Empirical studies of FFT in bipolar disorder
Family-focused treatment has been examined in two randomized trials with adult bipolar patients. In the first trial, 101 adult bipolar I patients living with parents or a spouse were randomly assigned to a 9-month, 21-session FFT program plus mood stabilizing medications or a brief psychoeducational comparison intervention called crisis management (CM) plus medications. Patients in CM received two family education sessions plus crisis intervention (as needed) over a 9-month period. Intent-to-treat analyses indicated that over 24 months, patients in FFT were more likely to survive the full study duration without having a fully syndromal return of depression or mania symptoms (52%) than patients in CM (17%) (p ¼ 0.003). The mean duration of remission for FFT patients was 73.5 weeks and for CM patients, 53.2 weeks. FFT was superior to CM in reducing depressive symptoms over 2 years (p ¼ 0.005; Cohen’s d ¼ 0.56) and to a lesser extent, manic symptoms (p < 0.05; Cohen’s d ¼ 0.40).
A randomized trial of FFT at the University of California, Los Angeles examined 53 patients assigned to FFT plus medications or an individually focused psychoeducational treatment plus medications. The individual therapy was given in the same frequency as FFT (21 sessions over 9 months). Survival analyses indicated no differences in time to relapse or rehospitalization during the first year of treatment. However, patients in FFT had significantly fewer relapses (28%) and rehospitalizations (12%) during a 1- to 2-year posttreatment period than patients in individual therapy (60% and 60% respectively). Patients in FFT were less likely (55%) to require hospitalization when they did relapse than patients in individual therapy (88%).
Family-focused treatment has been tested in an open trial involving bipolar adolescents and children. In this trial, 20 adolescent bipolar patients were given 21 sessions of FFT and standard pharmacotherapy over 9 months. The adolescents showed significant improvements in depression (Cohen’s d ¼ 0.87), mania (d ¼ 1.19), and total mood symptom scores (d ¼ 1.05) from a pretreatment baseline to a 2-year follow-up. There were also substantial reductions in parent-rated Child Behavior Checklist (CBCL) total problem behavior scores over 2 years (d ¼ 0.99). A two-site randomized trial of FFT for bipolar adolescents is currently underway. Thus, FFT has been empirically validated in two randomized and one open trial conducted in different sites and with different age groups. Its application to the treatment of suicidality is relatively new. In the forthcoming sections, we
describe how FFT is adjusted to the needs of families of adult or adolescent bipolar patients coping with suicidal ideation or behavior.
Overview of treatment assumptions
We begin with the assumption that suicidality, while part of the pathophysiology of bipolar disorder, is to some degree under environmental control. Suicidal behaviors can be inadvertently reinforced by well-meaning family members who ignore a bipolar, depressed patient’s persistent complaints about feeling badly but then show excessive concern when he or she mentions suicide. Suicidal behaviors can also be internally reinforced by the patient, such as when he or she discovers that self-cutting temporarily alleviates negative affect. Thus, suicidal thoughts or impulses are linked with the cycling of the mood disorder, but can also follow their own environmentally conditioned trajectory.
A second treatment assumption is that all suicidal expressions should be taken seriously by the family, even those of patients who frequently make suicide threats but have never acted upon them. Persons who commit suicide often do so quite impulsively. However, this poses a dilemma for caregivers: how can they attend to suicidal behaviors without unduly reinforcing them? Clinicians must help family members walk the tightrope between responding appropriately and compassionately to suicidal gestures but at the same time not inadvertently rewarding them. Notably, communication and problem-solving skills can assist spouses or parents in selectively reinforcing adaptive, non-suicidal behaviors of the patients.
Third, the clinician treating the family of a suicidal bipolar patient must be flexible in his or her approach. Although manual-based treatments like FFT follow a certain structure, this structure must be modified when patients become seriously depressed or contemplate self-harm. Increasing the number, length or frequency of sessions, altering the order of the modules (e.g., beginning with problem solving instead of psychoeducation to remove immediate triggers for suicidal behavior) and offering individual sessions to the patient or family caregivers are often critical modifications. Therapists require ongoing consultation with a treatment team, usually consisting of a psychiatrist and fellow therapists.
Fourth, suicidal episodes among bipolar patients can sometimes be addressed through changes in medications (e.g., an increase in lithium dosage) and/or a brief hospitalization. In most cases, however, medication adjustments will be only one piece of a complex puzzle. Preventing suicide is an ongoing process in which the family members, patient and treatment team must collaborate. Assessment of suicidal thoughts or behaviors Treatment of suicidality in mood disordered patients begins with a careful assessment of risk and protective factors. Brent et al. recommend that assessments focus on the degree, persistence and frequency of suicidal ideation, the presence of means to carry out intentions, the relationship of suicidal thinking to comorbid psychiatric syndromes (e.g., substance abuse), the nature of the triggers or precipitants, what factors have previously prevented the patient from acting on suicidal impulses and the patient’s current motivation to attempt suicide. Motivations can range from a true wish to die, a desire to escape distress and loneliness, a desire for attention or a means to express hostility or induce guilt in others.
In FFT, the assessment of suicidality includes a behavioral assessment of the patient–relative interactions that precede suicidal thinking and behaviors, and equally importantly, the impact of suicidality on subsequent family interactions. For some patients, suicidal acts garner attention and support from caregivers. In others, they lead to further escalation of pre-existing conflicts and alienation from family members. For example, bipolar teenagers often erupt into rage reactions upon being thwarted in their attempts to achieve a certain outcome (e.g., going out late at night). A teenager’s rage reaction may lead to impulsive suicidal behaviors or attempts (e.g., threatening to jump out a window, overdosing on pills), which may be followed by shame or guilt and the thought that he or she does not deserve to live. Parents, in turn, may respond with threats or accusations, or ignore the suicide threats or behaviors altogether such that they increase in intensity. As a first step in the FFT, the clinician identifies chains of emotion, thinking and behavior in the family’s interaction patterns, as a way to determine the point at which to intervene.
Psychoeducation, problem solving and the suicide prevention contract
Whereas in traditional FFT, the psychoeducation module precedes the problem-solving module by several months, the FFT of suicidal patients usually involves conducting the two modules in tandem. Specifically, the family learns through psychoeducation to identify stressors (e.g., life events) that have previously precipitated suicidal episodes of the patient, and through communication and problem-solving training to develop a suicide prevention contract.
The key concept conveyed by clinicians early in treatment is that suicidal thoughts and behaviors are a part of bipolar disorder, not the patient’s attempt to manipulate or control others or an indication of weakness of character. Many suicidal patients feel vulnerable and unable to control their behavior, but receive the implicit or explicit message from their caregivers that they have this control but are unwilling to exercise it. In a non-technical way, clinicians offer information to families about the genetic and neurophysiological correlates of suicidality. For example, the clinician says:
We’ve just talked about different types of manic and depressive symptoms. Paul, because you’ve been getting more depressed over the last few months, it is not surprising that you’ve also had more despairing and hopeless feelings. Suicidal thoughts and impulses don’t mean that you have some sort of moral weakness or that your life isn’t meaningful. In fact, these feelings are part of the significant biological changes associated with bipolar disorder. It may be hard for you to fully control those thoughts and feelings even though you may want to. At the same time, the clinician makes clear that the patient can use adaptive coping strategies to help bring the suicidal behaviors under control (e.g., self-talk, distraction). Family members learn that, even though the root cause of suicidality may be the biology of the mood disorder, its treatment will include environmental modifications as well as medication:
Although suicidal feelings are part of the illness, that doesn’t mean you as a family can’t do anything about them. As you’re going to soon see, there are things you (Paul) can do to help get your symptoms under control, and to know when and how to ask for help when that doesn’t seem possible. (To parents): Even the most severe medical illnesses, like diabetes or heart disease are affected by environmental stress, like family stress or life changes. Keeping your environment low-key and supportive, and focusing as much as possible on normal, healthy family life while managing the disorder, is going to be essential to Paul’s recovery.
The connection between suicidal ideation, behaviors and mood states is drawn. If suicidal intention is not imminent and patients do not appear to be in immediate danger, they are asked to track suicidal thoughts on a mood chart. After several weeks of mood charting, they begin to observe whether suicidal thoughts increase in intensity during certain clinical states (e.g., mixed affective symptoms or anxiety) or after certain triggers (e.g., a night of poor sleep, missing a dosage of medication).
Family-focused treatment clinicians make clear that suicidal intentions can be recognized early and prevented from escalating. A suicide prevention plan is usually best developed when the patient is not acutely suicidal, but its relevance to the family is highest when the patient has attempted suicide in the recent past. Family members often have significant difficulty with suicide prevention planning. Suicide is a difficult topic to discuss openly, and family members fear that discussing it will increase the likelihood that the patient will carry out his or her threats. Nonetheless, patients almost invariably report that they find it a relief to be able to openly express their despair to family members, especially if others respond non-judgmentally. Clinicians may encourage the discussion by saying, _This is difficult, but in the end it may save her life for you (relatives) to know what she’s going through and how to help her endure it._ Next, family members learn to recognize the early warning signs of suicidality. These vary from patient to patient, but may include increases in anxiety or panic symptoms, agitation, sudden behavior changes, withdrawal, aggressiveness or morbid preoccupations (e.g., adults who begin to talk about death or the meaninglessness of life; teens who draw pictures with themes of violence or destruction). Clinicians help family members and patients identify triggers for suicidal thoughts and behaviors, which may differ from each other. For example, an adolescent patient may experience an increase in anxiety and suicidal ideation when a parent leaves on a business trip, but suicide attempts may be precipitated by arguments with that parent regarding out-of-home privileges. An adult patient may experience suicidal thoughts after an interaction with a spouse in which it is implied that the patient is a burden to the family, but his actual suicide attempts may be precipitated by alcohol use.
In examining triggers, clinicians explain that suicidal threats or actions often represent one event in an interpersonal process that involves multiple members of the family. For example, a suicide gesture may begin as a reaction to unpleasant interactions with a significant other (for example, a teenage girl may impulsively scratch her wrists with glass in reaction to feelings of rejection generated by a telephone call with her boyfriend). In turn, the gesture may create difficult interpersonal circumstances in its wake (e.g., anger among siblings for the attention the girl receives from her parents when she cuts herself). These circumstances may in turn fuel more aversive interactions between the suicidal person and his or her family members, and possibly, more serious suicide gestures.
Next, family members and patients conjointly develop a suicide prevention contract. This contract usually includes a summary of triggers in the environment (for example, conflicts with certain family members, teachers, or peers), and what each family member, including the patient and where appropriate, the family therapist and psychiatrist should do if a trigger is present. For example, a parent may help a young adolescent to redirect him- or herself to a distracting activity; a spouse may sit with her husband and listen empathically and supportively or help him engage in _improving the moment_ strategies such as going for a walk, meditating or using relaxation exercises; or a parent of a young adult bipolar patient may decide it is best to leave him or her alone but be in an adjoining room to assure his or her safety.
Critical to the suicide prevention contract is deciding when to perform certain preventative maneuvers. For example, a call to the patient’s psychiatrist to modify the medication regimen may be helpful, especially if it is the patient who initiates the call, but it may be more effective earlier in the cycle of suicidal escalation than later. If the escalation has progressed to a certain point, the patient may view a relative’s phone call to his or her physician as a threat of loss of freedom (i.e., hospitalization). Likewise, deciding to talk with a patient about his or her reasons for feeling hopeless may be less effective when the patient is highly emotionally aroused than when the arousal has diminished.
Once a suicide prevention contract has been developed, family members are asked to rehearse its various components. For example, a mother can role-play with the clinician a conversation with the psychiatrist about her daughter’s suicidal behavior and the pros and cons of introducing antidepressants or increased dosages of mood stabilizers or atypical antipsychotics. A spouse can be coached on appropriate ways to ask his wife whether she is feeling suicidal. A father can be assigned the homework task of making a list of important phone numbers (e.g., the clinician, the psychiatrist, emergency room or suicide hotline) and placing it where other family members can find it.
- Miklowitz DJ, Bipolar Disorders 2006 Oct; Vol.8
Reflection Exercise #5
The preceding section contained information about family-focused treatment of the suicidal bipolar patient. Write three case study examples
regarding how you might use the content of this section in your practice.
How can well-meaning family members inadvertently reinforce suicidal behaviors in bipolar individuals? Record the letter of the correct answer the