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Book Forum: MOOD DISORDERS   |    
Bipolar Disorder: A Family-Focused Treatment Approach
Am J Psychiatry 2000;157:657-a-658. doi:10.1176/appi.ajp.157.4.657-a
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Miami, Fla.

By David J. Miklowitz, and Michael J. Goldstein. New York, Guilford Publications, 1997, 320 pp., $35.00.

Psychoeducational interventions for families have long been empirically validated as deterring relapse in schizophrenia. This book extends the basic treatment model to bipolar disorder. Based on a premise of diathesis-stress, psychoeducators view families as lacking in knowledge rather than functionally defective, and family transactions are considered potential risk factors for decompensation rather than etiologically significant. Michael Goldstein, who unfortunately died before the publication of this volume, was one of the first family therapists to study and advance psychoeducation. His student and later colleague, David Miklowitz, was a prime mover in developing the treatment model described in this book.

Family-focused treatment, a research-based intervention for families of people with bipolar disorder, is a modified version of behavioral family management, originally developed by Ian Falloon, Robert Liberman, and their associates at the University of California, Los Angeles, for families of people with schizophrenia. Family-focused treatment was adapted for families of bipolar patients, who tended to be higher functioning, with greater capacity for insight but also potentially more oppositional than patients with schizophrenia. They were more likely to be married and to have relationship conflicts related to the behavioral manifestations and cycles of bipolar disorder. Family-focused treatment was designed specifically to address problems, resistances, and conflicts of those who had had a recent manic or depressive episode and were living with or in close association with their families, typically parents or spouses.

Part 1 of the book describes the clinical and research background that led to development of the model (which, the authors claim, integrates clinical judgment with ongoing feedback from patients and their families). Part 2 is a manual that proceeds from selection of appropriate candidates to functional assessment, psychoeducation, communications enhancement, and problem-solving techniques. The psychoeducation component includes didactic materials on etiology, treatment, and self-management, including a "relapse drill," a dress rehearsal for what to do when the patient shows incipient signs of a manic or depressive recurrence. Also included are methods for dealing with resistances and with nonadherence to medication. Following this, four basic communication skills are taught (expressing positive feelings, active listening, making positive requests for change, and expressing negative feelings about specific behaviors). There is a special section on dealing with family problems common in bipolar disorder, with a problem-solving worksheet. This exercise is particularly useful in focusing families on a common goal and involving the patient in an egalitarian process of problem resolution.

An important chapter addresses crisis management, with individual sections on how to handle manic, depressive, suicidal, substance abuse, and other psychiatric crises. The book ends with termination of family-focused treatment, with materials on anticipating future problems, evaluating future treatment needs, and arranging for follow-up visits. Many case histories enrich the manual, and handouts are used throughout. The book has copies of the most widely used handouts, with selective permission to photocopy for personal use.

This book is useful for therapists who are willing and able to work with concerned families of adults with manic depression. Like most clinical manuals, however, it gives short shrift to other available resources. There is a brief and rather dismissive mention of the possible value of family support groups. Telephone numbers are given for three national self-help organizations, but these are described as helping those families who wish to disengage from the patient! In addition to behavioral management, families of adults with serious bipolar illness need the support and understanding of others who have shared their experiences. They also need familiarity with federal entitlements, rehabilitative and residential options, and, too often, the ways of the legal and criminal justice systems. Few clinicians know these important details, but other families often do. Clinicians can help with deciding how to use such information. The book has only a single mention of the National Depressive and Manic-Depressive Association, again as a resource for families wishing disengagement. This association offers education and mutual support to patients themselves, has numerous self-help branches around the country, disseminates state-of-the-art psychiatric information from leading experts, and provides an advocacy forum for increased funding for research and services. It is ill-advised to ignore a resource that provides continuing support for people with bipolar disorder and their families long after the termination of family-focused treatment.

A thoughtful foreword by Lyman Wynne points out that this is a flexible treatment model that is applicable to patients who can vary widely in functioning and evoke a range of optimistic or pessimistic responses from their families and therapists. One wonders, however, whether family-focused treatment is protean enough to be useful across cultures. In the same Los Angeles area, its precursor—behavioral family management—produced opposite results with families of low-income Latino patients with schizophrenia (1)

. Compared with case management alone, behavioral family management was associated with greater symptom exacerbation and poorer outcomes at 1-year follow-up, as well as higher expressed emotion among family members. The researchers indicated that highly structured programs with communication directives and take-home exercises may be experienced as intrusive and stressful by poor families from traditional cultures. As the present book suggests, we must also be sensitive to the limitations of focusing on family transactions alone in biologically based disorders, given the body of research on extrafamilial life events that may trigger decompensation and the dangers of again stigmatizing families as implicit toxic agents.

The majority of patients these days do not live with their families, and although family-focused treatment can certainly help alleviate stress in the family system, several studies have found that attitudes of the staff of residential and rehabilitation programs predict relapse as effectively as do family transactions. When psychoeducators talk about reducing complexity and overstimulation in the patient’s environment, we would do well to look at reeducating clinical staff and others who are a significant part of patients’ lives.

Telles C, Karno M, Mintz J, Paz G, Arias M, Tucker D, Lopez S: Immigrant families coping with schizophrenia: behavioural family interventions v case management with a low-income Spanish-speaking population. Br J Psychiatry  1995; 167:473–479


Telles C, Karno M, Mintz J, Paz G, Arias M, Tucker D, Lopez S: Immigrant families coping with schizophrenia: behavioural family interventions v case management with a low-income Spanish-speaking population. Br J Psychiatry  1995; 167:473–479

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