Family Therapy for Bipolar Disorder

Family therapy can take a variety of forms. It may include all family members or different combinations—parents and the child, the bipolar child and siblings, and extended family. In family therapy, one goal is to change dysfunctional patterns that have developed over the years (in part because of raising a bipolar child). Treatment can support the family in dealing with the difficult situation of raising such an unpredictable youngster; it may also provide education about Bipolar Disorder and ways of using behavioral interventions at home. Before this change can occur, however, it's important to address parents' questions and to deal with the pain and sense of loss they may have in accepting that their child has difficulties. A child's individual therapist will frequently recommend family therapy to help parents deal with these and other feelings, learn about the disorder, and come up with ways to help their child manage his illness. The importance of family therapy should not be underestimated: After all, the child lives within a family, not by himself. Parents should be involved with their child's treatment, as they are primary partners in the therapy process. Here are a few types of family therapy that seem most relevant to pediatric Bipolar Disorder.

Collaborative Problem Solving

Developed by Ross Greene, PhD, a Harvard-affiliated psychologist and author of The Explosive Child, the Collaborative Problem Solving (CPS) approach operates on Greene's mantra that "children do well if they can." Collaborative Problem Solving revolves around the idea that a child's rigidity and inflexibility can be thought of in the same vein as a learning disability, or, as Greene puts it, a "flexibility disability." He proposes that difficult children and adolescents" lack important cognitive skills essential to handling frustration and mastering situations requiring flexibility and adaptability."¹

The idea behind CPS, says Greene, is to ask not "What's it going to take to motivate this kid to behave differently?" but "Why is this so hard for this child? What's getting in his way? How can I help?" and to go from there.² The effectiveness of this method has been explored and demonstrated in studies conducted by Greene.

Greene calls on parents to prioritize their expectations for their child into Plans A, B, and C: Plan A contains behaviors that the child absolutely must follow (for example, not running with a knife); Plan C refers to situations in which parents consciously decide not to impose their will on the child (for example, whether he wears gloves to school in the winter).

But most conflicts eventually fall under Plan B, the main skill-teaching plan in CPS. This is the plan designed to help caregivers work through problems with kids to find mutually agreeable resolutions.

Let's look at the following scenario: Solomon wants to see his friend Lance for a playdate. His parents remind him for the third time that week that they are going on a family trip to the art museum.

In CPS, Plan B consists of three steps. The first is "Empathy (plus Reassurance)." Here, the goal is to identify and understand how a child feels about a given issue and to let the child know that the adult won't insist on his own way in resolving the issue. This is to indicate to the child that his parent respects and recognizes the importance of this issue to the youngster. The parent says, "I know that you want to play with Lance today. You guys are good buddies."

Next comes the "Define the Problem" step (under the CPS model, a problem is described as "two concerns that have yet to be reconciled"). This step is to identify the adult's concerns on an issue. The parent then says, "We made a commitment to both you and Griffen that today is to be family day. So it's important that you come with us." If this step came first, it would definitely create a frictional situation between the parent and child.

The last step is the "Invitation," where the child and adult are asked to brainstorm solutions together, with the goal of figuring out an answer that is realistic and acceptable to both the parent and the child. The parent says, "I know you haven't see Lance in a few weeks. However, we all have been looking forward to going to the museum as a family, and you're a very important member of our family. What do you think we can do to work this out?" After five minutes of discussion, Solomon comes up with the idea that "maybe Lance could come with us to the museum." Since everyone in the family likes Lance, this becomes the accepted resolution.

CPS is a wonderful model for many children; once a child is stable, this approach has the potential to be quite effective. But as any parent of a bipolar child knows, attempting to reason with a manic child can be an exercise in futility. When dealing with a child in this phase, picking and choosing your battles may not be totally under your control. If a bipolar child wants to fight, even if there's nothing to fight about, attempts at reason are typically ineffective. That's why stabilizing the biology is so important.

Collaborative Problem Solving is another type of therapy that incorporates a "listen to the words" approach. Part of its beauty is that it teaches the importance of flexibility on the part of both the child and the parent or clinician. Mutual respect is a crucial underlying component of this treatment.

Family-Focused Therapy

This therapy, developed by David Miklowitz, PhD, and colleagues, consists of an intensive, nine-month psychoeducational treatment that is conducted with patients and their family members. After three months of hour-long weekly sessions, therapy is biweekly for three months and is then continued on a monthly basis. In the sessions, family participants are educated about the disorder and the different medical treatments available, and they work on developing more positive family communication, improved problem-solving skills, and a relapse prevention plan.³ Studies show that medicated bipolar adults who participated in FFT with their families had fewer relapses, longer intervals of being well, and less severe depressive and manic symptoms. Research on this treatment has been conducted mainly with bipolar adults, although there have been some positive results from a preliminary study using Family-Focused treatment in adolescents.⁴ Miklowitz and his colleagues at the University of Colorado and researchers at University of Pittsburgh are studying the therapy's effectiveness in bipolar adolescents and their families.

In 2004, Mani N. Pavuluri, MD, PhD, FRANZCP, and colleagues at the University of Chicago reported on another potentially significant intervention for bipolar youth and their families. This new approach, called Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT), combines Family-Focused Therapy in children with Cognitive Behavior treatment. As with many of the other treatments mentioned here, more studies need to be done to determine the full effectiveness of this intervention.⁵

1. R. Greene, The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, 2001,(New York:HarperCollins, 1998).
2. Ibid.
3. D. Miklowitz, E. L. George, J. A. Richards, et al., A randomized study of family focused pyschoeducation and pharmachotherapy in the outpatient management of bipolar disorder, Archives of General Psychiatry 60 (2003): 904; M.Rea, M. Tompson, D. Miklowitz, et al., Family-focused treatment vs. individual treatment for bipolar disorder: Results of a randomized clinical trial, Journal of Consulting and Clinical Psychology 71 (2003): 482.
4. D. Miklowitz, E. L. George, D. A. Axelson, et al., Family-focused treatment for adolescents with bipolar disorder, Journal of Affective Disorders, 82(2004), Suppl. 1: S113.
5. M. N. Pavuluri, P. A. Graczyk, D. B. Henry, et al., Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Development and preliminary results, Journal of the American Academy of Child and Adolescent Psychiatry 43 (2004): 528.

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