek help. No participants reported having helpful or particularly informative conversations about their parent's diagnoses, and most participants reported feelings of confusion, a desire for more information, and feeling as though no one had explained to them what was going on. Summary of Narrative Elements. Overall, participants shared their stories following the archetypal genre of a journey. Participants navigate and endure hardship, with many turning points, including their diagnosis as a major turning point supporting them in reaching their goals. In sharing their stories, participant accounts included the schema of balance as they sought meaningful resolutions. The storyteller’s landscape, including the societal and cultural values, 146 mental health system, and the family system, were explored as impactful constituents in which the stories took place. Major Themes The cross-narrative analysis of the individual stories of each of the stories led to four major themes being identified. These themes are all goals the participants struggled with throughout their journeys. Although varying slightly in the unique stories of each individual, all participants explored communion, agency, personal identity, and “be the best that you can” in their accounts. Several of these themes have a counterpointed dimension, which is indicated in brackets. Communion (Isolation). Communion is a drive for connection with others. Participants expressed different experiences of an existing sense of community across various times of their lives and communities they forged, including the communities they were born into and communities they sought to escape. This was contrasted with feelings of isolation participants also described within their stories. All participants expressed some sense of loneliness in childhood or a lack of connection and community. Evelyn reflected that she had noticed this theme in sharing her story. All she wanted was a brother; she was alone a lot. Alissa describes her mother being all she had, and Charlotte caring for her mom alone, decorating a tree by herself while her mother cried in the bathroom. Frank describes feeling isolated from his childhood peers, community and neighbours. Ella and Evelyn described social isolation and bullying. Social isolation in childhood was explored in conversations about their parent’s mental health. Frank explored how the secrecy and shame surrounding his mother’s diagnosis fostered closed-door conversations and whispers from neighbours. Similarly, Evelyn discussed social 147 disconnectedness, missing out on playing with her peers to visit her mother at the hospital. Ella recalls being asked not to tell her friends about her mother’s diagnosis. Secrecy, shame, and burden feed into the feelings of isolation and disconnect from siblings. Through adolescence and early adulthood, participants described shifts from isolation to communion. Evelyn, Ella, and Alissa described finding like-minded peers with whom they connected. For Ella, this was online, and for Evelyn, at graduate school. With diagnosis and increased understanding, participants reported a greater sense of community. Alissa and Ella explored how group therapy allowed her to connect with others with the same diagnosis. Charlotte and Evelyn explored a desire to grow their community of peers with BD. All participants have worked to create their own support systems and community, whether it is Frank and his chosen family or Evelyn having found her “people.” Many participants explored the importance of social support and the roles of key people in their lives. Frank is rebuilding their connection with his siblings on his terms. Charlotte highlighted her desire to support her daughter in feelings of communion, sharing: “We are not meant to live life alone.” Social support was an essential component of a sense of communion. Participants described social acceptance of their diagnoses as important in their self-acceptance and compassion journeys. Ella describes the social support she received in adolescence through her online community as having saved her life when her family system was not there for her. Later in life, this shifted when Ella moved in with her mother; reconnecting with her being vital in facilitating her diagnosis and journey to well-being. Her mother “seeing” her, attuning to her needs, and providing that connection and support was pivotal in helping Ella access support. This contrasts Ella’s childhood experiences of feeling invisible or no one noticed. This shift from isolation to communion contributed to her journey towards balance. 148 Unmatched Communion with Parent. Participants also explored a sense of communion or connectedness with their parents with a shared diagnosis. All participants, except Frank, described a sense of unmatched connection, understanding, and support following their own diagnosis. Notably, this unmatched closeness did not express itself throughout childhood but emerged with the revelation of the shared diagnosis and commonality between the parent and child. Alissa feels fortunate to have a father with the same diagnosis, reflecting that without it, she would feel isolated. Similarly, Evelyn reflected on feelings of isolation associated with BD and how her mother's implicit understanding of her lived experiences is supportive. Once diagnosed, Evelyn experienced her diagnosis as bringing her and her mother closer together than ever before. Alissa, Evelyn, Charlotte, and Ella all explored an unmatched sense of understanding and connection, one that other family members could not provide. As Charlotte shared, "He's there for me in a way my mother isn't able to… from not understanding… from not having it." These participants described this special bond with the parent with the same diagnosis as being positive and supportive in their journeys to well-being. This is illustrated by this excerpt from Evelyn's story: Following Evelyn's diagnosis, she and her mother are now closer than ever. "The thing that put a big wedge between us originally is what is bringing us together." [My mom] gets it at least, when a lot of people can't, which is nice; this can feel very lonely and isolating." Her mother understands Evelyn's complex reaction to being diagnosed: her feelings of relief, paired with grief, regret, and impatience. How hard it can be, and how awful it can feel: feeling like a burden and uncertain about the future. "It has made us closer. It's made us closer in a way that I can't be with my dad or my brother. They don't have the same understanding." Seeing where Evelyn's mom is now is a source of hope for 149 Evelyn. "Knowing how she was before and seeing where she is now, it's like, okay, hopefully, I can get to that point myself." Alissa and Evelyn also described how this sense of unmatched communion was bidirectional, as they experienced their parents experiencing this connection. For example, as Alissa stated: "He can also sense or see that I actually really understand what he has been going through and what he's experiencing." Agency (Powerlessness). Agency was present across participant stories, explicitly in the content and, at times, implicitly in how participants shared their stories. Frank and Ella, who had had more time from their diagnoses, expressed and asserted more control over their diagnosis and their sharing of their stories. This was contrasted with descriptions of feelings of powerlessness and times participants felt they did not have agency or control over their lives. Participants all expressed a lack of control within their childhood, often describing being powerless to their parent's illness. Alissa describes feelings of powerlessness as her father's mental health deteriorated: "We were just waiting for the time we would hear that… he had… committed suicide... or… he was dead or something…. um…. and that was like…. really tough..." For some, the intergenerational component of BD exacerbated a feeling of lack of control. Evelyn reflected, "A part of me was always paranoid. Maybe I do have [BD]." Similarly, Alissa also described worrying that she might inherit her father's illness after learning about the hereditary nature of BD: "Shit …I really hope. I have not inherited that…That looks tough," but had her worries soothed by her mother's reassurances. Many participants described feeling a lack of agency before diagnosis due to their ongoing symptoms. Evelyn expressed feeling like a "ticking time bomb," as though she was "just waiting to go crazy." Similarly, Charlotte used the metaphor of feeling like she was "spinning 150 plates" and eventually reflecting that "[she] wasn't able to keep the plates spinning." The cyclical nature of BD perhaps exacerbated this feeling, as many participants reported experiencing periods of "calm" or of feeling "on track," which provided them hope that something could change before their symptoms "came back again" in a manner they could not control. Participants described attempts to gain agency or control by taking matters into their own hands and caring for themselves and those around them. Many participants described being a 'parentified' or 'adultified' child, providing care for parents. Many others also described caring for themselves, as others were not available to care for them. As participants aged, moving was also a way to assert control and attempt to escape hardships. Frank describes physically distancing himself from his family as a method of coping. For Evelyn, "Part of it is pursuing things; part of it is fleeing other things. Movement to escape things and myself." All participants explored their diagnosis as a turning point that helped them regain control over their symptoms. For Charlotte, "now we know what we're dealing with," her diagnosis is helping her to overcome a lifetime of seemingly unmanageable symptoms. All participants explored how diagnosis came with offering treatment and appropriate support, a way to take action and regain control over their symptoms. They were active advocates who sought help and support to gain agency over their symptoms. Participants were in varying states in their feelings of agency. Frank, for example, asserted agency over his life and said his BD was “just not relevant to [his] existence." In contrast, Evelyn and Charlotte were still working towards agency as they navigated accepting and supporting their newfound diagnoses. Evelyn continued to grapple with her sense of agency, reflecting both her hope, "It doesn't have to control me," and her worry, "I can keep control somewhat, but what if I lose control?" 151 With an increased sense of agency, Alissa and Ella explored how, although they may not be able to have complete control over their future, they acknowledge that events or triggers may result in fluctuations in their mental health. However, knowledge of their diagnosis can help them maintain agency over the uncontrollable. "It doesn't have to follow you like an evil shadow." Ella explored her awareness of what activities may have a greater risk for her and how she might mindfully approach the tasks to support her symptoms. Alissa echoed this, sharing that with her diagnosis, she can mindfully approach situations that may be triggered. These reflections illustrate participants' increased yet incomplete experiences of agency over their lives and symptoms, illustrating that this is a goal they will continually work towards. It highlights their reflection and mindful optimism when considering their futures. Identity (Confusion). Storytelling is a tool for negotiating and renegotiating one's identity (Linde, 1993). As such, a common theme across stories is identity, authentic self, and self-understanding, contrasting with feelings of confusion. As previously mentioned, many participants shared stories of isolation and feeling like they did not fit in early life. Similarly, many desired to be 'normal' or thought they did not belong. This shifted for participants as they negotiated and renegotiated their identities throughout their lives. This is consistent with the aforementioned narrative element of 'balance' as participants revisited their pasts to create coherent and balanced stories of their lives and themselves. In doing so, participants also grappled with their identity, as it is a basic form of coherence that can be created through narrative (Linde, 1993). Early in life, in addition to feelings of isolation, many participants described feeling like an "other," a "weirdo," or an "outsider," or like they did not belong. Evelyn and Charlotte both 152 grappled with a desire for 'normalcy' and expressed confusion about why they felt unable to live a 'normal' life. In renegotiating their identity after diagnosis, all participants explored attempting to disentangle their true selves from their symptoms and forge their identities, again exploring who their true selves are. Many participants internalized some of the more subtle symptoms of (hypo)mania as personality traits. In looking back on their lives with the knowledge of their diagnosis and examining their past actions, participants expressed confusion about what might have been their true selves and what actions might have been a result of a (hypo)manic episode. Evelyn and Charlotte specifically reported 'questioning everything they had ever done.' This was experienced in tandem with concerns and questions about who they were outside of their diagnosis. Following their diagnosis, participants also worked to integrate their diagnosed selves in relation to the world. Participants expressed concerns about the perceptions of others, including friends, how their diagnosis might define or influence their future, and if they would be defined or limited by their diagnosis. Ella sees her diagnosis as "a piece of me that can be a core part of my identity, but not something to be ashamed of, or define me." Similarly, Charlotte recalled wondering if she was "really crazy" due to her understanding of BD from the media. Participants varied in their acceptance and forging an identity integrating their BD diagnosis. Ella viewed her BD positively, in some ways, and described how it benefited her: "I know that I am a creative person, an intelligent person. I see some things slightly differently; part of that is because of the bipolar." Alissa's family motto had supported her in innately believing she was more than her diagnosis, more than just one thing, and that it did not 'have to follow her like an evil shadow.' "I can still be myself and have BD. I can manage these problems I am experiencing and still be me." In a similar vein, Frank believes his medication allows his true self 153 to come through, and having been on medication for decades, he has been able to live his life as his true self. Interwoven with the theme of agency, while participants learned more about and accepted their diagnoses, their increased self-understanding facilitated greater control and agency over their symptoms. Many participants described an increased sense of self-awareness, including feeling attuned to their bodily cues and triggers. This knowledge of the self and the resulting attunement and awareness facilitated their ability to engage in life mindfully and experience a sense of optimism, balance, and agency. Evelyn and Charlotte continued to work through self-stigma and diagnosis, having only recently been diagnosed. For participants earlier in their journey with acceptance, the diagnosis facilitated emerging experiences of self-compassion. Evelyn shared, "Maybe it wasn't all my fault," the uncertainty highlighted by her use of the word maybe. Similarly, Charlotte explored how her diagnosis helped to facilitate an overcoming of feeling as though her BD was a 'moral failing," as she reflected, "I am more than this." In Evelyn's story, she reflects that she experienced stigma, fear, and negativity from her childhood experiences as a result of her mother's diagnosis. Reflecting that her family's symptomology made things seem normal that weren't. Yet, Evelyn also felt her upbringing normalized BD, gave her an understanding of BD before she was diagnosed, and helped her accept her diagnosis. As she expressed: "If no one in my family had it, and I was suddenly diagnosed at 36, it would have been more shocking. Or I'd be like oh my god, I'm crazy." "I knew a lot about bipolar before I was diagnosed; it is a weird difference in understanding." "Even though there is some 154 stigma and some fear… negativity with the ups and downs, being exposed to it at a much younger age, it stigmatized but also normalized a bit. They're wrapped together." Participants also explored the way their language mirrors their understanding. Alissa shared that she is mindful of using the language "has" BD instead of "is" bipolar as it maintains her separation from her diagnosis. Similarly, Evelyn explored her current exploration of what language she feels fits when describing her diagnosis, consciously using person-first language. Who Am I in Relation to My Parent? In navigating their identity, participants also explored their identity concerning their parent with a shared diagnosis. Although seeking differentiation from your parents is not unique to experiences of intergenerational BD, potential processes are perhaps exaggerated when something central to each participant's experiences is shared with their parents. All participants also referenced some comparisons and the desire to differentiate themselves from their parents. For Frank, this was extreme; his life echoed distancing himself from and seeking opportunities to be different from his mother. This appeared to be central to Frank's identity and the sensemaking of his experiences and is illustrated in the following excerpt of his story: Frank asserts on many occasions how he is different from his mother. He began our first interview by sharing: "I think how my mom was diagnosed and how she responded to her diagnosis is quite different to how I responded to my diagnosis." Frank's mother felt she didn't need medication. "Look at how… unstable my mother is because she didn't take medication." Frank takes his unchangingly, almost as an act of rebellion. "If I take medication, it's like doing the opposite of what your parents do." 155 In contrast, despite Evelyn's previous feelings of relief to not be "crazy like [her] mother," Evelyn looked to her mother as a role model, an approximation of things to come, of hope. Ella and Evelyn both saw their mothers as potential predictions of the future, for better and for worse, expressing ways in which their mother's health was inspirational while also grappling with worries that they might end up 'like [their] mother.' In contrast, for Frank, his mother was, in his eyes, perpetually imbalanced, which facilitated his motivation to strive for "stability" through treatment adherence. Alissa's father influenced her to seek support, as she worried she might end up like her father if she did not. Both Alissa and Frank attributed their parents' symptomology to treatment adherence, as they were aware of what it might be like if they did not seek support. Charlotte's relationship with her father was unique, as she only recently connected with him as an adult. Charlotte thought her father's positive outlook towards BD was supportive in reducing her self-stigma and feelings of worry upon receiving her diagnosis. Her father helped her reach her turning point to receiving a BD diagnosis and was someone who understood her experiences. Other participants also explored the role of parents as a tool for diagnosis. Ella felt her mother's attunement to her symptomology, and her doctor's knowledge of her mother's diagnosis allowed her to be diagnosed and treated before she "spiralled too far," leading to what she believes to be the "best possible outcome." Similarly, Charlotte wondered how long it would have taken her to be diagnosed had she not connected with her biological father, as the knowledge of his diagnosis was what facilitated the shift to her being diagnosed with BD. For Alissa, we hear echoes of this during her first manic episode, as described in the following excerpt from her story: 156 When others suggested that Alissa might be going through a hard time, she recalls comparing herself to her father and thinking, well, I am not drinking as much, spending as much, or sleeping as poorly. This comparison shielded Alissa from her hypomania, as she felt she was functioning well, particularly compared to her father. During this period, a psychiatrist suggested to Alissa that she might have BD herself, but Alissa dismissed him. "You might know that my father also has a diagnosis, but I am not like him, and you should not assume that." Later in her story, Alissa recalls using her father as a template for what might come if she does not seek help and is therefore motivated to see a diagnosis of her own. This is highlighted when Alissa recalls her reflections on her own behaviour: "Ok, now you are just exactly repeating your father's pattern. Why don't you take the advice you gave him?" "You have seen what happens if you do not." "You have to get this under control." "Otherwise, I might end up like my father." "I do not want it to ruin my life when I am 40. If I even make it to 40." She sought a diagnosis and felt held and heard by the clinicians who supported her. "I am very grateful for the way the system took me in." These shifts between differentiation and the similarity between the parent and child focus attention on the complex experiences of intergenerational BD. This balancing act of positive and negative associations is central to intergenerational mental illness but also highlights the nuances of participant experiences. ‘Be the Best That You Can.’ Finally, a goal within the stories of intergenerational BD is striving to ‘be the best that you can.’ This theme was interwoven with the previous themes, as 157 participants described a self-referential goal of being the best that they can be. As Evelyn described, these shifts occur painstakingly, like climbing a mountain, one step at a time. Striving to ‘be the best that you can’ was expressed by Frank as he described his goals to be more stable, more open, and facilitate positive change for others. For example, in his work, he references teaching parents to have conversations that would have helped him as a child. He has worked to ‘be the best that [he] can.’ Similarly, Charlotte described her daughter as being a reason why she strives to be the best version of herself, reflecting that parenting is a “constant analysis of honesty and humility; you want to be the best that you can.” Charlotte hopes she had not “done too much damage” before her diagnosis and reflects on how she continually strives to ‘be the best [she] can.’ Similarly, Ella described ways her mother is there for her in ways that her grandmother could not be. This balance and compassion in understanding allowed Charlotte to accept multiple truths, differentiate her experiences with her mother, and see her as a human. It also provided hope and a template for how to work to shift and slow patterns across generations within a family system. In a broader sense, in considering societal shifts, Ella and Evelyn described ways in which the system did better unto them than was done to their parents. For participants, striving to be the best they can highlights a self-referential and balanced goal of growth they are continually working towards. Participants look to themselves to be the best version they can be rather than looking to others or for external referents. In these descriptions, participants’ language illustrates a sense of optimism, a sense that this goal is attainable, and an underlying sense that it is continually active and is something they are striving for. ‘Be the best that you can’ encompasses mindful optimism; it brings to mind the idea of compassion for the self, perfectly imperfect. However imperfect, Charlotte described how her 158 mother strove to do better than was done unto her, illustrating compassion for incremental positive shifts within the self and the other. Summary Of Themes. Participant stories highlighted four broad themes: agency (powerlessness), communion (isolation), identity (confusion), and ‘be the best that you can.’ These themes highlight the goals participants worked towards in their journeys of intergenerational BD. Throughout their journeys, participants actively worked towards these goals. A sense of mindful optimism was present, highlighting that participants were approaching these goals. Yet, an indefinite or cyclical nature underscored stories, highlighting that these goals may be something that they continually strive for. Motifs Motifs are common narrative features, signalling something important to listeners/readers. A motif can be an object, a place, a person, or an idea. Motifs underscore and reinforce themes; they also serve as connectors within a story, linking events and themes and may set the tone of the story. The motifs within these stories of intergenerational BD are cycles, secrets, and grief. Each motif is further discussed below. Cycles. Cycles were a motif across participant stories. Cycles were used repeatedly in participants’ meaning-making of their own experiences, experiences of symptoms, and in the language to describe their BD diagnosis. Cycles underscore the exploration of the themes that emerged in the cross-narrative analysis as participants toggled between the counterpointed dimensions of each theme. This was most explicit in participant experiences of regaining and losing agency in relation to the cycles of their symptoms returned. Evelyn specifically talked of experiencing ‘cycles’ of feeling as though she had regained agency and things were going well before a recurrent onset of symptoms, which 159 then led to a loss of agency and a return to her original sense of powerlessness. Similarly, Charlotte referenced “cycling” and BD being “cyclical,” particularly before accessing the appropriate treatments, and Ella expressed feeling ‘stuck’ in the cycles of her depressive episodes. The motif of cycles is explicit in each participants’ language and understanding of BD. Many described ‘rapid cycling,’ a clinical term for when at least four episodes of either depression or (hypo)mania occur within one year. Further, for many participants, examining their lives for ‘cycles’ of episodes was essential in differentiating their symptoms as being illustrative of BD specifically. Similarly, participants also referenced the ‘cycles’ of their parent’s behaviours, referencing patterns that occurred ‘again and again.’ For example, when describing her father’s symptoms, Alissa recalled thinking, “This comes back and back again,” “Okay, here we go again.” These recurrent experiences facilitated a sense of loss of agency and loss of their parent to their symptoms. As participants regained agency, they explored how they continued to work to shift or even break ‘cycles.’ This can be seen in participant descriptions of comparisons to their parents, being the best versions of themselves, and being mindful and intentional in attempts to slow intergenerational patterns and cycles. As is common in storytelling, all participants reengaged with their past through many cycles of understanding and meaning-making throughout their journeys. Diagnosis, as a major turning point, also leads to a reinterpretation of participant pasts. Evelyn and Charlotte specifically explored reinterpreting their lives with knowledge of their diagnosis as they sought a greater understanding of their past. This reinterpretation of the past is a component in seeking balance and resolution of their journeys. 160 Secrets. Within the family system, family patterns of communication were part of participant stories. Specifically, many participants emphasized a lack of communication and a sense of secrecy in their experiences. Participants expressed how this intentional withholding of information had rippling impacts throughout their lives. Many participants described an unspoken understanding of their parent's illness in childhood with a simultaneous lack of explicit communication. As Alissa described, "I could sense that something was being… kept as a secret from me… there was something hidden." This sense of secrecy facilitated experiences of confusion and isolation. Evelyn recalls these feelings of confusion being heightened during visits to her mother at the hospital and thinking, "Why is my mom here?" For some participants, the secrecy was more explicit. Ella described how she was not supposed to tell her friends about her mother's diagnosis. Alissa later described, after learning about her father's diagnosis, "It kind of felt like a big burden and a secret that I had to, like, keep up appearances." Similarly, Frank describes an ingrained sense of secrecy about his mother's mental health and how it impacts his relationships with his siblings today. Charlotte was not in contact with her father and was unsure how to navigate conversations about him without upsetting her mother. This sense of secrecy exacerbated participants' feelings of isolation and fear, particularly early in childhood. In a similar vein, many participants described a sense that their own feelings should be kept a secret as well. Specifically, many described in childhood a sense that feelings were not safe or that their feelings were unmanageable. Evelyn recalls thinking her mother was too emotional and that emotions were what led to hospitalization. Similarly, Ella recalled being sent to her room to manage her feelings independently from a young age. This led many participants 161 to minimize their feelings to focus on those of others. Perhaps having learnt this at a young age, participants also described later in life a pull to hide their own symptoms and challenges, with Charlotte describing her attempts to "push it down" and spin plates of normalcy. This potentially contributed to some participants' hesitation in seeking support for their own challenges. In reflecting on their pasts, participants thought explicit conversations might have supported them in their childhood. Specifically, Evelyn explored how communication about mental health in general might have been supportive, as well as conversations legitimating her right to have emotions of her own. Charlotte, who was not raised in the same home as her parent living with BD, described a sense of emotional intelligence and ease of conversation in discussing her maternal family legacy of anxiety, depression, and the associated experiences. Although this same openness has not translated to discussions about her diagnosis of BD, Charlotte credits this openness to helping her in being able to advocate for and seek help throughout her life. Alissa's family was the one in which there was clear communication of family mottos and understanding related to BD. Despite the explicit conversations later in life, Alissa's father's diagnosis was hidden from her until she was 13. Presently, Alissa shared that her family tends to avoid conversations about her father's BD as the conversations are often painful. This secrecy was mitigated by family mottos. During times of hardship, Alissa's family motto ("You can always be well again") instilled a sense of optimism and communion as the family navigated the hardships together. Alissa explicitly explored how this was supportive of her and still helps her with her feelings of agency and identity. Presently, participants described varied levels of familial communication, the obverse of secrecy. Evelyn pridefully shared her family's shift away from secrecy and work to have more 162 open conversations. For Charlotte, connecting with her father as an adult allows her to have open and honest conversations with him without the patterns of her childhood. All participants expressed some desire to shift away from the secrecy that improves communication within their family systems, particularly concerning BD. Similarly, Frank and Evelyn also described their own pulls towards secrecy regarding their own diagnoses and their attempts to be "more open" than their families. As Evelyn described, "Seeing my own family members with it, it's definitely had that stigma effect… don't tell people; they're going to think you're bad." Despite this ingrained sense of stigma and pull towards secrecy, Evelyn explored how she has worked to be more open, "Sharing has been helpful but scary. The more I tell, the more positive it is; it makes me more comfortable to share." This is a way in which Evelyn is working towards shifting intergenerational cycles of secrecy. Grief. Grief was also a motif in the stories. This includes experiences of grief throughout their journeys, as well as a sense of grief associated with receiving their diagnosis of BD. Many participants described the experiences of loss and associated grief as turning points within their stories. Evelyn described the loss of her cousin and the associated grief as mobilizing her desire to seek help for herself. Further, although not explicitly explored in the stories, participants may have experienced grief as they navigated the loss of agency, identity, and communion throughout their lives. Grief was an underlying idea explored in relation to parental symptoms. Alissa described a sensation of grief in navigating her feelings of powerlessness and having 'completely lost' her father each time he became hypomanic. Similarly, Frank's story shares a sentiment that he lost his mother to her instability, as he describes her physical presence but her absence as a parent: 163 "My mother wasn't… she was there, but she didn't have the capacity to parent me." These experiences of loss were challenging for participants as they navigated early childhood. Participants did not explicitly describe a sense of acute grief with the onset of their symptoms. However, they did describe experiences of grief upon receiving a diagnosis of BD, including a sense of loss of self and grief for their futures and past as they renegotiate and seek balance in their stories. As Evelyn shared, "I grieve a lot for what I could have had. If I didn't have [BD], where would I be?" Evelyn explores how this sense of grief is unique, and she feels only her mother can understand the complex emotional reactions to receiving a BD diagnosis. Participants also explored grief for their parents upon receiving their diagnosis. Alissa worried about telling her father of her diagnosis out of fear he might feel burdened with guilt. Similarly, Evelyn and Ella reported that both their mothers experienced a feeling of grief and hardship as a result of their diagnoses. This again highlights the complex emotional reactions to receiving a diagnosis, particularly for those who typically have a caregiving role within their family systems. Summary of Findings The participants’ stories are ultimately journeys of endurance and endeavour through obstacles and turning points to seek balance. They are stories of feeling stuck within cycles and the reclamation of one’s own power as agency, identity, and communion are built. These stories are underscored by experiences of grief, secrecy, and cyclical behaviour. They are shaped by the protagonists’ pull to differentiate themselves from their parent while simultaneously experiencing unmatched communion with them. They are journeys toward being the best that you can be through reflection, mindful optimism, and self-acceptance. 164 CHAPTER FIVE: DISCUSSION OF THE FINDINGS The present study aimed to understand how those within a family system with an identified family history of bipolar disorder (BD) make sense of their experiences. By asking adult children to share their retrospective accounts, the research questions used as a framework to guide this study are: (1) how do second-generation diagnosed individuals experience intergenerational BD? (2) how is intergenerational BD communicated and relationally experienced within families? In inviting participants to share the narratives they used to make sense of their experiences, I heard detailed and rich accounts highlighting the complexities, risks, and advantages associated with intergenerational BD. The following section will discuss the significant findings, limitations, implications, and future research and practice recommendations. Brief Overview This study sought to understand the lived experiences of those with intergenerational BD. The study's main findings are the five participants' re-storied narratives. Although commonalities across stories exist, each re-storied narrative is equally important in representing each participant’s unique voice, context, and sense-making. The stories are journeys of endurance and endeavour from powerlessness to agency, isolation to communion, and confusion to identity. Participants sought balance and to 'be the best that [they] can.' Within each theme, a vacillation between experienced hardships and advantages was explored; as Charlotte described, "It doesn't have to be one thing or another." Discussion of the Findings in the Context of the Existing Literature This section discusses the present study's findings in the context of the existing literature. I will review how the findings relate to the two research questions and explore how the findings 165 converge and diverge from what is known about intergenerational BD. Although the two research questions are interwoven, I have parsed them in the sections below for discussion. Second-Generation Experiences of Intergenerational BD The first research question asked how second-generation diagnosed individuals experience intergenerational BD. Specifically, I sought to learn about the experiences embedded within the intersecting identities, including as a child, an individual, and potentially, as a parent. I explore the findings as they pertain to participant clinical experiences, experiences with agency, communion, and identity, and narrative sensemaking. Clinical Experiences. Clinically, the experiences of second-generation individuals both converged and diverged from the extant literature. All participants described initially experiencing symptoms of depression and a delay between the onset of their symptoms and their diagnosis, as typically occurs within the BD population (Fritz et al., 2017; Hirschfeld & Vornik, 2003; Lish et al., 1994; Zimmerman et al., 2008). Alissa and Ella were both diagnosed through the lens of their parent’s diagnosis, which facilitated a diagnosis within five years of their initial symptom onset. This is substantially shorter than the average delay of up to ten years (Fritz et al., 2017; Hirschfeld & Vornik, 2003; Lish et al., 1994). Similarly, Frank was diagnosed within a similar timeline despite not knowing about his mother’s diagnosis of BD. Accelerated time to diagnosis through the lens of a parent may facilitate a number of positive outcomes, as delay in diagnosis has been associated with increased severity and quantity of depressive episodes, higher rates of unemployment and higher rates of mortality (Leboyer & Kupfer, 2010; Post et al., 2010). Charlotte and Evelyn both experienced years of misunderstanding and misdiagnoses prior to receiving their BD diagnosis, as is more generally described in the literature. Their stories provide rich descriptions of the hardship associated with these years and the associated 166 feelings of self-blame and doubt. For Charlotte, connecting with her biological father and learning about his BD diagnosis facilitated her own diagnosis. Thus, despite her delay in diagnosis, her parent’s diagnosis and the associated awareness did support her in accessing a diagnosis. Unlike the other participants, Evelyn experienced a delay in diagnosis despite knowledge of her family history of BD and her having sought mental health support and assessments. Evelyn and Charlotte both explored the role of the media in their misunderstandings of BD, specifically their symptoms of hypomania, as a factor which exacerbated their delays in diagnosis. Specifically, they described the ‘extreme’ media portrayals of BD as facilitating a misunderstanding, as well as experiencing their hypomania as relief from depressive episodes rather than symptoms themselves to report. Their reports are consistent with Leprich’s (2021) argument that misdiagnosis is systemic, citing a potential lack of knowledge among primary care providers or individuals not reporting (hypo)manic symptoms as they see them as being positive. Once diagnosed, all participants explored their parents as playing a role in their treatment adherence, regardless of their parents’ own adherence. Frank and Alissa’s parents presented cautionary tales and examples of what might occur if they did not adhere to their treatment. In contrast, Ella, Evelyn, and Charlotte’s parents were positive role models of treatment adherence, supported by information sharing and facilitating a sense of hope. Further, Ella said that her doctor’s knowledge of her mother quickly supported her optimization of medication quickly. Treatment adherence is a persistent challenge in supporting BD, with research estimating that about half of those living with BD are non-adherent with their prescribed medication (Jawad et al., 2018). Stigma and family attitudes have been previously identified as potential underlying variables to treatment nonadherence (Berk et al., 2004; Scott et al., 2012; Shoemaker & de 167 Olivera, 2008); however, to my knowledge, no study has previously identified the potential modelling of a parent with the same diagnosis. Overall, in considering the clinical experiences of those living with second-generation BD, this study highlights that these individuals may experience a reduction in the typical delay between symptom onset and diagnosis and increased treatment adherence. As treatment adherence and delay in diagnosis pose long-lasting and substantial challenges in the BD community, these findings are considerable. These findings pose pathways for further investigation. Experiences with Agency, Communion, and Identity. Within participant journeys, agency, communion, and identity were key themes and goals. These findings alone are not unique to experiences of intergenerational BD, as these have been themes documented in research in BD more broadly (Crowe et al., 2012; Pedersen et al., 2017.) However, within this study, participant stories highlight the unique ways intergenerational BD shaped their navigation of fluctuations within their senses of agency, communion, and identity. Agency has been defined within the mental health literature as the autonomy of the protagonist and the degree to which the protagonist is in control of the plot, feels empowered, and can initiate changes for themselves (Pedersen et al., 2022). This study builds on the extant literature that has found a loss of control or agency is prevalent in the lives of individuals living with BD (Crowe et al., 2012; Pedersen et al., 2017) in highlighting how intergenerational experiences of BD can lead to fluctuations within these experiences. The present study highlights how intergenerational experiences of BD can lead to reductions in individual feelings of agency, particularly early in life. Participants described not only feeling powerless to their symptoms prior to diagnosis but also feeling powerless to their parent’s symptoms as a child. Some 168 participants also described initial feelings of powerlessness specific to the hereditary and intergenerational experiences of BD. Specifically, in line with Crowe and colleagues’ (2012) findings that participants reported feeling as though they could have never controlled or avoided BD due to its hereditary nature, Evelyn described feeling ‘paranoid’ and like a ‘ticking time bomb’ prior to her diagnosis of BD. In balance, the present study also highlighted ways a shared diagnosis can help facilitate negotiations of agency. Evelyn’s reflections that her prior knowledge of BD due to her experiences with her mother was helpful in accepting her diagnosis. Similarly, other participants described how their parents’ diagnosis facilitated their turning points of diagnosis and self-acceptance. Thus, the role intergenerational experiences of BD play in experiences of agency is nuanced. It seems that intergenerational experiences may exacerbate a sense of powerlessness before diagnosis but potentially accelerate regaining agency following BD diagnosis. Similarly, the results of this study highlight the nuance within participant experiences of communion. The present study expands on Pedersen and colleagues’ (2022) findings that individuals living with BD express low levels of communion early in life by exploring how this experience shifts following a diagnosis. Specifically, with the revelation of a shared diagnosis many participants described an unmatched closeness, understanding, and support from their parent. Many participants felt grateful for having a parent with the same diagnosis, citing that their parents can be there for them in a way other family members cannot. To my knowledge, no research to date has identified this. Further, participants also expressed that their parents also felt an unmatched closeness with them, suggesting this sense of unmatched communion and its potential positive implications may affect not only the individual but also their parent. 169 These findings directly contrast Crowe et al.’s (2012) finding that individuals with BD described feeling misunderstood by their family members and Reichart et al.’s (2007) findings that individuals experiencing intergenerational BD reported increased experiences of parental rejection. Frank’s experience is similar to these findings, as he reported feeling distanced and let down by his parents throughout his life. However, Frank did not attribute these experiences to his BD diagnosis. Similarly, Charlotte found her BD diagnosis distancing between her and her mother. However, Charlotte described how this distance was counterbalanced by her unmatched sense of understanding, support, and acceptance from her father. Identity was another theme that was common throughout participant narratives. Although participants grappled with (re)negotiating their identity throughout their journeys, participants expressed having made toward negotiating their identity with some sense of resolution. Within navigations of their own identity, all participants expressed some desire for differentiation from their parents. This experience is not unique; family differentiation has been well documented as an expected and important phenomenon as adolescents transition into adulthood (Bowen, 1978). However, to my knowledge, there is yet to be a study that has highlighted disentangling the self from one’s family member with a shared diagnosis when renegotiating the self after a diagnosis. All participants compared themselves to their parent with a shared diagnosis, whether it was their parent as a template of what to expect, their parent as a cautionary tale, as a role model, or some combination of the three. Participants highlighted the complex ways they pushed and pulled from their parents as a template for understanding and identity. Thus, participants not only worked to renegotiate their identity to integrate the ‘sick self’ and the ‘healthy self,’ as described by Fernandez et al. (2014), but they also worked to integrate the ways they were similar and 170 dissimilar to their parent living with BD. This is a crucial way participants worked to renegotiate and make sense of their identity unique to the intergenerational experiences of BD. Finally, Ella and Alissa explored their reflections on having children themselves. In line with Dolman and colleagues' (2016) research, they expressed some worry about how their diagnoses may affect their experiences in parenthood. However, despite these worries, both Ella and Alissa maintained a cautious optimism that they would be able to manage these possible challenges and themselves 'be the best that [they] can.' Ella and Alissa's sense of agency may be an underlying factor in their mindful optimism about their ability to manage parenthood. Further, their positive experiences of communion and understanding from their parents with the same diagnosis may facilitate mindful optimism in considering their own potential roles as parents. Overall, the balance of advantages and hardships underscoring each theme highlight the nuance of the experiences of those living with intergenerational BD. This finding is consistent with Fernandez et al.’s (2014) findings that coping with BD can be understood as a ‘vacillation’ as individuals try to accommodate facets of their identity while preserving others. This study expands on this ongoing vacillation in the exploration of integrating the self as a child and as an individual, as someone reclaiming one’s own agency, and as someone both experiencing isolation and unmatched communion. Narrative Sensemaking. Participant stories were journeys of endurance and endeavour through obstacles and turning points to seek balance. Within these journeys, all participants described many turning points, with every participant describing turning points related to their parents. In childhood, many participants described an acute episode of their parent’s illness as a turning point. This is consistent with Miklowitz’s (2008) finding that manic and depressive episodes are described as significant life events for not only the individual but also their familial 171 system. Further, for participants whose parents experienced hospitalization in their childhood, this was always a turning point. In keeping with Yamamoto and Keogh’s (2018) meta-analysis, participants who experienced parental hospitalization found it a frightening experience with long-lasting negative impacts. Ella and Charlotte also described (re)connecting with their parents as a turning point for them in gaining a sense of communion, facilitating their own diagnoses and regaining agency. Thus, the inclusion of parents in turning points highlights the significant role they played in participant stories. However, the varied nature of the turning points illustrates how the parent’s BD could result in both hardship and support for the child. The narrative tone expressed across stories was one of mindful optimism. Optimism has been documented as an important component of stories of mental health recovery (Lapsley et al., 2002; Wisdom, 2008); the present study builds on this through the participants’ expressions of mindful optimism through their self-referential goal to ‘be the best that [they] can.’ Participants expressed an awareness of potential hardships to come while reflecting on their tools to overcome them. In considering the outcomes of these journeys, all participants described some sense of resolution. Participants described their lives with a sense of pride, reflection, and self-awareness. In interviews, participants pridefully described having built their rich lives. All participants had gainful employment, post-secondary education, and many graduate degrees. These findings are important to note in light of Gladstone’s (2006) call to highlight the resilience and accomplishments of children living within the context of intergenerational BD. Relational Experiences of Intergenerational BD The second research question that guided this study asked how intergenerational BD is communicated and relationally experienced within families. To answer these questions, I turn to 172 the theoretical underpinnings of this study, Family Systems Theory (FST; Bowen, 1978), and the understanding that actions and interactions between family members are continuously influenced by each other. Within this framework, participants described how they relationally experienced BD as the family system responding to the environmental conditions to meet the needs of family members. In their stories, participant descriptions mapped onto six of the eight identified concepts within FST (Bowen, 1978), further described in Table 6 below. In times of perceived need, many participants described sacrificing their own age-appropriate needs to assume a caretaking role within the family system. Parentification has been demonstrated to be a recurring pattern of experience within family systems experiencing parental mental illness (Maybery et al., 2005). Emerging research has suggested that parentification may lead to benefits such as increased self-esteem and resilience (Masiran et al., 2023). The present study did not specifically identify or evaluate the perceived benefits of parentification; however, it did highlight some sense-making participants engaged in related to their caregiving roles. Specifically, many participants described their roles as necessary, natural, or the only thing someone in their position might have done. Perceiving their roles as having been necessary may help to facilitate the increased self-esteem described by Masiran and colleagues (2023). 173 Table 5 Findings as they Pertain to the Core Concepts of FST Findings as They Pertain to the Core Concepts f FST Concept Definition Relevant Findings Family Projection A way in which parents automatically and unconsciously transfer their own emotional distress onto a child. Broadly parental projection can occur if a parent focusses on a child out of fear that something may be wrong with the child. Participants did not express experiences of family projection. In contrast, participants described their parents' emotions dominating the family system not leaving room for the child to experience distress themselves. It is possible parental needs were so great within this family system that family projection did not occur. Alternatively, given the participant's existent BD diagnoses, family experiences of projection may not have been recalled or understood as having been 'projection' but rather 'attunement.' Thus, it is possible that family projection did occur within the family system, only with other family members whose voices were not a part of the study. Multigenerational Transmission Process The unconscious and conscious transmission of patterns across generation. Bowen generally looked across three generations of a family. This was present across stories of 'be the best that you can,’ with many participants reflecting on how their parents also participated in incremental positive changes. An example of this is Ella's story, where her mother supports her in ways that her grandmother could not. Thus, Ella was able to benefit from the multigenerational shifts towards health. Similarly, Charlotte engaged in mindful attempts to do differently for her daughter through attempts to build a familial sense of support and avoid a multigenerational transmission of parentified children. Charlotte also reflected on how her mother could do better for her than was done to her despite her imperfections, acknowledging her mother's positive shifts across generations. These findings are consistent with Peterson et al.'s (2013) findings that mothers with BD reported being vigilant, mindful, and attentive to their own parenting behaviour and Boursnell's (2011) findings that parents with mental illnesses discussed wanting to 'break the cycle.' These findings are also supportive of Patrick et al.'s (2019b) call for more research investigating the parenting roles of adult children of parents experiencing mental health concerns. Triangles Within two-person conflict humans naturally include a Some evidence of triangles was apparent in participant stories; Evelyn described her father potentially feeling threatened by her newfound closeness with her 174 Concept Definition Relevant Findings third to alleviate tension. Triangulation can be a healthy way of reducing conflict but also poses the risk of facilitating one of the members of the triangle feeling like an outsider. mother following her diagnosis. Similarly, Ella, Charlotte, and Frank described frustration and hostility towards their 'well parent,’ particularly later in life. This potentially illustrates a function in which their unmatched understanding of and intuitive empathy for their parent with the same diagnosis facilitated frustration being redirected toward their other parent. This may be further amplified in cases where the increased frustration leads to the emotional cut-off or distancing of the ‘well parent.’ Differentiation of Self The degree to which a family member can separate their own emotional system from their intellectual system and keep their emotions and thinking separate. The ability to think rationally and logically even while upset. Participants had a somewhat reflective and balanced view of their parents showing compassion as they simultaneously described the hardships experienced, illustrative of differentiation of self. Alissa told her mother, "I hate my father, but somehow I like him better." Evelyn shared, "I still love my mom; she's my mom. There are good things; it was just a lot." Differentiation of self is a sign of relational health and a predictor of psychological health (Sandage & Jankowski, 2010). Participant indications of differentiation may have resulted from their experiences of parentification, in line with Hooper’s (2007) proposed theoretical framework. Specifically, she proposes that internal working models, including the meaning made of the parentification process and positive relational experiences, could lead to select positive outcomes, including adults who are high functioning, resilient, and have high levels of differentiation of self. Emotional Cut-off Managing unresolved tension or emotional difficulties amongst family members by cutting off emotional connection from their family system. Emotional cut-off was most apparent in Frank's story, where he physically and emotionally distances himself from his family following high school graduation. Frank reconnected with his siblings later in life but maintains some emotional distance from them, perhaps representative of unresolved anger towards his parents, whom he felt let him down. Similarly, Charlotte distanced herself from her mother early in life and potentially continues to experience emotional cut-off from her mother. Bowen (1978) posits that emotional cut-off leads to immediate comfort but leaves emotional issues unresolved and vulnerable to transmission across generations. 175 Concept Definition Relevant Findings Charlotte, perhaps attuned to this vulnerability, was explicit in her wishes to shift generational patterns with her own daughter. Other participants reported attempts to resolve tension and maintain emotional closeness with their family members, indicative of relational health. Nuclear Family Emotion System The complex patterns that govern where problems express themselves within a family system. The four patterns are emotional distance, marital conflict, dysfunction in a spouse, and transmission of the problem to a child. Emotional distance as a means of coping with family conflict was prevalent across stories. The most extreme examples described above in descriptions of emotional cut-off. Explicit descriptions of marital conflict as a result of family tension were not described in participant stories. Participant’s vacillation between closeness and distancing with their parent living with BD may be an example of the ways the family system may adjust to tension by dysfunction in a parent. This might also help us to understand participant descriptions of being let down by their ‘well parent.’ Participant symptoms were likely not an expression of excessive worry or negative view of the child but the interplay of genetic, neurochemical, and environmental factors which would impact BD symptom onset and development. Societal Emotional Process and Regression The extension of the family emotional system into a larger social system All participants described the role that the broader social system played in their stories. Participants explored the role of the societal and cultural system as well as the mental health system across stories. This was particularly notable in participation observations of shifts across generations and Charlotte and Evelyn’s descriptions of the role the media in their understanding and acceptance of BD. Sibling Position Each sibling position is thought to be associated with its own patterns, strengths, and weaknesses. For example, eldest children are more likely to take on responsibility and caregiving. Evelyn was the only participant who was the eldest child and described patterns of caregiving consistent with her sibling position; no other clear patterns were noted. Instead, most participants described parentification regardless of their sibling’s position. Parentification has been demonstrated to be a recurring pattern of experience within family systems experiencing parental mental illness (Maybery et al., 2005). This is potentially suggestive that within families experiencing intergenerational BD other factors outside of birth order may play a greater role in determining roles within the family system. Note. The concepts defined in this table are adapted from “The use of family theory in clinical practice” by M. Bowen, 1966, Comprehensive Psychiatry,7, pp. 345-37 176 In sum, the results of the present study are convergent with FST and the concepts and patterns identified by Bowen (1978) in many ways, with only family projection not explored to some degree and patterns of sibling position not being clear. Generally, the families described in the participant's narratives seemed to work as a system, with individuals shifting and stepping into various roles as the needs of the family’s needs shifted, with these patterns of roles explicitly noted and intentionally shifted across generations. The present study sheds light on some of the sense made of participant experiences of parentification, which has been found to facilitate potential positive outcomes (Hooper, 2007). Further, it highlights how participant experiences of unmatched communion with their parent with the same diagnosis influence the family system and processes within it, such as shifting dynamics with the ‘well parent.’ Familial Patterns of Communication. Within FST, Bowen (1978) posits that how a family communicates creates a template for future generations’ values, thoughts and experiences. Specifically, family narratives help to clarify and justify patterns within the multigenerational transmission process and provide direction toward choices, routines, and “how things are done” (Manoogian et al., 2010, p. 42). In the present study, in place of explicit communication, secrecy or ‘intergenerational silence’ was the dominant familial pattern of communication. Within family systems, the intentional withholding of information may be enacted to protect (the self and others) from negative experiences, maintain a sense of family stasis, or enable family patterns of avoidance (Siim, 2016). Although family secrets may occur with the best intentions, secrets implicitly communicate ‘things are done’ privately, without the support of others, and underscored with shame. Participants lived this experience when they encountered hardships, specifically describing feelings as unsafe or something to manage independently. This could be conceptualized as a function of parentification where participants sacrificed their own 177 emotional needs for those of their families, as well as a result of the undertone of shame associated with the secrecy of their parents’ hardships. The withholding or denial of one’s own hardship potentially exacerbated the delay between the onset of symptoms and diagnosis of BD, as some participants described an initial denial of their symptoms, efforts to hide them, and difficulties in seeking help. In their experiences of secrecy, participants expressed a desire for more conversations to have been had and wished they had more conversations with their parents about BD. This is consistent with Flood-Grady and Kellas’ (2019) argument that parents are “primary storytellers” and borrowing from Manoogian et al.’s (2010) referring to parents as “intergenerational lynchpins” in communicating how things are done. In keeping with these findings, although parents did not often explicitly communicate with these participants, something was implicitly communicated as many participants referred to their parents as either role models or cautionary tales. Thus, it illustrates the role of implicit communication in considering family stories of health. Alissa’s family was the only one to have described family mottos and explicit conversations about her father’s BD. Alissa explores how her family’s motto supported her ability to maintain hope and resilience through challenging times and understand herself as being “more than one label.” Still, Alissa also described a history of familial secrecy and avoidance. This potentially illustrates how families can work towards being ‘the best that [they] can’ in continuing to make incremental changes towards openness and developmentally appropriate communication. Similarly, all participants described their shifts toward increased openness in their own adult lives, in working to shift away from their familial patterns of secrecy. 178 Despite the lack of explicit conversations, some participants thought that having a parent living with BD helped them to identify symptoms, seek help, and know what to expect in managing their own symptoms. That is, some participants reported that their parents helped to facilitate this increased awareness and knowledge. Learning from others, including learning about signs and symptoms of mental illnesses, has been suggested to help facilitate recovery (Colom, 2011); however, to my knowledge, no study to date has explored how learning implicitly and first-hand from a parent can influence levels of awareness and knowledge. Participants said that their parents influenced their access to appropriate treatment and treatment adherence regardless of their parents’ own treatment adherence and the family pattern of communication. This suggests that despite familial secrecy, the nonverbal or indirect communication within the family systems supported participants in their decisions to adhere to treatment. This is supportive of Flood-Grady & Kellas’ (2010) findings that children can learn positive lessons from familial stories of mental illness regardless of whether the stories themselves are negatively valenced. In sum, family secrecy was the dominant pattern of communication within participant stories. Familial secrecy and intergenerational silence had negative impacts, including participant’s learning that their own hardships were something to manage independently. Despite familial patterns of secrecy, participants implicitly learnt signs and symptoms of BD and information which facilitated their own treatment adherence. Finally, all described intentional shifts towards openness in their own adult lives and attempts to slow the intergenerational patterns of silence. 179 Implications For Future Research This study sheds light on the sense individuals experiencing intergenerational BD make of their lives. The findings were consistent with many research findings while also shining a light on the unique experiences of intergenerational BD, including how having a parent with the same diagnosis facilitated both advantages and hardship. Future research should explore balancing the strengths and challenges associated with having the same diagnosis as a parent to help better understand and disentangle these opposing experiences. Research has demonstrated treatment adherence is a persistent challenge across BD (Jawad et al., 2018). Interestingly, all participants adhered to treatment, many referencing their parents with the same diagnosis as a reason for doing so. This is potentially due to the nature of the sample but may also have been influenced by intergenerational learning and role modelling. Similarly, some participants described being diagnosed through the lens of their parents, which facilitated accelerated time to diagnosis. Future research should seek to better understand these potential benefits and how to encourage them within family systems with BD and other mental illnesses that have a strong hereditary link. In considering identity and communion, this study highlighted that many participants experienced a transition from isolation towards an unmatched communion and sense of understanding from their parent living with BD once diagnosed themselves. As the potential for this experience of unmatched closeness may prove particularly protective within a population that experiences stigma, low levels of communion, and feelings of isolation (Dam & Hall, 2016; Pedersen et al., 2022) it is crucial to disentangle what might facilitate and prevent this sense of unmatched closeness. In the present study, participants who described an unmatched sense of closeness and understanding from their parent reported that their parent had also worked to 'be 180 the best that [they] can.' Perhaps the parents' own experiences of agency, identity, and communion are central in understanding their acceptance and understanding of their child, as it could be presumed that understanding and accepting oneself might be a precursor to understanding and accepting BD within another. Further research should seek to disentangle what facilitates or prevents this sense of unmatched communion. Similarly, this study touched on how having a parent with the same diagnosis shaped the participants' explorations of identity, as all participants grappled with some comparison to their parent and expressed desires to be different from their parent in their experience with BD. Future research may seek to understand in greater detail how having a relative with the same diagnosis may influence the understanding and forging an identity outside of your diagnosis. Specifically, it may seek to disentangle the potential benefits of having a parent with the same diagnosis by comparing individuals with and without a parent with the same diagnosis reports of treatment adherence, quality of life, and self-acceptance. Future research may expand our knowledge of intergenerational experiences of BD through varying methods of participant recruitment to provide an understanding of BD in a broader sense. Additionally, interviewing individuals at various points in their life, including childhood and adolescence may lead to further insight. As humans we tend to retrospectively revise our narratives to integrate new events or create unity within ourselves (Polkinghorne, 1988), memory being described as a “self-serving historian” (p. 76) (Tavris & Aronson, 2008). Thus, interviewing individuals at various times in their lives may illustrate differences in narrative sensemaking. Finally, a study focusing on the family as the unit of analysis could provide novel insights. Longitudinal research investigating a family system may prove helpful in better understanding how patterns unfold and how the roles of individuals as children and 181 individuals shift as they transition into parenting. Such research could explore how patterns across generations may be intentionally shifted or maintained. For example, investigating if the observed shifts in differentiation and the desire to be the best that you can will be successful for participants. This study illustrates the importance of improving the ways we communicate with children about their parent's mental health and well-being, specifically, the need for support in having open and developmentally appropriate conversations and the impact of familial secrecy. Further understanding and unpacking familial avoidance and secrecy may help inform future practice. Looking at Alissa's family and the benefits of their family motto, research may examine what components of family communication are most helpful and how they can be facilitated. For example, expanding on research has illustrated the positive effects of co-constructing family narratives (Saltzman, 2013). These co-constructions would also include and support the entire family system, including siblings who may not have the same diagnosis as the parent but likely still have experienced some associated hardships and advantages. Finally, in considering the societal system more broadly, this study highlighted the role of the media in influencing the stigma and misunderstandings of (hypo)mania. Thus, it should be considered a contributing factor to experiences and understanding of BD. Perhaps in looking at diagnoses that were perceived as being less stigmatized, such as anxiety and depression, the research could inform practices to attempt to reduce the stigma experienced towards BD. As all narratives are told retrospectively, the societal system has likely shifted since these stories occurred. Thus, future research may also seek to integrate the current cultural zeitgeist around mental illness and understand how shifts in society have led to shifts in experiences of stigma over time. 182 Implications For Practice Although the findings of this study are based on a small sample of individuals, the results help to shed light on specific areas of practice if taken mindfully. The detailed and rich accounts allow for an understanding of the human experiences of these children and the balance of positives and negatives associated with intergenerational mental illness. These findings help facilitate a more nuanced and mindful approach when supporting individuals and their families living with BD. This study helps us to understand some of the benefits of a shared BD diagnosis. For example, many of the participants were diagnosed through the lens of their parents. This study may help practitioners reflect on how they might support those with a family history of BD to be diagnosed quickly. Alissa's story and her initial quick dismissal of her diagnosis also highlight the importance of balancing a potential overreliance on a parental diagnosis. It heeds caution to the importance of attuning to the individual in front of you and supporting them in feeling heard, seen, and understood while still keeping in mind the knowledge of their family history. In Alissa's story, we hear the balance of these two pathways to diagnosis and the importance of supporting the child in feeling heard. Clinicians must continue to approach these conversations mindfully. Similarly, Charlotte and Evelyn described potentially underreporting or not reporting symptoms of hypomania, leading to delays in diagnosis, drawing attention to the importance of clinicians being intentional in defining and clarifying how symptoms of hypomania might present. Further, Evelyn highlighted how some of her experiences in childhood "normalized things that weren't normal," which affected her identification of and reporting of symptoms. This brings to light the importance of being mindful of how individuals, particularly those who 183 perhaps were exposed to BD symptomology from an early age, may report symptoms of BD themselves. In the present study, many participants described their engagement in caregiving roles as positive or the only thing they would have done. This highlights the importance of considering the needs of the family system when treating adults living with BD. It is important that clinicians both explore and consider the potential needs of their client’s family systems, in efforts to reduce the experienced need. This echoes research investigating families with co-occurring mental illness that highlights that family focused treatment facilitates the best treatment outcomes (Frederick et al., 2019). In the present study, participants described learning that "feelings aren't safe" or should be managed independently. This led participants to disavow their own emotional experiences and prioritize caregiving for others. Practitioners should be mindful of the communication, or lack thereof, with the children of adult clients about parental mental illness. Specifically, attention should be paid to the potential lasting impacts of neglecting the emotional needs of the children of those living with BD. This study has shed light on the importance of improving communication with children about their parent's mental illness. This finding echoes previous literature that illustrates increased communication facilitates a host of positive effects, including improving child confidence, mental health literacy, and reductions in fear and stigma (Reupert et al., 2015). Specific to BD, psychoeducation has been consistently found to be helpful to facilitate understanding and reduce experiences of stigma (Miklowitz et al., 2003; Nadkarni & Fristad, 2010). This information may be particularly beneficial for those at risk of developing BD. As we saw in Evelyn's story, it may help individuals identify signs and symptoms and practice self-compassion when grappling with their diagnosis. Further, through participant stories, we have 184 heard echoes of how the lack of communication, stigma, and anxiety ripple through the lives of these children as they grapple with their own experiences with mental health. This sheds light on the importance of supporting families in having these conversations. In Alissa's story, she explores how her family's motto supported her ability to maintain hope and resilience through challenging times. Supporting families in having these conversations and creating stories or mottos of coping may be helpful. Some authors have begun to explore these issues. For example, Falkov and Cowling (2004) and Reupert et al. (2016) have outlined practical guides for facilitating conversations with children of parents living with mental illness. Specifically, Reupert et al. (2016) highlight the role of the clinician in supporting parents in having these conversations. They encourage practitioners to arrange practice conversations, to help parents to reflect on their own worries about having the conversation, and provide key messages that parents can focus on conveying withing these conversations (Reupert et al., 2016). The current research findings support the direction of these efforts. Finally, although it was not a primary focus of this study, considerations around parenthood and a sense of caution were prevalent. This supports previous research illustrating parents' experiences living with BD (Lawrence, 2011; Venkatraman & Ackerson, 2009; Wilson & Crowe, 2009) and illustrates the importance of supporting individuals with BD in their considerations around parenthood. Conclusion This study sought to provide an in-depth exploration of the experiences of individuals living with intergenerational BD to provide nuance and context to the existing literature and 'misery statistics.' To date, little research has explored the experience of intergenerational mental illness. To my knowledge, this study is the first to examine the connection between these 185 intersecting identities, specifically, the complex phenomenon of being both an individual living with BD and a child of an individual living with BD. The findings of this study help us to understand how childhood experiences with parental mental illness shape individuals' journeys and sense made. 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I hope to provide more context and nuance to these numbers through hearing about your experiences. Throughout the interview, I may ask you some follow-up questions, ask for clarification, or ask for more details of your experience. You are free to share only what you are comfortable with, and you are not under obligation to discuss anything you are not comfortable with. Do you have any questions before we begin? The main question I will ask you is: 1) how do you, as a second-generation member of your family, experience intergenerational BD? And (2) how was/is intergenerational BD communicated about and relationally experienced within your family? 218 Possible Interview Probes • Using your life graph, can you tell me about some of the major events in your life or turning points related to experiencing intergenerational BD? o Can you describe some examples of events in… (childhood, adolescence, early adulthood, present day, future) § What were they like? § How did your family react to and communicate about these events? § Where did they take place? § How were they resolved? § Who was involved? § How does this event affect you now? How might it in your future? § How did this event impact subsequent events? § What could have been different for you? What helped, or might have helped? o How are different events related? § How did they impact or influence each other? § How might they impact your future? § What events do you see as similar? Why? § What was it about these events that made them recurrent? • Tell me about the artifacts (letters, photos, objects, notes, etc.) you brought with you to this interview. What events are they connected to for you? o What were they like? o Who was involved? o How were they resolved? 219 o How are they connected? • What stories were you told about BD? o What stories were you told about your parent’s BD? o About your own? § How did these stories affect you? o Tell me about what you thought about your future when you were diagnosed. Were those predictions correct? o Can you provide an example of how your parent’s diagnosis affected your own experience of BD? o Has there been a shift in your relationship with you and anyone in your family following your diagnosis? If so, can you describe it? • Who are some major people [characters] in your life as someone experiencing intergenerational BD? • What are some of the positive aspects that you have experienced related to intergenerational BD? 220 APPENDIX C Table of the Three-Dimensional Narrative Structure Interaction Continuity Personal Social Past Present Future Situation/Place Description Look inward to internal conditions, feelings, hopes, aesthetic reactions, moral dispositions Look outward to existential conditions in the environment with other people and their intentions, purposes, assumptions and points of view Look backward to remembered experiences, feelings, and stories from earlier times Look at current experiences, feelings, and stories relating to actions of an event Look forward to implied and possible experiences and plot lines Look at context, time, and place situated in a physical landscape or setting with topological and spatial boundaries with characters’ intentions, purposes, and different points of view (Ollerenshaw & Cresswell, 2002 p.12; as adapted from Clandinin & Connelly, 2000) 221 APPENDIX D Risk Assessment Protocol Has the participant previously reported thoughts of suicide, thoughts of harm to self, and/or others throughout this study? Yes/No Does the participant currently report thoughts of suicide, thoughts of harm to self, and/or others? Yes / No If yes to either, probe for and identify warning signs observed (more warning signs illustrates increased risk)  Threatening to harm or end one’s life  Seeking or access to means  Evidence or expression of a plan  Expressing ideation about suicide, wish to die, or death  Hopelessness  Rage, anger, seeking revenge,  Acting reckless, engaging impulsively in risky behaviours Potentiating risk factors: X Chronic mental illness  Unemployed or recent financial difficulties  Divorced, separated, widowed Examples of protective factors: • Strong connection to family and community support • Skills in problem solving, coping, and conflict resolution • Sense of belonging, sense of identity, good self-esteem • Cultural, spiritual, and religious connections and beliefs • Identification of future goals  Expressing feelings of being trapped with no way out  Increasing or excessive substance use  Withdrawal from family, friends, society  Anxiety, agitation, abnormal sleep  Dramatic changes in mood  Expresses no reason for living, no sense of purpose in life  Social isolation  Prior traumatic life events or abuse  Prior suicidal behaviour  Chronic, debilitating physical illness • Constructive use of leisure time (enjoyable activities) • Support through ongoing medical and mental health care • Effective clinical care for mental, physical, and substance use • Easy access to a variety of clinical interventions and support for help seeking • Restricted access to highly lethal means of suicide • 222 Determined risk level (circle): Very High Risk (has a specific and imminent plan, access to means, and several warning signs) Action: Discontinue interview. Seek immediate help from emergency services. Follow up with participant after to check in with them. High Risk (has a vague plan, or no access to means, and/or has many warning signs) Action: Discontinue or pause interview. Discuss current supports, reasons to live, positive aspects of life, strengths, and protective factors. Connect participant with a mental health professional. Monitor for development of other warning signs. Ask participant if they would like to continue in study. If yes, schedule another time to complete the interview. Low Risk (no plan, means, and few warning signs. Ideation is vague and not imminent) Action: Discontinue or pause interview. Discuss current supports and provide resources. Discuss current supports, reasons to live, positive aspects of life, strengths, and protective factors. Monitor for development of other warning signs. Ask participant if they would like to continue in study. If yes, ask participant if they would like to reschedule to complete the interview or return after taking a break. Describe immediate action taken and rationale: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe follow up plan: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Adapted from the Suicide Risk Assessment Guide (Perlman et al., 2011)
Thesis/Dissertation
eng
School and Applied Child Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
McKee, William Treen
Mathison, Sandra
"It doesn't have to be one thing or the other" : stories of second-generation bipolar disorder
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