Life Chart Methodology: Risks Associated With Failing to Assess Patient Preferences and the Sources of Poor Insight for Patients With Bipolar Disorder

van Bendegem, van den Heuvel, Kramer, and Goossens (2014) present important information about how patients with bipolar disorder experience the use of a treatment methodology referred to as Life Chart Methodology. This procedure has patients with bipolar disorder formally review and reflect on pertinent life experience with the goal of assisting them to become more aware of patterns of emotional experience and behavior that are signs of a potential relapse. The authors cite Daggenvoorde, Goossens, and Gamel (2013), noting that “early detection of prodromal symptoms can help patients gain control over their illness allowing them to undertake early inter-ventions to prevent exacerbations and thus promote self-management of illness” (p. 378). Based on unstructured in-depth interviews of 14 patients who used this treat-ment, the authors noted some positive outcomes linked with this methodology but caution that there was consid-erable variability in how this methodology was perceived and, in particular, that there were many in an early phase of illness who felt uncomfortable with these procedures.Lack of awareness of illness is a considerable problem for persons with serious and prolonged psychiatric condi-tions (Lincoln, Lullman, & Reif, 2007). Estimates sug-gest that a large number of persons either deny or cannot perceive symptoms, consequences, and treatment needs linked with mental illness despite the urging of well-meaning members of their family, community, and men-tal health professionals (Amador et al., 1994). Manifestly, this is deeply problematic given that without a coherent understanding of one’s medical condition, the chance of adherence to potentially helpful treatments is unlikely.Life Chart Methodology is, accordingly, a response to calls from many quarters for procedures that help persons with serious mental illness to become more aware of their challenges. Following and expanding on the reflections of van Bendegem et al. (2014) about the experiences of patients using the Life Chart Methodology, this commen-tary suggests that dangers to patient health should be acknowledged and considered prior to its use. In particu-lar, we propose that no matter how benevolent the inten-tions of the clinician are, if this intervention is not in close sync with patients’ agendas, and if there is no consideration of the different factors responsible for patients’ lack of insight, this approach may work against recovery.To begin, contemporary models of wellness in severe mental illness emphasize that patients must take charge of their own recovery in the sense that they must make their own meaning of their difficulties and decide, there-fore, how they want to respond. Thus, our first concern about the Life Chart Methodology is that unless patients seek the same ends as those intended by the Life Chart Methodology, the procedure risks placing these patients again in a passive role. The key issue we see is that not all patients may want the kinds of knowledge that this meth-odology may seek to provide. Many patients may not exactly know what they are “getting into” when they begin such an exercise. If they are not interested in becoming aware of their mental illness in the manner of the Life Chart Methodology, the insights this process generates may be experienced as something imposed on the patient and may, thus, despite well-intentions of clini-cians, become a paternalistic approach. It may be per-ceived as knowledge forced on them rather than as some kind of new awareness that is the product of mutual discovery.Worse though is that many others may experience the knowledge that they have a mental illness as oppressive. For instance, patients who hold stigmatizing beliefs about mental illness may find themselves forced to self-stigma-tize if guided and urged to accept that they are ill. Evidence that this could occur includes studies reporting that heightened insight is sometimes correlated with poorer quality of life for some with serious mental illness