Family-based Treatment of Bipolar Disorder

NOTE: All material adapted from: Miklowitz, D. J., & Goldstein, M. J. (1997).
Bipolar Disorder: A family-focused treatment approach. New York: Guilford.

The Rationale for Family-Based Treatment for Bipolar Disorder

Families provide the most important and enduring resources for individuals with a serious illness. For young adults with significant family involvement, the family the constitutes a critical support system. The burden of longer-term illness often falls upon the family. Families are a neglected resource for mental health professionals. This approach is 'family friendly'.

The immediate post-hospitalization period can be the most stressful for families dealing with bipolar disorder. There are two major familial style predictors that dictate whether the client will recover or face another episode:expressed emotion and affective style.

High expressed emotion is characterized by excessive, overt hostility, criticism, and over – involvement. Negative affective style is characterized by negative, conflicting interactions.

Dr. Miklowitz has developed an evidence-based approach called Family Focused Therapy (FFT) to provide psycho-education, and help families with communication skills and problem-solving skill in order to more effectively deal with the stresses related to having an individual member with a serious illness. Studies of family based treatment (FFT) suggest that in comparison to standard treatment, FFT reduces the likelihood of future episodes of illness and re-hospitalization one year after treatment.

Six Major Goals of Family Focused Therapy (FFT)

1. Help family to process and integrate experiences from episodes of bipolar.
Most families have difficulty recognizing the symptoms of bipolar, understanding the “inner experiences” of the patient, and accepting the seriousness of the illness.

2. Help family to accept that bipolar is a lifelong disorder – with future vulnerabilities!
Most families want to believe that the episode was a 'fluke'. Recognizing that the affected individual may have a future vulnerability involves reorganizing the patient’s identity and the family’s as well.

3. Help family to accept the need for ongoing medication for symptom control.
Most families agree that medications are needed immediately post-hospital, but believe that medications can be stopped once patient is “back to normal.”

4. Help families to correctly identify symptoms of bipolar compared to the personality of the individual.
Some families become hyper vigilant and label every sign as an impending relapse. Such overgeneralizations and negative labeling may create backfire and negative reactions and resentment. Family members may mistakenly believe that the patient is playing the “sick role.” Some patients stop medications in order to differentiate personality traits from bipolar disorder ("What's me and what's my illness?"). Some patients over-identify with the diagnosis and blame everything on their illness. It is often difficult for families to differentiate between 'bad behavior' and bipolar symptoms.

5. Help families realize that stressful life events trigger recurrences and give them methods to recognize and cope with stressors.
It is useful to help families understand the vulnerability – stress model. Stress acan be controlled and managed, whereas the innate biological or genetic predisposition to mood episodes is a given.

6. Help families reclaim pleasant and functional relationships after the episode.
Conflicts (between patient and family ) often involve angry feelings related to the episode, denial of the disorder, need to reestablish independence, and possible medication non-compliance. These conflicts can trigger a rapid deterioration of family engagement. Treatment works to restore family functioning and develop more positive interactions between family members.

Social Rhythm Stability Hypothesis:
A number of treatment approaches to bipolar disorder consider the role of stability in routines and sleep-wake cycles as a protective factor that reduces the likelihood of further severe mood instability. It is important to regularize routines and sleep-wake cycles to minimize deregulation which may make individuals with bipolar disorder more vulnerable to an episode.

"Social zeitgebers" provide an external clock to regulate daily habits.

"Zeitstorers" (disruptive events: time changes, over-work, late night overtime, swing shifts, loss of sleep, etc.) tend to disrupt daily rhythms.

Family-Focused Treatment (FFT) Core Assumptions:
This approach is 'family friendly'. The family is an important and underutilized resource for treatment. Episodes are highly stressful for the whole family and can produce family disorganization. The ultimate goal of therapy is to reestablish a new equilibrium and help the family as a whole cope with the illness. 

Suggested Readings and References

Craighead, W. E., Miklowitz D. J. (2001). Psychosocial interventions for bipolar disorder. Journal of Clinical
Psychiatry, 61(suppl 13), 58-64.
Miklowitz, D.J. (2002). The Bipolar Disorder Survival Guide. NY: Guilford Press.
Miklowitz, D. J., George, E. L., Richards, J.A., Simoneau, T. L., & Suddath, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar
disorder. Archives of General Psychiatry, 60, 904-912.
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar Disorder: A family-focused treatment approach. New York: Guilford.
Miklowitz, D. J., & Hooley, J.M. (1998). Developing family psychoeducational interventions for patients with bipolar and other severe psychiatric disorders: A pathway from basic research to clinical trials. Journal of
Marital and Family Therapy, 24, 419-435.
Miklowitz, D. J., Wisniewski, S. R., Miyahara, S., Otto, M. W., & Sachs, G. S. (2005). Perceived criticism from family members as a predictor of the one-year course of bipolar disorder. Psychiatry Research, 136, 101-111.

Note: Materials Adapted from a Presentation by Becky Conlon