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Bipolar Disorder Treatment - Family Focused Therapy and Interpersonal/Social Rhythm Therapy

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Family Focused Therapy (FFT)

family fighting Family Focused Therapy or FFT is a combination of two forms of psychotherapy. First, it is a variety of psychoeducation, which is a type of therapy whose main goal is to teach patients and their families about the nature of their illness. It is also a type of family therapy. Family therapies are different from other forms of therapy because of their attention to family dynamics and relationships as contributing factors that help or hurt illness.

Therapists working from this approach treat the entire unit in front of them (e.g., the entire couple; the entire family) as the patient. The individual members of these groups are seen as parts of that single patient. Families may start therapy by problems that a single individual within the couple or family is having. However, the family systems therapist will tend to view the identified problem as a problem shared by all system members. In this way of doing therapy, a husband's bipolar disorder is considered, at least in part, as a symptom of something going wrong with the relationship. It is not simply something going wrong with the husband.

Family therapy sessions dig into the details of the interactions between family members as a core part of treatment. It looks at the role of the person with bipolar disorder in the overall psychological well-being of the family, as well as the role of the family in creating bipolar symptoms. Family therapy aims to identify and then change destructive relationship patterns that may be contributing to the system's difficulties. For instance, if a family has been blaming one of its members, and that member has become depressed, the therapist will call attention to this blaming behavior. Family therapy can also uncover hidden issues and/or teach people new strategies for dealing with emotions and behavior.

Family therapy isn't generally viewed as a good primary means of receiving therapy for people with bipolar disorder. However, but it can be an excellent extra therapy strategy because people are both affected by and affect their relationship partners. Family therapy is most useful when a person's depressive or mania symptoms are: 1) seriously jeopardizing his or her marriage and family functioning, and/or 2) clearly being caused (or maintained) by dysfunctional marital and family interaction patterns. Patients with mood disorders have a very high rate of divorce. Many people report that they would not have married their spouse if they knew that he or she would develop a mood disorder. Family and couples therapy, therefore, can be a crucial and effective component of treating depression.

As an example of family therapy, the parents of an adolescent daughter with bipolar disorder may be quite upset by their child's illness. As a result of this, they may be acting in an over-controlling manner that the child then rebels against. The daughter's rebellion adds significant stress to her already complicated condition. Recognizing this dynamic, the family focused therapist might advise the parents to find less controlling ways to express their caring and concern. The therapist would also help the parents learn to manage their own stress in a more independent way from their daughter than they were able to do in the past.

Family focused therapists also educate all family members about the nature of bipolar disorder, bipolar treatment, and ways that family members can best support their affected member. For example, the therapist might teach family members about the nature of manic and depressive mood swings, about the differences between Bipolar I Disorder and Bipolar II Disorder, and about the need for bipolar medications to be the primary means of therapy. The therapist will often provide education and handouts with this information. They may also provide training to support the family's development of communication and problem solving skills.

Bipolar disorder is a very serious condition associated with impulsive and self-destructive behavior. Bipolar suicidal thoughts behaviors are frequent, as are impulsive sexual behaviors and reckless spending. Not surprisingly, families are frequently deeply affected by the member with bipolar disorder. Family members often experience a range of deeply felt emotions, not the least of which is a sense of helplessness to fix bipolar symptoms. This helplessness can easily turn into anger, frustration and aggravation that is expressed towards the family member with the illness. Caring for family members with bipolar disorder can easily lead a person to feeling exhausted or angry. Family members can get burned out from trying to help, particularly if the patient is not committed to treatment. Family members may eventually stop supporting the patient. Family focused therapists look for these sorts of feelings and interactions (or lack of interactions). Then they work to re-channel any anger that may be present, promote re-engagement of family members who have checked out. In general, the therapist tries to promote a balanced blend of acceptance of the patient's limitations, as well as the need for the patient to take age-appropriate responsibility for his or her own well-being. Addressing family emotion in FFT can be a powerful tool for fostering stability within the family unit.

Interpersonal and Social Rhythm Therapy (IPSRT)

Interpersonal and Social Rhythm Therapy (IPSRT) is based on the observations that bipolar disorders are essentially body rhythm disturbances, and that altered body rhythms (e.g., circadian rhythms, seasonal rhythms, and social/occupational rhythms) can lead to mood disturbances. Body rhythm disturbances such as insomnia and other sleep issues, can be corrected or managed by helping patients to set up and stick to healthy sleep routines. As sleeping routines are stabilized, many body rhythms problems tend to go away.

Patients in IPSRT are taught to keep a bipolar mood chart to track their mood states and their daily activities and body rhythms. Patients record when they eat, sleep, go to work, etc. on a social rhythm metric chart. They also complete an interpersonal inventory where they make note of social interactions, such as conflicts and stresses that have an effect on their daily body rhythms and on their bipolar mood disorder. For instance, an argument with one's spouse is recorded, particularly if that argument resulted in insomnia and agitation. The bipolar mood chart is analyzed and discussed with the therapist during sessions. This chart becomes an important tool for raising awareness of the relationship between body rhythms and mood. Therapists help patients to set up and maintain steady and stable routines such as taking bipolar medication consistently and going to sleep and getting up at regular times every day. They also help patients with bipolar disorder to recognize the sorts of activities and interactions that cause their body rhythms to become disturbed so that these situations can be avoided. For some patients, this self-monitoring and problem-solving type of bipolar therapy is effective in helping prevent recurring mood episodes.