A Psychoeducational Approach to Family Therapy: Comparing 3 Models
By Sara Fletcher and Nanci Schiman, MSW
A diagnosis of bipolar disorder for your child means more than finding a doctor and establishing treatment, both of which are complicated enough. It also means a complete shift in the family dynamic and your own parenting skills. You and the rest of your family will need just as much support as your child as you learn about the illness and steps towards wellness.
We are pleased to present three leading therapeutic models for the family raising a child with bipolar disorder. These three models, developed by Mary Fristad, Ph.D., David Miklowitz, Ph.D., and Mani Pavuluri, M.D., PhD are among the very few Evidenced Based Treatments for our families. What is Evidenced Based Treatment and why is it important? Evidence Based Treatment encourages clinicians to consider empirical evidence (research) and clinical expertise when implementing treatment. Its important because it has a greater chance of success. Early and effective treatment reduces the likelihood that your child will have to repeat therapeutic interventions again. (Think of the old adage: Do it right the first time.) While you may not have access to one of these researchers and their treatment programs, you can print this article and share it with your family therapist.
Family therapy is an important component in your child's treatment regime. Family therapy does NOT mean that you are a bad parent or have a dysfunctional family. On the contrary, it means that you are a good parent who is trying to address a very difficult illness. Mood disorders have a profound effect on the entire family. Gone are the days when we whispered about seeking therapy. Family therapy is as important to a child with a mood disorder as consultations from a dietician are to the parents of a child with diabetes.
It takes a long time for evidence based treatments to move from the accolades of the science journals to the practices of your local clinician. Through this article, the Balanced Mind Parent Network hopes to facilitate the dissemination of knowledge. Read on, and discuss this information with your child's treatment team. An educated and informed parent--YOU-- is the best advocate for your child's wellness!
We are grateful to Drs. Fristad, Miklowitz and Pavuluri for sharing their wisdom with us and to Northwestern student, Sara Fletcher for compiling this vital information.
Mary Fristad, PhD, Ohio State University
Individual Family Psychoeducational Psychotherapy (IF-PEP) or Multi-Family PEP (MF-PEP)
Length of program: 15-24 fifty minute sessions (IF-PEP); 8 ninety minute sessions (MF-PEP)
Dr. Fristad’s Psychoeducational Psychotherapy (PEP) focuses on psychoeducation for families and diagnosed children on bipolar disorder and its symptoms and then working through ways to manage the symptoms. This therapeutic model works with parents and their child in either Multi-Family (MF-PEP) or individual family (IF-PEP) groups.(IF-PEP).
IF-PEP consists of up to twenty scripted individual sessions, with four additional sessions that families can use as needed to address particular episodes or problem areas.
Each MF-PEP Multi-Family session includes five to eight families, and begins with parents and children together before splitting into a child group (aided by two therapists) and a parent group (aided by one therapist) to discuss related topics. Children have an in-vivo (‘in the flow’) social skills training opportunity via group games following the lesson of the day. Adolescents practice mindfulness skills. All family members learn breathing exercises as a calming technique. The entire group reconvenes at the end. Families are given projects to complete between sessions.
David Miklowitz, PhD, University of California Los Angeles (UCLA)
Family Focused Treatment (FFT)
Length of program: 21 sessions, broken into three components.
Dr. Miklowitz’s Family-Focused Treatment (FFT) approaches therapy on a single-family basis and generally focuses on older children and teens with bipolar spectrum disorders. Parents, siblings and patients are invited to sessions. After an initial introduction and a thorough diagnostic evaluation, the program proceeds with 3 major components:
1) Psychoeducation of families and children (usually 7-8 sessions): what is bipolar disorder, how does one recognize its signs and symptoms, how to develop a relapse prevention plan, and why taking medications is important;
2) Communication enhancement training–working with families on how to listen, negotiate, and make requests for changes in one another’s behavior (7-8 sessions);
3) Problem solving–identifying specific family problems and developing ways to work through them (5-6 sessions).
Length of Program: 12 weeks
Dr. Pavuluri’s CFF-CBT model engages both families and children with bipolar disorder, teaching them the same skills at the same time. Individual and group models are available. Both primarily focus on younger children and teenagers.
The model uses the image of a rainbow. The colors of the rainbow represent the different moods along the mood variability spectrum, from sad (ultraviolet), to moderate (green) to more manic moods or rages (red). “All colors are necessary for a balanced mood”, says Dr. Pavuluri.
RAINBOW is also an acronym for the components of the model itself:
- Affect (Emotional) Regulation
- “I can do this”
- No negative thoughts
- Be a good friend (child) / Balanced life (parents)
- Optimal problem solving (cooperative problem solving)
- Ways to get support.
The model also provides the opportunity for parents and schools to work together.
The Balanced Mind Parent Network: Why is it important for families to participate in psychotherapy?
Mary Fristad, PhD: The younger the child, the more important it is to have family involvement. Caretakers should develop a good understanding of the child’s mood disorder and how to manage it. It is our belief that families do not cause the mood disorder, but they can play a critical role in improving the course of the disorder.
David Miklowitz, MD: I think of the family as being either a risk or a protective factor in the course of bipolar disorder. Certainly, there are families that are very conflict-ridden and in which the child has a tough time getting stable. Sometimes the child has to stabilize first before the family stabilizes, and sometimes it’s the other way around. But there are also families that are extremely supportive and nurturing–not that they have to be nice all the time–but they know how to set limits effectively; communicate effectively; find services in the community; deal with teachers and childhood behavior problems, and when to seek out mental health professionals. I think families can be very strong protective factors. The child’s symptoms wax and wane in a family context, so it is critical to get the family involved in helping him or her to manage the disorder from the beginning.
Mani Pavuluri, MD: There are four reasons. Parents need to:
1) Understand the child and the need to be educated about the illness.
2) Receive support in dealing with a child with bipolar disorder.
3) Develop their own coping skills.
4) Learn new skills so that they can be a coach for the child.
Parents of children with bipolar disorder are not deficient, but have more of an obstacle course which they need to navigate. By participating in family therapy, parents are becoming educated and improving their parenting skills. They’ll be better able to modulate the child’s emotions after the combined sessions when they share what they’re learning and give positive feedback. Siblings who participate watch us work with their brother or sister and take the skills of our interaction and education to their own homes.
The Balanced Mind Parent Network: How would you define psychoeducation?
MF: We want kids and parents to understand the child’s symptoms. With parents, we talk more about the cause and course of illness. With kids, we want them to identify what symptoms hang together and we want them to be able to label their symptoms matter-of-factly, so they can shift to problem solving. Our goal is to have children and families learn to manage symptoms at home, at school and with peers. Language is very powerful. If you don’t have a language to describe your experiences, it’s very hard to deal with them. We give families the tools to talk about the symptoms and strategies to manage those symptoms.
DM: Psychoeducation is the marriage of two terms: psychological and education. You’re giving the people information about the disorder and how to cope with it. But you’re also trying to personalize it to them and help them use the information in a way that will be productive for their lives. It involves three levels. You have to:
1) Provide information;
2) Help them personalize it and;
3) Put it into action.
Just having information is not enough to treat a disorder.
MP: At the outset, we explain:
1) The disorder;
2) The RAINBOW therapy concept;
3) Each technique ; and
4) How we can help parents and children understand about themselves and their child.
We go over each concept in detail. There’s homework if the child is open to doing it, but we don't make it mandatory. There’s also illness management and reducing the burden on the family, and decreasing expressed emotions. We teach the parents how not to be reactive, avoid negative consequences, and be mindful.
The Balanced Mind Parent Network: At what point do you recommend starting therapy?
MF: If a child is so out of control that he/she cannot remain in the session, treatment won’t be useful for him/her. However, that is likely a time parents will benefit from support. Aside from that, we have worked with kids at varying levels of functioning and most of them could move forward from wherever they began in treatment. Our research has demonstrated that it doesn’t matter if you also have an anxiety or behavior disorder, it doesn’t matter if your parent has a mood disorder, it doesn’t matter how smart you are, just get treatment—you will benefit.
DM: Begin therapy as soon as possible. We try to get the family in after the episode has crested and they’re in the recovery phase. I don’t think about it as “are people well or are they ill.” Generally, therapy doesn’t go well if the child is[S7] acutely manic or so depressed that they can’t get out of bed, but just about every grey area in between, they can be engaged in family treatment Therapy may move slower when a child is ill with depression or hypomania. Nevertheless, you’re developing a relationship with a therapist when you see them when your family is most in distress. I’ve been surprised at how much families and kids can benefit when the child is symptomatic.
MP: If the child is extremely manic, kicking and screaming, they won’t do well in therapy. Mild mania is a little easier. Moderate to severe mania is hard because sometimes the kids won’t even sit down. But sometimes it’s so bad the parents want to come in without the child, and we’re fine with that.
The Balanced Mind Parent Network: Does involving parents ever imply blame on parents for their children’s disorder? Does that ever create problems for parent involvement within the program?
DM: The traditional family therapists, as clever as they were, would do this a lot. They would ask, “what about this family needs this kid to be depressed”. We assure parents that’s not the approach we’re going to be taking. Parenting skills can help any parent. The thing is, training is not a one-way street. We don’t just train the parent and not train the kid. What we’re training are two, three, or four family members (including the child) to learn how to talk to each other and solve problems, which involves a certain amount of skill building. I think that’s very different from saying, “the reason you’ve got a kid who has bipolar is because you did something wrong.” What we’re saying essentially is: Bipolar disorder is a very tough illness, tough for anyone to handle. Even the best communicators and best problem solvers are going to have difficulty with this. But it will be easier if you learn about the disorder and work on your communication as a family.
MP: Not really. They are helpful and they’re coming to help themselves and the children. My message to parents is that “we appreciate you being here because we want to help you and support you. I want to offer new tools and be there to help you navigate this with your child, whole family and in fact with yourself as you do need to take care of YOU.”
MF: We very explicitly say that is not why we invite families into treatment. We say it a thousand times over the course of our IF-PEP and MF-PEP sessions. Genetically, parents may have passed on the “responsible” genes, but we remind families that no one gets to pick out which genes they get from their parents or the genes they pass on to their kids. The motto we reinforce with the kids is, “It’s not your fault, but it’s your challenge.” We talk about that with the parents, too. We are not here to ascribe blame. We’re here to say: Here’s what the problem is, let’s identify it, and create solutions. You might be a naturally terrific parent, but that doesn’t train you for what to do when your child is manic or suicidal or psychotic. We want to help parents deal with very challenging parenting situations, not blame them for what any of us would struggle with.
The Balanced Mind Parent Network: How do you approach the reluctant patient?
MF: Most kids, even those who came in saying, “This is stupid–I don’t want to do this,” changed when they were around other kids in the group sessions. They almost always found someone to really bond with in the group and they had a group of kids who were very accepting of the struggles and very supportive of each other.
DM: There are some kids who will never participate , no matter how hard you try. All you can do is try. My goal is to get everybody into my clinic for one session. I tell everybody this is a “get acquainted session” and during the session we’re just going to see if this is going to be helpful or not. There’s no commitment you’re making to being in therapy.
I’d want to meet with the kid individually at that point and figure out why he’s so resistant to therapy. I’d want to meet with the parents to figure out if there are some issues that are keeping the kid from wanting to go to therapy. Maybe their kid thinks “Oh they’re just going to tear me apart and talk about how terrible I am and everyone else is going to get off scot-free.” I want to assure the kid that’s not the way we work. I try to convince the kid that his point of view is going to be heard. And that it’s not just about supporting his or her parent, but it’s about supporting him (or her). I do some work up front and try to help the kid understand, “Is there something you might get out of this? It doesn’t sound good to you now, but are there things that you want that could come out of this–not material things. But things like, ‘Gee I want to go to college, or I want to move out soon, or I want to be more financially independent.’ Is there a way that having treatment with your parents might help with that?”
MP: I tell the resistant child three things to get them on our side, so that it becomes a ‘pull’, not a ‘push’:
1) This is not going to be easy: This is really talking about your own personal stuff and it’s annoying sometimes. I understand.
2) I want to get to know all your strengths and see what else you need to cope with hard days and hard times.
3) Maybe when you’re ready, you’ll come. I’m not going to push this down your throat.
The Balanced Mind Parent Network: Are there any types of families that do particularly well with your program?
MF: Families who are willing to work hard while in treatment will get the most out of it. Perhaps both parents (or all parents, in the case of step-families) can’t physically attend each session, but the parent who does attend can share information with the other(s) so the same goals are agreed upon and worked on by all family members.
DM: Kids from families with a high degree of conflict and criticism show the most benefit from our treatment. The one situation I would steer clear of is active abuse within the family. If I have a parent who is abusing the child or the spouse, I wouldn’t want to start therapy until I knew that situation was under control. The other is anyone who comes into sessions intoxicated or acutely psychotic and unable to participate. Other than that, I’d take anyone who came to me.
MP: The greatest success with any program comes when both parents are on the same page, and enjoy, participate, and foster the process. When that’s not the case, we work with both parents and then we work with each one individually to help each to deal with the other. Negative consequences don’t work well with children! They don’t work well with parents either.
The Balanced Mind Parent Network: How are siblings involved and why?
MF: In MF-PEP, we don’t invite siblings to attend, as they could range in age from infants to college-aged students. We do, however, talk about sibling issues, both with the kids and the parents. In IF-PEP, in addition to talking about sibling issues as they arise throughout treatment, we also have a formal sibling session. If there are siblings in the family, we offer to bring them in for a session based on their age and needs. We make sure the child with the mood disorder understands this isn’t just going to be a session bashing him/her or blowing any confidentiality. We emphasize that the session is designed to help siblings deal with their feelings and issues and gives them a chance to vent. It also is to get across the message: You’re not the third parent in the family–your job is to be a kid and to take care of your own growing needs.
DM: In our program, siblings are actively involved in the treatment, whenever possible. My preference is to have them there every time. I think of siblings and patients as two-person dynamic systems: while it might be true that the well sibling is having a tough time with the bipolar kid’s angry outbursts, these outbursts don’t always occur in a vacuum: it can also be that the well sibling triggers the bipolar kid with subtle or not-so-subtle provocations. Interactions in families are always a two-way street: if you know that the child with bipolar is reacting strongly to his sibling, how is the sibling responding? Is there anything he or she could do differently that would help him or her to cope, while also helping the ill sibling? Does the well sibling relish the role of being the healthy one? Are both children stuck in roles that are hard to break out of?
Siblings are very influential to the patient, and vice-versa. For example, older siblings often know things the parents don’t know. I’ve had very productive sessions with a teenage patient and his or her older sibling, who may have struggled with some of the same issues at a younger age. Finally, we should never assume the sibling is emotionally healthy just because he isn’t the one who is labeled bipolar – this disorder runs in families and sometimes a sibling is struggling with a milder, undiagnosed form of bipolar spectrum disorder or depression. All the more reason to involve them in family sessions if they’re willing.
MP: We do four things:
1) We have a session with the sibling in which the parents listen in a chair on the side while we talk. We tell them about the problems that their brother or sister with bipolar disorder is having, and how hard it is for them to control their feelings and anger. We explain that, although their sibling’s bad behavior may feel personal, and cause friction, they’re not doing it purposefully. We tell them their sibling may at times be sarcastic, acidic and put them down, but that’s because of their intense low self-esteem and intense anger.
2) We help them understand the brain, and encourage them to have compassion for their sibling.
3) We tell them, “Life is very tough for him/her, but it is also very tough for you. You don’t deserve it. But what you get out of it is incredible patience, and incredible compassion and endurance.”
4) We tell them how to: help; have quality time; be supportive, active, and nice. And that’s where the parents join in.
The Balanced Mind Parent Network: In summary, the foundation of these three therapeutic models is education and inclusion. Family involvement provides families with an understanding of the biological basis of bipolar disorder. Validating the impact that the illness has on the entire family brings everyone into the healing process. “We tell families that the amount of work, time and effort you put into these sessions will be worth it,” says Dr. Miklowitz. “For kids, you are going to learn about how to manage your own moods, which will help you not only in your family but with your friends. For parents, there will be a positive outcome of all of this effort you’re making to help your kids cope with the disorder and find the right treatments. You may not learn it until they’re adults because kids aren’t known for coming up to us and saying, “Thanks for being such a great parent.” But there’s hope in this movement to involve families.”
For more information:
Mary Fristad, PhD
David Miklowitz, PhD