Coaching families in communication skills related to suicidal episodes
During the suicide prevention planning, the FFT clinician often focuses the family on ways to talk about suicidality. As discussed above, it is very painful for family members – whether parents of adolescents or spouses or parents of adult bipolar patients – to openly discuss the patient’s suicidal preoccupations or attempts. Some overreact to the extent that it becomes difficult for them to focus on the precipitant of the suicidal behavior. Others become dismissive and non-empathic, and ignore the behavior as just one in a series of manipulations.
The tasks in FFT are: (i) to encourage the patient to verbally express his or her suicidal despair, hopelessness, regrets, shame, or guilt to family members; (ii) for family members to respond calmly and validate the patient’s feelings without becoming punitive, anxious, or rejecting; and (iii) for the family to problem solve about how to ensure the patient’s safety. Consider the following interaction that occurred in an FFT session involving _Douglas,_ a 17-year-old boy with bipolar disorder. Douglas had avoided bringing up suicidal thoughts with his parents and older sister because he anticipated that each would react negatively in different ways. For example, he _knew_ that his mother would cry and become overprotective. He believed his sister would think that he was _really crazy_ and distance herself even more than she had already done. He believed that his father would be disappointed in him and think he was weak. The therapist asked Douglas to explain to his parents and sister why he thought about dying and the reasons why it was so hard for him to share those feelings. The clinician coached the family members on ways to listen actively, without interjecting advice or suggestions.
DOUGLAS: I just keep thinking that this is never gonna get any better. That this family would be normal if I wasn’t in it.
MOTHER: But why haven’t you told me you were feeling like this? How can I help you if I don’t know what’s wrong?
THERAPIST: Remember, Kate, that your job right now is to listen without trying to solve his problem. See if you can help Douglas express his thoughts by paraphrasing them.
MOTHER: So you think we’d be happier if you weren’t here?
DOUGLAS: Yeah, basically. And I didn’t want to tell you about it because I don’t want you to get all upset. You worry too much about me anyway. I don’t want you to be watching me all the time, like you think I’m gonna do something stupid.
FATHER: But Doug, why would you think we’d be happier without you?
DOUGLAS: Maybe not happy. More like, you know, relieved. You wouldn’t have to be coming to these therapy sessions and trying to figure out what’s wrong with me all the time if I wasn’t here.
THERAPIST: Dad? Can you paraphrase?
FATHER: So you think I’m unhappy about coming to these meetings?
DOUGLAS: I know you’ve got better things to do. You never had to do this kind of stuff because of Sandy (sister).
FATHER: Do you think I feel differently about you and Sandy because of that?
DOUGLAS: Look, I know you love us and all that. Sometimes it just seems like I’m so screwed up that no one would want to be around me. (To Sandy) I know you don’t want me around you and your friends.
SANDY (tearful): So you think I’d really rather have you gone for good? That’s crazy. I’d hate it if you were gone. You’re my brother.
Following this session, Douglas reported a temporary decrease in his suicidal ideas, which were closely intertwined with his belief that he was a burden on his family and that they would be better off without him.
Once family members have been able to listen empathically and validate the patient’s feelings in at least one session, the clinician asks the family members to express to the patient their own difficulties in coping with his or her suicidality. For example, a relative is encouraged to say, _When you get that way, I feel helpless. I want to help you but I don’t know how. You have to tell me how._ The family members then practice these styles of open communication at home with each other as part of the suicide prevention contract. They are asked to write down their various practice attempts on a communication skills assignment sheet and bring it in for the next session.
Finalizing the contract
The family’s prevention contract, which outlines early warning signs, triggers and preventative maneuvers, is usually best constructed as a written document which is signed by each family member, the FFT therapist and the treating psychiatrist. The contract may go through several iterations if the patient becomes suicidal again and the attempted prevention techniques prove unfeasible or ineffective.
Throughout the suicide contract process, family members are acquainted with local hospital resources and the procedures for getting the patient admitted under emergency circumstances. Equally importantly, the family discusses the immediate post-hospital period. If the patient is hospitalized, it may be for only a few days, and the same triggers for suicidality may reemerge once he or she has been discharged. These triggers will be more potent if the patient is not yet clinically stable. Thus, the family is encouraged to look ahead to the postepisode period and rehearse communication and problem-solving skills to promote a low-key, nonconfrontational family environment. Plans are made for family members to non-intrusively observe the patient and make sure that he or she is safe. Continuation of FFT sessions is critical during the post-hospital interval.
Case study: FFT with a bipolar adolescent with suicidal behaviors
Clare was a 17-year-old white female who lived with her parents and her 15-year-old younger brother. She received a diagnosis of bipolar disorder in early adolescence but had never responded well to mood stabilizing or atypical antipsychotic medications, at least partly due to her poor compliance. She was referred to a clinician who practiced FFT at a university-based outpatient clinic. She was being maintained by a university affiliated psychiatrist on a regimen of lithium carbonate (1175 mg) and quetiapine (400 mg). During the pretreatment assessment phase, the clinician learned through an individual interview that Clare thought about suicide almost daily, even when she was not depressed. She had made two prior attempts, both by overdosing on pain relievers and other medications she had found in her parents_ medicine cabinet. Surprisingly, neither of these attempts had come to the attention of her parents. Clare would get ill and vomit or sleep off the effects of the medication, and then _go on as if nothing happened._
The clinician’s first priority was to ensure Clare’s safety. Clare denied that she currently wanted or intended to kill herself. She acknowledged that she thought about it frequently but had mixed feelings about it, imagining the act as an escape but fearful of the practical details required to carry it out. The clinician explained to Clare that if she were behaving in life-threatening ways during treatment, the clinician would notify her parents in an effort to keep her safe. The clinician asked if Clare could promise not to make any further attempts until the issue could be discussed openly in family sessions. Clare agreed.
During the initial family psychoeducation sessions, when the symptoms of bipolar disorder were being reviewed, the clinician asked whether Clare would be willing to discuss her prior suicide attempts with her parents. Clare, who knew from the assessment interviews that this issue would be raised, reluctantly agreed to do so, and the clinician praised her for her willingness to face the issue. Her parents were surprised to learn the extent of Clare’s preoccupation with suicide. Her mother downplayed the danger of this thinking pattern but her father, who had experienced his own father’s suicide, was quite concerned. Her younger brother rolled his eyes frequently and seemed not to take the issue seriously. The clinician began by encouraging the family to seek solutions to the problem of Clare’s daily ruminations. The problem was defined as, _How to keep Clare safe._ Clare’s suicidal ideation was so habitual and ingrained that it seemed to have a life of its own, making it hard to identify triggers. Her actual attempts had more obvious triggers. The therapist guided the family in a discussion aimed at determining the situations in which Clare’s thoughts had translated into actions. This discussion revealed that both of her prior attempts had involved an interpersonal loss experience, which is a common precipitant of suicide attempts among adolescents. In one case, she had broken up with a boyfriend; in another, her parents had briefly separated.
Prior to encouraging _brainstorming_ of preventative maneuvers, the clinician posed several questions to the family including: Are you (Clare) willing to tell your parents if you become suicidal, and if so, how? What kinds of responses from your parents will you experience as supportive? Is it safe for you to be alone when you are thinking this way? At what point must action (e.g., removing all pain-relieving medications from the house) be taken? When that point arrives, who is responsible for seeing that it happens? At what point should you call your therapist or physician, and when should your parents do so? What are some things you can do to help your parents help you? Where can they get help for themselves?
The family was able to agree on a comprehensive plan that enabled Clare to notify her parents when she was feeling self-destructive, and for her parents to respond in ways that would reduce the danger. Both parents worked during the day, and Clare, who had left high school, was alone the majority of the day until 3:00 pm when her brother got home from school. Clare agreed to contact one of her parents when the suicidal thoughts were becoming excessively intrusive. If it was not possible to reach either parent at work, Clare would _page_ her father. The hope was that brief, supportive contacts with either parent would defuse the situation and help Clare to engage in activities that were constructive or at least distracting. It was agreed that the plan would be re-evaluated in 2 weeks, to determine if Clare had actually initiated contact with her parents when she needed to, and whether contact with either parent had helped derail her suicidal ruminations.
With this plan in place, Clare felt less alone with her disturbing thoughts and more protected by her parents. The therapist then worked with Clare to develop a mood chart, identify stressors associated with mood swings, and make plans for how to best handle bad days. These exercises helped Clare and her parents to gain a better understanding of her moods and subjective experiences.
At session 8, the clinician introduced the Communication Enhancement module. She began by having each family member express positive feelings toward at least one other member. At first, Clare and her 15-year-old brother resisted the roleplay exercises, protesting that they felt awkward and that the exercises were _stupid_ and _lame._ Nonetheless, they acknowledged that receiving positive feedback from their parents felt gratifying and that family members, including themselves, did very little of this at home.
Between this session and the next, Clare experienced a setback in her social life. She didn’t have many friends but had made one good neighborhood friend and the friendship had lasted for 4 years. When Clare learned that her best friend was moving out of state, she made another suicide attempt, overdosing on Tylenol. Afterward, she became afraid and induced vomiting. This time, she admitted to her parents what she had done. Her parents were upset that she had not followed the plan established earlier in treatment. At the next session, her parents, especially her father, expressed hurt and anger. Clare felt guilty but reacted angrily and defensively. The therapist took this opportunity to introduce the _active listening_ skill. It is generally better to initially practice these skills with low-key issues rather than starting with highly charged topics, but the therapist felt that the situation strongly called for empathic responses from Clare’s parents. Clare explained that she had been devastated by the news of her friend’s imminent departure and had not even thought about her contract to page her father. Instead, she had acted impulsively in the moment. Clare’s parents were able to validate her feelings
(through paraphrasing and labeling her emotional states) and ask clarifying questions. Then, they took the opportunity to express their own frustration while Clare practiced active listening.
The therapist reminded the parents that marked mood changes, impulsivity and suicidal actions are all symptoms of the instability of bipolar illness. She also pointed out that Clare had come to her parents and told them about the attempt (unlike her previous attempts) which suggested Clare’s willingness to behave more responsibly. The clinician suggested that perhaps Clare now felt closer and more connected to her parents, and Clare agreed. On the clinician’s urging, Clare scheduled an extra appointment with her psychiatrist, who recommended that she increase her dosage of lithium.
By the end of treatment, Clare remained mildly depressed but had not made any more suicide attempts. She had become more compliant with her lithium and quetiapine regimen and reported a better alliance with both parents. Treatment was ended at 9 months, but trimonthly maintenance sessions accompanied by telephone coaching were undertaken.
Suicide in bipolar disorder: cultural considerations
Clare lived in an upper middle class, Caucasian family with considerable healthcare resources. Less is known about how suicidal behaviors emerge among bipolar patients in lower socioeconomic and/or ethnic minority communities. Nonetheless, there is a relatively large literature on ethnic and socioeconomic factors in suicide in the general population. Treatments like FFT need to be adapted to the needs of bipolar patients from non-majority cultures. Native Americans, particularly males, have higher suicide rates than other racial groups in the US. Latinos in the general population have lower suicide rates than white persons, but Latino youths, both male and female, are more likely than white youths to have made suicide attempts. Suicide rates are on the rise in Japanese American and Chinese American teens, and higher rates of depressive symptoms have been recorded in Asian American than white, African American or Latino Girls. None of this work has specifically examined bipolar patients.
Application of FFT to suicidal bipolar patients from non-dominant cultures will be more effective when clinicians show comprehension and respect for cultural values and norms. For example, in working with Latino or Asian groups, what is the dominant language spoken in the home of the bipolar person? Can handouts or homework assignments be translated into this language? How recently has the family immigrated and to what degree are members being affected by acculturative stress? What religious values might protect the patient against suicide attempts? Is the family clinician open to different understandings of the causes of bipolar illness, including holistic views of mind and body (e.g., psychiatric illness as physical or spiritual problems) or the role of traditional healers? There is evidence that family warmth and cohesion may protect Latino patients from relapse and suicidal behavior more than white patients. Thus, interventions aimed at enhancing cohesion and _familism_ may be especially protective for Latino bipolar patients contemplating suicide.
Both African American and Puerto Rican patients are less likely than white patients to be diagnosed with psychotic affective disorder and more likely to be diagnosed with schizophrenia than white patients, even when ancillary psychopathology measures do not support the schizophrenia diagnoses. African American bipolar patients are more likely to have attempted suicide and been hospitalized, less likely to be prescribed mood stabilizers or benzodiazepines and more likely to have been given antipsychotic medications than white patients. Thus, when working with African American patients, FFT clinicians must explore and acknowledge prior negative experiences that the patient may have had with the mental health profession. Acknowledging the role of oppression, discrimination or marginalization as central causes of suicidal thoughts or attempts – as opposed to only the pathophysiology of bipolar illness – may also help with trust
Certain communication skills which are valued in white culture may be viewed differently by other cultures. For example, direct eye contact between a young man and his father, especially during conflict, may be seen as a sign of disrespect in Japanese American families. American psychiatrists are more likely than Japanese psychiatrists to view fathers in Japanese families as passive, withdrawn or non-interactive. The FFT clinician must be aware of cultural differences in expressiveness when carrying out communication skill training exercises and check in with the family as to whether the recommended strategies are consistent with cultural norms.
The stigma associated with mental illness and suicide may make it difficult for ethnic group members to seek necessary treatments or obtain help from other community resources. Integrating FFT and other suicide prevention services into primary care clinics may increase access to care and reduce feelings of shame among members of ethnic minority groups. Clinicians should make contact with respected local health authorities, organizations or influential community leaders. Finally, conducting focus groups to become aware of cultural norms or values that may conflict with the goals of FFT will almost certainly enhance the subsequent engagement and treatment of individual families.
Conclusions and future directions
Many bipolar patients report ongoing ruminations about self-harm and as many as half attempt suicide at least once in their lives. If parents or a spouse are available, combining pharmacotherapy with FFT may be effective in reducing the patient’s suicidal thoughts and behaviors. However, no randomized clinical trials of FFT or other adjunctive psychosocial interventions have addressed this question directly.
More generally, adjunctive psychosocial treatments, if effective in reducing suicidal impulses among bipolar children or adults, may reduce the need for antidepressants or high dosages of mood stabilizers. Alternatives to antidepressants are especially critical in the treatment of children and adolescents, in whom antidepressants may be associated with suicidal thoughts and behaviors and a high risk of treatment-emergent manic switch. Randomized trials of psychosocial interventions should consider medication types, dosages and compliance as relevant outcome variables. Lastly, interventions that have been developed specifically for the prevention of suicidal behaviors should be adapted to the treatment of bipolar patients. A good example is dialectical behavior therapy, which has been found to be effective in reducing suicidal behaviors among patients with borderline personality disorder. This model focuses on learning skills such as distress tolerance, mindfulness, emotion regulation and interpersonal effectiveness. A treatment development study of dialectical behavior therapy in combination with FFT is currently underway for adolescent bipolar patients.
The article above contains foundational information. Articles below contain optional updates.
- Miklowitz DJ, Bipolar Disorders 2006 Oct; Vol.8
Reflection Exercise #6
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.
What are three integral tasks of Family Focused Therapy for BD? Record the letter of the correct answer the