Making Treatment for Bipolar Disorder a Family Affair

Despite the compelling reasons for involving family members in the treatment of bipolar disorder, several barriers can get in the way:

• The patient has no family locally. In that case, try to enlist the cooperation of a friend, neighbor or someone else in regular contact with the patient.
• The family doesn't want to be involved in treatment. This is often due to stigma and shame surrounding mental illness --- or a feeling that seeking help with caregiving is a sign of weakness. The clinician should try to dispel these notions and encourage family members to talk about their experiences with the illness. Ask if the family member will try attending one session with the patient.

  If the family declines to participate in therapy, suggest a family support group or course, such as NAMI's Family-to-Family Program, a structured 12-week course for family caregivers of those with severe mental illness, available in communities nationally. A 2004 study found that participants who completed the program felt less burdened, more empowered and more knowledgeable about their family member's mental illness. The Depression and Bipolar Support Alliance also offers a national network of support groups for patients and their families. While these programs aren’t a substitute for therapy, they offer helpful psychoeducation and support.

• The patient doesn't want his family to participate in treatment. Often this is because the patient perceives his family as a threat, or fears that they and the therapist will "gang up" on him. In this case, try reassuring the patient and explain that the goal is to help the family understand him better. Ask the patient if it's OK to speak with a family member by phone -- then see if the patient will agree to bring that person to a session.
• Concerns around confidentiality. Clinicians may fear that working with patients' families could violate standards of confidentiality or open them up to lawsuits. In reality, the legal risks are minimal, provided that the patient and family agree -- ideally in writing -- to participate in treatment and to discuss the patient's symptoms openly. The clinician should also make clear when and how the patient should disclose to the clinician confidential information that he doesn’t want shared with family members.
• The clinician lacks experience in family-focused therapy. Willing clinicians can develop the needed skills through CME courses, seminars and other resources. A helpful professional guide is Miklowitz’s 1997 book Bipolar Disorder: A Family-Focused Treatment Approach. He is also developing an educational DVD for clinicians in conjunction with the American Psychological Association. Miklowitz cautions that based on his experience, a book or video is not enough to master the approach, and some consultation with an experienced clinician-trainer, in person or by phone, may be needed.
• Some clinicians view family intervention as counter to the psychoanalytic tradition of focusing on the patient’s personal insight and autonomy. Miklowitz asserts the opposite is true: "Say you have an adult male patient living at home with his mother. He wants to go out, get a job and live on his own. To help the patient achieve those things, you may need help from his mother."

Final pointers and pitfalls

To succeed with family-focused interventions for bipolar disorder, and to deal with the inevitable challenges, experts offer this guidance:

• Win the family’s trust early. It's crucial to establish a rapport with all family members from the outset. "Let them know you're on their side and you want to help them. Assure them you're not going to take sides with one person over another," Miklowitz advises.
• Help families and patients see each other's point of view. Through psychoeducation and open discussion, encourage the patient and family to see how the others view the illness and its symptoms.
• Involve all family members. Make sure all of the family members in attendance contribute to discussions; make efforts to draw out those who may be hanging back. Getting the buy-in of all family members is especially important when doing problem-solving.
• Make sure the family understands and supports the patient's medication regimen. Family members can play an important role in making sure the patient attends his appointments and takes his medication(s) as prescribed.
• Strike a balance between the disorder's effects and patient responsibility. "Family members often think, ‘He's acting this way because he hates me and wants to hurt me,’" Miklowitz says. "You need to help them understand it's the illness that's causing him to act this way. Still, you don't want to give the patient a blank check to do whatever he wants and blame it on the illness. The patient needs to take responsibility for his actions."
• Make sure the family doesn't feel blamed. Families are sensitive to any suggestion that their interactions might have caused the illness.
• Be patient and persevere. Miklowitz's research has found that it takes 6-9 months of family-focused therapy to produce clinically measurable benefits. That can seem like a long time, he acknowledges. "You have to be patient, believe in what you're doing and view this as a long-term investment."

Have comments or questions on this article? Please e-mail the author, Sara Selis, at sselis@cmp.com.


RELATED LINKS Research studies A Randomized Study of Family-Focused Psychoeducation and Pharmacotherapy in the Outpatient Management of Bipolar Disorder
Archives of General Psychiatry, September 2003 Psychosocial Treatments for Bipolar Depression: A 1-Year Randomized Trial From the Systematic Treatment Enhancement Program
Archives of General Psychiatry, April 2007 Prevalence and correlates of burden among caregivers of patients with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder
Bipolar Disorders, May 2007 Family factors and the course of bipolar affective disorder
Archives of General Psychiatry, March 1988 Psycho-education in bipolar disorder: effect on expressed emotion
Psychiatry Research, August 1997 Patient support resources NAMI Family-to-Family Program Depression and Bipolar Support Alliance Clinical practice guidelines (interim update) Guideline Watch: Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd edition
American Psychiatric Association, November 2005 Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd edition
American Psychiatric Association, April 2002 Treating Bipolar Disoder: A Quick Reference Guide
American Psychiatric Association, April 2002