The Essential Role of Family in Treating Bipolar Disorder
by Amy Mednick, MD and Alison Heru, MD

This article was originally published in Clinical Psychiatric News on October 18th, 2013 and can be found at this link.

Kevin was doing very well in law school, until he showed up at his professor’s house in the middle of the night. Normally a thoughtful, quiet, introverted young man, Kevin was hardly recognizable to his professor, who found him outside yelling loudly and demanding to speak about an underground conspiracy he believed he had uncovered. He had always been a good student, and his family was very proud of his accomplishments up until now. At the age of 24, Kevin’s first manic episode was triggered by late nights studying for his law school exams and marijuana use to cope with stress.

Police responded to noise complaints, and Kevin was hospitalized. The manic episode resolved surprisingly quickly in the absence of marijuana use and with the help of an atypical antipsychotic. The patient’s intelligence and articulate lawyer-in-training charm made his inpatient doctors hard pressed to justify an extended hospital stay, and he was discharged 3 days later with a prescription and instructions for follow-up. He promptly discarded both.

When his next manic episode arose, Kevin disappeared for 2 weeks, and after fearing the worst, Kevin’s family was relieved to receive a call from Kevin’s aunt, who lived across the country and had just found him at her doorstep. This time, without the involvement of law enforcement, there seemed to be no way for Kevin’s mother, father, older sister, and aunt to persuade Kevin to enter the hospital or to take medications. Kevin’s aunt accompanied him on a plane home, and in the face of Kevin’s unwillingness to enter treatment alone, they decided to enter treatment as a family.

Predictors of episodes

The strongest predictors of future episodes and poor outcome in patients with bipolar disorder are a greater number of previous episodes, shorter intervals between episodes, a history of psychosis, a history of anxiety, persistence of affective symptoms and episodes, and stressful life events. Some evidence has suggested that poor job functioning, lack of social support, increased expressed emotion in the family, and introverted or obsessional personality traits all might predict poor outcome in bipolar disorder (J. Psychiatr. Pract. 2006;12:269-82).

An overwhelmingly emotional home environment can make a large contribution to relapse. Multiple studies have shown that a high level of "expressed emotion" (characterized by overinvolvement and excessive criticism) predicts patient relapse independent of medication compliance, baseline symptoms, and demographics (Arch. Gen. Psychiatry 1988;45:225-31)

Because bipolar disorder is an unpredictable, potentially destructive illness, it is important to grab any factors that we and our patients might have control over and do our best to modify them positively. With this in mind, the Family Focused Treatment (FFT) model was developed, with the philosophy that by keeping patients well informed about the facts and realities of the disorder and working on the communication and coping mechanisms operating within the family, relapse prevention and emotional stability will be better maintained. In this way, the predictive factors of stressful life events, poor social support, and family-expressed emotion can be modified. FFT is a time limited (usually 12 sessions), highly effective treatment modality.

The principles of FFT were adapted into an ongoing-treatment model that can be implemented in a community setting, termed Family Inclusive Treatment (FIT) and used by the Family Center for Bipolar in New York City, for example. FIT consists of an engagement period at the initiation of treatment, focused on psychoeducation and relapse prevention planning. FIT is unique in that every patient is required to sign a release of information giving permission for full, open communication at all times between the patient’s clinician and a treatment partner of their choosing.

After the initial engagement period, there are quarterly family visits to supplement regular individual treatment. Other modalities such as individual therapy, pharmacotherapy, and group therapy are used according to the clinician’s judgment.

This form of treatment is innovative in that it treats bipolar illness just like any other chronic illness. It promotes open communication between families of patients with bipolar disorder and the patients themselves with regard to symptoms and medications. In this way patients are not isolated from their families; they can talk openly with one another and their clinician as they would do if somebody in the family had Alzheimer’s disease or diabetes.

It has been reported that up to 46% of the caregivers of patients with bipolar disorder report depression, and up to 32.4% report use of mental health services. These symptoms tend to be dependent on the nature of the caregiving relationship, suggesting that specialized interventions addressing the psychiatric needs of bipolar families might result in improved outcomes for both patients and their family members, in addition to decreases in health care costs (J. Affect. Disord. 2010;121:10-21).

Together with therapy and medication management, clinicians working in the FIT model strive to create an environment that minimizes, as much as possible, the impact of bipolar disorder on the affected individuals and their close loved ones.

Many studies have confirmed the efficacy of various psychosocial treatments for bipolar disorder (J. Consult. Clin. Psychol. 2003;7:482-92; J. Clin. Psychiatry 2006;67 [suppl. 11]:28-33; J. Affect. Disord. 2007;98:11-27), and there has been a push for the integration of psychosocial treatment with pharmacotherapy, as the latter is less often sufficient on its own in preventing relapse.

Patient, family begin journey

Kevin and his family entered into family treatment. They started off with the psychoeducation portion of the treatment, and many of the myths and misinformation that they had held about bipolar disorder were dispelled. Even Kevin was able to engage in the information exchange, which he initially approached from an academic, impersonal vantage point. The communication skills phase proved more problematic as it became more personal, but still, the focus was on the family’s communication and not on Kevin as a psychiatric patient, so he responded well.

It was uncovered that Kevin’s father has always been highly critical, and Kevin’s mother tends to overprotect her children to compensate. They were taught new skills to express their feelings toward one another, and especially toward Kevin, in more productive and positive ways. In addition, they got a chance to practice those skills in subsequent sessions.

The modules continued in this vein until the family portion of treatment had completed. By this time, Kevin had developed a good rapport with his clinician, and he continued treatment despite his persistent reservations about accepting his illness. The family environment improved, and though Kevin was only sporadically compliant with his medication, the reduced stress at home and improved coping skills drove him less often to use marijuana for "self-medication," which decreased his manic episodes.

Kevin’s family periodically rejoined him in treatment sessions at predefined intervals, to check in and assess his and their progress. They were comfortable speaking with Kevin’s doctor and would call when they noticed any of the warning signs that they had collaboratively determined as markers of upcoming mania. In this way, they were all effective at keeping Kevin’s moods stable and keeping him out of the hospital.

The psychiatrist in routine practice might neither follow a manualized algorithm for family treatment nor have the time or resources at her disposal to provide a full "curriculum." Still, she can have the same success in engaging a family in understanding their loved one’s illness and contributing to the family member’s stability.

Objectives for family-focused treatment

The following objectives are adapted from "Bipolar Disorder: A Family-Focused Treatment Approach," 2nd ed. (New York: The Guilford Press, 2010):

• Encourage the patient and the family to admit that there is a vulnerability to future episodes by educating them about the natural course, progression, and chronic nature of bipolar disorder.

• Enable the patient and the family to recognize that medications are important for controlling symptoms. Provide concrete evidence for the importance and efficacy of medications and the risks of discontinuation. Explore reasons for resisting medications, including fears about becoming dependent.

• Help the patient and the family see the differences between the patient’s personality and his/her illness. Make a list of the patient’s positive attributes and a separate list of warning signs of mania. Frequently reinforce the distinction between the two.

• Assist the patient and the family in dealing with stressors that might cause a recurrence and help them rebuild family relationship ruptures after an episode. Suggest methods for positive, constructive communication such as active listening (nodding, making eye contact, paraphrasing, asking relevant questions) and expressing positive feelings toward a family member related to a specific example of a behavior.

Film Review: The Last Interview of Thomas Szasz

This reviews was originally published in Psychiatric Times on October 22nd, 2013 and can be found at this link

The Last Interview of Thomas Szasz
Directed by Philip Singer, PhD • Documentary • 2013 • 50 minutes
A Traditional Healing Productions Film • Witness Films (www.witnessfilms.com)

Written by: Zimri S. Yaseen MD, Clinician at the Family Center for Bipolar

 The Last Interview of Thomas Szasz would make an excellent discussion piece for a psychiatry residency ethics seminar, because it pushes the viewer to think more deeply about the issues and principles that underlie capacity and informed consent. It would also serve well in any introduction to a psychotherapy course, since it draws out distinctly and compellingly the question, “What is the nature of the therapeutic conversation?”

Thomas Szasz, a psychiatrist and psychoanalyst, reportedly ended his own life last year, at the age of 92, after a spinal compression fracture.¹ His suicide might be a topic of debate, however, because some obituaries report that Dr Szasz “died of a fall.”²

Director Philip Singer, PhD, a medical anthropologist whose focus has been the cross-cultural study of healing practices, interviewed Szasz 2 years before his death. The interview focuses on the central argument in the 1961 book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, for which Szasz is best known. It forms the core of Szasz’s career-long sermon, a radical—which is to say, epistemological—attack on the construct of mental illness. Namely, he argues that illness belongs to bodies and not to minds; the brain can be sick, but the mind cannot.³

 

An important and elusive corollary of this observation is that mental illnesses must be defined syndromically in terms of mental and behavioral symptoms. The lack of change in the basic diagnostic system of DSM-5, which follows DSM-IV in this approach, speaks to this logic. What is easy to lose sight of is that where symptoms of an illness typically represent problems for the ill, those of mental illnesses, while certainly presenting problems for their sufferers, may more often also represent problems for somebody else; after all, many of the patients we see have been brought to us by loved ones who are distressed by the patient’s behavior or by the police for disturbing the peace. 

This epistemological argument is ultimately motivated, however, by Szasz’s unbending libertarian ethics; the point of saying minds cannot be sick is revealed in this interview to be a principled guarding against the intrusions of society on personal liberty and liberty of thought. Permitting such an intrusion might also allow for society to slip into totalitarianism. This might be paraphrased as “Don’t call your distress at someone else’s behavior their sickness; if a person wants help with a problem, it is their own responsibility to seek it. If they are bothering you, that is your problem.” Although Szasz indicates that some societal controls are acceptable, he resents the presentation of such controls as medical matters, a tactic that quietly removes them from the realm of social debate. 

Although principled, in this context, it is also a deeply emotional defense. That hidden emotionality makes the discussion difficult, but it also highlights its importance. In fact, such an argument highlights the importance of a questioning approach to the concepts that make up “mental illness,” and this emotionality should perhaps also be understood as a necessary “flaw” in the discussion. The questions themselves are essentially emotional ones. Insofar as we are social animals, the complex functions of a mind are necessarily to a great extent socially constructed, even as they necessarily have biological underpinnings (a physical event in the organism underlies the non-physical event of a thought). The controversial elimination of the bereavement exclusion from the major depressive episode criteria in DSM-5 is a prime example. 

Dr Szasz places equal demands on patient and doctor—of doctors, to act only in accord with the patient’s immediate (free) will, and of the patients, to act in accord with their best interests or (freely) suffer the consequences of their poor choices or bad luck. 

Singer, attempting to find a situation Szasz might regard as a moral gray zone in his critique of common psychiatric practice, is driven to call him “Jesuit” in his adherence to his conclusions. Here, something emotional has come into play; how do we recognize the imbalances in a doctor-patient relationship and how do we feel about them? Szasz’s avoidance here is telling. 

Indeed, the perplexing power of Szasz’s epistemological problem with “mental illness” is obscured at times by its complex, often tenuous, connection to the libertarianism that motivates it. This is not to say that his libertarianism is not powerfully thought-provoking in its own right and must give any psychiatrist pause when pursuing involuntary commitment or treatment over objection. Even if one is ultimately to disagree with Szasz (as, in practice at least, almost all psychiatrists do), such pause is an invaluable burden. 

Beyond these matters, which are readily available in Szasz’s writings, Singer’s film allows us to meet Szasz near the end of his life. I cannot help but feel that the hard edges of his arguments serve as guards against survivor guilt that could otherwise cripple a man of evidently deep, tender, and curious humanity. (Szasz emigrated to the US in 1938 to study medicine, wittingly escaping the storm of fascism already overtaking central Europe.) 

Throughout the interview, we find Szasz demands that the discussion be on his terms. “I never saw anyone before talking to them myself,” he explains. “My secretary didn’t make any appointments.” To explore this, Singer plays a prospective patient: “Help me to want to live again,” to which Szasz replies, “That’s not the kind of thing I can do. I would not make an appointment.” A pause ensues and, slightly frustrated, Singer tries again: “Okay. I’ve heard, Dr Szasz, that you’re a very good psychiatrist and I just don’t feel I can live this way anymore; can you help me?” Szasz responds, “Perhaps. Okay. We can have a conversation; come and see me.” The transcript reads perhaps as harsh, but in Szasz’s voice there is something ameliorating. When he says, “Come and see me,” he does not sound clinical. Rather, one hears a genuine and fully willed invitation. 

What is the difference between Singer’s first, rebuffed, approach and his second, accepted one, besides the compliment to Szasz? In the first, Singer lacks agency. He positions himself as seeking rescue. In the second, he seems similarly distressed but he takes ownership of his choice to seek Szasz’s help. Szasz demands ownership of his own choices; he decides whether he will see someone, but he demands that ownership of choice of others as well. “The goal,” he says, “is to assume more responsibility and therefore more liberty and more control over one’s own life.” 

Szasz’s fierce independence and his symmetric insistence on the responsibility of others for their own fate read to me as a defense against the emotional burden of having escaped the Holocaust. Indeed, that fierce independence seems to be one that he held to the death. Singer asks, “If you were dependent on someone else, caretakers . . . would you think . . . of killing yourself?” Szasz pauses and smiles before replying, “Off the record.” 

Should Szasz’s alleged suicide, then, be seen as a courageous adherence to the principles by which he lived or a symptom of a pathological avoidance of helplessness? Dr Szasz might reply that either way, it was his choice. 

- See more at: http://www.psychiatrictimes.com/film-and-book-reviews/film-review-last-interview-thomas-szasz/page/0/2#sthash.mT3cwc2X.dpuf

New Therapy Groups!!

The Family Center is excited to announce that we are starting two new weekly psychotherapy groups:

“Quality of Life”

“Sane Eating”

Those of you who are already in psychotherapy may think:”Why join a group? Will it add anything useful to my treatment?” The answer to this question is that group therapy is a unique resource that can nicely compliment individual treatment and deliver additional therapeutic gains. Bonding with other group members, receiving and offering emotional support, showing up for your peers are the things that facilitate learning new skills, expand your social competence and boost the sense of well-being. Those of you who are not in individual therapy in their turn may wonder if group therapy alone would be as beneficial as individual therapy. I am happy to assure you that group therapy can effectively stand on its own. Research shows that there is no difference in effectiveness between group and individual therapy although individual therapy appears to have a quicker effect.

So what do the two new groups have to offer? In the “Quality of Life” group you will learn and put to practice the three essential skills; mindfulness, emotion regulation, and interpersonal competence. Simply put, you will learn to become mindful of your internal experiences and surf the emotional waves without becoming crushed by them. In a supportive environment you will practice negotiating solutions to conflicts, asking for what you need and listening with open mind. This practice can help you to alter the course of your relationships and improve the quality of your life.  

The “Sane eating” group’s goal is to help you gain freedom from unhealthy persistent eating habits. The group will not teach you what to eat beyond some basic nutritional facts. Instead, using the wisdom of psychotherapy, it will help you to develop a healthy relationship with food. You will learn to understand and change the ways you think about and respond to impulses to eat. Stress reduction and emotional balance are additional anticipated benefits.

All we have to do is begin!

If you would like more information or are interested in signing up, please call Dr. Gaiane Kazariants at 212-844-1742.

What is a prodrome?

ˈprōˌdrōm/ noun:  an early symptom indicating the onset of a disease or illness

In psychiatry, the word prodrome is often used to describe a period of time during which an individual begins to display symptoms of a mental illness, typically accompanied by some type of disturbance in functioning, but before the disorder fully presents itself.  Classically it has often been used to describe a period of time of social isolation, change in mood or behavior, and change in functioning who go on to develop schizophrenia, but often people who go on to receive a diagnosis of bipolar disorder have a prodrome as well. 

Unfortunately, sometimes the prodrome is best identified in hindsight.  After a teen or adolescent develops a major depressive episode or a manic episode, parents and family look back and say “oh yeah … he WAS moody and irritable, he DID stop hanging out with friends, he DID seem a bit restless and agitated, he WAS very distractable, his grades DID drop significantly”.  Often in the moment, symptoms seem like normal adolescent behavior or “just a phase”, or often can be related to other issues going on, such as peer problems, academic problems, or other life stressors. That is because the symptoms don’t tend to be severe, may not happen all together, and are often non-specific - meaning that they could be seen in a variety of disorders, such as depression, anxiety, attentional disorders, drug and alcohol disorders, etc.

Bipolar disorder often cannot be clearly diagnosed during this period, unless there are symptoms that are specific to the disorder.  However, any changes in an adolescent’s mood or behavior that affects their relationships and their function at school, with peers, and at home, is worth evaluation by a child and adolescent mental health specialist.  This person can help you monitor changes in symptoms and response to treatment so that whatever may be brewing beneath the surface can be caught early and treated appropriately.

-Dr. Buchanan-