Jenna, a 16-year-old patient with bipolar disorder, her mother Kathryn, and her 13-year-old brother Justin received FFT for 21 sessions over 9 months. The children’s father had left the family before Justin’s birth, and there had been no further contact. Based on the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (KSADS-PL; Kaufman et al., 1997
), a research diagnostician identified Jenna as having Bipolar I disorder, with an acute mixed episode in the prior 3 months, and comorbid oppositional defiant disorder. Two months prior to starting FFT, Jenna had been hospitalized following a rage episode in which she had caused household destruction, threatened violence to her mother and brother, and attempted to jump out of a moving car while on the way to a psychiatric appointment. At the beginning of FFT, Jenna had “dysphoric hypomania,” marked by irritability, agitation, and subsyndromal symptoms of depression. Throughout the FFT sessions, Jenna was regularly seeing a psychiatrist and receiving a consistent regimen of mood stabilizers (Depakote and Seroquel).
During the initial three sessions, the two clinicians (a primary psychotherapist and a trainee) explained their view that bipolar disorder needs to be managed biopsychosocially. First, they encouraged Jenna’s ongoing work with her psychiatrist for medication management. Second, they emphasized coming to understand the impact of bipolar disorder on Jenna and her family as a necessary precursor to developing realistic communication and problem-solving skills. The therapists provided didactic material about bipolar symptoms, diagnosis, expected course over time, distinctions between age-appropriate moodiness and bipolar disorder, the basic biology and genetics of the disorder, risk factors (e.g., disruptions in sleep/wake cycles, alcohol and drug abuse, family conflict), and protective factors (e.g., medication adherence, good family problem solving, regular daily routines), the role of stressful events in evoking symptoms, and how the family and school could help Jenna recover.
The family then worked toward identifying stress factors that played a role in triggering Jenna’s mood episodes. Jenna’s input was strongly encouraged during this less didactic segment. While Jenna was at first very reluctant to identify herself as having bipolar disorder, she could easily describe problematic family situations associated with her negative mood states. The family came to agreements about how the prodromal signs of Jenna’s mania and depression presented themselves (e.g., increased irritability, decreased sleep) and some of her triggers (e.g., interpersonal difficulties with peers, high-intensity interactions with family members, school workload).
Discussions of family stressors allowed the therapist to concurrently assess the family’s communication styles. Kathryn complained of having little control over Jenna’s behavior, but was overly critical of her, often attributing Jenna’s aversive behaviors to willfulness. Based on Jenna’s past actions, Kathryn feared that Jenna would continue to make poor life choices and, in response, had become overprotective. Kathryn frequently commented on her perceptions of Jenna’s shortcomings and her inability to make good decisions. Kathryn had valid concerns about some of Jenna’s school friends, but had perpetuated a power struggle with Jenna by demanding that she not see certain friends for fear that Jenna would copy their bad behaviors (e.g., school truancy). Kathryn’s insistence increased Jenna’s desire to see these friends. Kathryn’s critical comments toward Jenna, in turn, led to caustic retorts from Jenna and her brother. Kathryn then felt that the kids were ganging up on her, and interactions quickly escalated into shouting matches.
The therapists encouraged the family to identify and reduce stress situations so that minor shifts in Jenna’s mood symptoms did not always erupt into family crises. In general, we have observed that parents tend to overrespond and overreact to minor perturbations in their offspring’s mood states, some of which are clinically significant but many of which are not. The therapists encouraged Kathryn to view some of Jenna’s behaviors as due to an illness rather than willful disregard of her parental authority. At the same time, Jenna was asked to self-monitor her own mood states and associated behaviors through a mood chart. Starting at Session 5, Jenna tracked her daily ups and downs as well as her sleep and any noteworthy stressors. This charting enabled her to begin to identify what conditions may have contributed to negative family interactions and poor personal choices (e.g., criticism from her mother, lack of sleep, occasional low blood sugar). Jenna’s willingness to undertake the mood charting helped to build some trust with her mother, who up to that point had felt that she was the only one being asked to make changes.
After establishing a common language and understanding of mood symptoms and family stressors, the family moved into communication skills and problem solving (Session 6), and continued this work over the next eight sessions. The therapists modeled effective verbal and nonverbal communication skills (e.g., active listening, paraphrasing, expressing negative feelings about specific behaviors, making positive requests for change). Kathryn was initially more hesitant than the children to engage in communication exercises, being much more apt to suggest how Jenna and Justin might improve their skills. The therapists slowly engaged Kathryn by first asking one of the children to role play Kathryn and the other to play him- or herself. The therapists then asked for feedback from Kathryn on how the children had played her role in the family, and how she would play it differently. She was then asked to model her own communication skills for the children.
The family continued to struggle with escalating verbal conflicts. In tandem with problem-solving strategies, the therapists provided modeling of expressing positive feelings. Each family member was directed to praise the other for some specific behavior the other had performed, and to say how this positive behavior made him/her feel. This was an extremely difficult task for Kathryn, who continued to resort to critical comments but developed an increased awareness of how this behavior exacerbated family tension.
As treatment progressed into its fourth and fifth months, the family became more comfortable with trying new in-session exercises. Kathryn experimented with communicating her requests for change in a productive fashion rather than making global criticisms of Jenna’s character. In Sessions 14 to 18, the FFT problem-solving structure assisted the family in defining a hierarchy of family conflicts. The therapists encouraged the family to solve a problem of moderate significance to the family in terms of emotional intensity (e.g., keeping the house free of clutter) so that they could gain a sense of competency before tackling the more emotionally laden family issues (e.g., the disrespect Kathryn felt that her children expressed toward her).
Kathryn identified inappropriate use of the phone as a long-standing problem in the family, with Jenna and Justin readily agreeing that this was a contentious family issue. Kathryn felt that she was unable to set limits about phone use because her children ignored her. In turn, Jenna and Justin complained of their mother’s unreasonableness. The siblings accused each other of “hogging” the phone, and the mother noted that conflicts over the telephone increased Jenna’s irritability. The FFT therapists coached the family to identify a range of solutions for when and how the phone would be used; for example, the phone could be used only for certain periods of time if someone else was waiting, and access to the phone was contingent on cooperativeness between the siblings. All family members were encouraged to brainstorm other ideas, and options were evaluated as to their advantages and disadvantages. Finally, they agreed on a specific solution: that the phone would be used only by each child for a maximum of 1 hr per night, before 10 p.m., and only after the day’s chores and homework had been completed.
This issue was revisited in later problem-solving sessions to determine if progress was being made and if the problem’s resolution had decreased Jenna’s irritability. Kathryn’s resolve on setting limits was tested multiple times by both Jenna and Justin, but she was able to maintain a firm stance and voiced that she felt she had more control as a parent. Kathryn, who was becoming more aware of triggers for her own and Jenna’s mood swings, added the following contingency for use of the phone: Jenna and Justin were not allowed their hour of phone time if they had not been consistent with their agreed-upon bedtimes and wake times, a preventive measure against mood swings.
In experiencing some initial success in problem solving regarding the phone use, the family was able to move on to discussing more emotionally laden conflicts. The family had been renting a room to a young woman attending the local community college. At times, the renter was verbally inappropriate, chastising Jenna for perceived lack of consideration of her personal space. In several cases, these encounters had escalated into shouting matches with verbal obscenities between Jenna and the renter, which was stressful for the family as a whole. One of these interactions had been a precursor to Jenna’s inpatient hospitalization 2 months prior. Although needing the extra income, the family was considering discontinuing the renter’s lease.
Having begun to establish effective communication and problem-solving skills, the family utilized FFT sessions to help Jenna strategize how she might better respect the renter’s personal boundaries while also working to de-escalate their potentially volatile encounters. At the same time, Kathryn made a request for positive change of the renter, asking that she refrain from any shouting matches or obscenities with Jenna. The mother and renter agreed that they would have family meetings to address any concerns the renter had with Jenna’s behavior. Kathryn was able to demonstrate to the family her willingness to address a stressful situation while maintaining clear expectations of the children’s behaviors. More generally, Kathryn had become much more proficient at making access to reinforcers (i.e., privileges) contingent on the children’s appropriate behaviors. The FFT therapists reinforced the family members’ awareness of the progress they were making and their ability to constructively and collaboratively overcome conflict.
The focus of later maintenance sessions was the creation of a relapse-prevention plan. Reporting peer stigma, Jenna continued to be resistant to the bipolar-illness label, but was adhering to her medication regimen, responding to Kathryn’s limit setting, and not showing the inflexible explosiveness evident in her past interactions with family members. The family worked together to assist Jenna in identifying an updated list of risk and protective factors. They conjointly developed a relapse-prevention plan involving keeping emergency phone numbers handy, balanced diets, regular exercise and sleep, and avoiding high-stress, provocative interpersonal situations at home and at school.
FFT ended with an understanding that the family might contact the treatment team for booster sessions in the future. At the end of treatment, Jenna continued to have subsyndromal symptoms of depression, but was clinically stable and remained on her medication regimen. Although she did not feel that she had gained full mastery over her tendency to resort to escalating criticisms and accusations when she felt that her parental authority was being challenged, Kathryn reported considerably less family conflict and greater self-efficacy as a parent.