Family‐Focused Therapy for Bipolar Disorder: Reflections on 30 Years of Research

• Author: Bowen Chung,David J. Miklowitz
• Published date: 01 September 2016
• Date: 01 September 2016
• DOI: http://doi.org/10.1111/famp.12237

Family-Focused Therapy for Bipolar Disorder:

Reflections on 30 Years of Research

DAVID J. MIKLOWITZ*

BOWEN CHUNG*

Family-focused therapy (FFT) is an evidence-based intervention for adults and chil dren

with bipolar disorder (BD) and their caregivers, usually given in conjunction with phar-

macotherapy after an illness episode. The treatment consists of conjoint sessions of

psychoeducation regarding bipolar illness, communication enhancement training, and

problem-solving skills training. This paper summarizes over 30 years of research on FFT

and family processes in BD. Across eight randomized controlled trials with adults and

adolescents with BD, FFT and mood-stabilizing medications have been found to hasten

recovery from mood episodes, reduce recurrences, and reduce levels of symptom severi ty

compared to briefer forms of psychoeducation and medications over 1–2 years. Several

studies indicate that the effects of FFT on symptom improvement are greater among

patients with high-expressed emotion relatives. New research focuses on FFT as an early

intervention for youth at risk for BD, neuroimaging as a means of evaluating treatment

mechanisms, and progress in implementing FFT in community mental health settings.

Keywords: Family-Focused Therapy; Expressed Emotion; Fa mily Interaction; Bipolar

Disorder; Psychosis; Functional Magnetic Resonance Imaging

Fam Proc 55:483–499, 2016

OVERVIEW

Family-focused therapy (FFT) was developed in the mid-1980s as an intervention for

patients with bipolar disorder (BD) who had just been in the hospital for an episode of

mania or depression and were going home to live with parents, a spouse, or another set of

familial caregivers. Over the last 30 years, we have learned a considerable amount about

families coping with BD and how to treat the disorder within a familial context. This arti-

cle reviews the format, key assumptions, clinical techniques, and empirical studies of FFT

as an adjunct to pharmacotherapy for patients with BD. We review studies of variables

that may moderate or mediate the effects of FFT on symptomatic outcomes, and recent

work on implementing FFT in community mental health settings. Finally, we discuss a

*Department of Psychiatry and Behavioral Sciences, UCLA School of Medicine, Los Angeles, CA.

Correspondence concerningthis article should be addressed to David J.Miklowitz, UCLA Semel Institute,

760 WestwoodPlaza Rm. A8-256, LosAngeles, CA 90024-1759.E-mail: dmiklowitz@mednet.ucla.edu.

Dr. Miklowitz receives research funding from the National Institute of Mental Health, the Carl and

Roberta Deutsch Foundation, the Kayne Family Foundation, Danny Alberts Foundation, Attias Family

Foundation, and the American Foundation for Suicide Prevention. He has received book royalties from

Guilford Press and John Wiley and Sons. Dr. Chung receives research funding from the National Institute

of Mental Health, National Institute of Minority Health and Health Disparities, the UCLA Clinical and

Translational Science Institute/National Center for Advancing Translational Research, Centers for Medi-

care and Medicaid Innovations, and the Patient-Centered Outcomes Research Institute.

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Family Process, Vol. 55, No. 3, 2016 ©2016 Family Process Institute

doi: 10.1111/famp.12237

key direction for psychosocial research in BD: implementing family interventions to

prevent the eventual onset of BD in high-risk youth.

HISTORICAL CONTEXT

Family-focused therapy emerged as a modification of behavioral family management

(Falloon, Boyd, & McGill, 1984; Miklowitz & Goldstein, 1990), a 9-month treatm ent for

schizophrenia patients and their families. Behavioral family management consists of ses-

sions of psychoeducation, communication skills training, and problem-solving skills train-

ing for patients with schizophrenia and their parent(s) or, in rare cases, their spouse or

adult siblings. Falloon et al. (1985) found that for schizophrenia patients who had just

been discharged from hospital, the combination of 9 months of behavioral family manage-

ment and neuroleptic medication was more effective in reducing rates of psychotic relapse

and improving social functioning than 9 months of supportive individual therapy and neu-

roleptic medication. The extension of family psychoeducation to other recurrent, impair ing

psychiatric disorders—including BD—seemed promising.

The mid-1980s was an exciting time to be pursuing studies of families with major men-

tal illnesses. The biological and genetic findings of the 1960s and 1970s led to a decisive

shift in the overall framework for working with families. Patients with schizophrenia or

BD were no longer viewed as victims of pathological family environments but rather, indi-

viduals with genetically based disorders who often lived in families that were distressed

because of their lack of access to information on effective treatments. The double-bind

hypothesis and the schizophrenogenic mother were no longer dominant paradigms; in fact,

consumer groups like the National Alliance for the Mentally Ill were quite vocal about

rejecting the blame of parents (and usually, mothers) inherent in these theories (Imber-

Mintz, Liberman, Miklowitz, & Mintz, 1987). The countervailing hypothesis was that par-

ents who expressed high levels of negative emotionality or unclear communication were

reacting to the stresses and strains of living with a person with schizophrenia (Miklowitz,

1994).

Unfortunately, our current efforts to avoid blaming parents have led to a different prob-

lem: an exclusive focus on patients without consideration of their familial context. The

position in the “Decade of the Brain” was that referring to psychiatric disorders as brain

diseases would reduce stigma and place them among the larger spectrum of medical disor-

ders. However, as articulated by Hinshaw and Cicchetti (2000) and others, the “brain dis-

orders” movement has had the effect of further stigmatizing patients with men tal

illnesses. Patients complained bitterly about being told they had a brain disorder, along

with the implication that they were crazy, could not be trusted, or were defective or devel-

opmentally disabled. To this day, those interested in family therapy struggle with finding

a midpoint between avoiding blame or stigmatizing parents and patients and being able to

help them restructure relationships, reduce conflict, and enhance communication in the

aftermath of an illness episode.

Studies of Expressed Emotion

The literature on expressed emotion (EE) provided a road map for investigators who

were interested in either treatment or basic familial processes in patients with severe

psychiatric disorders. EE studies usually proceed as follows: An investigator interviews

the parents or spouse of a concurrently ill patient using the 1- to 2-hour Camberwell

Family Interview (Vaughn & Leff, 1976) that focuses on the 3 months leading up to the

patient’s most recent period of illness. Later, a trained coder listens to tapes of these

interviews and rates the number of critical comments voiced about the patient (e.g., “I

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