family-focusedtreatment
Family-Focused Treatment for Bipolar Disorder
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All material adapted from: Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A family-focused treatment approach. New York: Guilford.
From a Presentation by Becky Conlon, Pacific Graduate School of Psychology
The Rationale for Family-based Treatment
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 seem to be associated with recovery for individuals with bipolar disorder: expressed emotion and negative affective style.
High expressed emotion is characterized by excessive, overt hostility, criticism, and over – involvement. Negative affective style is characterized by negative, conflictual interactions.
Dr. Miklowitz has developed an evidence-based approach called Family Focused Therapy (FFT) to provide psychoeducation, 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.
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 medicationss 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 hypervigilant and label every sign as an impending relapse. Such overgeneralizations and negative labeling create resentment. Others 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 the illness. It is often hard for faimilies 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 residual hostility, grandiosity, 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.
Family-Focused Treatment (FFT) Core Assumptions
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.
Common Family Reactions to the Illness
Guilt
Grief
Anger
PTSD-like stress responses
Social Rhythm Stability Hypothesis
It is important to regularize routines and sleep-wake cycles to minimize dysregulation 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.
Mechanics of FFT: Typical length is about 21 sessions in total
Initial Functional Assessment
Goals
Rapport and therapeutic alliance
Confirm bipolar diagnosis
Sample questions’s about prior illness for patient
When did you have your first episode?
What symptoms predominated?
How long did it last ?
Did you have to be hospitalized? How did your family cope?
Medications prior to and during? How effective? Compliance level?
Drugs or alcohol use?
Psychotherapy after episode? Was it at all helpful?
Significant stressors of important life events before or after episode? How is your family coping with conflicts?
Sample Questions’s about prior illness for family
When did the person first become ill?
How did hospitalization happen?
What were the main symptoms?
Typical day prior to episode?
Family arguments during the time?
How would you describe patient as a person?
How did you get along before?
What’s enjoyable about patient?
What’s most disturbing about patient's behavior?
Assessing communication assets and deficits
Are family structure, hierarchy and roles clearly defined?
What is the general affective tone of the family (angry, hurt, resentful, critical, concerned, etc.)?
What is the typical problem solving style used by the family?
How clear are communications in the family?
Psychoeducation with family and assessing prior knowledge of bipolar disorder
What are the symptoms of mania ?
What are the symptoms of depression ?
What are the causes of bipolar?
Course of disorder and future?
Effective treatments?
Behaviors indicating relapse or recurrence?
What would you do for relapse?
Behaviors indicating stability or improvement?
CET: Communication Enhancement Training (Taken from Miklowitz & Goldstein, 1999, Chapter 9)
Goal: enhancing the quality and efficiency of the family’s communication. To break taboos against talking about difficult, emotionally laden topics; bring out hidden agendas; and foster a “collaborative set” and a sense of hope about the future.
Four basic components:
Expressing positive feelings
Active listening
Making positive requests for change
Expressing negative feelings about specific behaviors
The skills are mastered via role play practice.
Model the skill for the participants
Set the scene
Ask clients to role play the interchange
Elicit feedback from all family members
Model alternative ways of delivering the message
Conduct new rehearsal with coaching
Offer praise for efforts
Give a homework assignment (handouts in chapter).
Expressing Positive Feelings
Start here. Having family members turn to each other and offer praise or compliments diffuses bad feelings, gives family members hope, and opens the door for more open communication about disturbing or conflictual matters.
Makes members feel valued and appreciated. Makes them want to do something in return.
Directions:
Look at the person
Say exactly what he or she did that pleased you
Tell him / her how it made you feel.
Active Listening
Directions:
Look at speaker
Attend to what is said
Nod head; say “uh-huh”
Ask clarifying questions
Check out what you heard
Making positive requests for change
“First line offense” in requesting behavior changes.
Begin in a positive light to foster cooperation
Request should be for another family member to do something rather than to stop doing something.
To stop something is actually a criticism in disguise
Understand that the request may be unrealistic or too difficult for the client
Directions
Look at person
Say exactly what you would like him or her to do
Tell him or her how it would make you feel
Make a positive request
I would like you to ….
I would really appreciate it if you would do …
It’s very important to me that you help with the …
Expressing negative feelings about specific behaviors
“Last line offense” when positive requests for change have not been met
When clinician is modeling, should use a fake situation involving an imaginary person
Prevents any member from feeling like the primary target of negative messages
Directions
Look at the person; speak firmly
Say exactly what he or she did that upset you
Tell him or her how it made you feel
Suggest how the person might prevent this from happening in the future
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.
Materials Adapted from Presentation by Becky Conlon. All Rights Reserved, 2014