Clinicians’ Treatment Manual:

Family-Focused Therapy (FFT) for Youth

and Young Adults with or at High Risk for

Bipolar or Psychotic Disorders

David J. Miklowitz, Ph.D.1.2

Mary P. O’Brien, Ph.D. 3

Danielle A. Schlosser, Ph.D.1

Aimee E. Sullivan, Ph.D.2

Elizabeth L. George, Ph.D.2

Dawn O. Taylor, Ph.D.2

Jamie L. Zinberg, M.A.1

Sandra De Silva, Ph.D.1

Tyrone D. Cannon, Ph.D.3

1
University of California at Los Angeles
2
University of Colorado Boulder
3
Yale University

Draft Date: December 18, 2018

Please do not circulate without permission. For correspondence please contact
Dr. Miklowitz at [email protected].

Table of Contents

I. Introduction.................................................................................... 3

II. Psychoeducational Sessions....................................................... 13

Session 1: Goal Setting, Treatment Overview............................
Session 2: Symptoms, Vulnerability Stress Model.....................
Session 3: Stress and Coping Skills...........................................
Session 4: Optimizing Family Support; Prevention Plan............

III. Communication Enhancement Training...................................... 64

Session 5: Expressing Positive Feelings....................................
Session 6: Active Listening.........................................................
Sessions 7 and 8: Making a Positive Request,
Communication Clarity, Expressing Negative Feelings

IV. Problem-Solving Sessions............................................................ 85

Session 9: Expressing Negative Feelings, Intro to Skills............
Session 10-12: Problem-Solving Skills.......................................
Termination Tasks......................................................................

V. Optional Treatment Exercises…………………………………….. 93

VI. References……………………………………………………............. 98

VII. Treatment Supplements…………………………………………………. 99

Attention Deficit Hyperactivity Disorder…………………………..
Oppositional Defiant Disorder……………………………………..
Anxiety Disorders…………………………………………………...
Suicidality…………………………………………………………….

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 I. INTRODUCTION

An Introduction to Working with Early-Onset Youth

The purpose of this manual is to explain an early intervention treatment for

adolescents and young adults who may already have, or may be at risk for, developing
bipolar disorder (BD), major depression (MDD) or psychosis (hereafter referred to as
Early-Onset Youth, or EOY). Family-Focused Therapy for EOY and their families
(FFT-EOY) consists of 8 weekly and 4 biweekly sessions (12 sessions over 4 months).

The relevant populations for FFT-EOY are age 9-25, with a recent onset of bipolar I or
II disorder (mania, depression, mixed, or hypomanic episodes); an episode of MDD; a
recent onset of psychosis (including first- or second-episode schizophrenia or
schizophreniform disorder); and the relevant “prodromal” forms of these disorders
(bipolar disorder, not otherwise specified; psychosis NOS; depression NOS;
attenuated psychosis syndromes). They must have family members who are willing to
come in regularly - parents, grandparents, or extended relatives who are in a
caregiving role.

For a thorough understanding of FFT, we recommend that you become acquainted

with the Miklowitz (2010) Bipolar Disorder: A Family-Focused Treatment Approach
manual (2nd Ed) before applying the treatment with your patients. In addition, The
Bipolar Teen: What You Can Do to Help You and Your Family (Miklowitz and George,
2008) or The Bipolar Disorder Survival Guide (Miklowitz, 2011) describes many of the
strategies discussed in this manual and are resources that can be made available to
families.

The overriding goal of FFT-EOY is to educate families about the symptomatic

presentation of the illness and offer tools to prevent its onset and/or worsening. There
are six subsidiary goals:

To assist patients and families to:

(1) integrate the experiences associated with episodes of mood disorder

or psychosis,

(2) assist the patient and relatives in accepting the patient’s vulnerability
to future episodes,

(3) accept the current or future role of psychopharmacology to manage

symptom states,

(4) enhance social and academic functioning,

(5) recognize and learn to cope with stressful life events that trigger
recurrences of mood disorder or psychosis,

(6) assist the family in reestablishing functional family relationships after

an episode.

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In this manual, you will learn how to proceed with administering FFT-EOY. The three
modules of FFT will be covered in a modified form. Case vignettes and typical therapy
interchanges are included. All names and identifying information of clients and family
members have been altered and disguised so that these persons cannot be identified,
consistent with guidelines for preserving the confidentiality of patients.

Note: In the sections that follow, “IP” refers to the “index patient” who is the
focus of your treatment (the 9-25 year old who has symptoms of mood
disorder, psychosis, or prodromal symptoms). The IP is also called the youth,
the young adult, the teen, or the “early-onset youth” (EOY). We wanted to mix
up the terms so you wouldn’t get bored! Keep in mind the differences that age
can make when planning these interventions.

Parents of Early-Onset Youth

The parents of early-onset individuals are resourceful and proactive enough to have
found treatment, and so from the very first encounter we want to communicate that we
value them, that their partnership with us is essential, and that we think that the efforts
they are directing toward helping their son/daughter matter. In fact, we think that their
son/daughter is very fortunate to have a parent in his/her life that is willing to put effort
into helping him or her.

While invariably parents entering such programs have tremendous strengths, at the
same time, parents first arriving tend to be feeling pretty overwhelmed. Often, they are
just beginning to come to terms with the fact that their son/daughter could develop a
serious mental illness. Because some of individuals you will see have not yet met
diagnostic criteria for a mood disorder or psychotic illness yet are exhibiting some
characteristic early warning signs, parents may feel confused and immobilized by this
diagnostic ambiguity.

If their son or daughter is exhibiting a lot of trouble with motivation and social
withdrawal, parents have a hard time knowing whether this is “typical teenage
behavior” or something more, such as negative symptoms or depression. Parents
may be feeling frustrated and fatigued by their son/daughter’s “refusal” or inability to
step up and function more independently. It is not uncommon for parents of early-
onset youth to spend a lot of time in the morning getting their son/daughter out of bed,
urging him or her to shower and groom, and then driving him/her to school. At the
same time, the parent may feel conflicted about subjecting him/her to academic and
peer struggles that seem more intense for their son/daughter than for other individuals
their age, and with which their son/daughter may seem less well equipped to cope. If
the IP has been spending an inordinate amount of time alone in his/her room, and is
no longer calling or initiating fun activities with family and friends, parents are
understandably concerned that their son/daughter may be lonely, disconnected, and at
risk for self-harm. It may be painful for these parents to watch their son/daughter
struggle, and they are often confused about what more they can do to help. At the
same time, they often wonder if they are doing too much for their son/daughter. In
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short, they are trying to figure out how best to keep their son/daughter “on track”
without over- or under- parenting.

These parents may feel isolated from other parents in the community who are having a
very different parenting experience. Advice that works for parents of “normal teens”
(e.g., “tell him he’s grounded if he won’t go to bed”) may not seem relevant to these
parents. Most likely, these parents would like to be able to step back a bit at this stage
of life, and let their son/daughter take greater control of his/her own life as is
recommended in many parenting guidebooks. However, the price for backing off may
be to watch their child flounder and fail. If parents find this price exorbitant and remain
quite involved, they run the risk of getting branded “over-involved.” It is important that
mental health professionals do not form opinions too quickly about a parent’s level of
involvement in his/her young person’s life.

Because of ongoing hypomania/mixed symptoms, depression, negative symptoms and

social skills deficits, many early-onset youth have attracted few friends and adult
mentors into their life to share the task of providing growth-promoting experiences, so
the burden of raising them falls more heavily on the shoulders of their parents.
Parents realize that other teens or young adults are spending time with friends,
perhaps dating, and engaging in a wide variety of extra-curricular activities. They
realize that their son/daughter is missing out on the skill development that is a by-
product of these activities. They see their son/daughter slipping further and further
behind and are often searching for ways to decrease the gap that is being created
between their son/daughter and his/her peers.

While other parents may be enjoying the fruits of years of labor as they watch their
son/daughter succeed in a variety of arenas, parents of early-onset youth may be
internalizing the message that they must have done something very wrong for their
son/daughter to be so “off track.” These parents may be exceptionally skilled with their
offspring, yet their parenting efforts may not be appreciated by extended family
members, friends or neighbors who only see the adolescent’s school failure or social
isolation. It may be easier for others to simply view school failure and social isolation
as a reflection of failed parenting than to understand the patience and skill it takes to
cope with and support an adolescent who is experiencing psychiatric symptoms. Of
course, it can be quite tiring for parents to feel misunderstood.

If their son/daughter is experiencing mania or positive psychotic symptoms, such as

elated mood, grandiose delusions, paranoia and unusual perceptual experiences,
parents may be confused and frightened by the symptoms and their implications.
While some empirical studies suggest that prodromal youth may benefit from the early
introduction of anti-psychotic medications (McGlashan et al., 2006; McGorry et al.,
2005), additional study is still required. Therefore, parents are asked to tolerate more
ambiguity as they collaborate with psychiatrists and begin the process of figuring out
whether medications make sense for their son/daughter.

In summary, parents often arrive at our doors in need of support and information.
Hopefully we can help them to feel like they have found a resource that will join with
them in their efforts to help their son/daughter.

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Youth with or at High-Risk for Bipolar Disorder, Major Depression or Psychosis

We see a variety of young people in our programs. Some of them have bipolar
disorder or MDD or schizophrenia already. Others have early “prodromal” symptoms
that don’t yet meet the full DSM-IV criteria, like mood swings, brief and recurrent
hypomanic periods, or mild psychotic symptoms. Most are in some distress and that is
what has prompted their visit. Typically their grades are dropping or they are having
trouble at work, they are becoming increasingly isolated, and they are starting to
wonder about their own future. Our main goal with them initially is to connect. Often
IPs express a sense of relief when they are able to talk frankly with a knowledgeable
professional about the symptoms that they have been experiencing. They may be
“testing the waters” with us before they are willing to fully disclose. They are often
relieved to hear that we have worked with many individuals that have symptoms
similar to what they are describing, and that we have some ideas about a variety of
coping strategies that may be useful.

The youth or young adult may also feel demoralized and confused. We want to help
these individuals reconnect with their strengths and interests, and learn how to cope
with the symptoms they are experiencing so that they can achieve their goals in spite
of the symptoms.

For patients under age 18, it is important that we are clear with them from the start
regarding the limits of confidentiality/what we share with their parents. Although it is
quite common for therapists who work with adolescents to keep information
confidential from parents, often a more collaborative approach works well for the
patients at our clinic and their families. We typically encourage the patient to share
information about the symptoms he/she is experiencing with his/her parents so that
parents can be as useful to the patient as possible. Parents are crucial in setting up
(and paying for) appointments with psychiatrists, therapists, school interventions, etc.
If parents know what is going on with their son/daughter, they have the opportunity to
be empathic and supportive and to set appropriate limits to keep their son/daughter
safe. When patients have been quite secretive regarding their symptoms and inform
us that their parents are largely in the dark, we encourage greater openness.

In general, our initial goal is to get to know the patient as an individual. We are
interested in hearing about symptoms and struggles, but also in hearing about
strengths, hopes, and goals for the future. With a solid understanding of where our
patients are developmentally, we can start to formulate a collaborative plan with them
regarding how they can move on with their lives and make progress toward reaching
their goals.

6
 Objectives of FFT-EOY

FFT-EOY consists of three modules: psychoeducation sessions (4 sessions),

communication enhancement training (4 sessions), and problem solving skills training
(4 sessions). In total, participants will complete 12 sessions over a 4-month period (8
weekly, 4 biweekly). Additional sessions may be scheduled if necessary. In some
cases, we may have a shorter treatment if the family and therapist are only available
for a short period of time.

Pacing and Flexibility of Sessions

FFT can be tailored to the particular family you are working with. While it is ideal to
have each family complete all 12 sessions, it might not fit the pace of the family you
are working with. For instance, a family might require two sessions to cover one
session’s worth of material. In this case it is acceptable to stretch the session out to
two sessions. In order to accommodate that change, you can skip a problem solving
session. On the other hand, if a family is able to address two session’s worth of
material in one session, it is fine to do so. Furthermore, you might notice that some of
the material may not be applicable to a particular family and it is fine to skip that
session (for example, their communication is clear so the “communication clarity”
handout is not needed). You will find that the educational module has a structured
outline at the beginning of each session indicating what you should cover during a
particular session. This is meant to be a guide rather than a rule. If you happen to
spend more time working on some objectives and you don’t get to all of the objectives
because it doesn’t seem appropriate for a particular family, that is okay.

Clinical Tip

The most important aspect of the educational material is that it is communicated to the
family in a way that the family is able to understand and finds meaningful and useful.
All of the handouts are simply tools to help convey information. If a particular handout
does not support your efforts to provide information to a particular population or to
facilitate constructive communication among family members, please feel free to drop
or modify the handout. The goal is not to get through a certain set of handouts each
session.

The manual can be thought of as a toolbox of techniques that the therapist can use
with family members at ANY point in the therapy that those techniques seem relevant.
For example, during the course of conducting a problem solving session, it may
become clear that a discussion of pleasant events scheduling or relaxation techniques
may help a family to get beyond an impasse in the problem solving process. This
may be the ideal time to teach a skill that didn’t seem relevant earlier in the treatment.

Emotional Tone of the Therapy

It is fairly common and understandable that a parent or other family member may
become tearful when talking about the impact the patient’s symptoms have had on him
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or her. Parents may experience a lot of grief over their son or daughter’s sudden
change in functioning and if symptoms are quite severe and precipitous parents may
need to “mourn” the change. Alternatively, family members may express anger over
how difficult it has become for them to work given the patient’s difficulties going to
school, or to invite friends over since the onset of the patient’s symptoms of
depression, reclusiveness, suspiciousness, and/or odd behavior.

It is very important to keep the sessions tolerable and low-key for the patient.
Therapists should step in fairly quickly to redirect family interaction when emotions
escalate during a session. In some instances it may make sense to spend time
gathering information and developing a better understanding of the family members’
emotions and what tends to provoke them. You always have the option of asking
the family member who is expressing a lot of emotion to schedule a time to meet
individually. During an individual meeting the therapist can discuss the family
member’s emotions further and provide some additional psychoeducation and/or
recommendations for individual therapy as appropriate. Alternatively, it may make
sense to work on some communication skills with the family earlier in the treatment so
that psychoeducation can proceed more productively once family communication has
improved. It may be useful to conduct problem-solving on ways in which family
support could be optimized so that family members understand the importance of
creating a low-key family environment.

Clinical Tip

With some families, you may find that the sessions have a stilted, overly didactic
quality, that participants seem to be blithely going along with the tasks, looking blankly
at the handouts, etc., but don't really seem to be aboard with your treatment goals. If
so, take a step back. Think with them about their own treatment goals, and explain
how the various tasks you've assigned them will help them meet these goals. If you
feel like you are missing out on discussing important issues because of the treatment
structure, depart from the manual to discuss what's on everyone's mind and then try to
bring them back on task. Once you've brought them back on task, try to adjust the
psychoeducational tasks to be more consistent with their goals.

Pretreatment Sessions

Sometimes family members express reluctance about participating in family therapy.

They may have misconceptions about what family therapy entails. For example, one
father reported (somewhat in jest) that he envisioned using little foam boppers to hit
family members over the head when discussing frustrating issues. He had never
participated in family therapy before and was relying on an episode from a sitcom to
help him form expectations of therapy. While many people may not be as forthcoming
as this father, they often have concerns about what they may be getting themselves in
to if they agree to family treatment. For those families that express some hesitation, it
may be useful to use the first session to lead the family in a discussion of their
concerns and get greater clarification regarding the content and process of this
approach to family therapy, and make an informed choice about whether they want to
do it.

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During the session it is important that you listen to family members’ concerns and
normalize them. Often parents are worried that they will be blamed by the therapist or
by their youth for causing the youth’s symptoms. Let them know that these concerns
are quite common, nobody likes to be blamed, and that assigning blame isn’t part of
this therapy.

It is often helpful to give the family a sample of what the sessions will be like by
presenting information that is relevant to a question they have raised. For example,
often parents ask about what types of expectations they should be setting for their
child. They may report that if the doctor says they should back off they will, but they
don’t want to just “let their child off the hook too easily” or “set different expectations for
this child than they do for other children in the family.” This is an excellent question,
and there really isn’t one standard set of expectations that applies to each and every
youth that is experiencing symptoms. Symptoms differ across people and even within
the same person over time. You can address the family member’s question by saying
something like the following.

“When there is a high level of stress in an individual’s life and/or he or she is

experiencing intense symptoms, one way to consider relieving that stress is to
lower expectations temporarily. When symptoms remit or stress is reduced
and/or coping strategies are supported, it may become possible to gradually
raise expectations.”

You should then ask the family members what they think about this approach to setting
expectations. Does this make sense given their experiences with symptoms so far?
Do they think this type of approach might help guide their efforts?

Throughout the therapy we will be presenting information and introducing skills and
then talking with family members about their reactions to this information. If they find
the skills useful we will think together about ways they can integrate the skills into their
daily life.

Some adolescents or young adults have expressed reluctance to participate with their
parents in therapy for fear that the therapist will disclose more information than the
youth is ready to share. If this is the case, let the youth know that his/her concerns are
common and understandable, and that you will be providing information to the family
about symptoms in general, and then inviting the IP and family members to share their
experiences with symptoms to the extent that they feel comfortable. However, you will
respect the youth’s boundaries, provided that the symptoms are not presenting a
danger to him/her self or others. Youths are often relieved to hear that they will be
given some control over the pace and content of disclosure about symptoms.
Alternatively, you may want to meet with the youth individually to make sure s/he tells
you what is off-limits for discussion (for example, her confusion about sexual
orientation) before starting the family therapy.

IPs may worry that once they start talking with their parents about their symptoms they
will be peppered with questions throughout the week and they will feel over-exposed
and overwhelmed. In these instances it may be useful to facilitate some negotiations
between the parents and the youth regarding what amount of follow-up discussion

9
would be tolerable between therapy sessions. Once boundaries have been
established, the youth may feel more comfortable proceeding.

Some young adults have expressed confusion about why they should participate in
family therapy when their parents are pushing them so hard to become more
independent. Why should their parents be interested in their business on the one
hand, but want them to function more independently on the other? This is seen by
some youths as contradictory.

Consider the following treatment vignette involving a 22-year old. Notice how the
clinician weaves in information about the therapy while also validating the youth’s
concerns about communicating with his father.

Son: My dad is pushing me to finish school, pushing me to get a job, and

pushing me to move out of the house. He keeps lecturing me about how I
need to be more independent. Then he tells me he wants me to do this family
therapy with him. Why would I do therapy together with my dad when he
clearly just wants me to do things on my own?

Therapist: Sounds like you are feeling like you are being pushed a lot by your
Dad. Dad, what do you think about what Brad just said?

Father: I have been pushing Brad a lot. He is my third child and I pushed the
older two when they were his age and they thanked me for it later because they
are now all functioning independently. If I change the rules for Brad now, his
younger brother will expect the same type of leniency, and that could really
mess up our household. I know that Brad may be going through something
different that the others, but I’m not sure what that means and I really don’t
know how to parent any differently. I definitely need some more information.

Therapist: Dad, is there anything in addition to information that you are hoping
to get out of the family therapy? Why do you want to do this with Brad?

Father: I am hoping that Brad will tell me more about what is going on with him
so that I can have a better understanding and figure out how I can be more
helpful to him. He and I used to be pretty close. We would go bicycling and
hiking together. Now he and I barely talk and when we do talk it seems like all
we do is argue.

Therapist: Sounds like you want to understand what Brad is going through and
have a closer relationship with him?

Father: Yes.

Brad: He can’t have it both ways. He is constantly pushing me out and then
he wants me to talk to him about my business.

Therapist: Brad, what do you want for yourself? Are you interested in finishing
high school or finding a job?

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 Brad: Yes, but it isn’t that easy.

Therapist: No, it certainly isn’t easy. In fact these types of transitions out of
high school and into the work world are really hard for a lot of people and they
can put a lot of stress on family relationships.

One thing that we would be interested in doing in the family therapy would be
to get a better understanding of your goals so that we could think together
about the best ways that everyone could support you in reaching those. How
does that sound to you?

Brad: OK.

Therapist: Brad, it sounds like you have felt pushed by your Dad lately and that
has sort of disrupted your relationship with him or left you feeling confused
about how to relate to him. Did I hear that right?

Brad: Yes.

Father: I feel really badly about that. I think we are both confused at this point.
I would like to have a close relationship with Brad throughout his life. I’m just
not sure what approach I am supposed to be taking right now to help him.

Therapist: It may sound contradictory, but a close relationship, one in which

people feel like they understand each other and can support each other, can
actually help people to function more effectively and independently throughout
their lives. Does that make sense?

Another thing we could work on in the family therapy would be opening up

channels of communication so that you might be able to talk more directly and
constructively about how to improve your relationship with each other. Is that
something that you would be interested in?

In other words, you can tell the family that the therapy is fairly structured, with
informational handouts provided at most sessions, but that the information will be
tailored to try to best meet the needs of a particular family.

Questions about who to involve in the treatment

Family members wonder about who should participate in the therapy. We explain that
when one person in the family is experiencing symptoms, all members of the family
are typically affected, and in turn family members’ reactions to those symptoms affect
the person who is experiencing symptoms. Because of this, it is often useful to have
everyone who is living in the family home participate in at least some portions of the
therapy. If the youth/young adult objects to having certain people participate (i.e.
siblings, step-parents, etc.) it may be useful to allow him/her to begin the therapy with
primary caregivers and then introduce additional members as he/she becomes more
comfortable.
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For example, some youths report that they will not discuss symptoms frankly with their
parents if their younger siblings are in the room, explaining that it is embarrassing to
them to discuss their “weaknesses” in front of their younger siblings. It makes sense
to honor this boundary, and then after the educational sessions, to ask the question of
whether the IP might be comfortable inviting the siblings to participate in some of the
communication and problem solving sessions. Other youths, however, have welcomed
the opportunity to have their siblings participate from the start. These contrasting
examples highlight the importance of giving thoughtful consideration to whom to
include in the various phases of therapy. This should be discussed and decided
collaboratively with the IP and his/her primary caregiver(s) during the first session.

Remember that if additional family members join the therapy process after the
beginning of the treatment, you will need to schedule some time with them to sign
treatment or other informed consent documents. Also, you may find that adding a
sibling, particularly a younger one, to sessions may be a hindrance more than a help.
Consider the age of the sibling, his or her health status, and the nature of the
relationship between the IP and the sibling before committing to including the younger
sibling in each session.

Meeting with Patient/Parents Alone

Throughout the FFT protocol, there may be times when conducting a session without
the IP present seems clinically advantageous. This is not typical and certainly, most
education, communication skill and problem solving sessions should be conducted
with the whole family present. An example of a problem that might be worked on
without the patient could be a discussion of the family’s financial problems; the
parents’ marital problems; or plans that affect the IP that have not been shared with
him/her yet. In this protocol, you may conduct sessions without the IP present, but the
IP should agree to this arrangement. The overarching goal of treatment is to teach
skills that the whole family can utilize. Nonetheless, there may be situations in which it
makes sense to meet with the parents alone, just as there may be cases in which you
will want to meet with the patient alone. Try to keep these alternative arrangements to
a minimum. Be aware that some families will interpret your flexibility to mean “It
doesn’t matter who comes as long as someone comes.”

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 II: PSYCHOEDUCATIONAL SESSIONS (Sessions 1-4)

Session 1: Goal Setting, Overview of Treatment

1. Joining

2. Acquaint family with goals, format and expectations of treatment.

3. Find out family members’ goals for treatment

4. Build a bridge between family members’ goals and the skills they will
master in FFT

5. Assign Homework (set up a weekly family meeting; add to family goals).

6. Check-in with family members about their reactions to the session

7. Plan for next session; joining/closing

Handouts Needed:
 1 (Family-Focused Therapy: What to Expect)
 Possibly 2a-2e (Mania, Depression, Positive Symptoms, Negative
Symptoms, Anxiety Symptoms)

In the first session you have several objectives, the most important of which is to join
with the family and start to establish a therapeutic alliance. The second objective is to
develop a treatment plan with the family. First, present the goals, format, and
expectations of the FFT program, and then discuss each family member’s goals for
treatment. Then, build a bridge between what each family member wants from
treatment and what we plan to provide. Finally, it is important to help them to establish
the routine of doing some “practice” (i.e., homework) between sessions, plan for the
next session, and gather their reactions to the first session.

Joining
The best way to build rapport at the beginning of treatment is through a process called
“joining.” Start the session by asking each family member to tell you something about
him or herself, unrelated to symptoms (e.g. what they do for a living, favorite movies,
hobbies, etc). You can introduce this process by saying something like the following:

“I would like to start our work together by getting to know you better as people.
Of course there is much more to each of you than the current problems
affecting you. It is important that I know about your interests and strengths so
that I can try to make the therapy as relevant as possible to each of you and so
that we can draw upon your strengths throughout the treatment.”

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Clinicians can model this by briefly introducing themselves (their role in the clinic,
personal and professional interests). Avoid “cutesy” facts about yourself like your love
of cats or your accomplishments in wind surfing. The goal is for the clinician to be
friendly and personable while maintaining professional boundaries. Remember that
the IP may have been struggling lately, and so avoid presenting a long list of
achievements and successes. Here is an example:

“I will start us off by telling you a bit about myself. As you know my name is
________. I have been a therapist here at our clinic for the past two years. I
went to college in Boston and did my graduate work at the University of
Southern California. I really enjoy working with young people and families and
I am excited about doing prevention work.

Now, why don’t you each say a bit about yourselves?”

Once each family member has had a chance to talk about his/her interests and talk a
bit about who they are, you can move the conversation to the goals of treatment.

Joining is an ongoing process that you will continue to work on throughout the
treatment. Maintaining an air of friendliness and introducing some levity into the work
can be very helpful. Also, be sure to chat with the family a bit about fun activities they
may have participated in over the weekends, sports teams they follow, or upcoming
plans they have for the weekend or other light topics (generally best at the beginning
or end of the session). Once you know their interests, you can follow-up on those with
brief questions to open or close later sessions. Some therapists may feel that they are
better able to connect with family members by asking the family members to introduce
themselves first so that the therapist can get a feel for each person’s interests and add
comments about him/herself that are relevant to family members’ interests. Either
approach is fine. The goal is to make the family comfortable with you, and allay their
fears that you will psychoanalyze them, make them feel like bad parents, or expose
uncomfortable secrets.

Tune in to the family members’ affective range and pace of communication early in the
session so that you aren’t completely out of sync with the family. A family that is
somewhat depressed may experience a very cheerful presentation as superficial.
Establish a tone that is calm, low-key and mature.

The Goals of FFT-EOY

Once you have spent some time getting to know the family members, acquaint the
family with the format, goals and expectations of the FFT-EOY treatment. Handout 1,
“Family-Focused Therapy: What to Expect,” accompanies this first discussion. Go
through each item on the list and let family members know what they can expect from
the therapist and what in turn is expected of them. You may want to say something like
the following:

“This is a fairly structured treatment. We have a lot of information that we would

like to share with you, and a lot of skills that we would like to introduce to you
14
over the next 4 months. We have 12 sessions planned. For the first 2 months
we will be meeting every week, and then we will meet every other week for an
additional two months. Does that sound manageable for all of you?

Next week we would like to talk about (mood, thought disturbance, or other
early onset) symptoms, what they are and how you might be able to reduce
them. Then over the next few sessions we would like to focus on how to
decrease stress, prevent symptoms from occurring, and how to cope at school,
with friends, and at home.

In later sessions we plan to work on strengthening your family’s communication

skills, and working on solving family problems. We know that people’s
symptoms tend to stabilize when families take a calm, constructive, and
structured approach to communication. We would like to teach everyone
techniques that will help you to work together in this way. Can you imagine
how this might be helpful?

Toward the end of our work together we will be integrating a lot of the skills that
we have developed. How does this sound?”

Check in with the family while you are presenting

this information. Avoid “talking at them” and pay
particular attention to anyone who seems
confused, bored, or annoyed. If so, ask them:
“you seem like you’re having a reaction to this.
Anything you’d like to talk about?”

Continuing on:

“Now let’s talk about what you can expect of me

during this therapy. I will start sessions on time
and make sure that we end in about 1 hr.
Therapy can be hard work so my job is to make
sure to keep our work manageable. If you need
to talk to me between sessions, you can reach
me at this number (hand family card), and I will
do my best to get back to you within 24 hours.

My role is basically that of a teacher or coach. My job is to teach you some

skills and then to practice those with you so that by the end of treatment you
can use the skills in your day-to-day life, and you no longer need my
assistance. I’ll ask you to practice the skills at home in-between sessions.

Sometimes I will ask you to practice some of the skills we are learning at home
or at school/work during the week. We recommend that families schedule a
family meeting every week to go over the therapy assignments. Just like
with any skill, the more you practice, the easier the skill becomes. So, we will
make better progress if you follow through with these assignments. Do you

15
 think this would be manageable? What questions/concerns do you have at this
point?”

“Can you think of a time when you’re all together when you could meet?”

When introducing educational sessions explain that “we’re interested not only in giving
you information but also in exploring your reactions to it and seeing how it fits your
circumstances.”

Note that we present this information about FFT before we ask family members about
their personal goals. If you were to start with family members’ goals, you may get
confused silence; knowing that FFT addresses how to cope with mood or psychosis
symptoms and communicate better as a family will help them hone in on what they
want to accomplish.

Also, notice that the clinician refers to himself/herself as ‘we’. This may indicate that
you are seeing the family with a cotherapist, or that there is a supervision team
watching. You can replace this with “I” if it makes more sense in your setting.

Tips for Practicing at UCLA: Clinic rules

The first session is the optimal time to address issues like the observation and
tape recording of sessions:

“We are a training clinic, so every family session is observed by our

supervisor, Dr. _____, and other trainees who are learning to work in this
treatment modality. We may also tape the sessions so that we can go over
them later with our supervisor and know what issues we want to follow up on.
Do you have any concerns about this?”

If you are practicing at UCLA-CHAMP, there will be a treatment contract

outlining when the 12 sessions will occur (or at least the first 6) – ask them to
specify when they can come in weekly, and whether they anticipate anything
getting in the way of regular sessions. They should sign and get a copy of this
contract.

Remind them of the cancellation policy: minimum 24 hours, but they will be
charged if they call that same morning and cancel. Give them the number of
the clinic coordinator (Vicki Ponce, 310-825-2836) and email
([email protected]).

Discuss your emergency contact/pager plans.

16
Family Members’ Goals for Treatment
Once you feel you have begun to connect with each family member, let the family
know that you are interested in hearing about what they hope to get out of the
treatment. You want to convey to them that you are knowledgeable about their
situation and that you have some ideas about what might be helpful to them, but what
is most important first is to hear about what they are interested in getting out of
therapy. You could say:

“I have a lot of ideas about what I think might be helpful to you in terms of
treatment, but I would like to hear a bit more about what each of you wants to
get out of our work together. In what ways would your lives look different if the
treatment were successful?”

In many cases it is useful to start with the IP when asking about treatment goals so
that he/she has the first opportunity to express what he/she wants to change in his/her
life. Youths are typically most interested in and motivated to achieve goals that they
select themselves. Even if the parents express the very same goals, youths are likely
to be less enthusiastic about the parents’ stated goals because they are experienced
as imposed upon them.

If the youth is new to therapy and is having a hard time understanding what you mean
by goals, you could structure the process a bit more by posting a list (like the one
below) of the various domains in life that one could think about setting goals. What is
going well within each of these domains and what could be going better?

-Feelings about oneself (mood, self-esteem, hobbies and interests)

-Managing Symptoms
-Relationships:
-with family members
Mom
Dad
Siblings
-with friends
-with classmates and teachers
-Functioning at school/work
-ability to get up in the morning independently and get there on time
-ability to get required work done
-satisfaction with tasks
-Skills of independent living (grocery shopping, cooking, doing laundry,
cleaning, managing finances)

Parents may be similarly confused about what types of goals you would like them to
articulate: goals for themselves or for the youth? Since the focus of the therapy is on
the IP, it would be helpful to hear the parents’ thoughts about goals that relate to the
youth. For example, are there particular symptoms that the IP is experiencing that the
parents are concerned about or certain aspects of the youths’ functioning at school, at
work, with friends, or at home that they think merit further thought? In addition,
parents might have goals involving their relationship with their son or daughter such as
improved communication or reduced conflict. Perhaps parents would like to learn how
to be more supportive of the IP. Alternatively, they may list goals that have nothing to
17
do with the IP, but which you may be able to help them with anyway (e.g., “I get very
nervous about job interviews. I’d like to know how to do better in them”).

Most family members will appreciate being asked about their goals and having an
opportunity to share their ideas. Some patients (or siblings) may tell you that they
don’t want to be here and that they were dragged to treatment by their parents. They
have just been “real” with you and have given you an opportunity to connect with them.
You could say something like:

“Thanks for being so honest with me. I appreciate that you are here tonight
despite your reservations about treatment. Hopefully over time you and I can
figure out how to make this work worth your time and effort. Is there anything
that you would like to have going a little better in your life? What about with
school/work? What about with friends? What about with your family?”

Some IP’s may offer an unconventional treatment goal like “I want to get a car.”
Although this goal may seem irrelevant, note that it indicates that they have some drive
and motivation. The depression or negative symptoms must not be that bad for this
IP. You could ask them a few questions about the type of car they are interested in,
and then say something like:

“I can see why you would want a car like that. Has this been an ongoing
discussion in your family? I’m interested in hearing some more about the kinds
of conversations you’ve had with your parents about this.”

It would be interesting to learn more about the context of this particular goal since it
might fit into a larger goal pertaining to autonomy/independence.

Another example might be an IP’s goal of, “I want to get my parents off my back.” A
strategy similar to the one used above of validating the IP’s experience and
contextualizing it a bit could be useful here. Something like:

“Yeah, a lot of teenagers/young adults raise the same goal in here. You are in
good company. And I imagine that your parents might actually enjoy getting off
your back as well? (Look at parents and see if they are agreeing with you). Do
you think your parents know you feel this way? Tell me some about the kinds of
things you think you could do without your parents’ reminders?”

You can get back to this comment later in the session when you are “building bridges.”
As you are outlining the FFT therapy, you can weave in the point that better
communication and problem solving often helps both IP’s and parents to find ways to
work more comfortably and effectively together so that there is less nagging and less
provoking.

In general, express a flexible attitude, knowing that the IP and/or parents’ goals may
not fit your therapeutic agenda.

This process of goal setting is very important and should not be rushed. These goals
are essential to making the treatment relevant to the family members so that they feel
that we are responding to their needs and not just imposing some pre-fabricated
18
treatment upon them. You should write down each family member’s treatment goal(s)
because you will want to refer back to these goals frequently as you introduce new
skills, making a connection whenever possible between the skill you are asking the
family to develop and their treatment goals.

While some family members might bring up several clear goals, keep in mind that
others might be unsure of what they want to get out of the treatment. They may be
content to hear what you have to offer and that may stimulate some ideas for them
regarding what they are most interested in learning. That is fine. It is important to
provide each family member with the opportunity to express his/her thoughts. Goal
setting typically works best when it is a collaborative process.

Building Bridges
Now that you have listened to what each family member has identified as his/her
treatment goals and outlined the FFT approach, you can make some clear connections
between their goals and how the skills learned in FFT may help them to reach those
goals. Pick out a few of the goals that each family member has stated and make some
connection to the various skills that you will be working on and talk briefly about how
those skills or those sessions will support each person in reaching his or her goals. For
example, you could say something like,

“OK, now let’s make sure we are on the same page here. Joe, you mentioned
that you wanted to understand more about these changes that have been
going on with you. We will start with that in our next session. How does that
sound? You also mentioned wanting to manage these changes better so that
you feel a bit more in control at school and at home. That is something that we
will get to fairly soon as well. We will spend sessions 3-4 talking about
strategies for coping with various symptoms.

Mr. X you mentioned wanting to figure out how to get Joe to wake up and get
ready in the morning more independently and to have him go to school more
regularly, right? I think that first we need to develop a common understanding
of the symptoms he is experiencing and how they play out at school and at
home. We will be doing that over the next few sessions. Then we will be in a
better position to think about strategies he can use to cope with the school
environment and perhaps accommodations that could be made at school to
help support him there.

Your desire to have Joe get up and out more independently in the morning is
one of the most common requests we hear from parents at our clinic. That is
something we will definitely take on during the problem solving sessions. How
does that plan sound to you?

Mrs. X you mentioned that there has been a lot of arguing in your house lately
and that you would like your son to know that you are on the same team and
that you are really just trying to help him. Joe you also mentioned wanting to
get your parents off your back. These are issues we deal with a lot here.
Symptoms often make communication more difficult for families and they can
put a lot of stress on relationships. At about session 5 we are going to work on
some communication skills so that you have the best shot at working through
19
 some of the issues that have been coming up in a calm, constructive manner.
Hopefully as we work on these communication skills all of you can feel a bit
more like you are on the same team again. How does this sound to you?”

Make sure to check in with the youth and his/her parents every so often to assess
whether they understand what you are saying. Are they reacting negatively to what is
being discussed (e.g., rolling eyes, or looking angry or distressed)? If you notice these
reactions, stop and ask about them. You could say something like:

Therapist: Tim, I think you may have been rolling your eyes when I mentioned
the part about communication training? Did I get that right?

Youth: Yeah.

Therapist: Can you tell me more about your reaction?

Youth: Well, when I went to summer camp one year the counselors forced us
to do some communication training. Every day we had to say something that
we liked about each camper. It was ridiculous. We were inventing stuff that
was completely insincere about kids that we actually hated. It just seemed
really pointless.

Therapist: That does sound like a bad experience with communication training.
I can understand why you might feel reluctant to put yourself in that type of
situation again. Have you had any other experiences with communication
training?

Youth: Not really.

Therapist: Well, hopefully the types of communication exercises that I have

planned will be more helpful to you and your family and less contrived than the
ones at summer camp. But, I will be very interested in your experiences of the
training as we are going through it and I hope that you will continue to be
honest with me about your reactions.

Avoid listing goals that cannot be achieved in this context

If family members have mentioned goals that really aren’t appropriate for FFT it is
important to be clear that you will not be working on those particular issues and to
provide your rationale. For example, if one family member talks about early abuse that
he/she experienced as a child and his/her desire to explore that because he/she thinks
that is contributing to current problems, you could say something like:

“That certainly does sound like an important issue and I am glad that you
brought it up. It is helpful for me to know that you have had some very difficult
experiences in your life. What we have found is that the timing of discussing
those types of issues is very important. While young people are experiencing
significant symptoms like the ones you (the IP) have described (feeling on top
of the world/depressed; feeling suspicious and uncomfortable around others) it
is important to do some work that will support your ability to cope with those
20
 symptoms and to reduce anxiety. Talking about and revisiting those early
abuse experiences can be make people very anxious, and we don’t want to get
into that type of work until (the IP’s) symptoms have lessened and you are back
functioning well at school and with friends. Once you are feeling better, then
you can decide whether you would like to take on those early issues in a
different therapy. Trying to do everything at once can be pretty overwhelming,
so we think it is important to break therapy into different phases. Does that
make sense?

A similar type of response would be important to use with parents who may have
marital/couple issues that they want to focus on. You could let the family know that
some of the communication and problem solving skills that we will be learning together
may be helpful with those other issues, but that the main focus of the treatment will be
on helping the IP to feel and to function better. If families try to change too much at
once it becomes overwhelming.

Avoid starting to solve problems in the first session

Use this initial session as an opportunity for getting acquainted and information
gathering. If the family starts arguing or insisting on talking about difficulties in school,
etc., you can redirect them by saying something like,

“I know there are lots of pressing concerns that you have, and we will want to
get to those as soon as possible. But, first we need to develop a plan for how
we are going to work together. Tonight we are just taking the first step that lays
the groundwork for all of our future work together. We will definitely get to the
school issues, and many of the other concerns you have.”

Make sure to take note of potential communication pitfalls and ways in which the family
may exacerbate problems or escalate conflict, although avoid mentioning them at this
point. Also, take note of family strengths that you can highlight and build upon in future
sessions.

Assigning a Practice (Homework)

Toward the end of the session, or even earlier if possible, give the family their
first between-session practice assignment, which is to schedule a family
meeting during which time they should discuss any questions/concerns that
they have about what was discussed in the first therapy session. During the
second session you will be discussing symptoms, so they could begin to think together
in a low-key way about how various symptoms impact the family.

Help the family schedule a regular

between-session meeting.

Ask the family to identify a day and time for the family meeting. The first family
meeting may be brief, perhaps only 10-20 minutes. This first meeting will help the
family to establish a routine that you would like them to continue throughout the family
treatment. The practice that you will assign will vary each week, but typically part of
that practice will be completed during the family meeting.
21
(Note that we avoid using the term “Homework” with families, even if we use it among
ourselves. “Practice” is a less onerous term).

Choice Point
At this point in session 1, you may be almost out of time and may feel like you’ve
covered enough material for one day. If so, close out the session and summarize what
you’ve said, and prep them for the next session (below). Alternatively, you may be
only 35 minutes into the 50-minute session and may feel like they (and you) could do
more! If so, move to “Facilitate a Family Discussion of the IP’s symptoms” (usually
covered in session 2). Go through one of the handouts, such as the handout on
depression or mania. The instructions on conducting this exercise are below, for
session 2.

Plan for the Next Session

If you have decided they’ve had enough for session 1, set up a date/time for the next
meeting, and remind the family that you will be starting with some educational
materials at the next session. Give the family an opportunity to ask any questions.
They may have been asking questions along the way, and if they have no further
questions that is fine. You could say something like:

“We have covered a lot of ground today. Questions may come up for you over
the course of the week, and I would like to start our next session by addressing
those questions.”

Summarize and Reflect

If there is time, provide a brief summary of the session and then check-in with family
members about their reactions to the session. You could say something like:

“Today was sort of an introductory session. We started to get to know each

other a little bit. What was that like for you?

“Then we talked about some goals. I plan to type out those goals and to
distribute them to you next week so that we all have a clear reminder of what
we want to address in our work together. If you think of additional goals during
the week we will add them to our list next week. Anything else you want to put
on our agenda?”

“I like the goals that you spelled out and it leaves me feeling hopeful and
excited about our work. I think that there is a lot that we can accomplish
together over the next several weeks.”

Joining/Closing
With this discussion we are emphasizing the importance of reflecting on our
experiences in therapy. As sensitive as we try to be, we cannot read the family
members’ minds and so it is important that we ask them regularly about their reactions
to what is discussed in therapy. Hearing their honest feedback will enable us to try to
pace and organize the therapy so that it is tolerable and meaningful for them. If the
session has gone well and you are feeling hopeful and enthusiastic, it may be

22
encouraging to the family to express that sentiment and to try to create an atmosphere
of optimism.

Spend a few minutes chatting with the family about something light, perhaps fun plans
they may have for the weekend, or current events that are relevant to your common
interests with the family. It is probably most important to direct efforts toward
connecting with the youth as you begin and end the first few therapy sessions. This is
especially the case if you sense some reluctance in the youth to participate in the
treatment. The more you can join with the youth, the better. If the parents don’t have to
drag the youth to treatment, the family will be more likely to attend regularly. Teens
are particularly skilled at quickly detecting when an adult is trying too hard, so keep
efforts low-key.

Use of Humor in FFT

Have some fun with each of the family members. Some playful banter will remind
them that you actually enjoy them despite some of the difficult conversations that may
have just taken place. They may trust you more as they realize that you are going to
help them to cope with their more difficult emotions before they leave your office.

Ideally, this therapy should involve a fair amount of shared low-key laughter. Often
parents come in with high levels of distress. This is understandable in light of their
circumstances. Of course you won’t be trivializing their concerns or the seriousness of
their situation, but you can try to balance all of that with some light-hearted moments.
This may prevent you and them from getting “burned out.” An underlying goal of the
therapy is to help patients and families to get on with their lives despite symptoms.
They can still work, have friends, and connect with each other in fun ways despite
symptoms. It may be reassuring to them to be reminded of that implicitly or
experientially by sharing some light moments together in therapy.

Good examples of humor are things that makes fun of yourself or the setting:

“This is the first time I haven’t bumped my head on the cameras.”

“Let’s see if I can find our next appointment on my IPhone without erasing all my
pictures.”

23
What Does “High Risk” Mean?

A common question that tends to come up in the first or second session is what is
meant by the IP having “early onset” or being “at high risk” for bipolar disorder, major
depression or psychosis. Consider including the following information in your
response, pitched to the educational level and language of the family.

“A “high-risk” state is one in which individuals are experiencing a group of symptoms

and changes in social and school/occupational functioning. It is the clustering of
these symptoms rather than any one symptom in particular, as well as the frequency
and intensity of the symptoms and the distress and disruption they create that
suggests a high-risk syndrome.

Common high-risk symptoms can include experiences like feeling very moody (up or
down, irritable), anxious, social withdrawal, a drop in grades, difficulty sleeping,
uncharacteristic peculiar behavior, increasing difficulty with concentration,
heightened sensitivity to signs, sounds, smells, touch, loss of motivation,
exaggerated beliefs about personal powers or influences, and suspiciousness of
others. We will be talking a lot more about these kinds of symptoms during our
session next week.

A fever is said to be an early warning sign of measles. This means that a fever may
be an indication that the measles are on their way. However, as you know, not
everyone who has a fever goes on to develop the measles. Similarly, these early
warning signs that I just described may or may not be the earliest phase of a mood
or psychotic illness. When an illness does develop, there is typically a “build-up”
phase of more mild symptoms that precede the most severe symptoms.

The available research suggests that less than 40% of people who meet criteria for a
“high risk syndrome” will go on to develop a full bipolar or psychotic disorder within 2-
5 years. This is good news indicating that less than half of the folks we have
identified through our assessment procedures as having a high risk syndrome or as
being in an at-risk state will go on to develop more severe problems. We would like
to bring that rate down even further and for that reason are providing family
treatment at a very early “high risk” stage. It is our hope that through our work
together we will decrease your risk and create a more protective environment for
you.”

Related to this issue is the question of what to call bipolar or psychosis symptoms. If
the IP has well-established bipolar disorder, she may prefer the terms mania and
depression. Some youth or young adults may prefer to talk about mood swings,
highs and lows, or other proxies for mania and depression. Ask the youth what
terms he or she prefers.

Likewise, the IP may object to the term psychosis. S/he may do better with a less
charged term like “thought disorder” or even “thinking problems.” Once again, ask
him how he would like you to refer to his symptoms.

24
 Session 2: Discussion of Symptoms, Mood Charts
and the Vulnerability-Stress Model

1. Joining/Check In: Ask whether the IP or family had any reactions to the first
session.

2. Review homework (family meeting; additional family goals; questions about

first meeting?)

3. Review the treatment goals that you discussed last week. Try to make a
connection between some of their goals and the discussion of symptoms
that is about to take place.

4. Family discussion of the IP’s symptoms.

5. Guide youth and family through development of a mood chart.

6. (If time permits) Introduce the Vulnerability-Stress model, Risk and

Protective Factors

7. Assign practice (family meeting, mood charts)

8. Plan for next session; Joining/Closing

Needed Handouts:
 2a-2e (Mania, Depression, Positive, Negative, Anxiety Symptoms)
 3 (“How I Feel”: Mood Chart)
 4 (Factors Affecting Health)
 5 (Risk and Protective Factors for Mood Problems)

There are two main learning objectives during this session. The first is to facilitate an
interactive exchange during which the IP and family members share their experiences
of mood and psychosis symptoms and you provide additional information about those
symptoms as needed. The second goal is to introduce the Vulnerability-Stress model
to the family to provide the theoretical basis for much of the treatment that follows and
to highlight the influence that risk/protective factors and stress can have on symptoms
and functioning.

Follow-up on the assigned practice

Ask them if they were able to have a family meeting and find out if they have any
questions/concerns that might have come up during that meeting. If they didn’t
organize a family meeting last week, let them know that it will be helpful to the
progress of the therapy if they get into the routine of meeting weekly between
sessions. This will give them a chance to review some of the educational material that
will be presented each week and practice some of the communication and problem-
solving skills. Ask them to identify the best time for all of them to talk together as a
family. Since this may be a change in their family routine, how will they remember to
25
meet during the specified time? Will they write the meeting time on the family
calendar, or will someone take responsibility for gathering everyone together at the
designated hour? It’s often helpful to appoint the youth/young adult as the person
responsible for making sure the family meeting occurs.

Review Treatment Goals

If there is a way to make a connection between one of their goals and the discussion
of symptoms that is about to take place, do so.

For example, “Dad, you expressed an interest last week in developing a better
understanding of X’s symptoms, and X, you wanted to help your parents to
understand what it is like for you to experience some of your symptoms. Those
are the goals that we are going to focus on today.”

Facilitate a Family Discussion of the IP’s Symptoms

Whether the IP has bipolar disorder, depression, psychosis, or an early-onset “high-

risk” type of each, it is important for you to review the medical records before sitting
down to meet with the family for this second session. A thorough knowledge of the
IP’s symptoms will guide decisions regarding the order in which symptoms should be
discussed. For example, imagine you are working with a youth who has some striking
mania symptoms (for example, grandiose delusions) or positive psychotic symptoms
(hearing voices, thinking that he can control other’s thoughts at times). His parents,
however, may be aggravated with his “laziness” and difficulty getting to school. In this
case, it might be most productive to talk about the manic or psychotic symptoms first.
Once the parents have a better understanding of some of the unusual symptoms that
the youth is experiencing, they may be more receptive to thinking that the child has
depression or negative symptoms rather than laziness.

A clear understanding of the youth’s symptoms will help you to select handouts that
are relevant to the family. For example, if the youth is experiencing comorbid anxiety,
then the optional handout (2E) regarding those symptoms may be included in the
discussion. Think about how best to pace the session, allocating most time to
discussion of the symptoms that are most problematic, distressing, and/or disruptive to
the youth and/or family. The goal is not to make sure every symptom gets discussed; it
is for everyone on the family to be on the same page about the symptoms and disorder
that is most relevant to the IP.

Before the session, you may want to consider whether the channels of communication
within the family are open regarding the youth’s symptoms. Some IPs are reluctant to
share details about their symptoms with their parents and so questions aimed to draw
them out will need to be asked with care. Other IPs seem quite oblivious to their
symptoms or maintain an “everything is fine stance” while the parents provide striking
examples (drop in school grades, staying up all night working on unrealistic projects,
inexplicable shouting in their room in a way that suggests they may be answering back
to voices, drop in attention to hygiene, etc.) These IPs may become angry and/or
withdrawn when the parent attempts to describe these symptoms to you.

Ideally, this session will allow for family members to develop a greater understanding
of each other’s experience of the IP’s symptoms. However, when there is a lot of
26
sensitivity in the family about “putting the issues on the table,” you can present the
symptom information in more of a didactic format. Given that this is only the second
session, we don’t want to stress everyone out by trying to force openness. We want
everyone to be “up to speed” on the various symptoms that we will be focusing on
during our work together.

Fortunately, the most common situation is that parents and youths are willing to speak
frankly about their experiences of symptoms when invited to do so. The IP is often
more forthcoming when he or she is asked to speak first about his/her own
experiences. Then, family members can add to this description or provide their own
perspective. Remember, the IP is the “expert” on his or her own illness.

Clinical Tip:

Exploring the IP’s symptoms should not feel like a repeat of the KSADS or
other clinical assessment, with the family serving as an audience. Instead,
the goal is to facilitate a deeper understanding on the part of family members of
what it is like for the youth to experience these symptoms, and perhaps a deeper
understanding by the youth of how his symptoms impact family members and
family life. So, if you are feeling that you’re just asking about symptoms and the IP
is saying yes or no, then step back and encourage a discussion with open
questions: What was that like for you, when your thoughts started racing (patient)?
When did you first notice it? Mrs. X, what do you notice when Jim gets this way?
Jim, what helps you to feel better? How do you know something is feeling
different?

When this session is going well, you shouldn’t have to do much; just ask the youth to
describe his experiences of, for example, depression, mania, suspiciousness or
apathy, and the family members should chime in with their own perceptions of his
behavior. Intervene if differing perceptions lead to arguments: say, for example, “it’s
not unusual for people in families to disagree about these symptoms or how they affect
others, but at this stage let’s just get everyone’s input on the table.”

Avoid asking about symptoms in a yes/no or either/or format. Avoid asking “Have you
ever had unusual ideas, or is that not something you’ve experienced? Or “Has it
always been that way, or has it been only recently?” Instead, ask these questions
openly, e.g., “Have you ever had unusual ideas? When did they start/worsen/get
better? What was that like for you?”

Finally, if the IP has had full blown manic or depressive episodes, it is useful to find out
what symptoms came first. That is, what was the first sign that a manic episode was
developing - decreased need for sleep, racing thoughts, irritability? For depression,
was it fatigue, negative thinking? Later, you will be able to use this information to
construct the Prevention Action Plan, which requires thinking of illness episodes as a
sequence of events.

Clarifying Manic or Hypomanic Symptoms in Youth with Bipolar Spectrum

Disorders

27
If the IP has bipolar I or II disorder, or is on the bipolar spectrum (bipolar NOS), you
will want to start by discussing manic (or hypomanic) and depressive symptoms. Give
the family Handouts 2a and 2b entitled “Symptoms of Mania” and “Symptoms of
Depression.” These lists are presented with pictures and simplified language to help
adolescents and parents understand how symptoms present within mood states. This
section of the education highlights the fact that a mood disorder has a developmental
progression, and that it is often comorbid with other disorders. It is important for family
members to be familiar with the presentation of bipolar disorder so they can talk with
the clinician about the IP’s variable mood states. Be open and inclusive of what youth
and family members consider symptoms of mood, behavioral and/or attention
difficulties, even though you may suspect that some of these behaviors (e.g.,
manipulativeness, argumentativeness, lack of follow-through) are developmentally
normative or represent personality traits. If a child also has a diagnosis of Attention
Deficit Disorder or another comorbid disorder, you may want to discuss these
symptoms as well and talk about how they differ from manic symptoms.

Adolescents with bipolar disorder often do not have the same symptoms as DSM-5
adult bipolar disorder patients. For example, they may be characterized by short
attention spans, anhedonia, low tolerance for frustration, sudden outbursts of anger
followed by guilt, lengthy states of arousal in response to minor events, and disruptive
behavior. Thus, it is important to not get locked into a “discrete episode” model of
bipolar symptoms in which the parents and the adolescent are asked to think in terms
of discrete build-up phases, active phases, and residual phases. Instead, ask the
family and adolescent to use their own terminology to describe the adolescent’s mood
swings, changes in activity, and behavior problems. Several of our adolescent patients
have not been able to identify symptoms of depression if they are asked “what
happens when you get sad?” They are much more likely to respond to questions
regarding times when they felt “bored,” or “wanted to get away from everybody and
everything.”

28
Most parents will want to talk about “raging,” which may or may not be a symptom of
early-onset bipolar disorder. For a parent to begin to understand the IP’s oppositional
and rageful behavior, they will need information about what is happening in the child’s
mind. If you know the pathophysiology of manic states well, you can explain rage in
terms the family can understand (e.g., over-activity of the amygdala and under-activity
of the prefrontal cortex). But the important point is that the IP may have little, if any,
control over these rages. We have drawn parallels for families between the onset of
these rage states and “a train leaving the station. Once it has taken off it follows its
own tracks and at some point no one can jump off, not even the conductor. The trick
is to try to keep the train from leaving the station in the first place.”

When the patient begins raging, the best laid plans for behavior management will
usually be ineffective. The IP will not be moved by threats, explanations, or rewards.
The consequences which the parent and IP have agreed upon can only be effective
when the IP is in a state of mind to appreciate their meaning (Greene, 1998). Later,
you can guide the family in planning how to proceed when the teen is symptomatic.
They can be taught to implement behavior management plans to implement when the
adolescent’s mood is beginning to escalate.

Reactions to the Diagnosis: Jessica

Jessica was a 16 year-old female diagnosed with Bipolar I Disorder. She was
chronically irritable during her manic or hypomanic stages with infrequent periods of
depression. Jessica showed her resistance to the education phase by getting “revved
up” during the sessions. When revved, she would become hyperverbal, interrupt the
clinician or her parents, and change the subject to unrelated topics. On many
occasions it was difficult to keep her on task. Her mother would comment that she did
not present this way just before the appointment. When asked, Jessica initially denied
the observation. We pointed out to her how obvious the difference was and she
agreed but was unable to identify the cause. She did say that she was uncomfortable
with sharing her own feelings. She also said that she (like many teens) was afraid if
she admitted to her problems caused by the illness that her parents would hold it
against her and limit her privileges (e.g., driving or outings with friends). Finally, she
said that she really struggled with seeing herself as different from others and maybe if
she did not talk or think about these differences then they would not be true. Admitting
this discomfort opened the door for her to discuss her feelings about the diagnosis
itself, within the context of the education sessions.

Clarifying Psychosis (or Prodromal Psychosis) Symptoms in Youth

Alternatively, you can start by giving the handouts on Negative Symptoms or

Positive Symptoms (also labeled 2c and 2d) depending on which set of symptoms
you believe best characterizes the IP and will lead to the most productive discussion.
You can use these handouts flexibly to discuss symptoms in whatever order makes
29
the most sense for a particular family.

Some family members are confused by the term “negative symptoms” and instead
provide examples of their son or daughter’s “negative” or “oppositional” behavior.
Likewise, some family members are confused by the term “positive” symptoms and
they think that refers to pro-social behavior or signs of improvement. We explain that
the term refers to cognitive or behavioral excesses. You may need to clarify that
negative symptoms are really “deficit” symptoms, or instances where there is a lack of
motivation or disinterest. For example, they may have noticed a change in their son
on daughter’s interest in picking up the phone and calling friends and initiating social
activities. The IP may be less interested in socializing, school or work activities.

If the IP has schizophrenia or another form of early-onset psychosis, family members

may have difficulty telling negative symptoms from depression. We typically
acknowledge this problem and use it as an opportunity to reinforce the importance of
tracking symptoms over time. We may say something like:

“Yes, you are right. These could be symptoms of depression. There is a lot of
overlap between symptoms of depression and the symptoms that accompany
psychosis. That is why we would like to track these symptoms carefully over
time to get a better handle on what is going on. Depression typically comes
and goes, while negative symptoms are more chronic and occur even when
someone isn’t feeling particularly sad.”

30
As family members offer examples, you can ask questions about the symptoms to
draw out relevant information. For example, you may ask the youth to elaborate about
what it is like for him/her to experience a particular symptom or may ask family
members what it is like for them to see their son/daughter or brother/sister
experiencing a particular symptom.

When describing unusual thinking, say something like:

“An example of confusion about what is real and what is imaginary might be
when you wonder about whether something actually happened or was just a
dream. Have you ever had that experience?”

After they respond you can say something like:

“Many people have this experience once or twice and it is brief and only
momentarily confusing. When these types of experiences persist for long
periods of time, occur frequently and are distressing, they are considered
symptoms of unusual thinking.”

Below is an example of how to describe suspiciousness:

“Suspiciousness refers to the thought that people are not trustworthy and/or
that someone is trying to harm you. Many of the young people that we see
have this experience. Jane (patient), have you ever had this kind of symptom?
What was it like?

At times it can interfere with being able to go to school or with making friends.
Did you ever feel suspicious and not want to go to school because of worries
that others at school would harm you in some way?

Mr. or Mrs. Hill (parent), are you aware that Jane is experiencing these
symptoms of suspiciousness? How do you know when she is experiencing
these symptoms? What is it like for you when she is experiencing these
symptoms? What do you typically do when she is experiencing these
symptoms? Jane, when your mom does X does that tend to help? (If Jane
says no, then ask Jane what would be a more helpful reaction. Does Mom
think she can respond in the way Jane proposed?)

Sometimes it is a good idea to also ask the other family members whether they have
experienced any of the symptoms you are describing. This may help the IP feel less
stigmatized and in the spotlight. It could also make the IP feel less alone in his/her
experience of dealing with mood or psychosis symptoms. So, for example, ask the
father if he has ever felt depressed or unusually suspicious of others, perhaps at work;
ask the mother whether she has ever had the experience of things feeling like she was
in a dream state.

When discussing symptoms of unusual thinking such as preoccupation with the

supernatural, some IP’s report that all of their friends must have psychosis because all
of them are interested in Wicca and Witchcraft. We may say something like:
31
 “Fair enough. Teenagers (or young adults) tend to be curious and open-
minded and willing to consider a broad variety of ideas. This only becomes a
cause for concern when a person becomes preoccupied with these thoughts
(such as spotting UFOs) and those preoccupations become disruptive to their
functioning at home, school, or work. Do you think any of these ideas have
caused problems for you?”

It is important for family members to be familiar with these symptoms so they can
better observe and understand what may be going on with the IP and talk with you
about what they are observing. Since a goal of treatment is to prevent the onset of a
manic/depressive episode or an episode of psychosis, it is important for family
members to be able to tell clinicians if they feel that their son or daughter’s symptoms
are worsening. Create an open and low-key atmosphere so that the full range of
symptoms can be discussed.

Guide each family through the handouts at a pace that is comfortable for them. At the
end of the discussion of symptoms, ask each person to identify the symptoms they find
most distressing, and which ones they would like help with first.

Exploring Anxiety Symptoms

If the youth is experiencing symptoms of anxiety, those symptoms should be
discussed as well. Handout 2e, “Symptoms of Anxiety,” may be useful when
describing these symptoms.

Help the family understand that anxiety can be a

symptom of BD, MDD or psychosis, but can also
be a separate “comorbid” disorder. Generally,
severe anxiety symptoms may require adjunctive
treatments such as exposure and response
prevention, panic control treatment, or other forms
of behavior therapy. SSRIs also have a significant
role to play in managing anxiety symptoms. You
may decide to supplement your treatment with
adjunctive CBT techniques for anxiety, such as
relaxation or mindfulness exercises. The
difference in FFT is that you should involve the
whole family in these exercises. A relaxation tape,
for example, can be listened to conjointly.

Handling Tensions that Arise During Discussion of Symptoms

Sometimes during the discussion of symptoms, the IP becomes angry when he/she
hears other family members describing his/her symptoms. Family members’
descriptions may not hit the mark for the IP and may make him or her feel
32
misunderstood or intruded upon, as if others are trying to tell him or her how he/she
feels. If you notice this, explore these feelings and reactions with the family.

It may be useful to validate the IP’s concerns and to remind everyone that the IP is the
expert on what these symptoms are like for him/her. Everyone else can comment on
their own experiences with similar types of symptoms, but they can only guess or
imagine what the symptoms might be like for another person. The tone and language
that family members use to share their experiences of the patient’s symptoms can
make a big difference in terms of how tolerable this information is for the IP to hear.

Clinical Tip
Patient-as-expert

Tell the IP that “you are the expert in your own

symptoms. We’re going to depend on you to educate us
about what this disorder is really all about. You’re the
one who’s been through it, and you have a perspective
that neither I (therapist) or your parents may share.”

Typically when talking about someone else’s internal experience, an attitude of

curiosity from the clinician provokes less reactivity than an authoritarian stance.
Phrases like “I imagine it might be X to experience Y” tend to work better than “You
feel X when you experience Y.” A statement like “I imagine it might be scary (X) to
think that others at school are trying to harm you (Y)” tends to be better received than
“You get scared when you think others are trying to harm you at school.“ When
tensions arise the therapist may consider encouraging family members to ask
questions so they can better understand the IP’s experiences, or to start with “I
imagine” or “I am guessing it might be…” to make any statement about the patient’s
experience.

At the same time, family members do have first hand experiences with the IP’s
symptoms and the effects of these symptoms on family members. Understandably,
family members may be perceiving the IP very differently from how he or she is
experiencing him or herself because the family members may be most aware of the
“externalizing” aspects of the syndrome, such as irritability, argumentativeness, or
school truancy. The IP may be most aware of internalized experiences such as
depression, feeling revved up, or distracting and perhaps anxiety provoking internal
experiences (hearing voices, difficulty concentrating, etc.)

In summary, when one family member is experiencing symptoms, it is common for

each family member to have a somewhat different experience of that complex event.
Each person’s perspective is helpful in understanding the impact of these symptoms
on the individual and the family.

Creating an Individualized Self-Rated Mood and Behavior Chart

From the first or second session, try to get the IP into the habit of tracking his/her
moods or other significant behaviors or thoughts. In this section, we focus on mood
charting as applied to patients with bipolar spectrum disorders. Consider how you
33
might adapt this assignment to a patient whose main problem is only depression, or
paranoia/suspiciousness or auditory hallucinations.

Mood charts are quite valuable in tracking a patient’s progress, identifying the
emergent signs of an illness episode, identifying diurnal variations, recognizing the
effect of stressors, and clarifying the role of sleep/wake cycle irregularities. They also
make the IP more self-aware and observant of her mood states and behavior. Self-
awareness is particularly important in managing a mood disorder. FFT is a good place
for the patient and family to learn the value of self-monitoring.

Begin by asking the IP to describe her

mood states and what descriptors go
along with each. If you have a flip chart
or a dry erase board, stand by it and
draw a horizontal line in the middle (or
give the IP Handout 3: How I Feel
chart). Ask the IP first (or parents if the
IP is hesitant) to give a label that
describes the absence of symptoms
(i.e., mellow, calm, normal, typical).
Then, draw a line right above and below
the middle line and ask the IP what
words she would use for mild ups and
downs (e.g. “pretty good” versus “a bit
sad” or “frustrated”). Explain that these fluctuations are representative of the normal
moods that someone might experience if she felt like things were going well or not
going well. Then, draw a line one step higher and one step lower than the lines you’ve
just drawn. Ask the IP to label each of these lines. For example, the top line might be
labeled “excellent mood” or “really happy,” whereas the bottom line might be labeled
“really bored” or “bummed out.” Then, use a separate line for anger and ask the IP to
place it on the graph where it most clearly fits for her. (Is it part of an up, active mood?
Is it part of the down, depressive cluster? Or both?). You may want to have lines for
anger in the up and down sections of the chart. Then ask the IP if there are any other
states that should be tracked (i.e., anxiety, suicidality, urges to use substances). Ask
the IP to determine where each of these lines should be placed on the chart.

Once the lines are in place and labeled, then each label is placed at the bottom of the
page as a heading. The IP begins listing symptoms that go along with each of the
states (for example, ‘excellent’ may include giggling, talking loudly, or feeling more
energetic; ‘angry’ may include cursing, kicking doors, or pushing or hitting). Of course,
some youth may not have had experiences of activated or angry states. Be sure to
accept the IP and family’s input regarding presentation of symptoms. Encourage the
parents to join in this process but take cues from the youth. Try to keep an air of
curiosity and levity in the room, recognizing that it can be difficult for the IP to focus on
her abnormal moods and behavior.

Once this chart has been created, the IP can use it on an ongoing basis. Ask her to
complete a mood rating at least twice a day (e.g., best versus worst; morning versus
34
evening) and even more frequently if she is willing. More specifically, ask her to put an
X on the line that she felt characterized her mood at various points in the day. Finally,
include two vertical spaces at the bottom of each day to record when she went to bed
and when she woke up each day. She can also record stressors for that week on the
chart to start to recognize how stressors can affect mood.

Give the IP a template that can be dated and copied for each day of the week. It’s
easiest if a single sheet can be used to characterize the whole week. This exercise is
often empowering for the youth in a move towards self-care skills and independence.
If the youth is resistant to monitoring mood and/or sleep you can point out that “this is
one of the few things you can do- other than just take medications – that puts you in
charge of your moods.”

Likewise, ask one parent to make a similar rating of the IP’s mood each day, or at
various times of the day. This is helpful for three reasons: to keep the parent attuned
to diurnal shifts in the IP’s mood states, to quickly identify a worsening of mood, and to
make clear to the youth that he or she is not the only one being given homework.
Parents usually appreciate the chance to record the youth’s ongoing mood states.
You can ask them to rate the same mood chart developed for the IP. Some parents
want to keep more detailed notes of the IP’s moods, rage outbursts, medications,
and/or stressors. Rating the chart may also help the parents confront the
misperception that the IP can control his mood swings and may generate more
compassion toward him. The chart can be customized to each family’s needs. Some
families like to take this exercise and create their own chart. As long as all of the
information is recorded, individualizing the chart for the family or patient is encouraged.
The more the youth and family feels the chart fits for them the more likely they will be
to complete it.

For some patients, you may want to suggest keeping the chart in an obvious place,
such as in her backpack or on top of the dresser. Alternatively, the IP may decide to
keep her chart with evening medications (if taken) and rate moods then.

If the IP has many mood switches during the day and evening, then he can place any
number of Xs on any of the lines corresponding to the times of the day listed. Try not
to make the task too complicated, however. Use your clinical judgment in deciding
what level of complexity will work best for the youth and ensure his compliance with
the task. Obviously, if the IP is an older adolescent or young adult, the more
responsibility should be ascribed to him.

Additional chart ratings can be made for other behavioral difficulties or symptoms the
patient and family reports. For example, you could ask a child with mild psychosis to
keep track of his suspiciousness toward others, her level of apathy or depression, or
her feelings of overstimulation.

Reflect
Pause for a moment and check-in with the family about the discussion you just had
with them. Ask the youth what it was like for him to speak about his/her symptoms,
and ask family members what it was like to hear what the youth said and to share
some of their own experiences. If it feels genuine to you, compliment the family on the
35
fact that they seem to have taken some risks and made some efforts to help each
other understand what is going on. This process of opening up channels of
communication is an important step in adapting to life with psychiatric disorders, and
eventually managing symptoms more effectively.

How much time do you have left in the session? Is the family worn out? If you
have twenty minutes and the family looks to be comfortable, transition to the
next section on vulnerability and stress. If it took you a long time to get through
the symptoms, and the family members look maxed out, then transition to
planning for the next session and assigning practice (e.g., the mood chart;
another family meeting) and start with vulnerability and stress at the next
session.

If you have time and the family still looks fresh and engaged, ask them if they have the
stamina to go through one more hand-out today or whether they would prefer to end
now and save it for next week. Make sure that you aren’t over-saturating the family
with information, and that you are keeping sessions to approximately 50 minutes in
length.

Vulnerability and Stress (How do People Get

Mood or Thinking Problems?)

The “vulnerability-stress” theory states that mood

or psychosis symptoms come about through an
interaction of genetic, biological, and stress factors.
This is a simple idea on the surface, but few of your
family members have thought much beyond “it’s
both genes and environment.” The objective is to
help the IP and family understand what is meant by
genetic predisposition and stress, without going
into long and complicated explanations of gene and
environment interactions.

The overriding goal is for the IP and family to

recognize that mood swings (or psychosis
symptoms) are not necessarily controllable by the
IP, but that s/he may be able to maximize use of
“protective factors” to prevent the current symptoms
from becoming more severe and chronic.

With reference to the Handout no. 4, “Factors Affecting Health Problems”, you can
say:

“We know that vulnerability (predisposition) to mood disorders and psychosis

runs in families (“genetics”). We can’t change the genetic vulnerability that
each of has, but we can change the amount of stress in our life (to a certain
extent) AND the way we cope with stress to try to keep ourselves healthy.
Does this make sense?

36
 “I am going to explain to you what each of these words mean in the rectangles
and in the arrows. Environmental stressors are a part of daily life. One might
decide when to change schools or move but there is always some stress in a
person’s life. In addition, our biological vulnerabilities or genetic
“predispositions” are things that we are born with that we are unable to change.
For example, some people are genetically predisposed to having cavities,
meaning that having cavities runs in their family. As a result, that person may
brush her teeth just as often and eat the same amount of candy as her friend
but she may have cavities and her friend may not. As you can see in the
handout, we believe that events or situations that we experience as difficult or
stressful can interact with our biological predispositions. This means that some
people are more likely to have mood swings even if they have only minor
stress, because of their genes or the chemistry of their brain.”

“We know that mood swings run in families. However, just because your brain
chemistry makes it more likely that you will have mood swings (or thinking
problems) doesn’t mean you will necessarily have them. We also think that
stress and other “risk factors” - things that make an illness worse - play a role.
But if a person learns to cope with the stress or other difficulties in her life then
she will have much less trouble with mood swings. Things we do on a daily
basis to manage difficulties so that we feel better – like getting regular sleep –
are called “protective factors”. Does this make sense?”

“Family members can be very useful with both of these tasks. They can help to
create a low stress environment for a vulnerable person and they can help the
person to cope effectively with daily stress.”

Follow this up with some probes: “You’ve talked about how ____ may be genetically
vulnerable because mood disorders run in your family. Can you say more about that?”

“What has caused you (the patient) stress in the past? Have you ever felt not in
control of your feelings?”

You may need to explain further what is meant by “stress” and “cope”. Many
adolescents have experienced stress (for example, bullying, being sexually harassed
by other teens) but may use other words to describe this experience (e.g., “lots of
drama lately”). Other family members may point out things that the teen has found
stressful. Ask each member of the family to give you examples of major life stressors
that precipitated an episode of physical or mood problems (e.g., the ulcer came on
after a large project at work was due, headaches developed after a period of
interpersonal stress involving other family members, depression followed a
geographical move).

Some family members react to the discussion of genetic vulnerability with guilt or
shame. If you notice this, explore these feelings with the family. Remind the parents
that, “none of us have control over the genes we inherit or pass on to others.” You
should also add that, “genes are only a part of the pathway by which a person
develops a mood (or a thought) disorder.”

37
 Clinical Tip

It is often useful after explaining these handouts to ask one of the family members to
repeat back in his or her own words what he or she has heard you say. Asking them
to put the material in their own words allows them to reach a deeper level of mastery of
the material, and allows us to fill in any gaps in their understanding.

We don’t want to put them on the spot or to communicate that we don’t think they are
bright enough to understand complex concepts. Phrasing it in the following way may
avoid those miscommunications.

“I have been talking for a long time, and I don’t always say things as clearly as I might
like, so I just want to stop and make sure that my message has gotten through. Would
one of you please explain to me what your understanding is of how people get bipolar
(psychosis, etc) symptoms so that I can be sure that I got my message across
effectively?”

Risk and Protective Factors

One way to help patients understand factors that
affect their course of illness is to talk about Risk
and Protective Factors. Use Handout #5.

Risk factors = anything that can make an illness

more likely to occur, or get worse. Examples are
drug and alcohol use, excessive amounts of stress,
family conflicts, poor sleep habits, and negative
self-talk.

Protective factors = anything that makes the person

less likely to become ill if they are vulnerable to
becoming ill. Protective factors are not just the
inverse of risk factors - they are the activities,
supports, or treatment resources that make people
better when they are biologically predisposed to
illness. Examples: consistent daily routines and
sleep/wake cycles, taking medicines, becoming educated about one’s illness and
learning to identify early warning signs of recurrence, supportive family relationships,
therapy or support groups. Ideally, we want to encourage the family to strike a
balance in which risk factors are minimized and protective factors are maximized for
the IP.

So, if the family is having trouble with terms like “coping strategies,” try asking, “what
protects you from getting ill?” If they equate “stress” with “negative thinking,” then
explain that negative thinking is a risk factor, but it is a reaction to stress.

Try to help people distinguish environmental stress from “when I get stressed out.”
The latter usually means worrying excessively or getting irritable. The important issue
is, what stressors are most likely to get you stressed out? Relationship problems, work
38
problems, schoolwork, traffic? Having to wait in lines? Work with the family to identify
those experiences that contribute to stress.

Addressing Marijuana use

Drug and alcohol abuse are classic examples of risk factors in mood and psychotic
disorders. You will have multiple opportunities to address drug abuse throughout FFT,
but none will be particularly effective with youth who have decided to keep using no
matter what. In these cases, you may find it more effective to refer the youth for
chemical dependency treatment or 12-Step programs.

If relevant to the youth you’re seeing, say:

“We are going to talk a lot more about stress next time, but I’d like to touch on the
marijuana thing a bit more. Invariably young people wonder why we keep telling
them not to smoke weed because they see other young people casually
experimenting with using it and not having a lot of symptoms. Cannabis is a
stressor to our biological system. Some folks with low genetic risk may be able to
get away with smoking weed without experiencing symptoms, but once a person is
experiencing symptoms, it can make them a lot worse. The same amount of weed
can have a much more problematic impact.”

Answer Questions
Give the family an opportunity to ask any questions. Say something like, “We have
covered a lot of material today. What questions come to mind, or what reactions do
you have to the material that we discussed? Pause and allow them to think for a
moment. Make sure that you look interested in hearing what is on their mind.

Plan for Next Session and Assign Homework

Remind them of the headlines for the next sessions. You could say something like:

“Next session we are going to try to figure out what is causing the greatest
amount of stress in your lives, We will begin to evaluate how you are coping
and whether additional coping strategies might be useful to you.”

If there is a tie in to family members’ goals, you should mention it by saying something
like:

“Manuel, I remember that you were particularly interested in hearing about

some additional ways to cope with symptoms and with stress, so next week we
will start getting in to that important material. How does that sound?

Remind the IP to keep his mood or thinking chart.

Ask the family to schedule a family meeting between sessions to review the material
you’ve presented and to talk about any questions they may have or any reactions to
the material. Ask them to share some of those questions or reactions with you at the
beginning of next week’s session. Also, ask them to notice sources of stress in their
lives, as this will be the focus of next week’s session. Set up the next meeting time.
39
 Sessions 3-4 Overview:
Development of The Prevention Plan

In the psychoeducational sessions that follow, you’ll find specific strategies for
managing symptoms among teens and young adults with bipolar or psychosis
symptoms. The overarching goal of these psychoeducation sessions is to develop a
Prevention Plan, which identifies:

 Early warning signs of symptom intensification

 Stressors that may be provoking symptom intensification
 Coping skills the youth can use to manage the symptoms,
 Ways that family members can help the youth to reduce stress, and
 Strategies to overcome obstacles that can be undertaken by the youth and his
or her relatives at key points in the symptom escalation.

The family will develop this plan over sessions 3-4. The specific sessions cover the
following:

Stress
 Identification of relevant stressors that may elicit symptoms
 Identification of typical reactions to stress
 Development of the “stress thermometer” that will help IPs and family
members communicate about their experiences of stress

Coping: Building a Tool Box

 Identification of coping skills the youth can use to manage symptoms,
which may include sleep/wake cycle regulation, behavioral activation
plans (e.g., pleasant events scheduling), relaxation training or
mindfulness meditation, and maintaining consistency with a medication
regimen.

Prevention Plan
 Pulling all of the strategies together into an action plan. The plan will be
most successful if it is developed when the youth is less symptomatic,
so that he or she has maximum ability to practice skills that will be
needed should symptoms intensify.

40
 Session 3: Identifying Stress and Coping Strategies

1. Joining/Check In

2. Review weekly practice assignment (family meeting; mood charts)

3. Stressors: Facilitate a discussion of the main stressors the IP and other

family members are dealing with in their lives. Use the handouts to the
extent that they are useful for a particular family in supporting this goal.

4. Stressors: Help family members to identify how they experience and

express stress. Do family members differ in their expressions of stress?
Do they know when they are starting to experience stress at a low level so
they can catch it and cope with it early? (stress thermometer)

5. Coping Strategies (include medication information and adherence and

sleep habits as indicated).

6. Assign homework (mood charts; stress or coping skill exercise)

7. Plan for next session; Joining/Closing

Handouts Needed:
 6 (Sources of Stress)
 7a (Stress and Coping Thermometer)
 7b (Coping Ideas List)

Optional:
 8 (Medications Commonly Used in Outpatient Settings)
 9 (Good Sleep Habits)
 “Pleasant Events” Lists (optional handouts)

Goals of session 3
The first goal of this session is to help the IP and each family member to identify
stressors from different domains of their lives, such as stress generated by the family,
the school and the work contexts. Family members may be able to identify their own
typical reactions when they are feeling “stressed out” (e.g. “I get angry, withdrawn, I
reach for a cigarette, I get high”). The second goal is to develop a list of coping
strategies that will become an important component of the prevention plan.

Review practice from last week

Check in with the IP: has s/he filled out and brought in the mood chart? If so, what has
s/he learned from it so far? What are some of the connections between mood and
sleep? How variable has her mood (or thinking patterns/paranoia) been?

Hopefully, she has brought it in and you can examine it with her: “sounds like you had
some ups and downs last week. Why do you think you were so down on Thursday?”
Or, “Have you noticed how much your sleep times change throughout the week? Do

41
 you think that affects your mood (or your thinking processes)?” If the IP is complaining
about paranoia: “Do you feel more/less suspiciousness when you’ve had a change in
your sleep hours?” Review other family members’ completed mood charts as well.
Note any patterns you may see across the family as a whole, or between particular
family members.

If they did have a family meeting, how did it go? Did they talk about any of the content
of the sessions? Did they start to think about the various sources of stress in their
lives?

Clinical Tip:
Addressing Homework Noncompliance

Many of your patients and family members will come in without having completed any of
the practice assignments you recommended. You will be less frustrated by this if you
expect it to happen. For example, assume that, even if you’ve explained the mood chart
well, the IP will not have filled it out, and the family members may have no memory of it.

Take a low key approach to noncompletion. Say, “how about we try filling one out now.
How is your mood today? How high/low? Have you had any of the suspiciousness you
described last week?”

“Let me explain again why I think this will be useful. A mood chart will help you see
whether you have lots of ups and downs during the week, and whether these changes are
related to your sleep. Later, we may be able to figure out how stress affects you, and for
how long. Does this seem like it would be useful? Would it be good if your (mom, dad,
sister) reminded you to do it?”

Likewise, if the family did not have a family meeting, normalize it (e.g., “lots of families
have trouble finding a time when everyone can sit down for 15 minutes and have a
discussion. It can be like herding cats. But is there a natural time when you’re all together,
like after dinner?”). Explain again how a family meeting will help them get more from the
treatment. It will allow them to generate questions for you, practice skills, and learn to
collaborate more effectively in the IP’s problems.

If they did not have a family meeting, ask them why: was it a scheduling problem? Were
they unclear why they were meeting? Briefly problem-solve with them regarding how they
could make it happen in the upcoming week. We would like them to establish this routine
while they are in FFT.

Please do not rush through the review of the practice assignment. If we don’t convey
interest in what they have done between sessions, they will view the homework as
unimportant. If they have engaged in practice assignments, praise them and ask them to
show you the chart and talk about what they observed/learned.

Stress Identification
42
“As we talked about last week, stressful experiences can lead to symptom
intensification. A first step in containing stress is to identify the various sources of
stress in our lives. When stress remains “invisible” and unidentified, it can wreak the
most havoc. Once we know where stress is coming from, we can think about how to
deal with it more effectively.”

Distribute Handout #6, “Sources of Stress,” to

each family member.

“This handout shows the types of events that

typically generate stress for people. There are
major life events such as when someone in your
family dies or you move to a different house.

Even positive events like the birth of a new brother

or sister can also cause stress. Why do you think
these positive events are considered stressful?”
(They are emotional events and often require
change in routines)

If you have a sudden change in routines, like

when the school year starts or you start a new job,
that can feel pretty stressful. Having a predictable
routine helps to keep stress low.”

“Daily hassles such as driving in traffic or forgetting homework assignments can be

stressful too. These are the small stressors that are often “invisible” in that we don’t
stop and deal with them like we do with something big. We may not realize the toll they
are actually taking because they pile up little by little. Have any of these experiences
happened to any of you?”

“Conflicts with others, especially family members, but also friends or teachers can be
very stressful. Isn’t it interesting that not enough activity, “boredom,” can generate
stress as well? Humans seem to need a balance between too much and not enough
activity to minimize stress.

Some may be surprised to hear that boredom or not having enough to do can generate
stress, partly due to too much time left for rumination or worry. Sitting on the couch
and watching TV for hours can seem like a “low stress” thing to do, but can generate
stress when an individual starts to feel uncomfortable about not making more progress
in their schoolwork or social life. Also, a lot of sedentary activity may throw off sleep
wake cycles, such that it is hard to sleep at night and feel rested the next day.

The Stress Thermometer

Ask each family member to talk a bit about what his/her experience of being “stressed
out” tends to be like. Do family members know they are stressed out because they feel
irritable and they snap at others? Do they have a lot of negative or critical thoughts
whirling in their heads? Do their bodies feel tense and their shoulders hunch way up?
Do they find themselves declining social invitations and shutting down?
43
It will be useful for the IP and family members to become aware when they are getting
stressed out so they can catch it early, at a time when they can cope most effectively.

Also, it is helpful for each family member to become skillful at identifying other family
members’ signs of distress. Every person reacts to stress differently. While one
person may get quiet when overwhelmed by stress another person may become very
chatty and another argumentative. Once family members understand each other’s
signs of feeling stressed, they are more likely to be able to help each other more
effectively by providing space or reducing expectations, or providing emotional or
practical support during times of stress.

Distribute Handout #7a, “Stress and Coping Thermometer,” to the IP and each
family member. The purpose of this handout is to:

1. Identify Stressors: Explore recent events, even minor ones that have led to
mood swings, rage reactions, or periods of depression. Ask the IP to describe
any events that have stressed him or her out lately.

2. Identify different levels of distress. Help them describe the feeling states (or
bodily sensations) associated with different amounts of emotional distress. For
example, high emotional distress may mean paranoia, intense anxiety, severe
irritability, or severe depression. Medium distress might be “feeling
overwhelmed”. Low distress may mean feeling jittery, “kind of bummed,” or
“ticked off”.

3. Identify Coping Strategies. Make an initial list of things the IP can do to make
himself feel better, preferably activities that involve other family members or
other persons who can introduce some balance into the situation.

You can explain the following:

“In the next two sessions, we’re going to

be developing a prevention plan to help
you get better control over your mood
swings (or thought problems). First, we’re
going to figure out what causes distress for
you. Then we can develop a plan to help
you manage your stress levels.
Sometimes just having a plan can provide
some immediate relief.”

Start by asking the IP to imagine recent events that have been associated with feeling
upset, angry, or enraged. So, being told to stop playing a video game might make a
teen feel annoyed but not angry (lower distress), whereas being grounded for a week
might provoke a rage reaction (high distress). You can also identify stressors or
events, even positive ones, associated with “happy” or “very happy” (i.e., hypomanic or

44
manic) moods (e.g., getting accepted for a date). When discussing a stressful event,
ask the IP, “when that happens, how would you rate your mood, from 1-10?”

Family members may want to chime in about specific events that caused stress for the
IP or for themselves (e.g., “when I got a call from her teacher”). The main purpose of
this task is to begin to develop the Prevention Plan – try not to get in to problem-
solving at this point. Right now, we are only asking them to identify what is feels like in
their body or how they behave and express themselves when they are under varying
levels of stress.

Over time they will better understand what types of events are most stressful for the IP
and other family members. Perhaps social situations provoke the strongest stress
reactions for one family member while school tests and homework assignments
provoke the strongest reactions for the IP. The stress thermometer may be a useful
tool for individuals as they experience life events, implement coping strategies, and
then reevaluate their distress level to see if their coping efforts have been effective.

Mobilizing Coping Efforts

The next step is to start to list efforts the IP and family can take to cope with stress and
changes in mood.

The following strategies will likely be useful for the IP in coping with stress and the
resulting symptomatic changes (see Handout 7b: Coping Ideas List , below):

 Talking to others, especially supportive interactions with family members or

friends
 Positive self-talk
 Pleasant life events scheduling
 Staying on a regular medication regimen
 Using relaxation or meditation exercises

In the sections that follow, we will consider several of these coping options. There are
other possibilities as well, as described in the Optional Topics below.

Coping with stress

Distribute Handout # 7b: Coping Ideas
List”. Explain that a coping strategy is
really just a way of dealing with stress.
Some strategies may help you to feel
better or less upset about the problem,
while other strategies may help to
actually solve the problem directly. Ask
the IP and other family members which
of these strategies they’ve used at
times of stress. Have they worked well?
Do they feel could benefit from new
strategies? What additional strategies
do they think might be useful? This
discussion will allow family members to learn about the types of coping strategies that
each person tends to use now, and often leads to additional suggestions for coping.
45
For example, consider a 19-year old with early-onset psychosis who says that he is
having a hard time in math class because he is sitting in the front of the room and it
feels like everyone is staring at him and it becomes “really distracting and
uncomfortable.” The way the youth copes with those feelings during class is to
imagine that he is somewhere else. While this helps with managing the feelings of
self-consciousness, not surprisingly his math grade has been dropping. Family
members suggested talking to the teacher and asking for a change in seat
assignment. In fact, one of his parents was willing to help with this. The clinician
suggested some brief mindfulness exercises before he goes into class.

Developing a Toolbox of Coping Strategies

At this point in the treatment, you are likely to have a much clearer sense of the
stressors that are present in the individual, family, and school/work contexts for the IP,
and of the strategies that s/he is currently using to cope with those stressors. During
session 3, you have the opportunity to introduce the importance of scheduling
pleasant life events, medication adherence and sleep regulation (often issues for
young bipolar and psychosis patients) or one of the other coping strategies discussed
in the Optional Handouts (school accommodations, relaxation training, mindfulness,
social skills training). For example, you can let them know about relaxation techniques
or mindfulness exercises that might be useful with reducing anxiety or helping to get to
sleep at night; pleasant event scheduling if they are feeling down because there aren’t
enough rewarding interactions going on in their lives; the social skills unit if it seems
like identifying potential friends and initiating contact are stressful. If there is another
topic that you think would be more relevant, this session provides you with the time to
teach that skill.

In developing a list of coping strategies, consider whether you should introduce a new
skill now or whether it belongs in another part of treatment. For example, consider a
family who has raised the problem of the youth’s medication inconsistency. You may
want to address this issue now, in the context of education about symptoms, the
vulnerability/stress model and the increased likelihood of recurrence with
nonadherence. Alternatively, you may decide to wait until you’ve taught basic problem-
solving skills, especially if the nonadherence has to do with concrete issues such as
forgetting to take medications that could be addressed through solution-generating.

Another example: Sleep-wake cycle regularity. For most youth, suggesting regular
sleep/wake patterns is useful. However, the way in which the youth implements these
skills varies widely: One patient may benefit from an earlier bedtime, and another from
not “sleep-bingeing” during the weekends. If you want to address the issue now, you
will probably need to enter problem-solving mode to help the youth generate a sleep
plan, rather than just presenting regular sleep as a good thing to do.

Pleasant event scheduling, relaxation training, or social skills training may also be
introduced later on, during a problem solving session. Basically, as opportunities
arise throughout the therapy, you are helping the family to develop a “toolbox” of
coping strategies that they may use as needed.

46
Optional Topic 1: Pleasant Events Scheduling

Often the IPs we see do not have enough enjoyable activities in their lives. They are
isolated from peer and school/work satisfactions, and spend inordinate amounts of
time with technology (computers, televisions, etc.) or sleeping. This may be due to
depression, negative or positive psychosis symptoms, social anxiety, and/or
medication side effects. Sometimes by talking about the patient’s reasons for avoiding
activities, the therapist and family can figure out strategies that may help the patient to
re-engage. We typically ask family members about activities they enjoyed in the past,
but that they aren’t currently involved in, or anything they would like to do but haven’t
been able to get started for whatever reason. We may brainstorm regarding how they
could get those activities back in their lives. Alternatively, consultation with the treating
psychiatrist may lead to medication changes that alleviate the problem for the youth.

In other cases, however, the reason for the inertia is not clear, and youths may seem
pretty stuck in very restricted lives. Enticing them back into engaging more actively
with their community, family, and peers and helping them to find greater satisfaction
are important steps on the road toward higher functioning. Explain to the family that it
is difficult to cope with the many stressors one
encounters in life if there isn’t a “stock pile” of
pleasant experiences to balance the situation. It
would be great if the youth could start enjoying
him/herself more.

Sometimes it is the case that families have

become immobilized by the symptoms and have
stopped enjoying pleasant activities together. It
is difficult to communicate well if family members
are not sharing some fun times together. So, the
pleasant event list may support individuals and
families in creating more pleasurable and
collaborative experiences in their lives.

47
We share with them the list of “Pleasant Events” (see Optional Handouts appendix)
which is a modification of the Adult Pleasant Event Schedule found in the Skills
Training Manual for Borderline Personality Disorder by Marsha Linehan (1993). There
are multiple versions of this list, so select the handout that you believe will be most
appropriate for the family. The goal in using this list is to get them to broaden their
thinking about possible events they can schedule into their lives.

Have family members take turns reading items from the list aloud, and ask each of
them to circle the events that pique their interest. After the family has reviewed the list,
you can invite them to add some ideas of their own to the list. Then you can ask that
they spend a few minutes picking out a few of the activities they have circled that they
would be willing to try over the next few weeks.

After they have each identified several activities they would be willing to try, spend
some time developing an action plan with each of them regarding when and how they
can make sure to follow-through with these activities. Help them schedule the events
as clearly and specifically as possible.

This activities list is particularly useful when the parents have tried repeatedly to
suggest activities, or require activities of the youth and this process of trying to get the
youth to become more active has turned into a tension filled power struggle within the
family and perhaps within the therapy room during a particular session. In these
cases, one goal of introducing this “pleasant activities for families” list is to decrease
the tension in the family and to change the dynamic in the room from one of the
parents pushing and youth resisting to a process in which we invite and entice the
youth to try something new. When the family members read through the list we want
them to linger on items that may spark memories of particularly good times that they
have shared together, and to talk about those experiences. By reflecting on these
pleasant events, we may create a different mood and atmosphere in which the youth
feels a little more flexible and receptive. We would like to rekindle interest in some
activities that he/she used to enjoy but has forgotten about or entice the youth to try
something completely novel that he/she hasn’t thought about before.

Also, we would like to support the family in having some enjoyable experiences
together. Usually warmth and connection “grease the wheels” for all of the
communication and problem solving work to follow. Do not be put off if the youth says
that the items are stupid; instead, ask the parent(s) if they have better ideas. Allow
them to laugh about the items together. For example, while reading through the list of
pleasant family activities, one youth commented that the item about reading the
newspaper in another language was totally ridiculous and should be on a list of
homework assignments rather than of pleasant events. After everyone laughed, his
mother reminded him that she routinely reads the newspaper in Spanish, and that in
fact most of the family’s favorite recipes have come from that newspaper. The son
asked her why they haven’t had paella in a while, and she reminded him that he is the
best paella maker in the house. They decided to go shopping for ingredients together
that weekend and to cook some other favorite dishes as well.

Another youth read the item about “drinking an ice cold glass of water” and laughed
out loud mockingly. He thought that was a ridiculous pleasant event and couldn’t
48
believe that we would have something that stupid on the list. We asked him if he ever
had the experience of drinking water after a long walk, and he agreed that it could
actually be quite pleasant. That led to a discussion of all kinds of simple pleasant
experiences that often get overlooked because we are too preoccupied to really pay
attention to them. The family talked about how humans seem to be wired to focus on
negative things that happen or problems that are unresolved rather than ruminating
about all of the hundreds of pleasant little moments that occur every day. The family
was encouraged to shift their focus for a week to appreciating small pleasant moments
(see Mindfulness exercises).

Another youth and mother that were at an angry impasse during a session because
the youth was refusing to do anything active. They read through the list and it
stimulated a discussion of how they used to take their dog out for a walk together
every evening. The mom started recounting stories about how the dog had stolen a
gentleman’s hat one time and led them on a merry chase, and the son remembered
how the dog constantly chased rabbits and squirrels, but never actually managed to
catch one. They wondered about why they were able to enjoy walks together when
the dog was alive, but had such difficulty now, and the son suggested that it was
because they had the dog to entertain them and they didn’t have to talk. Now when
they walk the mom constantly asks the son questions about how he is doing and he
finds that very irritating. They agreed to try taking a few walks during the week
provided that conversation was held to a minimum (or the mother would save up
entertaining stories to tell and would not ask the son any questions about his health).

Optional Topic 2: Enhancing Medication Adherence

(Address this issue if you have reason to believe the IP has been inconsistent with
medications – whether these are mood stabilizers such as lithium, Depakote or
Lamictal or atypical antipsychotics like Risperdal, Seroquel, Latuda, or Abilify).

Often, during the education component of FFT, the issue of medication nonadherence
emerges. This is an important issue for individuals with psychiatric disorders in
general, and is even more pertinent to adolescents and young adults. At one time or
another, many of our adolescents or young adults have either forgotten doses of
medication, “played with” the doses and times to take the medication, or ceased taking
their medication altogether. In most cases the parents were unaware until they began
noticing emergent/intensified symptoms in the adolescent or young adult.

FFT assumes that people are more likely to commit to a regimen of psychotropic
medications if:
(1) they receive information from mental health professionals about their
symptoms and how the medications may help;
(2) they are approached with compassion and with the position that taking
medications doesn’t change one’s identity;
(3) it is their own decision and not one foisted on them by others; and
(4) dosages can be adjusted or other medications substituted to control side
effects.

Clinical Tip:
How do you ask about medication adherence?

The most effective way to assess nonadherence is to ask about it directly: 49

 Do you have any difficulty taking all of your prescribed medications?
 How often do you try to cope on your own without the medication?
 Many people miss taking their medications from time to time; how has it
been for you?
Sometimes it helps to give the family a handout summarizing the various medications
he or she is taking (Handout 8). Use this handout if you
think your patient and family would benefit from knowing
what his or her medications are doing; which ones are
meant to stabilize mood and which work on psychotic
thinking or hallucinations (atypical or typical
antipsychotics) and which are antidepressants,
anxiolytics or sleep medicines. Try not to get into a
prolonged discussion with the IP or family about side
effects. If they have concerns about side effects (e.g.,
weight gain on antipsychotics; trembling hands on
lithium), refer them to their psychiatrist or GP for a
discussion about changing agents or altering dosages.
This is especially true for FFT clinicians who are
psychiatrists; the family may lean on you for information
about the choice of medications or how to adjust them.
Avoid stepping into this role.

Case Example: Alicia, age 17

One family called between sessions to talk about their concern about their 17 year-old
daughter Alicia. They said that Alicia had become more defiant, impatient, silly, and
had been sleeping less; she had also become irritable, was withdrawing more, and
received failing grades on two tests over the past week. They were unsure as to what
they should attribute her change in behavior. After several days of this change in
behavior she told her parents that she had not been taking her medications for the last
seven days. Her parents called to make sure that we would spend time on this issue
in the next session. This event provided an opportunity to educate the IP and family
about medication nonadherence and to talk about prevention.

Therapist: So, it sounds like over the last couple of weeks that there was a
period of time where you stopped taking your Depakote.

Alicia: Yeah.

Therapist: And are you back to taking it now?

Alicia: (pauses). Yeah, I guess.

Therapist: What made you decide to stop taking it? The last time we met you
said that it was really helpful to you.
50
Dad: She quit taking her medicine because she wanted to drink on her
birthday and the doctor told her that she couldn’t drink and take her medicine
too.

Alicia: That’s not true. You always think the worst.

Mom: Well, why did you quit taking your medicine?

Alicia: I was just feeling a lot better and I wanted to see if I still needed it.
Obviously I do (stated dejectedly).

Therapist: It seems that there are a number of issues here. First, it may be
helpful for us to talk a bit about the importance of medication to treat your
particular symptoms. Second, Alicia, you have some feelings about having to
take medication to make yourself feel better and I would like to hear more
about those. I’d also like to hear more about this increase in your symptoms
and see how your family deal with it (summarizes issues within a prevention
framework)

Dad: Well, this time things certainly seemed to go a little better. We got into
the same kind of conflicts we have gotten in before which led to Alicia moving
out. This time we just asked her what was going on and that she seemed like
she was having more symptoms and that generated some discussion, diffused
the situation, and for the first time in a long time, Alicia didn’t just walk out.

Alicia: I almost did.

Therapist: (to Dad) So it sounds like you noticed that she was experiencing
more symptoms, and this time you were able to talk about it instead of getting
into a fight. (reinforces family for coping efforts)

Dad: Yes, it seemed to make a difference. But it has still been very hard.

Therapist: I’m sure it has. It is often very difficult for family members when they
see that their kid is doing so well and then they go off of their medication and
things get really difficult again. Let’s talk about why people quit taking their
medication.

First, often the medication has side effects that the person taking the
medication doesn’t like. A person may quit taking the medicine or reduce it to
decrease side effects. Second, when people start to feel better, as you did
Alicia, they think that they don’t need the medicine anymore. They kind of think
of it like aspirin, “I take it when I have a headache and then quit taking it when
the headache goes away.” Finally, some people just forget to take their
medication. It is often difficult with a busy life to get into the habit of taking and
carrying your medicine with you. Do any of these fit for you,
Alicia?(summarizes reasons why people become inconsistent)

51
 Alicia: The feeling better one. I didn’t think I needed it or ever really needed it
in the first place.

Therapist: I can understand that, but it’s important for you to know, Alicia, that
taking your medicine is one of the most protective things you can do against
having more symptoms, even when you are feeling fine. The medicine you
take is similar to the medicine people take for high blood pressure. The
medicine keeps the symptoms from intensifying. One of the reasons that you
are feeling better now is probably because you are taking the medicine, not
because you don’t need the medicine. Do you understand how this could be
so?

Alicia: It’s a drag that I have to take medicine for the rest of my life. I hate it.

Therapist: That’s understandable. In fact, that’s the other issue I wanted to talk
about today. Feeling frustrated with having to take medication is pretty normal.
But if you’re not able to find a way to manage that frustration it could make you
want to stop taking it.

Alicia: What’s the big deal about going off the medication anyway? I can just
take it again if my symptoms get worse.

Therapist: Well, it’s actually a bit more complicated than that. There are
studies that have shown that for some people who discontinue their
medications all of a sudden, they can get worse.

Mom: You mean it could stop working?

Therapist: Yes, for some people that is the case.

Alicia: I actually do care when I don’t get along with my parents, and the
medicine really isn’t that bad, but I just don’t like being different.

Therapist: Well, that’s understandable, but you’d be surprised to find out how
many of the kids at school have to take some medicine to manage their health.
People don’t necessarily talk about it.

Alicia: Yeah, there are a lot of kids at my school who have to take drugs for
something. My friend Stacy has to take this medicine for her eyes all the time.

In this section, the clinician has done several things: clarified Alicia’s reasons for
believing she doesn’t need medication; normalizing those reasons; making analogies
between the medical treatment of psychiatric disorders and the treatment of other
medical disorders; and educating Alicia and her family about the hazards of
nonadherence.

Key Themes in Medication Nonadherence

In our experience, medication adherence among adolescents and young adults can be
facilitated by the following:

52
  Help the adolescent develop cues for pill storage and use (for example, pill
boxes, watch alarms, post-it notes, telephone reminders from family members)
 Examine the role of medications in the patient’s family or marital relationships;
 Examine subtle or overt pressures from family members to discontinue
medications
 Clarify the “symbolic significance” of taking medications (e.g., loss of creativity,
fears about giving up one’s experiences of emotions, relationships, music, or
other pleasures)

In some cases, the issue is “grieving over the lost healthy self,” when adolescents or
young adults fear that taking medication means giving up aspirations, goals, or their
view of themselves as a person with a future. These and related issues are discussed
in more depth in Bipolar Disorder: A Family-Focused Treatment Approach, 2nd ed.
(Miklowitz, 2010).

Importantly, when discussing medications, take a more exploratory and empathetic

stance, especially toward the youth. The youth or young adult has already heard her
parents (and perhaps her psychiatrist) drive home the point that she will have a
recurrence if she stops medicines. This is a time to form an alliance with the kid, and
show that you have some idea of what it might be like to feel different because you
take medicines that stabilize mood; and how those feelings may make you want to
prove something to your parents or others.

Who Should be in Charge of the Adolescent’s Medications?

While there are no hard and fast rules about this, use the following guidelines when
helping a family decide to what extent to hand control over to the young person.
These guidelines will be less relevant to young adults.

 If the youth is to take responsibility, he or she must buy into the clinical
concerns and treatment plan
 The youth must be cognitively able to handle the dosing requirements
 Issue of boundaries: is the youth more or less likely to take medications if the
parents play an active role?
 Older adolescents/young adults are more likely to be able to take responsibility
than early adolescents
 Make sure that medications do not become the battleground in which
autonomy battles are fought.

In many late adolescents or young adults, battles over medications is a stand-in for
battles over autonomy and independence. The key here is to show the adolescent that
his or her goals toward independence are more likely to be achieved if her mood is
stable.

Optional Topic #3: Addressing Sleep Problems

(Address this issue with most adolescents and young adults – once again, you are in
the section on coping strategies for stress, and getting regular sleep and keeping
regular routines is a major way to fend off the effects of stress on mood and thinking).

53
Sleep problems are often a central complaint among IPs with psychiatric disorders and
their family members. Fortunately, you can acquaint the parents and IP about the
options available to them when they have insomnia or restless sleep. For example,
you can encourage the adolescent to structure the bedtime routine with very
predictable times for turning off the television, brushing teeth, reading, and finally,
turning out the lights. Many families, however, do not have a “bedtime ritual” or even
an agreed-upon bedtime for their adolescents. This is not because they haven’t
thought of doing this. Rather, the adolescent has been quite resistant to following
through.

We stress that having the same bedtime and awakening time for the adolescent or
young adult may help with this problem. The list below offers many possible
alternatives when coping with sleep problems. Specify whether the problem seems
more biochemical (i.e., the IP lies in bed and feels too “revved” to fall asleep) or more
behavioral (i.e., there are no consequences for the IP for failing to follow an agreed-
upon bedtime routine). The solutions may also be quite different for younger and older
adolescents or young adults.

One family brought in the bedtime routine as a topic for problem solving. The parents
described how difficult it was to get their two adolescent boys (ages 12 and 13) in bed
and have them keep the lights out and go to sleep. Once the kids were in bed with the
lights out, they were able to fall asleep, but getting them to bed was a major hassle.
As a family, they engaged in problem solving and came up with a solution generated
by the boys. The all agreed that if the boys got in bed at the agreed upon time with
lights out that they received points toward the purchase of DVDs (each point was
worth $.50). If they did not follow the agreed upon bedtime plan, their consequence
was that they would not have TV the next day. The family implemented the plan that
night and all went well. This is an example of how sometimes sleep difficulties can be
changed behaviorally.

For older adolescents and young adults, the

reinforcers for maintaining a good sleep/wake cycle
tend to have to do with access to peers, job
demands, and academics. So, for example, a 19-
year old contracted with his parents to be in bed by
12 each night, and up by 8, in exchange for use of
the car on weekends.

Try to determine why sleep problems are occurring:

are they related to antecedent-behavior-
consequence chains or are they highly correlated
with other symptoms? Implement an intervention
appropriate to the nature of the problem. There are
cases where the sleep difficulties are related to
unresolved symptoms and may require additional
medications. Be sure to involve the treating
psychiatrist in designing sleep plans with the
family. Avoid recommending certain sleeping
pills (including melatonin) unless you are either the treating psychiatrist or you
have discussed this with him/her.
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Pass out Handout 9, “Good Sleep Habits.” Spend some time discussing each bullet
point with the IP: does s/he have a regular bedtime? What does she do right before
trying to sleep? How much do her sleep habits vary from the week to the weekends?
If she has been keeping a mood chart and writing down sleep/wake times, you can
refer back to these to develop some solutions to the problem of sleep disturbance.

Ending Session 3

Reflect
Summarize for the family what you’ve covered today, but do it in a “Socratic” format:
 What kinds of stress affects you most?
 What are the symptoms you experience when you’re under stress?
 What are some of the things you can do when you’re under stress?
 Pleasant activity scheduling?
 Sleep solutions?
 Medication consistency?

 How can your family help you?

Answer Questions and Assign Homework

1. Ask family members to complete mood charts over upcoming week.

2. Design a stress/coping assignment that encourages them to think ahead to the

next session and practice new skills you have taught them. There are several
assignments you can give them:

 To parents and IP: keep having a family meeting, only this time everyone
should make a list of stressors that have affected them this week, and how
they coped with them. If you haven’t completed the handout in session,
you can ask them to use Handout 7A before next session.

 To IP: Keep your mood and thinking chart only this time make sure to track
your sleep patterns (or an important stressor, such as homework load,
family stress, etc.) and take notes.

 Ask family members to complete coping skill “experiments” – try out

different coping skills in response to stressors over the upcoming week,
and note what did or didn’t work to reduce stress.

Try to determine what the IP and family can handle this week. If the session has gone
smoothly, err on the side of expecting them to do more. Once you have given them
an assignment, you may want to ask them to repeat it back to you. If they have
not been consistent with homework so far, ask them: what could get in the way
of getting this done?

55
 Session 4: Optimizing Family Support and Drafting
the Prevention Plan
1. Joining/Check In

2. Review homework (mood charts; stress or coping assignment)

3. Introduce the role of the family environment

4. Talk with family about what family members do that is experienced as

helpful by the IP, and what others do that makes stress worse for him/her.
If time allows, ask other family members talk about what is helpful and
difficult for them regarding what others do when they are stressed out.

5. Go over handout “How the family can help”.

6. Develop a draft of the Prevention Plan, building on coping strategies you

discussed in session 3.

7. Assign homework (mood charts; work on prevention plan)

8. Plan for next session; Joining/Closing

Needed Handouts:
 10 (How the Family Can Help)
 11 (Prevention Plan)

The main learning objectives during this fourth of four psychoeducation sessions are to
(a) explain that the family environment can play a key role in improving the patient’s
symptoms by reducing the patient’s experience of stress and supporting his/her efforts
to cope with stress, and (b) help the IP and family develop a prevention plan.

Answer Questions and Review Practice Assignment Related to Coping

Ask the family whether they met and discussed stress and coping, and if they made a
list, to show it to you. Review the IP’s mood/thinking chart, and ask him if he had any
thoughts about the content from last time. Did he/she have any insights into the role of
stress in his or her disorder?

Nonadherence with Practice Assignments

If the family did not do their assignments from last week, spend some time discussing
this. You are on the fourth session and if they haven’t picked up the habit of having
family meetings, mood charting, or practicing coping, you will need to explore with
them whether they are getting as much as they can out of treatment. Consider the
following interchange:

Clinician: So, it sounds like the assignments didn’t get done this week.

56
Mother: Yeah, we were really busy. Holiday shopping, making vacation reservations,
all that stuff. But he’s been doing better with the Abilify.

Clinician (pauses and waits). (To youth): That’s great that you’re doing well with the
Abilify, and I know this is a busy time of year. But what about that mood chart?

Youth: I don’t know, I just decide it wasn’t worth the time. My mood is stable and I’m
not really changing up or down.

Father: How can you say that after Sunday? Your sister was practically hiding under
the table!

Youth: She was not. We were just playing.

Mother: He was really manic. And days like Sunday make me wonder whether the
Abilify is at the right dosage.

Clinician: Let me hold on this for a minute, because we’re all talking about different
things. I’m hearing that Carl had trouble getting his mood chart done, and the two of
you think that his mood is not stable, but he doesn’t agree. Have you discussed that
as a family?

Mother: (pause) No.

Youth: There’s nothing to talk about.

Clinician: So it sounds like family meetings have gone by the way-side.

Father: Well, not entirely. We talked on the way over here.

Clinician: Tell me more.

Father: We talked about what we wanted to talk about here (laughs complicitly with
mother).

Clinician : Such as?

Father: You know, how to communicate better and stuff.

Clinician: That’s a start. But tell me, what gets in the way of doing assignments
between sessions? I think you’d get a lot more out of this treatment if you did.

Mother: If you came over and organized everyone’s schedule so we were all in the
same place at the same time, that would help!

Clinician: Well, as you know, I can’t come over to your house, but I’d be happy to help
you schedule family meetings. Let’s talk about that next. But first, tell me, are the
family meetings difficult in some way? Awkward?

The clinician here has not accepted the idea that the issues are about being too busy.
She explores what happens during the family meetings – in fact, there was only one,
right after the first session, and no one was clear on what they were supposed to do,
so they all went back to what they had been doing.

57
She might then explore what the kid dislikes about the mood chart, or why they didn’t
implement any pleasant events. Then, she gave them the same set of assignments
for the next week, always coming back to “I want you to get what you can from this
treatment, rather than just during the treatment hour.”

Introduce the Role of the Family Environment

Introduce this topic:

“Today we are going to build off of what we have been working on in the past
couple of sessions. Last week we talked about stressors and strategies that we
can use to cope. Today we are going to focus on what each family member
can do to help each of us to cope with our stress, and in turn what each of us
can do to make it easier for family members to help us.”

Start by asking someone other than the IP to say what others in the family have done
when s/he is under stress. Ideally, we’d like a husband to say “my wife givens me a
back rub” or for the mom to say, “Curt (son) asks me what’s wrong and listens.” Try to
redirect the discussion if the family’s first impulse is to blame the IP for making the
world stressful for them. We want to know what others do that helps.

Next, ask the IP how each family member responds when he is under stress or has
mood symptoms or psychosis symptoms. What do they do when you’re sad? How do
they react when you’re irritable? How do those reactions impact the IP? What do
family members do that is helpful? Ask the family to think about what would be most
helpful to the IP when s/he is symptomatic. And how could the IP express his needs so
that he has a better chance of getting support from family members?

If there is time, go through some of the other family members’ stressors as well (or
mood problems) and ask them what others could do to be helpful to them in those
situations. What do others do that tends to be helpful? What do others do that tends
to make matters worse?

Try to work through a couple of examples during the session. At times, parents may
have trouble responding to their son/daughter’s symptoms or problems with day-to-day
functioning.

For instance, consider a patient that had listed “trouble with focus and attention
related to increased sensitivity to sounds,” as one of her areas of concern. Due
to the IP’s trouble with attention, she has not been getting her homework done.
The patient is so far behind in her classes that she is at risk of failing. The IP,
wanting to do well but unable to focus enough to get her work done, is
experiencing a high level of stress. The IP explained that her parents reacted to
her poor academic performance by closely monitoring her time spent studying,
but she noted that this has made her feel more stressed out and led to
increased conflict.

The clinician should (1) ask the IP how she has experienced her family’s reaction to
this problem, (2) ask the family members if they believe their responses to the IP are
58
working effectively. If not, facilitate a discussion of alternative responses. For instance,
in reference to the above example, the patient identified that an alternative helpful
response would be to study on her own and then show her parents her homework
when she is done with it.

Make sure to encourage alternative responses, as appropriate. For the example being
discussed, you might suggest that the parents talk with their daughter’s teachers about
allowing her to have more time to complete assignments in light of her recent troubles.
In addition, you could suggest that the parents decrease their expectations during
times of worsening symptoms. If there are two parents, emphasize the importance of
“being on the same page” regarding how to address problems that involve their
son/daughter. Keep in mind that such discussions are likely to continue throughout the
course of treatment and that alternative responses will improve with practice.

No matter how well the discussion has gone, praise them for their openness to talking
about what is helpful and not helpful with each other. Allow for them to reflect on the
experience a little bit.

Let them know that their ability to listen and their willingness to try new strategies and
experiment with various ways of helping each other is a real strength and often leads
to more satisfying and effective solutions to problems. Remind them that you will be
helping them with these issues more directly when you get to communication training.

How Can the Family Help?

Much of the material in Handout 10: How Can the

Family Help has been discussed already, but your
families will find it helpful to have it all in one place.
Also, this material will be important in the
prevention plan. You may need to explain some of
these items. For example, when discussing
“maintain a tolerant and calm home atmosphere,”
possibilities include: be willing to walk away from
arguments; institute the “three volley rule” where
family members agree to terminate or derail
discussions that have reached three negative “back
and forth” interactions; or use “time outs” as a way
of helping family members calm down in intense
situations. When you get to the last bullet point,
“use good communication skills,” lead the family in
a discussion of what communication is like at home
and ask whether the family uses specific skills like active listening or praise or
acknowledgement. The family can supplement these discussions by reading Chapter
9, “Family Management and Coping” in The Bipolar Teen (Miklowitz and George,
2008).

Concerns about a teenager’s school performance or behavior are often at the forefront
of parents’ minds. If there are school problems, find out how much the parents know

59
about getting help or accommodations from the school to increase the chances of their
teen being successful.

When explaining “structure and consistency,” point out that irregular bed times in teens
can often be traced to irregularities in the family’s overall routines. For example, if no
one in the house eats dinner together, the IP’s dinnertime is likely to vary from night to
night. If there is no “bedtime ritual” (for example, the internet is unavailable after 11;
the TV goes off at 10; quiet is expected after a certain hour) then the youth is unlikely
to get to bed on time. Although older teens and young adults may no longer be tied to
the parents’ or younger siblings’ routines, it is not unreasonable to ask the parents to
set time expectations such as the above to help the young person regulate his hours.

Tensions Arise During the Discussion of Family Support

Sometimes parents struggle with what they perceive to be a contradictory message.

We tell them that they did not cause the symptoms, yet we also tell them that there are
things they can do to decrease symptom severity. Some people think that if they have
some control over symptoms, then they are essentially blameworthy for causing the
symptoms to begin with. If parents start to look uncomfortable, or you suspect that the
parents are starting to feel blamed, you can introduce the following material that does
help them to see that although they aren’t responsible for causing the symptoms, they
still can be helpful with reducing them.

Christopher Amenson, Ph.D of the Pacific Clinics explains that:

“If you are a family that likes to rearrange your house a lot and move the
furniture around from room to room every few months to create a new
experience of the house, this is not a problem. In fact, it may help keep things
fresh and interesting and there is nothing problematic about being this way.
However, if you suddenly have a child that gets an illness and becomes blind,
you would need to rethink your redecorating habit. Your redecorating didn’t
cause the blindness, but now that the situation with your child has changed,
you will need to adapt and refrain from moving the furniture because that would
cause your child some problems. Your family will need to adapt to the changed
situation and find some other ways to have fun as a family.”

After this general explanation, get back to concretizing it for the particular the family,
e.g., “In other words, just because Robert is extra-sensitive to loud voices, that
doesn’t mean that talking to him loudly made him become that way. But it may
suggest that he’ll adapt easier in an environment where people keep their voices
down.”

Introduce the Prevention Plan

At this point you have the opportunity to integrate a lot of the material that has been
covered into the development of a plan to help prevent symptoms from getting worse.
You can draw from the discussion about symptoms, sources of stress, coping skills,
and family support to develop an intervention strategy that the family can use if
symptoms worsen.

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The action plan consists of four steps:
(1) identify relevant stressors that may be affecting the IP or the family as a whole,
(2) identify early warning signs that moods or mental health functioning is deteriorating,
(3) mobilize efforts to cope with stressors and early warning signs, and
(4) plan ways to overcome obstacles.

In introducing the plan, you can explain that developing a prevention plan is indicated
since research has shown that early interventions are much more effective than
waiting until symptoms are at a more severe level. Explain to the youth that “this is a
way to maintain control over your life
even when your thinking/mood/energy
start to change.”

Provide the family with the Prevention

Plan (Handout #11). There are several
options included in the handouts; select
one of these options or generate your
own, as appropriate for the family’s
needs. Ask them to discuss what should
go in each column. Ideally, the IP will be
in charge of filling out the form as you go,
although you may also want to appoint a
parent or sibling if the IP is resistant.

The following are instructions for completing the 4-column version of the Prevention
Plan. The first column is “Stressors-Triggers.” Invite the family members to pull from
the prior discussions on identifying stress, or invite the IP to report on recent stressors
from her mood chart. Remind them that stressors can change from week to week.
You can also put “triggers” here, such as “my irregular sleep patterns,” “missing
several days of medications,” or “fighting with my parents about my room.”

The next column, “Early Warning Signs,” should be familiar to everyone at this point.
Remember that EWSs are different from symptoms – these are the first signs that a
person is going into an episode of depression, mania, or psychosis, and that
functioning is becoming harder. Examples of “Early Warning Signs” might include, “I
have more trouble concentrating,” “I seem to need more (or less) sleep;” “my mood
gets more irritable,” “it’s harder for me to get my responsibilities done,” or “I am feeling
more suspicious of other people and haven’t wanted to go out with friends, “ or “It’s
harder to get up in the morning.” Family members can draw from the items that they
listed in the first column. For instance, for an IP who put that things are going well for
him/her when he/she wants to spend more time with friends, an early warning sign
could be, “avoiding seeing friends.”

Sometimes, EWSs are specific to the person. One parent said that her son “gets this
wild look in his eyes.” Another parent said that his daughter “starts hiding food under
her bed.” Another said that her daughter “gets these big movements, talks with her
hands more – it’s like Broadway versus the small screen.” Once a number of EWSs
have been listed, encourage the IP to record them on the Plan sheet.

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Third, and most importantly, they should list coping/prevention skills. These can be
pulled from the prior discussions, which may include some of the items on the
“Protective Factors” list:

o Taking medications more regularly

o Sleeping more regularly
o Talking with others about difficult feelings
o Monitoring one’s mood more regularly
o Staying away from alcohol and drugs
o Keeping the household low-key
o Reducing conflicts (e.g., the three-volley rule)
o Engaging in pleasurable activities (e.g., hobbies)
o Exercise

The next column is “Overcoming Obstacles.” The clinician explains that sometimes
when things aren’t going as well, it can be more difficult to utilize some of our coping
skills. The goal with these columns is to proactively look ahead at obstacles to
implementing coping skills that may come up when symptoms arise. These barriers
can be overcome more easily if anticipated with an action plan already in place. For
instance, when we are feeling healthy and happy, it may be easy to draw on our
coping skills such as engaging in hobbies or spending time with friends. However,
when we aren’t feeling as well, there can be obstacles to using these much-needed
coping skills. A bipolar patient who is currently well and says, “when I’m getting manic
and elated, my parents should tell me and bring me back to earth” is unlikely to be this
insightful when actually getting manic and elated.

For example, Jonathan, age 23, relied on spending time with friends as a coping skill,
but his tendency to withdraw when depressed was an obstacle to using this coping
skill. An action plan that was set up ahead of time involved a discussion with his
girlfriend when he was doing well. Jonathan informed his girlfriend that his early signs
of depression included withdrawing and self-isolating, which inhibited him from
reaching out to her or to friends. Together they decided that when Jonathan started to
pull away, his girlfriend would take the initiative to draw him out more and become
more active in making plans to see each other.

Ramon, age 25, enjoyed the euphoric feelings that came with getting hypomanic or
manic. As a result, he did not want to take medications at those times, although he
was usually very compliant. He said that “my parents should tell me I’m getting high,
and remind me to take them. I won’t like it at the time, but they should do it anyway.”

Melissa, age 19, listed spending quiet time alone in her room as a coping skill.
However, one of her early warning signs included a tendency to shut down and not
communicate. Family members became concerned by Melissa’s withdrawal and
thought they were being helpful by constantly checking in and offering suggestions or
inviting her to spend time together. This led Melissa to have difficulty communicating
her need for alone time. The family developed a “signal” to relieve Melissa from
having to explain her need for some space and time alone. In this case, the family
decided to have Melissa put a note on her door stating, “Alone time ‘til 6pm.” This met
both Melissa’s need for her quiet time along with her parents’ need to know that she
was okay and that they could check in with her at a specific time.
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Answer Questions and Assign Homework
At the end of the session, review the patient’s prevention plan worksheet and
allow time to answer questions. Be sure to give all participants praise for their
efforts.

Remind the family to have a family meeting between sessions and review the
materials that were introduced during this session. Encourage the IP to continue filling
out his mood chart but also to think about what else could be added to the prevention
plan.

Plan for/schedule next session

Let them know that you will be transitioning out of the psychoeducational segment of
your work together and into communication enhancement training as a primary focus.
You will revisit the prevention plan throughout treatment but the next focus will be on
improving the emotional “climate” of the family.

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III. COMMUNICATION ENHANCEMENT TRAINING (Sessions 5-8)

Session 5: Overview of Communication Skills;

Expressing Positive Feelings

1. Joining/Check In

2. Review homework (mood charts; prevention plan)

3. Discuss Family Members’ Current Communication Styles

4. Preview Skills of Communication Enhancement Training

5. Teach Skill #1: Expressing Positive Feelings

6. Assign Homework (mood charts; Catch a Person Pleasing You)

7. Plan for the Next Session; Joining/Closing

Handouts needed:
 12 (The Five Basic Communication Skills)
 13 (Expressing Positive Feelings)
 14 (Catch a Person Pleasing You)

Prior to introducing the second module, review the prevention plan homework and
answer any questions that might have come up between sessions. Review the IP’s
mood chart. If the IP or family are stuck on how to move forward with the Prevention
Plan, spend some time discussing it and help them complete the plan.

Background Information Regarding the Communication Enhancement Training

The second module of FFT, communication enhancement training (CET), runs for
approximately 4 sessions (sessions 5-8). These sessions are not as tightly structured
as the prior sessions. Families learn at different paces, and there may be significant
material from sessions 1-4 that needs further review. So, if you have not adequately
covered all of the communication skills by session 9, use some of the problem-solving
sessions to further practice the skills.

CET is guided by two assumptions. First, aversive family communication reflects

distress within the family due to family members’ attempts to deal with the IP's
symptoms and trouble with functioning. Second, aversive communication patterns can
be improved through skill training and practice. CET uses a role-playing format to
teach patients and their relatives five communication skills: giving positive feedback,
active listening, making positive requests for change in others’ behavior,
communication clarity, and expressing negative feelings.

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The purpose of communication enhancement training is to create a home atmosphere
that is protective against increased symptoms. These skills – if practiced earnestly -
foster a feeling of collaboration between members of a family. However, it may take
some time for family members to get used to the role-play format.

For each skill, the clinician gives the participants a handout listing its components
(e.g., for active listening: making good eye contact, paraphrasing), and models the skill
for the family. Then, the participants practice the skills with each other, with coaching
and shaping by the clinician. A practice assignment, in which the participants keep a
log of their efforts to use the skills, facilitates generalization to the home setting.

Evaluate Current Communication Style

The communication module begins with a discussion regarding the importance of
using good communication skills to create an environment that is calm, clear, and
supportive. Good communication skills are typically in each person’s best interests:
they are more likely to get what they want when they are able to listen to and address
each other’s concerns.

Ask the family: what currently goes well in your family’s communication; what doesn’t
go so well? Is it any different when _________ has symptoms? How about when
(mother or father) are under stress at work?

If someone in the family describes their tendency to get worked up or to yell when
something is upsetting, normalize this: “most families do this to some degree. It can be
especially difficult to listen to someone else’s perspective when you feel like you’ve
been wronged. People get wrapped up in how they’re going to respond instead of how
to connect with the other person.”

Introducing the Communication Skills

Give the family Handout 12, “Communication Enhancement Skills”. Then, preview
the skills that you intend to teach the family. The key task in CET is role-playing, both
inside and outside of the session. It is important for the family to understand the role-
playing process. Describe it by saying:

“You are going to learn five communication

skills: expressing positive feelings, active
listening, communication clarity, making
positive requests for change, and
expressing negative feelings about specific
behaviors. You’ll be learning the skills
through role-playing. This means that we
will be asking you to turn your chairs to
each other and practice new ways of talking
and listening. It may be a little awkward at
first but you’ll be surprised at how quickly
you get used to it when everyone else is
doing it too. In fact, it can be fun for the
family to try out these new ways of talking
to each other.”

65
Briefly make connections between the ways they want to improve their communication
and the skills on this handout. Then continue with the introduction:

“Good communication and problem solving leads to less family tension and fewer
mood symptoms (psychosis symptoms). Having the skills makes it much easier to
solve problems that may have been there for a long time.”

Make sure that everyone in the family understands what you mean by good
communication. For younger adolescents, “communication” can seem like an adult
word. It may be necessary to say to them “it means making sure you and another
person understand each other.”

Introducing Skill #1: Expressing Positive Feelings

After introducing the concept of communication, start to teach the first of the five skills.
First, present the skill of expressing positive feelings. This skill is taught first because
it is an easy skill to learn and usually leads to a sense of connection and good feeling
between family members. To begin, briefly summarize the nature and purpose of the
skill: it is a direct way to make other members of the family feel valued and
appreciated, and makes them want to reciprocate those good feelings in the future.
Also, it helps to create a balanced approach to family life. It can be very easy to
identify ways that other people irritate us, and we can easily take for granted the many
things that others are doing each day to help us out. The most satisfied families tend
to praise each other a lot more often than they ask for changes.

Then explain the components using Handout 13,

“Expressing Positive Feelings”. It is sometimes
hard for individuals to come up with “feeling words.”
For example, a family member might say, “It made
me feel like you cared,” which is really not a
disclosure of his or her own feeling state. Help
family members to find the right feeling that goes
along with that experience, such as “happy”,
“appreciated”, or “touched”. Don’t be satisfied with
“good” for everything.

Explain to the participants that expressing positive

feelings typically goes better if the praise is offered
for a relatively specific behavior instead of a
generic attribute such as being a “terrific person”.
Finally, model the skill for them. For rapport-
building, direct your modeling to the IP as the
receiver.

For example, say,

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“Keith, I really appreciate that you’ve been willing to talk about your school problems
so openly. It makes me feel good that our time has been well spent.”

Or,

“Mr. Williams, I really appreciate how you have come to every session and tried to
participate even though it has been hard for you some days. Your involvement makes
me feel encouraged about our work together.”

If your attempt to model the compliment falls flat, try not to become defensive. Try to
bring humor to the situation (e.g., “boy, that one went over like a lead balloon”). Your
willingness to be vulnerable and persevere in the face of rejection may make family
members and the IP feel less defensive themselves and more open to the process of
positive communication.

Once it is clear that family members know the features of positive communication,
have them think of something specific and pleasing that someone else in the family did
in the last week. Once a family member is ready to give feedback and has chosen a
recipient, instruct the members of the dyad to turn their chairs toward each other
(unless they are already sitting such that they can easily talk to each other), and talk
directly to each other with the one giving the feedback designated the “speaker” and
the one receiving the feedback the “listener”. Your role is to direct the interaction,
based on the dyad’s need for direction. Make sure that the family members feel
supported but also give them feedback on how to do the skill correctly.

Consider the following example. A father agreed to compliment his 19-year old son on
his attempts to stay out of trouble with the police. The father told his son,

“I am really glad that you didn’t get into any trouble this week. ”

The clinician praised the father’s efforts at coming up with a compliment for his son,
and pointed out to him that another way to state his compliment was to say what his
son did that he appreciated, as opposed to what he did not do.

The father tried again and stated,

“Son, your behavior was really exceptional this week and it made me really
happy to see you behave so well.”

At this point the clinician gave a lot of praise to the father for being flexible and
performing the skill in the way it was intended. However, she still encouraged the
father to try again, giving examples of what he meant by “really exceptional behavior.”

Sometimes, there will be resistance to replaying the exchange (and in so doing,

practicing the skill) in accordance with the therapist’s feedback. If this occurs, explain
that the skills are like trying on a new pair of shoes. If they do not fit, the speaker is
welcome to take them off. However, he or she will only know whether they fit if they
are “walked in awhile to see if you can break them in. It’s the same way with these
skills – you’ve got to mold them to your particular style before they’ll feel natural.”

67
Next, ask each member of the family to practice the skill while you praise and provide
direction. Ideally, each member of the family will have practiced giving a compliment
to someone else, and will have been the recipient of one as well. If one person is
being left out (i.e., no one said that mom did anything well), encourage the family to do
so (e.g., “No one has said anything about what Beth did this week. I imagine she must
have done something nice for someone in here.”).

Assign a Practice
Once you are fairly certain that each of the family members – including the IP – is
using the positive feedback skill in the correct manner, assign the homework sheet,
“Catch a Person Pleasing You Task” (Handout 14). This assignment (to be
completed between sessions) can be treated as a game. Each member of the family
is given one sheet. The goal is for each family member to try to do something every
day that he or she perceives as pleasing to another member of the family (which can
vary day by day). What they record on their sheets, however, is when something
pleasant was done for them by another member of the family. They also record
whether they acknowledged (i.e., expressed positive feelings) what was done. This
can lead to a discussion of what family members “catch” (or notice) and what they
miss.

For example, in one family, the father brought a

box of chocolates to the mother. He was very
surprised when his gesture was not “caught” by
her. She explained to him that she was actually
offended because she was trying to decrease her
sugar intake and recalled that he had commented
earlier in the week that she had been gaining
weight. She did express positive feelings about
some other things he had done, however (i.e.,
rubbing her back, playing with the kids when he
came home). He was surprised that these
behaviors meant so much to her. Family members
may realize that the efforts they expend to please
each other are ineffective because they are not
always in sync with the other person’s desires.
What better way to demonstrate the importance of
direct communication!

Troubleshooting Expressing Positive Feelings

Most of the time family members will be receptive to this approach and perhaps even
enjoy the exercise. However, if family members persist in expressing strong negative
reactions, discuss their feelings and consider modifications. For example, one single-
parent father and his son laughed out loud during this exercise and stated:

Dad: Doctor, guys just don’t talk like that. I don’t mean any disrespect, and I
can imagine how you might say things in this way, but in my world it just won’t
happen. I just want to be honest with you

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 Therapist: I appreciate your honesty. Tell me some more about what feels
weird to you about this approach.

Dad: My son and I do nice things for each other, and I like to let him know that
I appreciate what he does, but I would give him a high five and just say
“thanks,” or I might say “good job with the laundry, pound it (father puts up his
fist).”

Therapist: So you are noticing what your son is doing and you are praising him
for it in your own way. You have a briefer style that doesn’t involve talking
about how it makes you feel and so on.

Dad: Yeah. Those words just wouldn’t be mine. It would feel really stilted.

Therapist: Ben, how do you tell your Dad when he has done something that
you like?

Son: I just say “thanks for picking me up from school Dad, or thanks for
cooking chicken tonight, that’s my favorite.”

Therapist: You know, I like the way that you communicated there and I’m glad
that you brought this up because the whole point of this exercise is really just to
remind us to focus on and comment on the good things that we are doing for
each other. Sounds like you guys have your own way of doing that and it
works for you.

Son and Dad: Yeah.

Therapist: OK, but you also said earlier that a lot of things you do that don’t get
noticed by each other. Do you think that there is room for you to be a bit more
aware of what you are doing for each other day-to-day and to comment on it so
that you feel more appreciated?

Dad: Yes, there is definitely room for that. I can see what you are saying
about the need to keep a balance so that I’m not just always telling him to pick
up his room and do his homework.

Therapist: What about you Ben? Do you think that your Dad knows when you
appreciate something he did for you?

Son: I think so, but I’m not sure.

Therapist: Would you be open to going through the role plays again only this
time using whatever way feels comfortable for you to express positive feelings?

Dad: Sure.

Alternatively, the clinician here might have accepted the family’s way of expressing
positive feelings, but assigned the Catch a Person Pleasing You task so that they
69
could keep track of how often these exchanges occurred. Instead of writing down
“What did you say to him or her” they could record an abbreviation like “pound it”.

Ending Session 5
When wrapping up this session, summarize the skill the family has learned and why
each is important. Ask them to repeat back to you what they’re supposed to do with
the “Catch a Person Pleasing You” assignment. Offer praise for their attempts to
master the skills, even if very modest.

Mostly, encourage them to practice these skills at home, and with others. The skills
will feel increasingly comfortable as they generalize to other settings.

Remind the family that, at session 9, you’ll be switching to every other week. That is,
the first 8 sessions are weekly, and then we switch to biweekly. This will not be a big
issue for many families, but it will give them some time to prepare. Pair this statement
with, “Because we’ll be meeting less frequently, it will be extra important for you to
have a family meeting and practice these skills between sessions. Are you still having
a family meeting?”

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 Session 6: Active Listening

1. Joining/Check In

2. Review homework (mood charts; catch a person pleasing you)

3. Teach Skill #2: Active Listening

4. Assign Homework (mood charts; communication skills assignment)

5. Plan for the Next Session; Joining/Closing

Handouts needed:
 15 (Active Listening)
 16 (Communication Skills Assignment).

Review Homework
Start out session 6 by reviewing the “Catch a Person Pleasing You” homework from
the previous week. Ask them how it felt to give each other more positive feedback
during the week. What was it like for them to hear others noticing and commenting on
some of the efforts that they made to be helpful or supportive? If they haven’t done the
assignment, ask them each to come up with one positive thing another member of the
family has done in the intervening week, and to express it now in a rehearsal within the
session. Remember to coach them to be specific about the feeling they enjoyed
(pleased, relieved, happy, touched) and also about the behavior the other person
performed.

Introducing skill #2: Active Listening

An essential building block for good communication is the ability to listen. It is in many
ways the basis for all of the other communication skills. However, active listening is a
more difficult skill to learn and can be anxiety producing for family members, so
expressing positive feelings is often an opportunity to begin communication training
with a concrete skill that has a positive tone.

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 Offer Handout 15 and describe Active Listening
to the family by saying: “This is a skill you are
probably all familiar with, active listening. It’s a skill
that is useful anytime, but it is really helpful when
there is an argument or disagreement. It helps to
slow things down because each person has to let
the other person know that they heard what was
said. That way, the other person feels like you’re
listening. It’s a skill that can come in handy during
an argument, because whoever is talking to you
feels acknowledged, and then is often willing to do
the same for you.

There are a couple of parts to it. If you want to let

a person know you are listening to them, look at
them, nod your head, and ask some questions to
make sure you understand, like ‘When did that
happen?’ It’s also a good idea to try to tell the
person what you heard them say, what we call “checking out what you heard.” Mrs. X,
when someone listens to you and asks you questions, how does it feel?”

After introducing the skill, model the skill for the family. That is, be the listener and ask
a member of the family to talk to you. You may want to ask for a volunteer. Once you
have modeled the listening skill, solicit input from family members as to their
experience of the demonstration (e.g., “What did you see me doing just now? How did
you know I was listening?”). Next, ask for volunteers to try practicing the skill (a
speaker and a listener).

It is important to start with low conflict topics for active listening, given that it is difficult
to learn a skill in the face of anxiety and/or criticism. Practicing the skill should not
provide an opportunity for a parent to give the patient a lecture.

As with the other skills, continue to model it, and give positive reinforcement for the
family member’s efforts, even if these efforts are only modest. There is often more
direction involved in the active listening skill than the others because of its difficulty
and complexity.

Clinical Tip
Coach one person at a time

When teaching Active Listening, it can be tempting to coach the speaker and
the listener simultaneously. For example, some clinicians try to get a parent to
practice “Making a Positive Request” while the son or daughter listens actively.
In our experience, this doesn’t work well. The speaker may bring up a topic that
is hard for the listener to summarize, or that may make the listener feel
defensive. Typically, coach the person who is learning the new skill only. For
example, when teaching Active Listening, most of your coaching should
concern the listener. The exception to this is when another family member,
assigned the role of speaker, uses it as an opportunity to criticize the listener.
Ask him or her to revise the topic to something more neutral, “like something
that happened to you at work today, so ___ can practice listening.” 72
If there are more than two family members participating in the therapy, assign a
speaker and a listener and give the other family members the job of observing to see if
the listener is following all of the steps. Sometimes it is easier for people to learn the
skills when they are not in the “hot seat.” After the role-play, ask the observers what
they noticed. What did the listener do well? Did the listener follow all of the steps?

It is very common for family members in the listener role to answer back to the
individual who is speaking by defending their own actions or expressing their own point
of view on a particular topic. Let them know that while this is an expected response, it
is not what we mean by active listening. Help them to summarize what the other
person said or to ask follow-up questions to clarify the other person’s perspective. Let
them know that they will have a chance to share their own perspective, but for now we
are practicing listening skills. When everybody is talking and nobody is listening, there
will be a breakdown in communication, and conflicts usually worsen.

Clinical Tip

Sometimes, families get confused about whether the goal of role-playing

is to listen or solve a problem. So, for example, a mother listened to her
son talk about his difficulty with homework and responded appropriately,
with statements of empathy such as “you get nervous when there’s a
page full of math problems and you hear me or dad yelling at you to
come to dinner.” However, when the father was asked about how his
wife did with the listening skill, he said “I think if Rob started his
homework earlier we wouldn’t have this problem.” Rob’s mother added,
“but what about basketball practice?”

In this example the family has transitioned into problem-solving before

active listening has been mastered. The clinician here reminded the
family that “we’re not trying to solve the problem of his homework just yet.
We’ll deal with that soon, but the goal here is to work on active listening,
about any number of topics. Dad, what did you like about the way mom
listened just now? Which of the elements on the handout did she use?”

If the IP is experiencing problems with memory or concentration/attention, he/she

could consider jotting down notes while the other person is talking. That way, s/he will
have an easier time reflecting back what was said and asking relevant follow-up
questions.

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 Case Example: “Dad, You’re Getting Abstract Again”
Ben, a 13-year-old with both bipolar disorder and ADHD began to experience
frustration during the communication module. When the family was asked what
they would like to improve in their communication, Ben’s father, Richard, said that
he would like for he and Ben to share more with each other. Ben asked him what
he meant. His father said that he would like to “know what Ben wanted out of life,
what made him happy, and where he saw himself in the future.” Ben, becoming
increasingly frustrated, told his father that he still did not understand. The clinician
tried to help Richard focus his request a little more but he had a very difficult time
defining what he meant. Finally, Ben said, “Dad, I’ll tell you about my day today,
OK?” and proceeded to give his father a very detailed account of all he did at
school and after school. The clinician assigned Richard the task of listening and
reflecting. This role seemed to please Richard very much who thanked Ben by
saying, “that helps me know what makes you happy and what is happening in your
life”. Ben was, understandably, less than enthused about this reaction.

In this vignette, Ben was able to intercept what was becoming an uncomfortable
impasse by making a guess about what his father wanted. The clinician can help
parents avoid abstract dialogue and focus on the concrete, specific communication
to which the child will respond more positively.

Some youths will say: “it is obvious that I’m listening because I am sitting here and she
doesn’t want me to just repeat back what he/she said.” Encourage them to consider
that if they summarize the other person’s point, that person will feel understood and
won’t have to keep trying to get a point across. This is a big shift for many youths who
tend to have little experience with active listening. Parents may be more familiar with
the concept, but may still find it difficult to actually put into action.

Give a Practice Assignment

Continue the process of integrating
communication skills into the family’s
daily life by assigning homework. If
you’ve already explained the “Catch a
Person Pleasing You” assignment, you
will have an easy time explaining the
Communication Skills Assignment
(Handout 16). Explain that only the first
two skills should be practiced
(Expressing Positive Feedback and
Active Listening) - they should not fill
out the information regarding
“communication clarity” or “positive
Requests for change” until you review those skills. Instruct the family to practice active
listening with various people in their daily lives, and to describe each instance on the
practice sheet.

74
Troubleshooting the Active Listening Skill
Because of the importance and difficulty of mastering active listening techniques, it
may take more than one session to practice this skill. You may want to make
modifications to the active listening training based on the comprehension of a
particular youth or family member. Feedback from the family and careful observation
of the interactions are essential processes for ensuring that the teaching hits the mark.

“Angry Birds”
One 15 year-old boy had a very difficult time listening to his mother talk. His mother
became aggravated with him during the role-play exercises because he would stop
making eye contact with her, which she felt was disrespectful and a sign that he wasn’t
listening. He explained that it was hard for him to deal with people’s facial
expressions, that he found them confusing and overwhelming, and that he could listen
better when he could look away from their face, or could do something with his hands
(e.g., play “Angry Birds” on his cell phone). He said that, far from distracting him,
using his hands to play the game helped to ease his anxiety and helped him focus on
another person’s message. The mother was surprised to hear this and became more
understanding of his difficulty with eye contact. She proceeded to talk with him while
he was looking at his cell phone, and he was consistently able to summarize what she
had said. In fact, she discovered that he actually listened better when he was able to
busy himself with his hands, especially when they were talking about emotionally
charged topics.

This example serves to highlight that the goal of the listening exercise is to facilitate
effective communication in a family. A therapist may need to modify the listening tasks
to accommodate the needs of particular individuals with unique sensitivities and
characteristics.

If you’d like more examples, consult pages 221-228 of Bipolar Disorder: A Family-
Focused Treatment Approach.

Ending Session 6
When wrapping up this session, again summarize the skills the family has learned and
why they’re important. Ask them to repeat back to you what they’re supposed to do
with the Communication Skills Handout assignment. Offer praise for their attempts
to master the skills, even if very modest.

Mostly, encourage them to practice these skills at home, and with others. The skills
will feel increasingly comfortable as they generalize to other settings.

75
Sessions 7 and 8: Making Positive Requests for
Chang, Communication Clarity, and Expressing
Negative Feelings
1. Joining/Check In

2. Review homework (mood charts; communication skills assignment)

3. Teach Skills #3: Making A Positive Request

4. Teach Skill #4: Communication Clarity

5. Teach Skill #5: Expressing Negative Feelings about Specific Behaviors

6. Assign Homework (mood charts; family meeting focused on making a

positive request, communication clarity, or expressing negative feelings)

7. Plan for the Next Session; Joining/Closing

Handouts Needed:
 16 (Communication Skills Assignment)
 17 (Making a Positive Request)
 18 (Communication Clarity)
 19 (Expressing Negative Feelings)
 20 (Expressing Negative Feelings about Specific Behaviors practice sheet)

Review Practice
Ask the family whether they completed the Communication Skills assignment, and to
describe their attempts at practicing active listening and what they observed about
their conversations. Are they starting to get a feeling for what good listening feels like?
Ask them to talk about the kinds of situations when they may want to use active
listening in the future, and the kinds of situations when this wouldn’t be feasible (e.g.,
when they are in a hurry and don’t have time to open up a conversation). Often people
are able to report that the listening skills deepened their conversations and that they
felt more satisfied with the outcome of these discussions. If necessary, explore with
them the reasons they did not complete the assignment (see above).

Change-Oriented Communication
Two communication skills, making positive requests for change and expressing
negative feelings, address a family member’s desire for change in another family
member’s behavior. Making positive requests (for example, “I would appreciate it if
you would take out the trash”) is the first step in requesting behavior changes from
other people (see Handout 18). Communication clarity stands between these two
skills, as it teaches a general method for being specific in one’s messages to others.
Finally, Expressing negative feelings about specific behaviors (e.g., “When you
start rolling your eyes, it hurts my feelings; what can we do about this?”) is
76
recommended when positive requests have not achieved their desired effects
(Handout 19). There may be cases where it seems more appropriate to teach
“Positive Requests” and “Negative Feelings” back to back.

Teach Skill: Making a Positive Request

There are two caveats to keep in mind when teaching positive requests:

 First, the request should be for another person to do something, rather than
stop doing something.
 Second, the person receiving the request is not under obligation to do what is
being asked of him or her.

The request may best be conceptualized as one of a number of solutions to a family

problem that can be taken up further through the problem-solving venue (see Problem
solving section).

Consider the contrast between these three ways of presenting feedback regarding a
family member’s tone of voice:

 “I hate it when you use that negative tone of voice.” (criticism)

 “I would appreciate it if you’d use a more respectful tone of voice when we
talk.” (positive request for change)
“I’ve asked you to speak to me in a respectful tone several times, but you
haven’t followed through. What are we going to do about this? (expressing
negative feelings about a specific behaviors)

To proceed with ‘positive requests,’ pass out the “Making a Positive Request”
handout, and introduce the skill:

“The next skill is called making a positive request. This is a good skill to use
when you want someone to do something differently. As you can see in the
handout there are a few parts to this skill – look at the person, say what you
would like him or her to do, and say how it would make you feel.”

77
 After presenting the
components of the skill,
model the skill, either by
asking for a volunteer or
including someone in the
family who has been
“hanging back” during the
treatment. If you feel
you have a good relationship
with the family, you can use
this as an opportunity to
address an issue that’s been
bothering you as a clinician.
For example, “Alan, I’d
appreciate it if you’d let me
know if you need to cancel by
calling me the day before. I
understand there are things
that can get in the way of
attending, but it’d be easier
for me – and I think I could
give you better care -
because I could plan around
it.”

Once you have modeled

the skill, ask all family
members to make a
request of another family
member (or of you) and then role-play the skill in pairs. As with the other skills,
praise all members of the family for their efforts, and provide feedback to each family
member to make sure the skill is being performed correctly. If you are working with an
unusually large family, it may make sense to break into pairs of two and ask different
pairs to practice simultaneously.

Once the family has practiced this skill for a while, you can introduce some variety into
the work. Ask the family to think about phrases that they hear a lot around the house.

For example,
Between siblings:
“Stop being such a pain;”
“Don’t touch my stuff.”

From parents to youth:

“How can you live in that room of yours, it’s so gross?”
“Why are you watching TV when you have homework to do?”
“What are your dishes still doing in the living room?”

From youth to parents:

78
“Get off my case.”
“I took out the garbage yesterday, it’s Karla’s (sister’s) turn today.”
“I’ll walk the dog later…..why are you always nagging me?”

Next, how could each of these statements be rephrased so that they are expressed as
positive requests for change? Ask them to role-play these new approaches to
communication. Remember to coach the family member through these exercises.
Examples of how we’d like them to express the above might include:

“I’d really appreciate it if you’d ask me first if you want to borrow my clothes. It
would make me want to share them with you more often.”

“I’d appreciate your getting your homework done before you watch another TV
program That way, I wouldn’t have to worry about whether it’s getting done.”

“Sometimes I’m in the middle of something when you ask me to do a chore. I’d
appreciate our working out a time interval when these things are supposed to
get done. That way I’d feel like I have some control over my free time.”

Summarizing Positive Request Skill

Ask each member of the family to discuss the usefulness of the Positive Request skill.
Some skills are more useful to one family member than another. Ask the family to
practice making positive requests over the next week and to track their efforts on the
“Communication Skills Assignment” (Handout 16).

Teach Skill: Communication Clarity

Throughout treatment the clinician may have encouraged family members to use
concrete and brief statements instead of abstract and lengthy statements (see the
example of Ben and his father, above). The goal of ‘Communication Clarity’ is to help
the IP or family members stay on track and direct their statements toward the goal of
sharing a topic of conversation.

Provide the family with Handout #18, “Communication Clarity.” Go through and
explain the purpose of each item.

79
 Figure out what you want to say:
Getting to the main point quickly
will result in fewer
misunderstandings. Organize your
thinking so that you communicate
the most important points.
Oftentimes we can get caught up in
providing too much detail and our
point can get lost.

Use short sentences to highlight

the main points: Short
statements are easier to
understand and respond to than
lengthier statements.

Be specific rather than abstract:

Using language that is specific is
less confusing than abstract and/or
general statements. For instance,
making the statement, “I noticed
you have been spending more time
alone lately, is there something
wrong?” is a clearer statement than
“What’s wrong with you? You seem
to be in the clouds lately.”

Bring up one topic at a time: Attempting to discuss many topics at once can be
confusing and overwhelming. For instance, making the statements “You have been
sleeping constantly, I don’t think you’ve been taking your meds, and you haven’t been
spending time with your friends,” could be overwhelming. Instead, it would be more
effective to prioritize and convey one point at a time, such as, “I’ve noticed that you
have not taken your medications for the past 2 days and I want to talk with you about
it.” Leave the other issues for another time.

Once you have reviewed the handout; it’s time to practice. Ask family members to
think of one problem they would like to discuss. Ask them to take turns in the speaker
and listener roles with any additional family members serving as observers to coach
the speaker. Ask the speaker to try to follow the guidelines and to discuss the one
problem he/she has selected briefly, getting to the main points and then stopping.

Ask the observers to comment on whether the speaker followed the guidelines on the
handout, and ask the family members to change roles and continue practicing.

Below is a case example of a possible scenario in which the clinician could intervene
and educate the family regarding the importance of more focused communication.

Case Examples

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During sessions the clinician noticed that Anthony, a 15 year-old, was having difficulty
getting his point across and appeared confused. During today’s session Maria,
Anthony’s mother, tried to help Anthony by explaining what had been covered so far in
the session, “Anthony, we are talking about how to get better at communicating and
(Ms. Alvarez, the clinician) wants to know what we are doing now. I think it would be
better if you shared more.” Anthony asked her what she meant. Mark, Anthony’s
father, stated, “It’s not that difficult, we just want to hear from you more.” The clinician
intervened and suggested that Maria and Mark provide more specific, concrete,
requests for what they mean by “sharing more” or “hearing from you more.” Anthony’s
parents tried again and stated, “We want you to talk with us if you are having a bad
day and tell us how we can help.” Anthony, responded, “Well sometimes it’s hard to
talk about things, but I’ll try.” Anthony was able to follow the content being discussed
once it was presented in a brief and specific manner.

Dusty, a 14-year old, very strongly believed that she had bipolar disorder, even though
her diagnostic evaluation suggested that she had major depression (with mood
instability) but not bipolar disorder. During the communication clarity task, Dusty
chose to tell her father how hard it was to focus “when I’m manic, which is like, all the
time.” In explaining this state, she illustrated jumped from one topic to another, and
spoke in vague generalities such as “when I’m elated, my mind is really, like, stylin’,
and I have so many ideas and I want to get them all out.” The clinician asked her to
explain the same issue to her father in one sentence. She had considerable trouble at
first, and then questioned why she should have to do this: “My parents say they want
to know what’s going on with me, so why should I short-cut it?”

After much coaching, Dusty was able to pare down her explanation to, “Dad,
sometimes my mind gets all frenzied and I can’t focus. When I do that you should
slow me down by signaling me or something, or tell me to take a breath. I promise I
won’t get mad.” The clinician gave her much positive encouragement for following
through with the task, and she admitted that, at least for this issue, it had helped her
focus.

Introduce Communication Skills #5: Expressing Negative Feelings About

Specific Behaviors

There is one more communication skill to learn - expressing negative feelings about
specific behaviors- which can be difficult for people because it involves negative
emotional content. This skill sets you up to transition into the problem-solving module.
“Negative Feelings” can be introduced toward the end of session 8 or the beginning of
session 9, depending on whether you think the family is ready for discussing more
affectively-laden topics.

In many ways, expressing negative feelings is the most difficult skill to learn because it
involves delivering an unpleasant message. Specifically, it is a way to give another
family member constructive criticism about his or her behavior. Family members
need to express their frustration with each other from time to time and may not have a
productive forum for sharing this type of feedback. This skill offers family members a
useful alternative when positive requests have been ineffective. Explain to the family
that expressing negative feelings is a recommended step only as a last resort if other
attempts (i.e., positive requests) have failed. But criticism in any form is difficult to
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accept. Given that it can stir up disagreement, the expressing negative feedback skill
should be used as a segue into problem solving.

Pass out Handout 19, “Expressing Negative

Feelings about Specific Behaviors,” and
introduce the skill:

“What do you do if you’ve made a positive request

for change and you don’t feel that anything has
been accomplished? The final communication skill
we want to teach you to is ‘expressing negative
feelings about specific behaviors.’ It is useful when
someone is doing something that bugs you, and
you want that person to stop or to do it differently.
Our handout shows you one way to do this. When
someone is doing something that bothers you, look
at the person, say exactly what he or she did that
upset you, how it made you feel, and suggest a
way he or she could prevent it from happening in
the future.”

As with the other skills, facilitate a role-play with a family member. To alleviate the IP’s
concern that he or she will be the primary target of negative messages, structure the
first role-play so that family members practice as if they were speaking to someone
outside of the family. Often, adolescents feel that they are a continual target of
parental disapproval. The example of Kevin (inset), a 16-year old with bipolar I
disorder, illustrates the initial role-play of this skill.

“Don’t Copy my Homework”

CLINICIAN: Kevin, tell me about something that someone you know, other than your
parents, does that really bothers you.
KEVIN: A friend of mine has been asking to copy off of my school work. It really
pisses me off. He’s like… whatever.
CLINICIAN: What bothers you about it?
KEVIN: He’s like, a moocher. He always wants something, like your homework, or
your money, or food, whatever.
CLINICIAN: So, what do you think you could you say to your friend?
KEVIN: Nothing. I don’t want him to stop hanging out with me but I don’t wanna hand
him my homework either cause I could get in trouble.
CLINICIAN: I understand. Well, that’s a hard one. How do you think he would respond
if you said, “(Name of friend), you’ve been asking to copy some of my work. I
know you’ve been having a hard time with some of the assignments, but I don’t
want to get in trouble if we get caught. It makes me uncomfortable to say this
‘cause you’re my friend.” What do you think he would say? (Clinician models
skill);
KEVIN: (thinks) It was pretty long, and I think he might get ticked off, but I don’t know.
It might work.

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CLINICIAN: Well, you know, those were just my words. Maybe there are better ways
to say it. Why don’t you pretend I’m your friend and say it the way you’d do it?
KEVIN (thinking): Um, Nate, I am not down with you copying off of me anymore. I want
to help you out but I so don’t want to get in trouble again. How about we hang
out and I can show you how to do some of the stuff for class or something.
CLINICIAN: That’s a really good effort, Kevin. Richard (father), how did you like the
way Ben just said that? What else do you think he could say?

The example of Ben (inset) also illustrates the initial role-play of this skill.

Call on Me!

CLINICIAN: Ben, tell me a behavior that either a teacher or kid at school does
that really bugs you.
BEN: Well I hate it when I have had my hand raised forever and the teacher
doesn’t call on me and keeps calling on the same nerdy kids over and
over again. I told him about it before and he just ignores me.
CLINICIAN: So, what do you think you could you say to your teacher?
BEN: Nothing, I’d be scared that he would take it out on me when he was
grading my next test.
CLINICIAN: Well, how do you think he would respond if you said after class,
“Mr. _____, I often raise my hand in class and you don’t call on me. I
know there’s lots of kids who want to talk but it kind of hurts my feelings.
What should I do differently when I think I have the answer?” What do
you think he would say?
BEN: I think he’d be blown away, none of the kids ever talk to him that way,
they usually just complain behind his back or are obnoxious in class.
But I don’t know.
CLINICIAN: Why don’t you pretend I’m your teacher and say it the way you’d
do it?
BEN (thinking): Um, Mr. _________, could you call on me more? Sometimes I
have the answer but you always call on Jeff or Karen.
CLINICIAN: That’s a real good start, Ben. Richard (father), what else do you
think Ben could say?

Once you feel that family members understand the skill, ask them to practice
with each other. Start with problems that seem to be at the forefront of their
minds (e.g., disagreements over homework or screen time) but that they
haven’t made much traction in solving. Make sure that the IP has an experience
with being both speaker and listener. Again, the recipient of negative feelings is
not obligated to change their behavior in response to this expression.

Handout 20, the “Expressing Negative Feelings About Specific

Behaviors” Assignment, is given to the family once each member has

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practiced the skill. Ask family members to practice it in the upcoming week (if
relevant in their day-to-day lives) and record their efforts on the form.

Summarize the Skills

In this final session of
communication training, the family
may be asked to role-play each skill
one final time, to make sure that the
skills have been retained and are
being used correctly. After the skills
have been practiced, ask each
member of the family to discuss
which skill was the most useful to
their family.
One mother said that Active
Listening was the most helpful skill
because she often did not know (a) whether her son was listening and (b)
whether he understood what she was trying to say to him. She admitted that
she sometimes spoke abstractly. His learning to paraphrase made her more
certain that he was comprehending her, and also reminded her when she
needed to be clearer.
After this discussion, the clinician moves to the problem solving module.
He or she reminds the family periodically that they should continue to practice
the skills, given that they will be using them to discuss family problems in the
upcoming sessions.

Ending Session 8:
Assign a Practice, Answer Questions, and Plan for Next Session
Ask the family to practice communication clarity and expressing negative feelings over
the next week, and track their efforts on the “Communication Skills Assignment”
(Handout 16) and the “Expressing Negative Feelings about Specific Behaviors” (20)
chart.

Ask the family if there are other communication skills that they think would be useful to
learn. Dusty’s parents mentioned that they wanted the atmosphere at home to be
“lighter”; everyone took things too seriously. The clinician spent some time talking
about ways they might introduce more levity into their family meetings, or how, during
the skill practices, they could allow more spontaneity. For example, all of their
meetings had been held in the living room; could they switch rooms or hold one
meeting outside? Dusty was asked to choose a music CD to play in the background
while the family talked and practiced.

Remind the family that session 9 will be in two weeks, not one.

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IV. PROBLEM-SOLVING SESSIONS (Sessions 9-12)

Session 9:
Introduce Problem-Solving Skills

1. Joining/Check In

2. Review homework (mood charts; relevant communication skills

assignments)

3. Review Skill #5: Expressing Negative Feelings about Specific Behaviors (if

necessary)

4. Review the Prevention Action Plan (if needed)

4. Introduce Problem-Solving Skills

5. Assign Homework (Mood chart; Family meeting focused on Problem-Solving

(handout 22))

6. Plan for the Next Session; Joining/Closing

Handouts Needed:
 19 (Expressing Negative Feelings About Specific Behaviors),
 20 (Expressing Negative Feelings About Specific Behaviors Assignment)
 21 (Solving Problems)
 22 (Problem Solving Worksheet)

Review Practice
Ask the family whether they completed the Communication Skills assignments above,
and if they did, what they observed about their interactions.

 Was it hard for people to make clear specific positive requests during the
week? This is a skill that takes some thought and some practice. How did it
go? Did the requestor get more cooperation when making the effort to phrase
things this way?

 Did anyone try to communicate more succinctly? Did anyone else notice?

 Were they able to express negative feelings when specific situations came up?
What difficulties were encountered?

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  If necessary, explore with them the reasons they did not complete the
assignment (see above).

Rehearse Expressing Negative Feelings

Spend the first 10-15 minutes going through Expressing Negative Feelings (or other
skills taught in session 8 that you feel have not been fully processed). Consider this
vignette:

**********************************
“A Bicycle Built for One”

Derek, a 21 year old, had a difficult yet highly dependent relationship with his wife,
Gabrielle. He complained about her behavior frequently, but his complaints were
vague (e.g., “She’s not there for me”).

Clinician: Derek, would you go over again what bothered you, only follow the steps on
the handout involving expressing negative feelings? Turn toward Gabrielle and tell her
what she did that displeased you, how it made you feel, and what you would like her to
do differently in the future. Try to be as specific as you can.

Derek: Well, Gabrielle, I was really hurting at the end of that race, I was waiting for
water or Gatorade or something. I was mad because, just like last time, you weren’t
there at the end.

Clinician: OK, anything else about how you felt? Or what she could do differently?

Derek: Just annoyed. Not like burning angry or anything.

Clinician (pauses, waits to see if there is more content): OK, Gabrielle, can you say
how you felt being the listener?

Gabrielle (tearing up): It sucked.

Clinician: Can you tell him what sucked about it?

Gabrielle (gathering herself): I know I let you down, but you don’t have to get all wiggy
about it. And like it says on the sheet, tell me what you want me to do next time, not
just what I did wrong.

Derek: Isn’t that obvious? Bring me some water!

Gabrielle: No, it’s not that obvious. I didn’t know whether I was on the right street or
when you would come across that point. Plus there’s like a million bicycles going by.

Derek: I don’t mean you should’ve run out into the street and handed me water while I
cycled by. I meant meet me at the end.

Clinician: Derek, can you be more specific about what she might do next time?

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Derek: Well, any number of things, like come earlier, or get to the end at the same time
as me. And … after the race while I’m rehydrating maybe we could spend a few
minutes together.

Clinician: Ok, could you try it again, only this time try to get all the components in, like
what exactly Gabrielle could do differently, and why it’s important to you?

Derek: Gabrielle, I was really hurting at the end of that race, I was waiting for water,
and you never arrived. Do you think you could get there earlier next time and wait ‘till I
get to the finish line?

Clinician: Good. Gabrielle, what was your reaction this time? Was it useful feedback?
Gabrielle: Yeah, that was better. To be honest, even though I got defensive before, I
kind of felt bad about leaving him hanging like that.
***************************

It’s best to have each dyadic pair practice expressing a negative feeling to each other
at least once, with coaching from you and the other family members. Knowing how to
deliver constructive criticism – either through making a positive request or
expressing a negative feeling, followed by problem-solving – is key in the
changes we hope to achieve in high expressed emotion families.

Introduce Problem Solving Skills

When family problem solving (Clarkin & Miklowitz, 1997) is conducted with adults, the
focus is on collaboration. However, teens (and sometimes, young adults) do not
necessarily have equal say in the decisions that get made in a family. It may be more
appropriate for the parent to come up with two or three choices for the IP, and then
allow the patient to help decide which choice seems to be the most appropriate. This
may be a particularly important adjustment for younger people who sometimes believe
that they are their parents’ equals if not their parents’ superiors. When parents try to
assert their authority over their sons/daughters, the kid feels a strong need to resist,
fearing domination.

It may be necessary to build in a reward and/or consequence system to ensure follow-

through once a solution has been chosen, but only if the reward is developmentally
appropriate. The rewards for a younger adolescent (e.g., access to a cell phone,
computer time) will not be the same as for a late adolescent (use of the car, money,
curfew times). Young adults may not be responsive to rewards from their parents at
all.

The purpose of the problem-solving sessions is to reduce the family distress and
tension that develops in response to life events, including the ups and downs of living
with a son/daughter with functional impairment and distressing symptoms. Other
objectives are to (1) open up a dialogue in the family about difficult problem topics, (2)
allow a forum for expressing reactions to the issues raised and (3) offer youth and
family members a framework for solving problems. The first step is to offer the family a
rationale for problem solving.

“Up until now we have been talking about how you communicate or talk with
each other. Now we would like to look at some of the problems you’ve
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 described and work together to solve them. We are going to teach you a
model for working as a team.”

Provide the family with Handout 21 entitled Solving Problems.

“We think of problem solving as having several

steps. These steps are a little like what we do in
our heads automatically, but there are some tricks
to doing it as a family that make it go better. First,
you need to define the problem, which means
identifying what the problem is and agreeing on it.
In this step you’ll use a lot of active listening
because different people often have different ideas
about what the problem is. The more specific you
can be about defining the problem, the better.
Next, give as many different solutions as you can
think of – what we call ‘brainstorming’. Then
together you decide what the advantages and
disadvantages (or pluses and minuses) are. Then
you pick one or more solutions that you think will
work and decide when and how you will put these
solutions into practice.”

If time permits, ask the family to begin listing potential problems to be addressed with
the Problem-Solving Skills in the upcoming sessions.

Assign Homework, Answer Questions, and Plan for Next Session

Remind the family to practice expressing negative feelings over the next week and to
track their efforts on the “Expressing Negative Feelings About Specific Behaviors”
assignment (Handout 20). Spend some time summarizing and reflecting upon the
importance of this communication skill.

This is also a good time to check in with the family about the IP’s prevention plan. Has
there been any opportunity to use it? Have any early warning signs emerged? Do
they want to add anything to it? Make sure they are aware that they have a plan in
case the IP’s symptoms get worse, and that they now have some communication skills
to go with it.

Remind the family that session 10 will be in two weeks, not one.

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 Sessions 10-12: Problem-Solving Skills Practice;
Treatment Termination

1. Joining/Check In

2. Review homework (mood charts; expressing negative feelings assignment or

problem-solving assignments, as appropriate)

3. Identify a specific problem for problem solving

4. Complete problem-solving steps (repeat in each session)

5. Termination tasks (as appropriate):

 Review skills learned

 Ask family members to reflect on therapy

6. Assign Homework (mood charts; problem-solving steps)

7. Plan for the next session; Joining/Closing

Handouts Needed:
 21 (Solving Problems)
 22 (Problem Solving Worksheet)

Review Homework
How did the communication assignments go? Did they have opportunities to express
negative feelings about specific behaviors? What did they notice while practicing the
skill? How have they been doing with using the other communication skills at home
(active listening, communication clarity, etc.).

Problem-Solving Skills
Review the steps in problem solving for the family (Handout 21), which were
introduced at the end of the last session. Help them identify a practice problem.
Summarize some of the goals the family stated at the beginning of treatment. Do they
feel that each goal has been met or should it be on the agenda for problem solving?
Invite the IP and family members to list additional issues that may be more pressing.
For example, the youth may not have been in school at the beginning of FFT, but may
be planning to go back for the next semester and needs help in planning her schedule.

As with communication training, problem solving works best when simple,

relatively nonconflictual problems are chosen as illustrations first, saving the
more difficult problems for when the parents and IPs have some mastery over
the skill. Guide the family to start with more simple problems since even the simplest
problem may be the “tip of the iceberg.” A more central, global conflict may be
underneath the surface. Of course, use your clinical skills in choosing problems and
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guiding the family through the problem-solving process. If your instinct is telling you
that a certain problem is too “hot” to illustrate the problem-solving technique, you are
probably correct.

As was true in communication training, your role in problem solving is that of an active
facilitator or coach. Guide the family through the problem-solving steps, keeping them
on task and consistently praising them for their efforts, no matter how small. It is
helpful to point out to families the importance of using the communication skills when
defining problems or evaluating advantages and disadvantages (e.g., practicing
positive requests while generating solutions). Recommend that families try the
problem-solving format (below) on their own at home as an exercise between
sessions.

Often, in the midst of brainstorming it becomes apparent that the family has not agreed
on the definition of the problem. Rather than forging ahead with generating solutions,
return to active listening so that a clearer and more specific understanding of the
problem can be achieved. Elicit the different perspectives that family members hold on
how to define it. If necessary, facilitate the transition back to defining the problem by
owning the mistake: “Looks like I jumped ahead too quickly in encouraging you to
throw out solutions before I fully understood what the problem was. Let’s go back to
defining it.”

The Format of Problem Solving

Working through a specific problem is aided by the introduction of the “Problem
Solving Worksheet” (Handout 22, two pages). Whether using the worksheet or an
easel or whiteboard, help the family generate a problem definition, several proposed
solutions, advantages and disadvantages of each, and implementation strategies;
record each step on paper.

If you have a problem ready to submit to this method, choose one member of the
family as the “secretary.” That is, one person writes down what everyone else has
said and tries to keep everyone on task. Usually, this is done by the IP (who may
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relish his/her role as the one who organizes the family’s work on this task). But you
can also encourage a parent who hasn’t said much, or a quiet sibling.

Once the family has solved a couple of problems in the sessions, ask them to take
another small, specific problem and work on it outside of the session. If it seems like
the process is not fully within their grasp, ask them to take a specific part of the
problem-solving process (e.g., brainstorming and evaluating solutions) to work on at
home after defining the problem in the session. Encourage the family to implement
one problem solving session on their own between sessions, using the Problem
Solving Worksheet to record their efforts.

Transitioning from one Problem-Solving Session to the Next

Start off every session by asking how the problem-solving went (or whether they had
an opportunity to practice new communication skills, such as expressing negative
feelings). Ask to see any completed communication or problem-solving skill forms.

Be creative in how you integrate communication with problem-solving skills. For

example, the family may be having a hard time defining the problem because one
member is long-winded; this is an opportunity to practice communication clarity (“OK,
let’s talk one at a time, and try to keep your suggestions to a single sentence that
_____ can write down on the form”).

Recall that you are now meeting biweekly. When switching to biweekly sessions it is
important to explain to the family that fewer sessions can help them implement the
skills in their natural world.

Consider how to address the following: many events have occurred between the
current session and the last, but there has been little effort to utilize the problem-
solving skills. Keep emphasizing to the family that most of the work needs to be done
outside of the session during these final phases. The sessions should be seen as
“booster sessions” or “tune-ups” regarding use of the problem-solving skills (and where
relevant, the communication skills) and a chance to help the family get out of
intractable conflicts that the members have felt incapable of solving. Try to get through
one full problem-solving task, from problem definition to solution implementation, in
each of the final sessions. Continue to integrate education, communication skills, and
problem solving depending on what the family brings into each session.

Typically, the therapist is most central in structuring and directing the problem solving
process when introducing it to the family, but it is important to take a less active role
over time and ask family members to lead the family through the various steps of
problem-solving. Coach them to develop a well-articulated and feasible action plan by
the end of the session.

Troubleshooting Use of the Skills

It is not uncommon for a family member to complain that he or she is practicing the
skills and trying to implement them into daily life, but others don’t seem to be doing so.
In sessions 10-12 (if not sooner), check in with family members about how they are
doing with implementing stress management, communication, and problem-solving
skills in their daily lives. If they are struggling with these, it may be helpful to have a
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problem-solving discussion on this topic. How can family members implement the
skills they have learned in therapy into their daily lives?

Termination
During the final sessions, discuss the family’s reactions to the therapy. Ask questions
of the form, What did you like/not like about the treatment? How was it helpful? How
could it have been more helpful? What was your reaction to the education? The
communication training? The problem solving? If we were to do the program with you
all over again, what would you want to do differently? The issues described in the box
below can guide the questions you pose to them.

You can also communicate your own reaction to working with the family. Underline the
progress the IP and family have made (if this is the case) and express optimism about
the future. Encourage each member of the family to express their feelings, positive or
negative, about treatment ending. Keep in mind that if the patient or one or more family
members is “happy we’re done,” this may be a good thing and indicative of growth.

Issues to Explore in the Final Sessions

Has the IP and parents made sense of their experiences of mood or psychotic
disorder? Do they agree on what the symptoms and prodromal signs of episodes
are?

Have they come to accept the notion of recurrence and vulnerability to future
episodes?

Are they on the same page about the IP’s need for medications?

Do the parents and IP have a clearer idea of what consititutes the illness and
what are his or her personality attributes?

What have they learned about stress and how to cope with it?

How has their family communication and problem-solving changed? How can
they keep from “sliding back” into old habits?

Discuss the family’s transition out of FFT and about their ongoing commitment to
treatment (and, if relevant, research). If they want to continue with therapy, talk with
them about treatment options either at your clinic or in the community .

Good luck in your implementation of FFT!

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 V. OPTIONAL TREATMENT EXERCISES

Optional Topic 1: School Accommodations

If the youth has a history of academic difficulties, you may wonder whether he has a
learning disability. Or, the striking social and emotional problems and perhaps nearly
psychotic symptoms that are exacerbated by school attendance may point to the
importance of making changes in the school context. The family may not know that
there are many services the youth can obtain through the public school system, and
many changes that can be made within each classroom to support the youths’
functioning.

The optional handout entitled “How the School

Can Help” is very useful in educating families
about what they can expect from the schools in
general terms (for example, the right to learn within
the least restrictive environment; the notion that
school accommodations can serve to create a less
stressful environment for the youth). This form is a
useful tool for helping the therapist to focus family
discussion on what is working well in the school
environment and what may not be working well and
require intervention.

Ask all members of the family to participate in the

discussion with the eventual goal of generating a
list of issues and a plan for addressing those
issues with the school. Ideally, the family should
be supported in taking responsibility for setting up
meetings with teachers, and/or the school
counselor and/or the school psychologist. It is important that the family has control
over the amount of information they feel comfortable sharing with the school. They
may want to talk about the best way to phrase requests and about how much
information is necessary to share within the school context to get the services that they
need. Communicating with school officials is an ideal time for the parents to practice
their communication skills!

Optional Topic 2: Relaxation Training

The goal in this lesson is to teach the IP and his/her family a behavioral technique that
they can use to reduce anxiety in a variety of situations. We tend to use an
abbreviated form of the “relaxation via tension-relaxation” technique described In
Goldfried, M. R. and Davison, G. C. (1976) in their book entitled Clinical Behavior
Therapy on pages 88 –89. Family members are told that after some practice, this is a
technique that they can use inconspicuously in class, at work, or when out with friends.
Usually we introduce the technique and help them to tense and relax several muscle
groups, but do not go through all of the muscle groups described in the text.

For example, we instruct family members to sit back and relax and to close their eyes
if they feel comfortable doing so. We then read the following from the Goldfried and
Davison text:
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“Direct your attention to your left hand. I’d like you to make a fist with your left hand
and to squeeze that fist tightly. Study the tension in your left hand and arm (5 second
pause). Now relax the left hand and let it rest. Notice the difference between the
tension and the relaxation (5 second pause). Now squeeze your left hand into a fist
again, tightly, and notice the tensions in your hand and arm. Study those tensions (5
second pause), and now let go. Let your fingers spread out and relax. Notice the
difference between tension and relaxation.

Now let’s do the same thing with the right hand. Repeat the steps above with the right
hand. Then invite the family to take note of the difference once again between the
tension and the relaxation and enjoy the contrast.

Now clench both your hands into fists and bring them towards your shoulders. Feel the
tension in your arm and shoulder muscles (pause 5 seconds). Now relax. Let your
arms drop down to your sides, and notice the difference between the tension that was
in your arms and the relative relaxation that you feel now (5 second pause). Let’s do
that once again now. Clench both hands and bring them up toward your shoulders,
trying to touch your shoulders with your fists. Study that tension. Hold it. Study it.
And now relax. Once again, let the arms drop and study the feelings of relaxation, the
contrast between tension and relaxation. Just keep letting go of those muscles further
and further (5 second pause).

Now we can direct our attention to the shoulder area. Shrug your shoulders, bringing
both shoulders up toward your ears, as if you wanted to touch your ears with your
shoulders. And note the tension in your shoulders and up in your neck. Study that
tension. Hold it. And now relax. Let both shoulders return to a resting position. Just
keep letting go further and further. Once again, note the contrast between the tension
and the relaxation that’s now spreading into your shoulder areas (5 second pause).
Do that once again. Bring both shoulders up as if to touch the ears. Feel the tension
in the shoulders, in the upper back, in the neck. Study the tension in these muscles.
And now relax. Loosen those muscles. Let your shoulders come down to a resting
position, and study the contrast once again between the tension and the relaxation (5
seconds).”

After this introduction, the IP may be better able to “tune in” to his/her body and
describe what muscles they tend to clench when stressed. Then, those particular
muscle groups can be targeted in further work. For example, if one adolescent says
that he/she tends to furrow his/her brow, the family can practice wrinkling up their
foreheads, creating tension in their foreheads, and then relaxing their foreheads. The
therapist should continue tailoring the relaxation exercise to the habits/tendencies of
the participants.

If some family members have difficulty falling asleep at night, they could try this muscle
tension/relaxation technique, starting with the top of their head and working their way
down to their toes, briefly tensing and relaxing all of the various muscle groups in their
face, neck, shoulders, arms, stomach, back, legs, and feet. This type of focused
relaxation may help them to calm their bodies and minds down enough to fall asleep.

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Relaxation techniques may be particularly useful for people who experience
distressing positive symptoms, such as perceptual abnormalities or paranoia.
Relaxation techniques may help them to refocus their attention.

Optional Topic 3: Social Skills Enhancement

It is useful to start out this section by checking in with the youth and asking about
his/her level of social functioning. You can say something like the following:

Clinician: Sara, I know in the first session you mentioned that you have not
been spending much time with friends because you ‘haven’t felt like
it.’ What’s it like for you when you are around your peers at school?

Sara: I don’t know. I guess I’ve noticed that this whole school year I’ve just
felt kind of awkward around people, like I don’t know what to say. I
get nervous and worry that people are going to make fun of me. I
usually just spend time by myself when I’m at school.

Clinician: I’ve talked with many young adults) in our program who have said
the same thing; they don’t know what to say to people and they feel
nervous in social situations. Oftentimes this can be a stressful
experience since so much of our day-to-day lives take place in social
situations. Sara, if you are interested, I think it could be useful to talk
some more about this.

Sara: Okay, that’s fine with me.

Typically, it is difficult to figure out whether the patients we see in our program are
experiencing social functioning impairments because they lack social skills, suffer from
depression or negative symptoms, have some mild paranoia, have social anxiety and
related social avoidance, or have co-morbid Asperger’s or Pervasive Developmental
Disorder NOS. Despite the difficulty discerning what factors are influencing the youth’s
social impairment, it is a good idea to introduce the potential relationship between
symptoms and social functioning. For instance, you can explain that positive
symptoms, such as suspiciousness and/or odd beliefs, can cause the patient to be
ostracized or feel worried about taking social risks (e.g. meeting new people, initiating
social contact, entering into a conversation, etc.). Ideally, it is best to tailor this
discussion to the family you are working with. You can highlight the particular
symptoms that you believe could be impacting the youth’s functioning. Below is an
example of how you might initiate this conversation,

Clinician: Many of the people we see in our program talk about having a hard
time socially. Sometimes symptoms such as anxiety, depression, or
feeling suspicious can make it difficult to be in social situations.
Jonathan, have you noticed a change in your level of interest in
being social?

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 Jonathan: Well I don’t like to be around lots of people. It makes me nervous.

Clinician: Do you know what it is about being around people that makes you
nervous?

Jonathan: I guess I think that people are talking about me. I know that sounds
stupid since they probably aren’t, but I still worry about it.

Clinician: I don’t think that sounds stupid. It is actually really common for many
of the young people we see in our program to have suspicious
thoughts and to feel nervous around people. If you could learn
strategies to make yourself feel more comfortable in social situation,
do you think you would be more interested in being around people?

Jonathan: Yes, but it’s hard to imagine not feeling nervous.

Clinician: Well perhaps we can spend some time talking about what kinds of
goals you have in regards to being social. For instance, do you want
to learn strategies to identify people that might be kind and
supportive friends? Or would you like to brush up on some
conversation starting skills? I bet your parents might have some
ideas too.

Identifying Goals for Enhancing Social Skills

At this point in the session many concerns about social functioning might have already
been brought up. You should draw from some of those concerns and facilitate a
discussion aimed at defining the specific goals you plan to work on during the session.
Examples could include,

1. I want to meet some new people.

2. I want to learn how to start a conversation with a new person.
3. I want to feel more comfortable in social situations.

You should write down some of the goals on a piece of paper with 2 columns (1 for
goals and the other for social skills strategies). If the IP is having trouble generating
ideas for particular goals you can offer up some of the above examples as common
goals that individuals like to work on.

Develop and Practice Social Skills

Once you have listed about 3-4 goals you can work with the family to generate ideas to
help develop social skills and coping strategies. It is a good idea to work through each
goal one at a time.

Here is an example of working on the goal of learning how to initiate a conversation

with a new person: Turn to the parent and ask,

“_______(mother’s name), how do you typically start a conversation with

someone new?”
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Write down some of her ideas. You can ask for more ideas from other family members.
Be sure to create an idea-friendly atmosphere by not being too quick to criticize the
suggestions. You can also add some ideas of your own once the family members have
listed a number of suggestions.

Once you have listed a few strategies, it is a good idea to role-play some of them. It is
normal for individuals to feel awkward and/or feel resistant to role-playing at first. Try
turning to the IP and ask if he/she would be willing to practice some of the strategies
with you. If he/she seems uncomfortable you can have one of the parents role-play the
strategy with you first. Once a strategy has been practiced, you can encourage the
patient to try it out with the person of their choice in the room.

If a goal is not conducive to role-playing that is fine. An example of a goal that might
not warrant a role-play, at least initially, is if the IP stated that she wants to meet new
people but she does not know how to go about finding someone to talk to. A good
strategy for tackling this goal is to encourage the IP to identify her interests (music,
videogames, skateboarding, etc). Next you can ask for ideas about where to find
someone who shares those interests (e.g. music store, school club, skate park, etc).
Once you have generated some ideas about where to find potential friends, you can
ask the IP if he/she knows how to initiate a conversation with someone new. If he/she
is uncertain about how to do that, then you can move on to a role play exercise.

97
 VI. REFERENCES

Amenson, C., Schizophrenia: A Family Education Curriculum, Pacific Clinics, 1998.

Caspi, A. (2003). Influence of life stress on depression: Moderation by a polymorphism

in the 5-HTT gene. Science, 301(5631), 386-389.

Clarkin, J. F., & Miklowitz, D. J. (1997). Marital and family communication difficulties.
In T. A. Widiger, A. J. Frances, H. A. Pincus, R. Ross, M. B. First, & W. Davis
(Eds.), DSM-IV sourcebook (Vol. 3, pp. 631-672). Washington, D. C.: American
Psychiatric Association.

Greene, R. (1998). The explosive child. NY: Guilford.

Goldfried, M R. (1976). Clinical behavior therapy New York: Holt Rinehart and
Winston. Inc.

McFarlane, W R. (2002). Multifamily groups in the treatment of severe psychiatric

disorders.. New York, NY, US: Guilford Press.

Mueser, K.T., Gingerich, S. (1994). Coping With Schisophrenia: A Guide for Families.
Oakland, CA, US: New Harbinger Publications.

Miklowitz, D. J. & George, E. L. (2004). Treatment Manual for the Family-Focused

Therapy of Adolescents with Bipolar Disorder (FFT-A). University of Colorado,
Boulder.

Miklowitz, D. J. (2010). Bipolar Disorder: A Family-Focused Treatment Approach, 2nd

Ed. New York: Guilford Press.

Papolos, D. F., & Papolos, J. (2000). The Bipolar Child: Broadway Books.

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 VII. TREATMENT SUPPLEMENTS

Supplement to Clinicians’ Treatment Manual for FFT-EOY

Comorbidity with Attention Deficit/Hyperactivity Disorder

Kim Gallelli, Ph.D.

Stanford University, CA

Elizabeth L. George, Ph.D.

University of Colorado at Boulder

David J. Miklowitz, Ph.D.

University of California, Los Angeles

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Attention Deficit/Hyperactivity Disorder and Bipolar Disorder

Attention Deficit/Hyperactivity Disorder (ADHD) and Bipolar Disorder (BD) share some
common symptoms such as hyperactivity, impulsivity, and inattention. However, these
symptoms vary in intensity, duration and often require different treatment approaches
depending upon the disorder they are associated with. ADHD primarily affects
attention and activity, with a mild presentation of mood variability, but the extremes of
“high” or “low” moods are generally not as extreme as in children with BD. A child with
BD tends to have extreme mood states—such as mania and depression--and may
also demonstrate much more aggression, irritability or uncontrollable rage in
conjunction with these mood states.

Often children with ADHD or BD need to learn how to slow down, focus, and organize
their thoughts and behaviors with the help of medication or behavioral treatments. In
addition to these skills, children at risk for BD need to learn how to manage extreme
mood shifts from destructive hypomania to severe depression with the help of more
aggressive medical and behavioral treatment.

ADHD is highly comorbid with pediatric BD (Faraone et al., 1997; Wozniak et al.,
1995). Recent research has suggested that the onset of childhood ADHD followed by
later BD development might be a certain subtype of early-onset BD (Chang et al.,
2003). ADHD, in combination with other factors such as a family history of mood
disorders, may be a risk factor for future development of BD. Therefore, it is extremely
important to identify the diagnostic criteria for ADHD as well as to delineate the
differences between the two disorders. Distinguishing between ADHD and prodromal
BD is crucial because there are extremely different medical and behavioral
interventions, different parenting techniques that are appropriate, and often great
differences in the course and outcome of each disorder.

What is ADHD?

The DSM-IV makes a distinction between three types of ADHD: a predominantly

hyperactive-impulsive type, a predominantly inattentive type, and a combined type.
The term attention-deficit/hyperactivity disorder (ADHD) is used to refer to all of the
subtypes.

According to the DSM-IV (1994) ADHD is a “persistent pattern of inattention and/or

hyperactivity-impulsivity that is more frequent and severe than is typically observed in
individuals at a comparable level of development … symptoms must have been
present before age 7 years, … impairment from the symptoms must be present in at
least two settings, … [and] there must be clear evidence of interference with
developmentally appropriate social, academic, or occupational functioning. The
symptoms of inattention include failure to give close attention to details or makes
careless mistakes in schoolwork, has difficulty sustaining attention in tasks or play
activities, doesn’t seem to listen when spoken to directly, doesn’t follow through on
instructions and fails to finish various tasks, has difficulty organizing tasks and
activities, avoids and/or dislikes tasks that require sustained mental effort, loses things
100
necessary for tasks, is easily distracted by extraneous stimuli, and is often forgetful in
daily activities.”

Hyperactivity-impulsivity is defined by “often fidgets with hands or feet, squirms in seat

and difficulty remaining seated, runs or climbs excessively or for adolescents a
persistent feeling of restlessness, difficulty playing or engaging in activities quietly,
appears “driven by a motor”, talks excessively, blurts out answers, difficulty waiting
turn, and often interrupts or intrudes on others.”

Barkley (2000) proposes that attention deficit without hyperactivity may actually be a
different disorder than the hyperactive-impulsive type and the combined type. Children
with attention deficit disorder without hyperactivity (ADD) appear to be more passive
and fearful than other children. They often appear more “spacey” or in a mental fog
and not attentive to what is going on in their environment. They appear to be lethargic,
sluggish, or slowmoving, wandering through life only half-attending to things around
them. They are likely to be quiet while working but that does not mean they are
attending in an effective manner and often make errors due to the inability to sift out
the relevant from the irrelevant material. On a positive note, these kids do not appear
as aggressive and have less trouble with their peer relations. Whereas kids with
ADHD show more problems with over-activity and impulsiveness, kids with ADD may
have more problems with memory, perceptual-motor speed, and the speed with which
the brain processes incoming information. Little is known about treatment for ADD
though some reports suggest that a lower dose of stimulant medication is useful.
However, research has shown that 30% or more of those with ADD do not respond at
all to stimulants, compared to fewer than 10% of those with ADHD (Barkley, 2000).

How are Bipolar Disorder and ADHD different?

As mentioned above, many children with BD often first present with ADHD, and it is
considered a risk factor for the development of a specific familial subtype of BD.
Therefore it is essential that we delineate how the common symptoms differ with each
illness.
 In children with ADHD, the symptoms of inattention, hyperactivity, and
impulsivity are always prevalent. These same symptoms seem to wax and
wane in children with BD depending upon their mood state.
 To obtain a diagnosis of ADHD, symptoms must onset before age 7.
When these symptoms onset later in childhood and adolescents, they are more
likely to be related to BD. However, a child with ADHD may experience a
worsening of symptoms later in life (usually closer to puberty). Although they
still have baseline problems with attention and behavior, these problems
escalate with more severity and duration.
 Children with ADHD may have problems with some mood swings, but they are
often less intense than children with BD. Children with ADHD do not display
the severely debilitating depressive as well as manic or euphoric features
exhibited in children with BD.
 The duration of outbursts and/or tantrums usually differ. Children with ADHD
may calm down within half an hour, whereas children with BD may rage for
hours.

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  Children with ADHD may be struggling in school and with peers but can often
manage with interventions, whereas many BD children are unable to attend
school and have minimal peer relationships.
 Children with BD typically engage in more risky, impulsive and dangerous
behaviors. ADHD kids may engage in dangerous behaviors, often unaware of
the dangers, whereas kids with BD can be extreme risk-takers. For example, a
kid with ADHD may leave school with friends and get in trouble for ditching. In
contrast, a 15 year old girl with bipolar disorder may be getting on the back of a
30 year olds’ motorcycle to spend the night drinking with him in the mountains.
 Children with BD tend to have early sexual interest and behavior.

Here are seven proposed criteria for differentiating ADHD from bipolar disorder (Lynn,
2000):
1) Are mood shifts moderate or extreme? Are they characterized by depression,
rage, or aggression?
2) Does the child have a first-degree family member diagnosed with bipolar or
unipolar mood disorders?
3) Is the child’s speech pressured, uninterruptible or hypomanic? Children with
ADHD may speak quickly or loudly, but they can often be refocused and
slowed down. Children with BD have little or no control over the propensity of
their speech.
4) What is the typical nature of the dangerous or risky behaviors that are
exhibited? The ADHD child often searches for stimulation in an impulsive
manner—reacting to environmental cues. The child with BD often seeks out
and engages in risk behaviors while being driven by enormous attention and
energy, with minimal sleep—often unable to attend to anything else. As
mentioned above, the nature of these risky behaviors are often more
destructive and potentially lifethreatening.
5) Does the child rage (bipolar disorder) or get angry (ADHD)?
6) Does the child appear psychotic—with auditory or visual hallucinations, or
unusual thoughts and beliefs? Does the child speak or tell stories that are
completely unintelligible and/or illogical? ADHD children can be silly and
creative and even tell tall tales, but tend not to have hallucinations, delusions,
or thought disorder.
7) Does the child show a decreased need for sleep—able to function well (often
like the “energizer bunny”) without fatigue with only a few hours of sleep?
ADHD children may be hyper or overactive during the day with multiple projects
and/or games started and uncompleted, but tend to have more regular sleep
habits.

Medication Issues

Typically, ADHD symptoms are successfully treated with medications referred to as

stimulants. Commonly prescribed stimulants are Ritalin and Concerta. Other
medications such as Strattera have also been used to treat ADHD. However
prescribing stimulants can be dangerous if the problematic symptoms are evident of
BD, instead of ADHD. Although there exists conflicting research, it has been
suggested that stimulants may trigger or exacerbate manic symptoms in children and
adolescents with BD. Also, antidepressants such as Selective Serotonin Reuptake
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Inhibitors (SSRIs) have been implicated as exacerbating or triggering mania in children
with BD, whereas they can be helpful in treating comorbid depressive symptoms in
children with ADHD. Proper medication management of symptoms in children requires
clinicians to thoroughly examine the nature of overlapping symptoms. However, in
those cases where BD and ADHD co-occur, stimulants may help the BD child after
his/her mood symptoms have been stabilized with other medications such as mood
stabilizers or antipsychotic medications.

Addressing ADHD within the Education Module of FFT-EOY

If it is apparent after the initial evaluation that the child has ADHD, the clinician reviews
the symptoms of ADHD with the family during the discussion of mood symptoms using
a handout of DSM-IV criteria. To delineate the differences between BD and ADHD the
clinician shares the table below. It is helpful for parents to understand the difference
between ADHD and BD given that ADHD is a suggested risk factor for BD. The family
should be quite clear when they are continuing to observe symptoms of ADHD and
when the illness has moved into a bipolar presentation.

Table for Psychoeducation Module

Differentiating between ADHD and Bipolar Behaviors and Characteristics
Bipolar ADHD

Extreme variability in mood Fairly consistent mood over time

Triggered by particular situations Consistent across situations
Mood may be effected by time of Consistent all year
year/season
Skills and functioning vary—even when Attention-concentration is key problem
focused
When anger or rage presents, often Supervision and guidance can help
cannot be redirected or soothed.
Can argue for hours Easily distracted, loses interest in fight
Unbelievable intensity/energy Energized, but not as intense
Pressured speech Talkative
Takes big risks/looks for danger or thrill Does not intend to get into big
trouble/eventually learns
Often does better at school Often does better at home
Medication is often unwanted/seen as Medication seen as a tool to help
the enemy functioning
Internally distracted Externally distracted
Self-destructive thoughts Low self-esteem
High energy /inappropriate giggling Normal laughing/fun
May be overly sexual Sexuality not major issue
Stimulants may exacerbate or trigger Stimulants improve symptoms
mania
Extreme anxiety fears Normal worries
Antidepressants may be harmful/trigger Antidepressants can help with
mania associated depressive symptoms

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 Symptoms worsen/ exacerbate with age Symptoms improve with age

Many times you will hear parents ask, “How do I know if this bad behavior is due to his
ADHD or to his mood disorder?” “Does the nature of the symptoms affect the way I
intervene with my child’s symptoms or problems?” Since the nature of the symptoms
does affect the way the parent may structure an effective intervention or coping
strategy, understanding the nature of symptoms is extremely helpful. Since ADHD
symptoms are often present before the onset of the more extreme mood symptoms it
is helpful to have the parent and child delineate the problems he/she had in
elementary school. Problems that may have occurred associated with ADHD might
include inability to concentrate, having to re-read chapters, and/or frequently getting
out of his/her seat in school. It is helpful for the parents to note how and when these
symptoms may have begun and worsened. For example, one child went from getting
out of her seat 3-4 times in class, to being unable to sit still at all with continual pacing.
Another example might be a mere difficulty in reading progressing to an inability to
complete schoolwork at all.

At this point in the education you can help the family decide if they want to chart ADHD
symptoms on a mood chart. The family may have a line to delineate ADHD symptoms
and mark an X when they have gotten worse or are causing significant difficulty in
functioning. Alternatively, the parents may want to rate the ADHD on a 1-5 scale with
1 being no symptoms/no behavioral problems and 5 being very symptomatic/extreme
behavioral issues. You and the family can decide how you want to chart ADHD
symptoms in addition to mood and this chart can be customized to each family. A
chart will help the parents with further delineation of mood versus ADHD symptoms
and evaluation of medication effectiveness for each condition.

In addition to listing symptomatic onsets and worsening, it is also important to establish

what the child’s baseline of functioning has been in regard to attentional, cognitive, and
impulsive capacities. Emphasizing the biological nature of ADHD and success of
medication and behavior interventions will lessen parent’s anxiety about their child’s
future academic and social functioning. However, parents will need to be wary of
significant worsening from baseline functioning and attend to the possible onset of a
mood disorder. Again, at this point it is helpful to review that if a mood disorder does
develop, exacerbation of symptoms will wax and wane from the child’s initial baseline
level of functioning.

Parents are also often concerned about the impact different medications can have on
their child’s mood. It will be important to educate parents about the efficacy of
stimulant treatment in authentic ADHD. However, if mood symptoms are developing,
treatment with stimulants may exacerbate the child’s mood symptoms and it is
possible that they will need to be temporarily removed from their stimulant medications
until the mood symptoms are under control with mood stabilizing medications.
Handout 8, Medications Commonly Used to Treat Mood Problems, will be
provided to address various classes of medications used for each disorder. Parents
will be encouraged to work collaboratively with their child’s physician when changes in
mood are detected.

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Addressing ADHD within the Communication Module

The communication module of FFT-EOY is designed to provide a neutral and

nonthreatening framework for discussing family issues. Communication training is the
first step to resolving problems that arise in the family. During the communication
skills module the family’s goal is to arrive at a better understanding of each person’s
position and feelings as they relate to a personal or family problem. Often, the
behavior of a child with ADHD can be extremely frustrating and disruptive to the entire
family. It is important to review that the child’s “bad” behaviors may indicate a
worsening or mismanagement of the illness. It is helpful to remind parents that the
child is not a bad child—just exhibiting some difficult behaviors. Also, the child needs
to be reminded that he can help control his behaviors with the help of parents and
doctors. The child should be taught to note any changes in feelings or behaviors and
communicate with parents about self-observations.

Barkley (2000) lists 14 guiding principles for managing ADHD that may be quite helpful
in managing mood disorder symptoms as well.
1. Give your child more immediate feedback and consequences.
2. Give your child more frequent feedback.
3. Use larger and more powerful consequences.
4. Use incentives before punishment (positives before negatives).
5. Externalize time and bridge time where necessary.
6. Externalize the important information at the point of performance.
7. Externalize the source of motivation at the point of performance.
8. Make thinking and problem solving more physical.
9. Strive for consistency.
10. Act,don’t yak!
11. Plan ahead for problem situations.
12. Keep a disability perspective.
13. Don’t personalize your child’s problems or disorder.
14. Practice forgiveness.

Many of these points are very similar to the principles of the communication skills
module in FFT-EOY. Specifically, the first skill taught, Expressing Positive Feedback
is a direct reflection of principle4 above (use incentives before punishment). We ask
the family to spend a week or two, depending on whether they are meeting weekly or
bi-weekly, catching each other doing positive things and giving positive feedback. It is
only after sufficiently spending time praising each other for positive behaviors that we
move to changing behaviors through positive requests and expressing negative
feelings about specific behaviors/problem-solving. Even during the portion of
communication that addresses changing specific behaviors, we begin with the positive
and then move to the negative.

Addressing ADHD within the Problem-Solving Module

The symptoms of ADHD can be distressing to both the child and the family. Most
likely, families will focus on the child’s poor academic and social functioning and cite
numerous examples of missed appointments, lost and broken items, and impulsive
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and self-destructive behaviors. As mentioned earlier it is important to have the child
note how she feels about these behaviors, which often induce feelings of shame, self-
doubt, and low self-worth. At this point in treatment, the clinician helps the child and
family to anticipate and respond better to problematic situations that will inevitably
occur.
Case Example. The mom of a 10-year old became extremely frustrated because the
child kept losing his coats and schoolbooks on the bus. There was a great deal of
yelling around this topic. The child also acknowledged that he was quite upset
because he most recently lost his “lucky” jacket. Also, he was getting upset because
of getting “incompletes” on his lost/missing homework assignments.

After briefly identifying feelings of all family members, the clinician helped the child to
generate several possible solutions. The child suggested putting his name and phone
number inside his clothing and books, and the mom suggested contacting the bus
company to get their address and number to retrieve lost items the same day. The
therapist suggested setting up a behavior management plan of rewards when the child
remembered to bring home his belongings each day. The child and parent decided
upon appropriate rewards. Also, the family was encouraged to examine whether
certain illness parameters related to these frequent occurrences. For example, the
child realized that by the end of the school day, his distractibility and inability to
concentrate worsened significantly. This required a consult with the child’s doctor to
shift the time of his medication administration.

In addition to aiding the family in problem solving around symptom management,

families often need time to discuss issues that have not gone well in the family in
general. For example, 16 year-old Melissa who had comorbid diagnoses of prodromal
BD and ADHD struggled with special occasions. Whether it was her birthday,
someone else’s birthday, Christmas, or any other occasion where presents were being
received, she had a “meltdown” and in the words of the other family members, “ruined
the time for all”. We decided to address the problem by going through the problem
solving worksheet and coming up with various solutions the family could use for the
next special occasion. In this way the family was planning ahead for what they had
identified as a problem situation. It is helpful for families to have a sense of mastery
over the various problems that occur given how taxing the symptoms of mood and
attentional disorders can be.

Conclusion

In conclusion, FFT-EOY for comorbid ADHD and prodromal BD contains specialized

education regarding ADHD symptoms and medication. It is very important for
clinicians to understand how ADHD and pre-onset BD differ and to be facile in helping
the family with various strategies depending on what the family is presenting.
Handouts that describe the differences between mood disorders and ADHD, and case
examples of children with ADHD, BD, and both disorders are extremely helpful to
families in developing behavioral plans for this difficult presentation.

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 References

Barkley, R. A. (2000). Taking Charge of ADHD: The complete Authoritative Guide for
parents. The Guilford Press: New York.

Chang, K.D., Steiner, H., Dienes, K., Adleman, N., Ketter, T. (2003). Bipolar Offspring:
A window into bipolar disorder evolution. Biological Psychiatry, 53, 945-951.

Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-

IV).(1994). American Psychiatric Association.

Faraone, S.V., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., O’Donnell, D.
(1997). Is comorbidity with ADHD a marker for juvenile-onset mania? Journal
of the American Academy of Child and Adolescent Psychiatry, 36, 1046-1055.

Lynn, G. T. (2000). Survival Strategies for Parenting Children with Bipolar Disorder.
Jessica Kingsley Publishers: London.

Wozniak, J., Biederman, J., Kiely, K., Ablon, J.S., Faraone, S.V, Mundy, E., &Mennin,
D. (1995). Mania-like symptoms suggestive of childhood-onset bipolar disorder
in clinically referred children. Journal of the American Academy of Child and
Adolescent Psychiatry, 34, 867-876.

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Supplement to Clinicians’ Treatment Manual for FFT-EOY

Comorbid Oppositional Defiant Disorder

Elizabeth L. George, Ph.D.

University of Colorado at Boulder

David J. Miklowitz, Ph.D.

University of California, Los Angeles

108
Oppositional Defiant Disorder and Bipolar Disorder

Oppositional defiant disorder (ODD) is frequently comorbid with bipolar disorder in

children and adolescents (Geller & Delbello, 2003). Preliminary reports from the
Stanley Foundation Childhood-onset Bipolar Disorder Consortium reported that 80
percent of children and adolescents with bipolar disorder met DSM-IV criteria for ODD
(Post, et al., 2008). ODD is a disorder that puts parents and their children in an
entrenched power struggle around what types of behaviors are acceptable or not.
Typically, the child expects much more autonomy and freedom than the parent feels is
appropriate for the child’s chronological and/or developmental age. These children
and adolescents tend to push appropriate limits that the parents have set and do not
seem willing to compromise.

At times, the parents are responding to demands from the child or adolescent that
would be considered age-normative. However, the parent may feel that, due to their
own child’s immaturity, the child must demonstrate more personal responsibility before
more privileges will be granted. Herein lies the problem. Oppositional children have
an inordinately difficult time taking responsibility for their behavior and compromising
with others.

Given that increasing the child’s freedom is contingent on the very behavior that is
difficult for the child to display, the parents and child often find themselves in an
immovable standoff. Due to the conflict around this pattern, issues related to
oppositionality are typically at the forefront of family-focused therapy.

The DSM-5 identifies ODD as:

A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward
authority figures that persists for at least 6 months and is characterized by the frequent
occurrence of at least four of the following behaviors: losing temper, arguing with
adults, actively defying or refusing to comply with the requests or rules of adults,
deliberately doing things that will annoy other people, blaming others for his or her own
mistakes or misbehavior, being touchy or easily annoyed by others, being angry and
resentful, or being spiteful and vindictive. To qualify for ODD, the behaviors must
occur more frequently than is typically observed in individuals of comparable age and
developmental level and must lead to significant impairment in social, academic, or
occupational functioning. The diagnosis is not made if the disturbance in behavior
occurs exclusively during the course of a Psychotic or Mood Disorder or if criteria are
met for Conduct Disorder or Antisocial Personality Disorder.

It is often difficult to look at a list of criteria in DSM-5 format and relate it to the aspects
of the child’s behavior that a parent may encounter on a day-to-day basis. For this
reason Riley (1997) has come up with a practical list of the types of behaviors and

109
attitudes a parent may observe in their child which might lead to suspicion of ODD
(Table 1).

________________________________________________________________
Table 1. List of practical criteria for identifying ODD in a child or adolescent.

Oppositional Defiant Disorder

Source: Riley, 1997

How to tell if your child may have Oppositional Defiant Disorder (ODD).
 Rule 1: Oppositional children live in a fantasy land in which they are able to
defeat all authority figures.
 Rule 2: Oppositional children are optimistic.
 Rule 3: Oppositional children fail to learn from experience.
 Rule 4: You must be fair to me, regardless of how I treat you.
 Rule 5: Oppositional children seek revenge when angered.
 Rule 6: Oppositional children need to feel tough.
 Rule 7: Oppositional children believe that if they ignore you long enough, you’ll
run out of moves.
 Rule 8: Oppositional children believe themselves to be equal to their parents.
 Rule 9: Oppositional children from middle-class homes emulate the behavior of
their least-successful peers.
 Rule 10: Oppositional children and teenagers attempt to answer most
questions with “I don’t know”.
 Rule 11: Oppositional logic revolves around denial of responsibility.
________________________________________________________________

There is inherent difficulty in diagnosing adolescents with a mood disorder and ODD.
If symptoms of ODD occur only during mood disorder episodes, then the child
or adolescent is not diagnosed with ODD. Given that many children with bipolar
disorder are continuously cycling in and out of episodes of mood disorder it becomes
very difficult to discern if the defiant behavior is part of the bipolar disorder or if ODD
has become an additional piece of the diagnostic picture. Thus, despite the apparently
non-overlapping criteria sets for ODD and mood disorder, there is difficulty in
diagnosing the comorbidity of these two disorders.

If the clinician and/or parents suspect that the child has ODD, the clinician reviews the
symptoms of ODD during discussion of mood symptoms in the education portion of
FFT-EOY. It is quite helpful to parents to have a list of the criteria for ODD. Some
parents are relieved because, although their child is oppositional, they realize that he
or she does not appear to have the syndrome of ODD. Other parents are relieved to
see that their child does meet the criteria for ODD because it helps them focus on how
to understand and manage the oppositional behavior. During this portion of the
education the clinician may also inform the parents of the comorbidity rates of ODD
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and bipolar disorder, major depression, and ADHD in children and adolescents.
Learning about the high prevalence rate of ODD in prodromal mood disorder
populations may help parents to feel less isolated in their struggles with their child.

You may present this material with or without the child present depending on how
defensive he or she may be. Some children who feel particularly labeled by having a
mood disorder may feel quite resistant and disheartened by having another label
tacked on to their behavior. On the other hand, some kids tend to feel unable to
control their defiant behavior and hearing that this may be a condition which can be
treated may make them feel more understood. If you are able to discuss the
symptoms of ODD in a non-blaming, informative manner the child may be quite open
to the discussion and even share some of the experiences he or she has had in the
midst of a “defiant episode”. It is of utmost importance to read the child’s reaction to
this material and be on the lookout for more labeling and blaming as a result of
identification of the diagnosis by parents and/or siblings.

Contrasting Views on the Relationship between ODD and Early-Onset BD

Authors of popular books on bipolar disorder have different views on the relation of
ODD and bipolar disorder. Unfortunately, none base their observations on empirical
studies but rather, clinical observations. Nonetheless, their contrasting views are
worth noting.

Papolos and Papolos (1999) do not view bipolar disorder and ODD as separate
diagnoses, but instead identify oppositionality as a hallmark trait/behavior in children
and adolescents with bipolar disorder or the bipolar spectrum. They have observed
that the oppositional behavior frequently occurs in contexts that are stressful for
children with bipolar disorder (i.e., transitions). According to these authors,
oppositional behavior is not a separate diagnosis but rather an aspect of the bipolar
condition.

In contrast, Waltz (2000) distinguishes the two disorders from each other. She gives
three reasons for this distinction. First, in the case of ODD the child or adolescent
usually has an easily articulated reason for his irritability, tantrums, or aggressive
behavior whereas the bipolar spectrum child or adolescent may not have an
understanding or even accurate memory of his or her angry or aggressive episodes.
Second, children and adolescents with ODD often become oppositional under the
influence of peers, which, according to Waltz, is less likely with bipolar children and
adolescents. Finally, ODD children and adolescents do not display the elevated or
irritable mood fluctuations that occur during the bipolar spectrum child’s outbursts.
The ODD child/adolescent is characterized as always angry and mean.

Given Waltz’s distinction it can be illustrative to have parents rate oppositional

behavior on the mood chart designed for children and adolescents with bipolar
spectrum disorders. If the ODD symptoms co-occur with the mood disorder episodes
then this oppositionality may be more appropriately coded as part of the prodromal
bipolar disorder. If the defiance is more pervasive then there may truly be a separate,
comorbid ODD diagnosis. There are different strategies to use with children who only

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display oppositionality during mood disorder episodes and those with the more
pervasive oppositionality characteristics of ODD, as will be discussed.

Ross Greene (1998) has a different conceptualization of children who are comorbid for
ODD and bipolar disorder. He notes that besides being diagnosed with ODD, these
children are likely to be diagnosed with ADHD, Tourette’s disorder, anxiety disorders
(particularly obsessive-compulsive disorder), language-processing impairments,
sensory integration deficits, nonverbal learning disabilities, and Asperger’s disorder.
Greene refers to these children that don’t fit a specific category in the DSM-IV,
inflexible-explosive. He views their explosive behavior as “unplanned and
unintentional and reflects a physiologically based developmental delay in the skills of
flexibility and frustration tolerance” (Greene, 1998, pg. 14). The common
characteristics of inflexible-explosive children are as follows:
1) A remarkably limited capacity for flexibility, adaptability and
coherence in the midst of severe frustration;
2) An extremely low frustration threshold;
3) An extremely low tolerance for frustration;
4) The tendency to think in a concrete, rigid, black-and-white manner;
5) The persistence of inflexibility and poor response to frustration
despite a high level of intrinsic or extrinsic motivation;
6) Inflexible episodes may have an out-of-the-blue quality;
7) The child may have one or several issues about which he or she is
especially inflexible;
8) The child’s inflexibility and difficulty responding to frustration in an
adaptive manner may be fueled by behaviors – moodiness/irritability,
hyperactivity/impulsivity, anxiety, obsessiveness, social impairment –
commonly associated with other disorders; and
9) While other children are apt to become more irritable when tired or
hungry, inflexible-explosive children may completely fall apart under
such conditions.

Greene describes these types of explosive episodes as having three phases: vapor
lock, crossroads, and meltdown. In the vapor lock phase, the child exhibits early
warning signs that he is stuck. This early phase typically begins after a request from
parents to “switch gears,” to which the child responds with frustration due to cognitive
and emotional deficits that inhibit him or her from being able to make these transitions
easily. At this initial point, a child may still be capable of rational thought and
catastrophe may still be prevented. The crossroads phase is the last chance that
parents have to respond in a way that facilitates communication and problem
resolution and prevents further deterioration. If the parents do not successfully
navigate this phase, then meltdown begins. During meltdown, inflexible-explosive
children display their most destructive and aggressive behavior. During meltdowns
kids are thinking irrationally, are not able to listen to parents, are not able to learn or
reason, and do not respond well to punishment. In addition, punishment fails to
prevent the child from having meltdowns in future frustrating conditions. Sadly, once
the meltdown is over these children often express deep remorse for what they have
said or done, although they may have difficulty recalling what actually occurred or why
they became as upset as they did.

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The therapist must show empathy for the parents’ and siblings’ frustration in dealing
with these episodes of seemingly irrational oppositionality. Without acknowledgement
of the pain associated with these aversive experiences, families move into an avoidant
stance and eventually feel that they cannot continue to live with the oppositional child.
Since often these explosions occur in the midst of mood episodes, the child can feel
very hurt and rejected by the family once they begin to avoid him or her.

The position taken in FFT-EOY is similar to Greene’s: children at risk for bipolar
disorder who are also oppositional are not seen as having two distinct disorders but
rather as having poor emotional self-regulation or inflexibility. As this example
illustrates, parents often must contend with hostility in their bipolar/oppositional child,
and need to develop strategies for preventing these escalations from occurring.
Education, communication and problem-solving skills training can be adapted to the
needs of families coping with this combination of conditions in the child. The sections
that follow describe these techniques in more detail.

Education Regarding ODD

As mentioned, it is quite helpful to cover the symptoms of ODD after discussing mood
and/or thought symptoms. Some of the symptoms of bipolar disorder are similar to
symptoms of ODD. Some parents wonder how anyone can ever tease these two
disorders (as well as ADHD) apart. This often leads to a productive discussion around
the importance of observing and being familiar with the child’s risk factors and mood
cycles so as to be able to anticipate and prepare for the episodes of oppositionality
that may occur. Again, if therapeutic, the child may be involved in these discussions to
help delineate the triggers for oppositional behavior and his or her particular
experience of the defiant symptoms.

During the portion of the education section that covers medications (Handout 8:
Medications Commonly Used in Outpatient Settings), parents may ask questions
about drugs for ODD. There are not specific medications designed to treat ODD.
However, many of the medications that are prescribed for the symptoms of bipolar
disorder may be helpful with the anger and rage attacks associated with ODD. For
example, atypical antipsychotic medications (e.g., olanzapine [Zyprexa], quetiapine
[Seroquel]) are commonly used for agitation, sleep problems, and hallucinations and/or
delusions with bipolar disorder. These medications may help children who experience
the uncontrollable rage and anger/irritability that go along with ODD to pause before
“flying off the handle”. In addition, the mood stabilizer Tegretol [carbamazepine] is
commonly used to treat the anger associated with bipolar spectrum disorder and may
help with ODD symptoms as well. ODD is not hypothesized to have a
relapse/remission course as it is viewed as a relatively consistent behavior pattern.
Parents may therefore always be managing symptoms of ODD to one degree or
another. However, most of the families in FFT-EOY have noticed a remarkable
decrease in ODD symptoms with the remission of mood disorder symptoms.

When ODD symptoms do diminish with remission of mood symptoms, it is likely that
during a relapse of mood symptoms the child will also have a reemergence of defiant
and oppositional behavior. For some families the parents and child identify defiant
behavior as one of the initial symptoms of a mood episode relapse. One mother
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described being at the mall with her daughter who had been effectively treated with
Lithium for months. One of the main symptoms that disappeared was the daughter’s
chronic irritability and oppositionality. While shopping for clothes the daughter
snapped at her mother in a manner that was reminiscent of behavior before treatment.
In the past, the mother would have seen this as further justification that she had a
“bad, disrespectful” kid on her hands. This time she made a call to the psychiatrist and
therapist to address a potential relapse of mood symptoms. The daughter had a
Lithium level drawn and it was low. The psychiatrist was able to adjust the daughter’s
Lithium and the oppositional behavior disappeared. Through education about and
charting mood symptoms and oppositionality the family was able to catch an early sign
of relapse and avoid mood worsening.

As Greene describes families need to exercise their communication and problem

solving skills to avert major meltdowns. Medical intervention by the psychiatrist may
also be indicated when these oppositional symptoms begin to appear.

Empowering Parents in Learning to Manage Children at Risk for Bipolar Disorder

With ODD

Many parents ask what can be done for their children who display noncompliant and
defiant behavior in response to limit setting, requests, and family rules. As there are
divergent theories about the comorbidity of bipolar disorder and ODD, there are
discrepant theories on the treatment of ODD. There appear to be two primary schools
of thought. The first proposes a behavioral response to the child’s defiant behavior in
the form of consequences. The second proposes more of a cognitive approach in
working with the child to be able to problem solve and compromise around difficult
issues in the family. We employ both of these methods in FFT-EOY in different
circumstances.

Behavioral Responses: Setting Up Contingencies for Good Behavior

The families we have treated have typically used the behavioral techniques of
identifying undesirable behaviors and introducing consequences for those behaviors.
There is much support for using consequences in the research literature (i.e.,
punishment or, at minimum, withdrawal of reinforcers), as outlined in Riley’s book, The
Defiant Child: A parent’s guide to oppositional defiant disorder (1997). Riley’s
perspective, based on his clinical experience, views the child as a conscious agent in
his or her oppositional behavior. Given that he sees the child as at least to some
degree in control of this behavior, it makes sense that his goal is to have the parent
use techniques to shift the child’s behavior. Some of the consequences designed to
shift the child’s behavior include but are not limited to:

 Time Out
Time out is a period the child must spend thinking about how his or her thoughts
and behaviors have gotten him/her into trouble and how to replace those thoughts
and behaviors with others that will not cause trouble. Time out should always
begin with a brief, clear description from the parent of the behaviors that have
gotten the child in trouble along with an explanation of how long the time out will
be. It should end with a brief discussion of the decisions the child has come to
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about new behaviors, new thoughts, and how to stay out of trouble. This form of
punishment may not be appropriate for children over the age of 12. However,
adolescents vary in their maturity level and in what feels punitive to them. With a
little creativity, a parent may be able to use time out to his or her advantage.

For example, for a 13-year old boy in one of our families, time out was the only
intervention that worked during his defiant and aggressive phases. Separating the
adolescent from the family appeared to serve two purposes: first, he felt that it was
aversive to be isolated in his room; and second, it reduced the level of stimulation
to which he was exposed, which helped him de-escalate.

His parents had tried many of the skills learned in FFT-EOY (i.e., communication
and problem solving) during these episodes. Unfortunately, use of clear
communication skills seemed to provoke even more unreasonable and aggressive
behavior from him. Removing him from the family seemed to calm him down, and
then, after a period of time, the parents were able to return to the FFT-EOY skills
and come up with possible solutions to help prevent future defiant and aggressive
behavior.

 Access to reinforcers and privileges

Privileges and reinforcers come in many forms. They may be favorite foods or
drinks, activities, use of objects and devices (i.e., cell phones), designer clothes,
and so on. Each adolescent’s list is highly individual and it is up to each family to
make a list that fits each child. In order to get control of an oppositional child or
adolescent the parent must be willing to take control of the reinforcers that are
specifically important to him or her, and make sure that he or she does not have
access to them unless earned by appropriate behavior. In choosing reinforcers,
parents should adopt the premise that everything in the home belongs to them.
This includes things that the teen has purchased with his or her own money or
items that others have given the teen as gifts.

A child’s access to reinforcers should be in inverse proportion to his or her

oppositional behavior. The general practice is to remove access to several of the
most important ones for periods ranging from one hour to three hours, depending
on circumstances. If less intense increments do not work, the parent must be
willing to take away access to everything for periods ranging from several hours to
days – whatever is necessary to get the child to change his or her oppositional
behavior.

Some of the families we have worked with have chosen to deny the child access to
his or her cell phone, car, going out with friends, television and media, and
computer access except for educational purposes. This strategy has proven to be
quite effective if used in the appropriate way (see examples below).

The families we have worked with have made lists of egregious behaviors and the
consequences for those behaviors in the form of lack of access to reinforcers
combined with aversive tasks the child has had to perform (e.g., sweeping the
garage).

 Level systems
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 The parent explains to his or her child that, at the end of the day, the parent will
briefly give the child feedback on his or her behavior for that day. In the level
system, the child’s performance today determines the level he or she starts on
tomorrow. The level the child is on determines how much or how little access she
or he has to reinforcers. Someone on level III gets “usual” access to reinforcers.
On level II everything is cut by at least two thirds. On level I everything is taken
away.

This system can be overly complex for some families. Parents, however,
appreciate having a number of options that they can refer to in times of conflict.

Special Issues in Setting Up Behavioral Contingencies with Children at Risk for

Bipolar Disorder

Most families find that the more options and the more creative consequences they
have available, the less helpless they feel. In the case of children at risk for bipolar
disorder and disobedient behavior, start by empowering the parent through setting up
a list of consequences that the parent can enforce. It is helpful to get the child’s input
on these consequences as they typically come up with better (and often, more
stringent) punishments than their parents. However, the child should not construe this
to mean that the parent is not the authority and it is important for the clinician to make
it clear to the family that the parent has the final word.

It is ideal if the consequence is either a natural consequence of the “offense” or if it is

related to the offense in some way (i.e., being physically aggressive to a sibling and
then doing that sibling’s chores as the consequence). The list of consequences made
by each family will need to be individualized and flexible.

Remind parents that they may need to stick with certain plans for a time before
abandoning them. Some parents are quick to drop a set of contingencies when the
child stops responding. Of course, this teaches the child that all he or she needs to do
to uproot a plan is simply to be uncooperative. It is important that the parents make a
concerted effort for at least a month before deciding that imposing consequences
(combined with rewarding good behavior) will not work. However, as the clinician, you
must keep in mind that if the child is not interested in engaging in this process even the
most thoughtful plans will likely be ineffective.

“Time out” may not work with an adolescent. Parents and adolescents may feel it is a
waste of time or the teenager may end up listening to music or looking through a
magazine if the parent is not continually supervising. If the parents do view time out as
useful, ask them to structure it in such a way that the teen spends time in his or her
room doing something that he or she may not enjoy but that may be productive. For
example, the adolescent may be asked to record on paper which aspects of his or her
behavior resulted in receiving a “time out” and what he or she could do differently in
the future. The act of journaling may help the adolescent to organize his or her
thoughts and think preventatively. Again, each family needs to be creative and
attuned to which consequences are appropriate for their teenaged child.

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With any consequences for aversive behaviors it is important to monitor how the child
is responding to the duration of the punishment. If the child perceives that he has no
chance of regaining privileges, he may begin to act out due to a sense of unfairness
and hopelessness. For example, one 15 year-old female client was grounded for a
month and continued to act out in fairly extreme ways. The parents began to feel
helpless because all they knew to do was increase the amount of time she was
grounded. The girl said that she was continuing to act out because she did not think
she would ever have a chance of not being grounded. Because she was being
punished, she felt that she might as well behave in a manner deserving of punishment.
When the family presented this difficulty to the FFT-EOY clinician, she helped them
devise a list of offenses and consequences. Table 2 presents the list of behaviors and
consequences these parents and this adolescent devised.

________________________________________________________________
Table 2. Sample offenses and consequences from a family of an adolescent
with bipolar disorder and ODD

Offense Consequence

Borrowing without permission Not allowed to borrow anything

from that person for a week

Continuing to fight with sister when Pick up trash bag full of trash
told to stop

Not doing chores $5.00 off allowance

Arguing and/or insults Writing sentences, the worse the

offense, the more to be written

Lying Grounded from TV for two nights

Physical violence against sister Do sister’s chores for one week

Come home late without calling Grounded next non-school day

and/or night

Cussing at mom Grounded from phone one night

Cussing at sister Say sorry and give her a hug and

do dishes for her

Ditching school Go to bed one hour earlier for

each class ditched
________________________________________________________________

Greene’s Cognitive/Problem-Solving Approach

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Although it can be helpful for parents and children to collaborate in creating a list of
target behaviors and consequences, many parents report that when the at risk child
gets into a particularly bad place, no consequence, threatened or real, makes a
difference in his or her behavior. In observing the children and families in our clinic,
we have concluded that many have the problems that Greene (1998) identifies in his
description of chronically inflexible children. Due to mood swings and what appears to
be uncontrollable behavior, even the best laid plans for consequences and reinforcers
do not seem to work. These children are truly not in control of their behavior and need
parental assistance and guidance at the point at which it is most difficult for the parents
to help, due to the aversive nature of the child’s behavior.

Greene argues that there are neurophysiological events that lead to oppositional
behavior. He proposes that the parents work toward establishing what he calls a more
“user-friendly environment” for the child. He uses the analogy that asking these
children to navigate their current environments without modification is like asking
someone who must use a wheelchair to go up a flight of stairs without a ramp. He
recommends several techniques that parents can use to help their children navigate
their environment. His framework is built around two basic themes: that it is of utmost
importance that the number of meltdowns the child or adolescent has must be
reduced, and that the child or adolescent must learn to maintain coherence in the
midst of frustration. The parent must figure out ways to help the child establish and
maintain coherence even in the most frustrating situations.

Greene lists eight steps toward a user-friendly environment. First, the parent must
make sure that all adults in the child’s environment have a clear understanding of the
child’s difficulties and what fuels his or her inflexibility-explosiveness. Second, the
parent must carefully establish priorities in the goals they have for their child such that
they reduce the expectations and demands for flexibility and frustration tolerance
placed on the child. Third, parents need to identify in advance the triggers for
inflexible-explosive episodes. Fourth, once the family has identified the warning signs
of an episode, they need to have a plan of action in place when they occur. Fifth,
parents should not personalize or misinterpret incoherent behaviors as anything but
what they are, incoherent behaviors. Sixth, it is important to understand the ways in
which the child’s inflexibility-explosiveness may be triggered by the parents and others
in the child’s environment. Seventh, it is helpful to use a more accurate language that
everyone in the family understands to describe aspects of the inflexibility-
explosiveness. Finally, parents are encouraged to come to have a more realistic view
of whom the child is and what is likely for the child and in the parent-child relationship.

In addition to the items above, Greene proposes a system for reducing the number of
meltdowns that occur. He suggests that if there are fewer meltdowns the child will be
more coherent in his or her environment and will be more capable of displaying
reasonable behaviors. Once enough time has passed, the child will be much more
capable of functioning, problem solving, communicating, and relating to others in an
adaptive manner. The technique Greene recommends is using a “basket framework”
for handling conflict in the home. He proposes labeling behaviors as non-negotiable
(basket A items); negotiable (basket B items); or not worth mentioning (basket C
items).

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The only items in basket A are safety items. These are behaviors about which the
parent feels so strongly that they are willing to endure the child’s meltdown to ensure
their performance. For example, one of our parents decided that a basket A item was
restricting her son from spending time with a peer who sold drugs and had spent time
in jail. The mother noticed that her son seemed to have been using substances after
spending time with this friend. Due to safety concerns, the mother decided that she
would endure endless meltdowns in response to her decision to restrict her son’s
involvement with this peer. Due to the volatility of setting inflexible limits with these
adolescents, Greene states that few things should go in basket A. The second basket,
B, contains behaviors about which the parent and child must work out a compromise.
This basket is quite important for children with oppositional behaviors because it
teaches them to communicate with others, take another person’s perspective, and
problem solve in the midst of conflict. The parent has to be adept at keeping the child
from melting down and remaining coherent in the midst of the conflict.

Children at risk for bipolar disorder with ODD often have poor negotiation skills and it
may take time for them to learn to compromise. In the meantime, it means a lot of
practice and in some particularly entrenched situations, foregoing the item in basket B
and putting it into basket C. Basket C is full of behaviors that are not important enough
to risk having a meltdown over and should not be mentioned to the child again. For
example, if a parent decides that having the child’s clothes match when he or she
leaves the house is a basket C issue, then the parent should not bother to comment on
the child’s taste in clothes (unless to compliment, as long as that does not bring on a
meltdown). Greene proposes that if the parents feel empowered to prevent a
meltdown from occurring, the parent is in a much better position to respond to “vapor-
lock” in a rational manner. The parent’s response is one of the keys to a successful
resolution of conflicts that otherwise would lead to a full-blown meltdown. When
meltdowns occur despite the parent’s best efforts, the skills to use are “distraction,
empathy, comforting, separating, suggesting an alternative activity – to defuse the
situation, restore coherence, and ensure safety as quickly as possible” (pg. 158).

When children have mood disorders, and sometimes become irrational when thwarted,
we have found that some of Greene’s principles can be employed. How are these
principles (as well as the principles of behavioral management discussed above)
applied within FFT-EOY? This is the topic of the next section.

Addressing Oppositionality Within the Education Module

In the treatment of these difficult children, medical intervention is sometimes the best
approach. In other cases, Riley’s “consequences” method seems most appropriate
and with others, Greene’s “problem-solving” approach. FFT-EOY for children at risk for
bipolar disorder who have ODD combines these three approaches. Through educating
families about the cycling of symptoms of prodromal bipolar disorder (e.g., during
medication changes, after stressful events) parents become better able to differentiate
the defiant behavior that accompanies typical childhood/adolescence from ODD and
from the type of defiance that occurs in the context of a mood disorder. Through using
appropriate communication skills (e.g., negotiation), families may learn to anticipate
when meltdowns are starting to occur and derail them. Through problem-solving,

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parents and children may be able to set up contingency contracts for preventing future
conflicts involving oppositionality.

Addressing Oppositionality Within the Communication Module

The communication module of FFT-EOY is specifically designed to provide a neutral

format for discussing issues that arise in the family. This is the first step to resolving
problems that may arise in the family. During the communication skills module the
family’s goal is to arrive at a better understanding of each person’s position and
feelings as they relate to the particular familial problem. This model is quite similar to
Greene’s proposed technique for averting meltdowns. If each family member is able to
see the situation from the other’s perspective the possibility of mutual understanding
and compromise exists. Many of the oppositional children in the study have been able
to describe to parents during communication exercises the negative impact of certain
phrases the parents use. For example, one boy shared with his parents that when
they threatened him with a punishment in the midst of an argument or if they said,
“because I said so” in response to him asking them why he had to do something, a
meltdown was imminent. He shared that he was unable to stay coherent once he
heard either of these responses. The family worked, through communication, to come
up with different ways the parents could respond that would keep the boy in a more
coherent frame of mind.

Communication is also quite helpful during discussion of consequences for

inappropriate behavior. Typically parents have consequences in place for the child’s
difficult behaviors but have not discussed with the child how he or she perceives the
consequences. For example, one parent sent his child to his room when he became
defiant and/or misbehaved in some way. The parent did not notice a decrease in the
child’s problematic behavior as a result of this consequence. During communication
skills the adolescent shared with his mother that he liked going to his room because
his Nintendo was up there and that sometimes he misbehaved so that he would be
sent to his room. This discussion led to a new framework for misbehavior and
contingencies in the household.

A final benefit of communication skills training is that these children often have
significant skill deficits in the areas of communication and compromise. For example,
a 15 year-old girl in our program told us that if she budged at all from her position
towards a compromise with her mother, even if her mother met her more than halfway,
then she felt she was giving in to her mother’s wishes. Through the communication
exercises she became more practiced at the art of negotiation without feeling overly
compromised. Another child, an 11 year-old boy, took charge in one session by
introducing skills that the speaker needed to use to facilitate listening. This was his
way of introducing structure for his parents who tended to be very verbose and vague
in discussions with him. He often felt overwhelmed by the amount of information they
gave him and by how unclear the messages were. He was able to empower himself
by setting limits with his parents around aspects of their communication that he felt
triggered meltdowns for him.

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We have found that although communication is very helpful to maintain coherence and
rationality in the face of oppositional behavior it is not complete without problem
solving.

Addressing Oppositionality Within the Problem-Solving Module

As mentioned, communication skills are essential to the problem-solving process.

Everyone in the family must understand and agree with the problem definition, which
will require lots of active listening. If this step is not successful the rest of the exercise
will not be effective.

When addressing behaviors and consequences the format for problem solving
deviates from the traditional FFT-EOY problem-solving model. With the FFT-EOY
model the problem is identified, solutions are brainstormed, pros and cons are
delineated, and the best possible solution is chosen. In assignment of consequences
for problematic behaviors the family lists the offensive behaviors and consequences
are assigned to each behavior according to what seems fitting to all members of the
family. As previously mentioned, the child often has the best suggestions for
consequences in response to disruptive or problematic behaviors. If the child chooses
the consequences he or she may be more likely to follow through with them after a
transgression has occurred. It is important during the assignment of consequences to
go through the last few steps of problem solving after choosing the best fit for each
behavior. These include setting a date to implement the new contingency contract,
anticipating what could go wrong during implementation, ideas about how to respond if
the new contract is not effective, and reviewing how this set of consequences worked
after a trial period. During assignment of consequences to particular behaviors it is
imperative that the clinician gets a sense of whether the child buys into the
consequences and is willing to go along with the plan. As mentioned, a child who is
unwilling to follow through with the agreed upon consequences can keep the most
thoughtful plans from being successful.

FFT-EOY problem solving is very helpful to families with an oppositional child.

Typically the family becomes embroiled in power struggles with little movement and
few options. Through this model the family is able to have a more fluid discussion and
identify many options so that the problem does not seem immovable. Again, the child
must be engaged and willing to discuss problems and solutions for this to be a
collaborative effort. However, the model can be used with only the parent(s),
sibling(s), and/or therapist(s) input. For example, a 16 year-old girl in our program was
unwilling to discuss any options during problem solving. She would sit to the side and
make disruptive noises during the brainstorming portion. The therapist made clear to
her that she could choose not to be involved in brainstorming but that she was not
allowed to disrupt the process and would need to leave the room if she continued to
make noises. Her mother, father, and brother were generating solutions for a family
problem. She was able to remain silent during the brainstorming portion and remained
in the session. Though she did not offer any solutions, she became quite engaged
during the evaluation phase and was able to feel as though she was contributing to the
problem solving exercise.

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Though oppositional children and adolescents are quite poor at generating workable
solutions to problems, they are very skilled at refuting and criticizing potential
solutions. These youth are typically not valued for their critical minds because they are
typically seen as being negative and argumentative. The FFT-EOY model for problem
solving helps children learn in areas where they are deficient (i.e., generating hopeful
solutions) and shows the family that the child can play an important role as trouble
shooter in the process of identifying what can go wrong with proposed solutions.
Typically the child has felt that he or she has no role in working with the family. With
problem solving he or she may have the experience of being valued for finding what
will not work in any scenario. It is often helpful to point out to these children that their
keen insight about what can go wrong is invaluable and that they can learn from the
other family members how to generate hopeful solutions.

During problem solving, though the child may seem resistant in the beginning, they
often come around. Oppositional children have a very difficult time remaining
disengaged. Unfortunately, if they are not engaged in the process, they are often
engaged in disrupting the process. If the child insists on disrupting the process they
may not stay in the room, and the therapist sets this limit the first time disruptive
behavior occurs. Hopefully the child will respond to limit setting because it is very
helpful to have him or her stay. Even if it appears that the child is tuned out, they are
typically listening to everything and often have very good insight about the family
process (in an “the emperor has no clothes” fashion). The other reason it is helpful to
have the oppositional child in the process is that he or she may object to certain
solutions. If the child is not willing to follow through with a proposed solution it is
doomed to failure. For example, one family identified this problem: ‘how can we keep
the egg separator from being ground up in the disposal again’. One of the solutions
proposed was that family members would stick their hands down the drain to see if the
egg separator was in there before they turned the disposal on. A 14 year-old boy said
that he would never stick his hand down the disposal because he thought it was
disgusting. The parents were in favor of this solution and continued to try to argue that
this solution was preferable to all the others. The therapist pointed out that if their son
was unwilling to follow through with this solution, it did not make sense to choose it.
The family eventually chose a solution that everyone agreed to.

Conclusion

Oppositional children and adolescents are very difficult for the family to manage and
usually very resistant and disruptive to the process of therapy. Because oppositional
characteristics are part of the picture of bipolar disorder and there is such high
comorbidity of oppositional defiant disorder (ODD) and bipolar disorder, it is imperative
that anyone who works with youth at risk for bipolar disorder also understand and have
training in working with ODD. By combining many different methods for addressing
oppositional behavior and implementing a response plan in a structured environment,
the therapist and family may achieve success in working with this group of disruptive
children and adolescents.

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 References

Barkley, R. A., Edwards, G. H., & Robin, A. L. (1999). Defiant Teens: A clinician’s
manual for assessment and family intervention. The Guilford Press: New
York.

Geller, B., & Delbello, M. P. (2003). Bipolar disorder in childhood and early
adolescence. New York: Guilford.

Greene, R. W. (1998). The explosive child: A new approach for understanding and
parenting easily frustrated, chronically inflexible children. New York, N.Y.:
HarperCollins.

Papolos, D. F., & Papolos, J. (1999). The Bipolar Child. New York: Broadway Books.

Post, R. M., et al. (2008). Incidence of childhood-onset bipolar illness in the USA and
Europe. British Journal of Psychiatry 192, 150-151.

Riley, D. (1997) The defiant child: A parent’s guide to oppositional defiant disorder.
Taylor Publishers.

Waltz, M. (2000). Bipolar Disorders: A Guide to Helping Children and Adolescents:

O'Reilly & Associates.

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Supplement to Clinicians’ Treatment Manual for FFT-EOY

Youth with Comorbid Anxiety Disorders

Elizabeth L. George, Ph.D.

University of Colorado at Boulder

David J. Miklowitz, Ph.D.

University of California, Los Angeles

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Anxiety Disorders and Prodromal Bipolar Disorder

Anxiety disorders are frequently comorbid with bipolar disorder or high-risk conditions
in teens and adolescents. Comorbidity of all anxiety disorders (i.e., separation anxiety,
generalized anxiety, specific and social phobias, obsessive compulsive, panic, and
posttraumatic stress disorders) ranges from 32% to 50% for adolescents with bipolar
disorder depending upon the study (Geller & DelBello, 2003). When examining
subsyndromal bipolar disorders, the comorbidity rate is 33.3%. In the broader adult
population, rates of anxiety disorders among bipolar patients range from 10.6%-62.5%
for panic disorder, 7.8-47.2% for social anxiety disorder, 7-40% for posttraumatic
stress disorder, 3.2-35% for obsessive-compulsive disorder, and 7-32% for
generalized anxiety disorder (e.g., Cassano et al., 1999; Chen et al., 1995; Dilsaver et
al., 1997; Kessler et al., 1994; Kessler et al., 1997). Because anxiety is so common in
adolescents and adults diagnosed with bipolar disorder, it is important to address
anxiety disorders in working with kids at risk for developing bipolar disorder.

A typical clinically observed developmental path for teens with bipolar disorder is to
have been diagnosed with many anxiety disorders before the bipolar diagnosis is
identified. For example, many clients initially receive a diagnosis of separation anxiety
disorder in early childhood, go on to develop a “sensory integration disorder”, then an
obsessive-compulsive disorder diagnosis, and finally a generalized anxiety disorder
before a psychiatrist, usually after observing a poor response to an antidepressant,
diagnoses the child/adolescent with bipolar disorder. Given the duration of the anxiety
symptomatology by the time the child becomes an adolescent, he or she may have
developed many maladaptive behaviors in response to the anxiety that the family and
clinician must address.

Depending on the presentation of anxiety, managing this symptom cluster in the child
can cause a lot of frustration for parents. Often the kids who struggle with anxiety are
alternatively needy and defiant. Their anxiety may manifest in needing more support
from parents at times and then switch to fear around being too needy and pushing the
parents away. Parents often feel confused and frustrated in response to this push-pull
from the child. Anxiety may also appear as temper tantrums, rage attacks, or
withdrawal in the child making it even more confusing for parents to understand the
origins of their child’s difficult behavior.

Kids with mood or attention symptoms and anxiety may be more likely to abuse
substances and therefore complicate the treatment and familial relationship further.
Many adolescents do not report feeling relief from anxiety with treatment of their mood.
In fact, many report being more aware of their anxiety once the “noise” of the mood
symptoms has subsided. They may turn to marijuana or harder drugs, believing that
these substances relieve their symptoms of anxiety more effectively than any of their
medications.

Given the potential for maladaptive behaviors and family disconnection, FFT-EOY can
be quite helpful for kids coping with anxiety disorders, as well as parents trying to cope
with the child’s sometimes frustrating and irrational behavior. Through FFT-EOY the
child and family can learn more adaptive coping strategies for managing anxiety.

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Addressing Anxiety Within the Education Module

If it is apparent from the initial evaluation (i.e., K-SADS) that the child has significant
anxiety or a diagnosable anxiety disorder, the clinician reviews the symptoms of the
anxiety disorder during the discussion of mood symptoms in the education portion of
FFT-EOY. It is quite helpful to parents to have a description of how anxiety presents
itself and the child’s idiosyncratic response to anxiety. Due to lack of knowledge and
extreme discomfort, children often choose maladaptive patterns for managing anxiety.
Some kids isolate more when they are anxious, become more defiant due to the
agitation driven by the anxiety, or self-medicate with alcohol or illicit substances.
Through education, clinicians can help the family and the child find more productive
ways of managing the anxiety.

During this portion of the education the clinician may discuss the high rates of anxiety
for individuals with mood symptoms, and how these disorders can be distinguished
from each other. Acquiring this information will decrease the child’s sense of being
different and feeling isolated. The clinician may present a model for recording anxiety
on the mood chart. Some children record anxiety as a separate line with
accompanying symptoms. Other children place an A on the mood line that anxiety
accompanies. It is often interesting to note that anxiety may accompany hypomania
and depression. For example, a child may have more separation anxiety from parents
when depressed and more panic attacks when hypomanic. We discuss FFT-EOY and
each of the separate anxiety disorders below.

The discussion of anxiety symptoms often leads to productive discussions about the
importance of observing and being familiar with the child’s risk factors and mood
cycles so as to be able to anticipate and prepare for episodes of anxiety. Anxiety is
such a common experience that this may be an opportunity for other members of the
family to talk about their own experience with anxiety and help the child to feel less “in
the hot seat.” Often, family members have good suggestions for how they manage
their anxiety. The child can also feel some sense of competence in this discussion by
sharing techniques for managing anxiety that may prove helpful to other family
members.

It is quite helpful to explain various techniques (i.e., cognitive restructuring, relaxation

techniques, exposure) that can be used for anxiety disorders and symptoms. Self-help
books such as Mind Over Mood: Change how you feel by changing the way you think
(Greenberger and Padesky, 1995) or Mastery of Your Anxiety and Panic: Workbook
(Treatments that work; Barlow and Craske, 2007) can be recommended. Behavioral
techniques will be discussed in more detail as we describe how FFT-EOY addresses
each of the different anxiety disorders.

When medication is covered (Handout 8, Medications Commonly Used to in

Outpatient Treatment), parents often ask questions about medication for anxiety
disorders. There are several medications that can be used for managing anxiety. You
can educate families on the medications that are addictive (i.e., Klonopin) or that may
not be helpful given the at-risk child’s vulnerability to mood cycling (e.g., Paxil). This
discussion may prepare the family to discuss options with the psychiatrist and not feel
hopeless about addressing this cluster of symptoms.

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When you discuss mood episode prevention, address worsening of symptoms of
anxiety also. If the family and/or the child notices an increase in anxiety symptoms,
make sure they have a plan that includes using coping skills learned in FFT-EOY (e.g.,
talking to parents, reducing stress), calling the clinician, and/or calling the psychiatrist.
Catching and treating these symptoms early may make them less debilitating,
especially if kids are also taught adaptive behaviors to manage them.

Addressing Anxiety Within the Communication Module

The communication module of FFT-EOY is designed to provide a neutral and

nonthreatening framework for discussing family issues. Communication training is the
first step in resolving problems that arise in the family. At this point, the family’s goal is
to better understand each person’s position and feelings as they relate to a personal or
family problem.

Often, a child’s response to anxiety may seem quite irrational and out of context. The
communication skills provide a forum for the child to discuss how his or her frustrating
behavior may be the best response he or she has for managing significant anxiety.
For example, Kurt, a 16 year-old boy with Bipolar NOS, ADD and significant GAD, was
caught smoking marijuana by his mother in his room. When we met as a family she
was furious and considered finding an alternate living arrangement for Kurt. She
stated that the family had a “no drug” policy in the home and that this behavior was
unacceptable. Kurt began to cry and said, “You just don’t get what I am going
through”. The FFT-EOY clinician, while holding firm on her stance that marijuana
could ultimately worsen Kurt’s anxiety problems, encouraged Kurt to describe to his
parents how he felt and why he used marijuana. His parents were asked to use the
active listening skill. He shared with his parents that he was frequently anxious, sick to
his stomach, and suffered from muscular aches and headaches. He told them that the
only relief he got was when he smoked marijuana. Though his parents were unhappy
about his drug use, this discussion prompted a compassionate series of problem-
solving exercises focused on how they could address the anxiety as a team. Kurt and
his parents agreed to be more conscientious about using the relaxation techniques
they had learned in FFT-EOY and getting a consultation with the psychiatrist to see
what anxiolytic medications Kurt could take that might decrease his desire for illegal
and harmful substances. Kurt was also referred for individual drug counseling.

Addressing Anxiety Within the Problem-Solving Module

Though the symptoms of anxiety are distressing, it is usually the child’s maladaptive
response to the anxiety that is the topic of discussion in problem solving. If a child has
begun to experience extreme anxiety, the family may not be aware of what he or she is
feeling. They may, however, notice that the child has begun to self-isolate and spend
less time with the family. He or she may spend time in compulsive ritualizing. This
maladaptive coping puts a strain on family relations and becomes the focus of the
problem-solving exercises.

For example, Marissa, a13 year-old with bipolar, NOS depression and anxiety,
stopped going out to eat with her family. Until recently the family had gone to dinner at
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their favorite restaurant every Friday night. It was the most significant time they spent
together as a family. During the communication module of treatment they learned that
she was experiencing obsessions about germs and was beginning to engage in
compulsive washing behavior. Though she missed spending time with the family, she
felt that going to a restaurant would be very stressful for her.

Once the family better understood the problem, they were able to generate several
alternative ways they could spend time together as a family. Marissa began to feel
less anxious when she no longer felt that her family was displeased with her. In
addition, the family was able to feel less annoyed by Marissa’s anxiety since they
understood that it was not personal. This is an example of how effective problem
resolution can make a positive shift in family tension and reduce or alleviate anxiety
symptoms.

FFT-EOY and Specific Anxiety Disorders

Though the modules of FFT-EOY address the problem of anxiety in general, the
specific anxiety disorders present in very different ways and must be addressed
separately. In many of the cases discussed below, treatment was supplemented with
anxiolytic medications. We also referred patients to individual cognitive-behavioral or
group therapists who specialized in anxiety disorders when we felt that issues
provoking anxiety could not be fully addressed in the family context.

 FFT-EOY and Separation Anxiety Disorder

Many of the kids we work with still have symptoms of separation anxiety.
Separation anxiety may present as: a child who does not want to go to school,
a teen who at 14 has not yet spent the night away from home at another teen’s
house, or a child who becomes belligerent when one or more parents takes a
business trip.

Nate, a 13 year-old boy with Bipolar Disorder NOS, described becoming terribly
anxious when away from his parents. His fears were complicated by the fact
that his parents both worked and had recently separated. The arrangement
developed by the family to manage Nate’s anxiety was taxing for the whole
family. When Nate arrived home from school early in the day, he immediately
called his mother to quell his anxiety. If she was unable to soothe him on the
phone, he flew into rages and “meltdowns.” She usually had to return home to
assure his safety. This pattern put a burden on her ability to function at work.
In the evening, Nate’s father drove over to the house and put Nate to sleep
every night, a process that took hours and was very draining for the father.

In this family it was evident how the anxiety problems (fear of being alone)
interacted with the mood dysregulation (raging when needs weren’t met) in a
maladaptive manner. It was very important for the clinician to provide
education about the two different disorders – how the separation anxiety
manifested itself and precipitated the exacerbation of the mood symptoms. All
agreed (his siblings and his parents) that they found Nate’s symptoms stressful
but did not know how to change their responses. We used the communication
module for Nate to talk to his parents about his fears and concerns related to
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 being separated from them. He also expressed how uncomfortable he found
the anxiety. Through talking about the situation the family was able to identify
the actual problem – his fears about the dissolution of his family and his
difficulty soothing himself when certain anxiety-provoking thoughts arose.

Once this set of problems was clarified, the family was able to proceed with the
problem-solving module. His parents felt very bad about his difficulties with
mood (which developed at an early age), were scared of what he would do if
they did not meet his demands, and felt guilty because of their breakup. It did
not occur to them that Nate could take some responsibility for his emotional
reactions.

Fortunately, Nate was quite interested in having tools to manage his anxiety so
that he did not have to be so dependent on his parents – a new and more age
appropriate goal for him. There were several solutions proposed to help Nate
soothe himself in the absence of his parents. He could watch a funny movie,
play videogames, do homework, call a friend, spend time with his sister, do a
chore to earn some money, or fix a snack. The family agreed that if he’d tried
several of these solutions and was still anxious, he could then call his mother.
His list was very effective and Nate only called his mother one day in a week (a
day when there was a thunderstorm which frightened him). Overall, Nate took
more responsibility for soothing himself, which reduced family tension and
moved him into a more age appropriate role.

 FFT-EOY and Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) involves excessive worrying and the
physical symptoms that go along with that state of mind. Sufferers may worry
about the future (“I’ll never be able to pass the test tomorrow”) or the past (“I
bet Tracy thought what I wore to school today was really ugly”). They may be
excessively self-conscious, even rehearsing what they plan to say before they
say it. They may be overly concerned about their competence and worry about
every possible mistake they have made or may make. They may frequently
ask for reassurance that what they’re doing is OK. This level of worrying often
leads to somatic complaints (e.g., frequent headaches or stomachaches)
and/or to physical symptoms of anxiety like muscle tension or aches,
restlessness, fatigue, difficulty falling asleep, relaxing or concentrating.

Sandy, a 17-year-old young woman with Bipolar Disorder NOS received a

comorbid diagnosis of GAD during the administration of the K-SADS-PL. Her
parents described her as “obsessing about things” and being preoccupied with
“doom and gloom.” They portrayed her as “constantly worried about how
others see her,” frequently second-guessing what she had said to friends that
day and worrying about how it had been taken. They described an incident the
previous week during which she had said something to an acquaintance, the
acquaintance had gotten upset, and Sandy became so distressed about having
said the wrong thing that she left school for the day. Sandy saw herself as
extremely self-conscious and stated that she worried a lot about her future,
even thinking frequently that she would die young due to her health problems.

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 One of Sandy’s mood problems involved extreme anger outbursts during which
she lost complete control. She became verbally abusive toward her family at
those times, threw objects, punched holes in walls and hit or kicked family
members. Her parents reported that, at least in some instances, her anger
outbursts were preceded by periods of worrying, feeling keyed up, and being
unable to relax. In designing Sandy’s mood chart, we decided that it would be
important to track those periods of worrying and feeling physically keyed up to
see how often the anxiety symptoms led to severe mood dysregulation. This
proved to be helpful to Sandy as she was eventually able (sometimes) to see a
“meltdown” coming in advance and to take steps to try to address the anxiety,
rather than, in her parents’ words, “Turning it into anger.”

The FFT-EOY therapist also taught Sandy and her parents the basic elements
of cognitive restructuring, including keeping track of automatic thoughts and
their triggers, rating anxiety states, evaluating the evidence for and against
each thought, developing new, more balanced interpretations of events, and
observing improvement in anxiety symptoms. Homework assignments using
thought records helped generalize these skills to the home setting.

 FFT-EOY and Phobias

Specific phobias are commonly observed in the pediatric bipolar population.
Sometimes, anxiety becomes associated with a specific stimulus, resulting in a
severe anxiety response when confronted with that stimulus. The stimulus is
then avoided or endured with significant distress. The patient generally
understands that the intensity of the response is irrational and extreme.

Rob, a 15-year-old with severe depression, had developed a phobic reaction to

a character in a science fiction movie (E.T., the Extraterrestrial). The movie
had originally come out when Rob was about five years old and had made a
lasting impression on him. For years afterward, Rob was terrified of E.T. dolls,
movie advertisements, and memorabilia and even refused to let family
members mention the name. Our knowledge of the existence of the phobia
emerged during the administration of the K-SADS. On the surface, it seemed
that this phobia would not cause much difficulty in terms of Rob’s current
functioning, because it was a stimulus that could be easily avoided. However,
the ten-year anniversary of the release of the film occurred during the course of
FFT-EOY, and there was quite a bit of media attention to the re-release. Rob’s
mother brought it up to his therapists before the anniversary date, in
anticipation of an increase in the adolescent’s stress and anxiety level. We
discussed it using the problem-solving exercise when the adolescent was not
present. The biggest decision was about whether to name it as a problem for
the whole family to discuss or to maintain a more low-key approach to it. The
concern was that by labeling it a potential problem and having the adolescent
participate in the discussion, we could be unnecessarily raising Rob’s anxiety
and creating a self-fulfilling prophecy.

After considering the advantages and disadvantages of both approaches, the

mother decided to downplay the issue and see what happened. As it turned
out, the re-release passed without any significant crisis. The family did not go
to the theater to see it, and although the adolescent maintained his avoidance
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 of talking about the movie and the character, and continued to insist that it was
not to be mentioned at home, no further adverse psychological reactions
ensued. It’s probable that in this case, the severity of the phobic response had
actually diminished over time, although the patient’s maturity level and need for
control over his anxiety level precluded him from being able to confront it
directly.

 FFT-EOY and Obsessive-Compulsive Anxiety Disorder

Many of the youth in our program have components of obsessive-compulsive
disorder. These symptoms are very distressing for the child and usually
annoying for the family. Sue, a 12 year old with moderate depression, was, at
times, immobilized by obsessions. She envisioned herself picking up a knife
and slitting her mother’s throat. These obsessions were so terrifying for her
that she had begun to avoid her mother and spend most of her time in her
bedroom. She had never heard of obsessions before and though she did not
want to hurt or kill her mother she was very confused by these images and was
scared that somewhere inside this was how she really felt. We spent a
significant time during the symptom component of the education section
discussing the difference between negative thoughts, delusions, and
obsessions. We discussed how, though the obsessions were scary for Sue,
they did not represent her real feelings about her mother. We also talked about
options for managing the obsessions. One strategy was for her to use
cognitive restructuring and remind herself when she had the obsessions that
they were just part of her chemistry and did not represent her real feelings. We
taught her relaxation techniques to use a couple of times during the day each
day to hopefully help with the anxiety symptoms in general. We discussed her
symptoms with the psychiatrist who recommended a low-dose SSRI. We
taught her several distraction techniques. Some of the things that helped when
she had the obsessions were playing video games, calling a friend on the
phone, snapping a rubber band on her wrist, and riding her bicycle. Through
the various techniques she learned in the program she was better able to
manage the obsessions and began spending more time with her mother so that
her fears of harming her diminished naturally (behavioral exposure). Though
she learned to manage her anxiety, once the symptoms of depression
lessened her obsessions decreased as well.

 FFT-EOY and Panic Disorder

Individuals with bipolar spectrum disorders often have panic attacks in addition
to mood disorder symptoms. One of the main troubles with panic is that the
response of the individual to the panic symptoms can exacerbate the original
panic response, either in the moment of an attack or gradually over time. Panic
disorder can be extremely debilitating for the individual and the family. This
illness can lead to the child being housebound. Often, the family must
completely alter their lifestyle to address the needs and concerns of the child.

There are two parts to treating panic disorder with children. The first involves
helping the child cope with the actual panic attack (e.g., learning not to
catastrophize internal bodily sensations) and the second centers around
helping the child resume typical activities that he or she has given up as a
result of fear of having a panic attack. To address managing internal bodily
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 sensations related to panic, it is recommended that patients seek interoceptive
exposure treatment.

David, a 17 year-old boy with Bipolar NOS and many symptoms of depression
and anxiety, had been having panic attacks for several years. He had become
so fearful of having a panic attack in public that he was housebound and did
not take part in any family activities. This was a huge loss for his parents and
younger sister who missed his presence during their family outings. With
appropriate medical treatment the panic attacks stopped but David’s fears of
leaving the home continued. Given that this problem was one of the most
concerning for his family, the clinician addressed this issue early in the
treatment using the problem-solving module. The family identified the problem
as “not having enough mobility to do things together as a family.” They were
able to come up with several options to try. Part of the solution involved David
trusting that though he may become anxious during an outing, he would be
able to handle it with some relaxation techniques the therapist had taught him.
The FFT-EOY clinician created a relaxation tape that David could use at home
twice a day.

Once David had learned to self-relax, he worked with his family on imagining
different anxiety provoking scenarios (i.e., going to the movies) and then used
the relaxation techniques he learned on the tape. Later, when David became
anxious, he was able to respond to cues from his mother to use his relaxation
techniques. His family was instructed on gradual exposure exercises (e.g.,
gradual excursions outside of the home) and given reading materials on
managing panic disorder using graded exposure techniques. In this manner
he was able to manage his anxiety more effectively. He and his family were
able to do more together.

 FFT-EOY and Posttraumatic Stress Disorder

Many children with bipolar disorder also have had traumatic experiences in
their lives. In some cases, a parent with a mood and/or substance disorder has
been abusive. These parents’ own mood symptoms may have put their children
in situations that are traumatic (i.e., suicide attempts, hospitalizations), or the
parents may choose mates who become abusive or tormenting. Thus, the
possibility of exposure to trauma is high in bipolar populations, and by
extension, in children at risk for developing bipolar disorder. Leverich, et al.
(2002), found that those with bipolar disorder who endorsed a history of child or
adolescent sexual or physical abuse had many more comorbid DSM-IV
disorders, a more cycling presentation of the illness, more suicide attempts,
and were more likely to have a psychosocial stressor set off an episode than
those without early abuse. It is apparent from this research that traumatic
experiences are problematic for the present and future course of the illness and
for symptomatic outcome.

The triggers that set off a PTSD reaction put the child at risk for mood instability
due to his or her extreme vulnerability to stress. This continuous symptomatic
presentation is debilitating to familial and social relationships. Though it may
be helpful for children to discuss their symptomatic response with family
members, sometimes the most helpful response is to get professional support
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 outside of the context of FFT-EOY if he or she continues to struggle with
PTSD.

Kate, a 16 year old with depression, anxiety, and substance abuse had been
quite distant throughout the FFT-EOY treatment. She did not connect with the
therapist and was very disengaged from her family. Her mother was
concerned that Kate seemed distant and withdrawn and didn’t show any
initiative. Kate complained of extreme anxiety. The psychiatrist prescribed an
anxiolytic medication but nothing seemed to alter the anxiety. Toward the end
of the treatment Kate shared that the reason she had not engaged in treatment
was because she couldn’t let go of something she had done that was “horrible”.
One night while drunk she impulsively left a friend of hers with a boy nobody
knew so that Kate could go off with some other friends. Her friend was
assaulted once Kate left. She said that she would never be able to get past
feeling down and anxious because of her part in what happened to her friend.

We spent several sessions brainstorming different treatment options for helping

Kate deal with this trauma. We considered medications, individual therapy,
and group treatment. She was able to use the communication skills to express
her guilt and frustration to her mother, and her mother expressed empathy and
understanding toward her lapse in judgment. We also discussed ways in which
she could make amends with her friend and how she might help her friend get
access to the appropriate post-trauma treatments.Kate began work with an
individual therapist who specialized in working with PTSD. She is making
progress on managing her anxiety and depression.

Conclusion

Children at risk for bipolar disorder who have comorbid anxiety disorders can be a
difficult group to treat. It is imperative that anyone who works with these at-risk youth
also has training in working with anxiety disorders. In our FFT-EOY study, there have
been times when medical intervention has proven successful or the anxiety symptoms
have abated when the mood symptoms were under better control. Other times
medication has not proven to be as helpful and behavioral techniques taught by the
therapist have helped with relief of symptoms. Generally the family and child benefit
from using the communication and problem-solving skills to understand and manage
the anxiety, regardless of the form it takes. By combining different methods of
addressing anxiety and developing a plan to be used in case of symptom
exacerbation, a therapist and family may have success in improving these complicated
comorbid conditions.

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Cassano GB, Pini S, Saettoni M, Dell'Osso L: Multiple anxiety disorder comorbidity in

patients with mood spectrum disorders with psychotic features. Am J
Psychiatry 1999; 156(3):474-6.

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Guilford Press, 2003.

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Supplement to Clinicians’ Treatment Manual for FFT-EOY

Handling Suicidal Crises

Dawn O. Taylor, Ph.D.

Elizabeth L. George, Ph.D.

University of Colorado at Boulder

David J. Miklowitz, Ph.D.

University of California, Los Angeles

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Handling Suicidal Crises in FFT-EOY

In treating children at risk for bipolar disorder, suicidality may emerge as a concern.
As experienced clinicians know, if this issue arises, it must take priority as an agenda.
The communication and problem-solving skills can be used to help structure a
discussion of this usually highly emotional topic. You will often need to depart from the
treatment protocol in order to deal with a suicide-related crisis; you may need to
increase the frequency of sessions, make them longer, switch from one module to
another (e.g., education to communication skills) or have individual sessions with the
child.

There is a distinction between suicidal behavior and self-injurious behavior without the
intent to die. Suicidal behavior is driven by an express desire to end one’s life. Self-
injury [as defined in Bodily Harm (Conterio, Lader and Bloom, 1999)] is the deliberate
mutilation of the body or a body part, not with the intent to commit suicide but as a way
of managing emotions that seem too painful for words to express. This is a different
problem in many ways. It tends to be part of an ongoing pattern of behavior rather
than an acute condition and, although certainly to be taken seriously, is generally less
lethal than suicidal behavior. We address suicidality and self-injury as separate topics.

Assessing Suicide and Thinking Preventively

You will have inquired about suicide in the assessment phase of treatment and will
know whether (a) suicidal ideation has been a problem in the past and (b) there has
been any history of suicide attempts. If the child or family members bring up concerns
about suicide, or if the child is suffering from moderate to severe depression during the
course of treatment, you must follow the standard clinical protocol for assessing the
seriousness of the situation. Brent and Poling (Cognitive Therapy Treatment Manual
for Depressed and Suicidal Youth, 1997) list the following components of an
assessment of suicidalilty: degree of suicidal intent, relationship to other psychiatric
symptoms and syndromes (for example, a chronically depressed patient who has an
exacerbation of suicidality following abuse of marijuana), the nature of the precipitant,
and motivation. Motivation may be a true wish to die, but for about two-thirds of
adolescent attempters, the motivations are different from this, and include a desire to
escape, to gain attention, express hostility or induce guilt (Hawton, Cole, O’Grady &
Osborn, 1982). Essential questions during the assessment include:

 When does the patient experience suicidal ideation?

 Are there identifiable triggers?
 Does he or she have a plan?
 How long does it take for the ideation to develop into active intent?
 How long have these thoughts been occurring?
 How frequent are they?
 What does the patient do when s/he has these thoughts?
 What typically prevents the patient from acting on the suicidal ideation?

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In comparing 120 consecutive youth suicides(younger than 20 years old) to 147
matched community controls in greater New York City,results showed that
psychosocial factors had an effect size comparable to diagnostic factors in increasing
suicide risk. The most notable risks were derived from school problems, a family
history of suicidal behavior, poor parent-child communication, and stressful life events
(Gould, Fisher, Parides, Flory, & Shaffer, 1996). These results underline the
importance of working to improve family communication and bolster strategies for
coping with stress in adolescents with mood problems.

In our work, we have observed another situation that often results in suicidal thoughts
or actions. The child who erupts into out-of-control rages often feels intense guilt
afterwards. These frightening acting-out episodes have some similarities to seizures
in that, once past a certain point, reining the behavior in appears beyond the child’s
control. Nevertheless, the child may feel great shame and remorse afterwards, and
begin to think that he or she does not deserve to live. Regardless of whether an
episode of rage occurs, conflict with parents is one of the most common precipitants
for suicidality (Brent & Poling, 1997). This underscores the usefulness of adopting a
family therapy approach to treating suicidal youth. If the family can learn less
conflictual ways to solve problems, the incidence of suicidal episodes in general
should hopefully be reduced.

Young people, true to their nature, seem to act more impulsively than adult suicide
attempters and may make attempts that seem to come out of nowhere, with little
warning. The thinking leading up to the attempt may seem irrational (“My best friend
didn’t talk to me in school today; she must hate me, I want to kill myself”), grandiose
(“Once I’m gone, everyone will be sorry and know I was right”) or psychotic (“My soul
is empty and I have no right to continue to exist”). Suicide in general, and especially in
children and adolescents, is difficult to predict. Given that the capacity to prevent will
be imperfect, the importance of treating the conditions that lead to risk or that increase
impulsiveness (e.g., depression, anxiety, psychosis, substance abuse) is enormous.

When the issue of suicide comes up, the reactions of parents can vary widely. Some
parents seem to under react, perhaps because it is too painful for them to think and
talk about the possibility of their child’s death. Sometimes parents see suicidal
ideation as manipulative and respond by ignoring it so as not to reinforce the child’s
attempt to “get attention.” Other parents may overreact, sometimes becoming so
distressed that it is hard to keep them focused on the precipitating problem of suicidal
ideation. Your task is to try to facilitate the parents’ attempts to listen empathically and
respond calmly. As mental health professionals know, suicide is a very real possibility
that must be taken seriously and that requires both the child and those who care about
him or her to take responsibility and make whatever effort is necessary to ensure the
child’s safety.

Keeping the Child Safe

Several precautions must be taken with a highly suicidal child. You may need to have
an emergency session with the child and/or an emergency family session. You must
try to negotiate a no-suicide contract with the child. According to Brent & Poling (1997)
the child must be able to agree 100% to the following.
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 1. That he/she will not attempt suicide/harm between now and the next
outpatient appointment.
2. The child will inform an adult should he/she feel in danger of acting upon
suicidal/aggressive thoughts.
3. Should there not be an adult available when the child feels in danger of
acting upon suicidal/aggressive thoughts, he/she will phone or present
himself/herself to the nearest emergency room.
4. The child will try to avoid activities and situations that may increase the
chance of feeling suicidal/aggressive.

If the child will not contract for safety or does not seem reliable enough to follow
a safety plan, you may need to speak with the family about arranging for
someone to be with the child 24 hours a day. Hospitalization may be necessary.
Make sure you have a release of information form completed so that you can
communicate with the child’s doctor and make him or her aware of the situation.
Sometimes, suicidal episodes can be handled with the addition or adjustment of
medication.

Addressing Suicidality Within the Communication Module

The communication skills taught in FFT-EOY provide excellent tools to help keep
these highly charged discussions about suicide moving in a constructive direction.
Consider the example of Douglas, a 17-year-old patient with recurrent major
depressive disorder who received FFT-EOY with his parents and older brother, Dave.
Douglas had never made a suicide attempt, but thoughts of suicide had become more
frequent and more intense over the previous few months, as Douglas had slipped
gradually from a moderate to a severe depression. He had avoided bringing the
suicidal thoughts up with his family because he was anticipating that each would react
in a way that would feel uncomfortable to him. He “knew” that his mother would
overreact, cry, and become overprotective. He believed that his brother would not
know what to say, but would think Douglas was “really crazy” now and distance himself
even more. He was concerned that his father would be disappointed in him and
perhaps think he was weak.

Previous psychoeducation sessions had described suicidality as part of the symptom

complex of depression and bipolar disorder. Thus, suicide was not framed as a moral
or family failure but rather, part of Douglas’s condition. The therapist, putting the
suicidal thoughts in the context of Douglas’s mood problems, told the family:

“Suicidal thoughts and impulses are in themselves symptoms of mood

instability and depression. As Douglas has been getting more depressed over
the last few months, it is not surprising that he also began having these
despairing feelings. Suicidal feelings are at least in part a product of his
condition.”

The therapist then asked Douglas to try to communicate his thoughts and feelings to
his family: his feelings about dying and the reasons why it was so hard for him to share

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those thoughts. She asked the family to listen actively, without interjecting advice or
suggestions.

DOUGLAS: I just keep thinking that this is never gonna get any better,that
this family would be normal if I wasn’t in it.

MOTHER: But Douglas, why haven’t you told me you were feeling like this?
How can I help you if I don’t know what’s wrong?

THERAPIST: Remember, Kate that your job right now is to listen without trying
to solve his problem. See if you can help Douglas express his
thoughts by paraphrasing them.

MOTHER: So you think we’d be happier if you weren’t here?

DOUGLAS: Yeah, basically. And I didn’t want to tell you about it because I
don’t want you to get all upset. You worry too much about me
anyway. I don’t want you to be watching me all the time, like
you think I’m gonna do something stupid.

FATHER: But Douglas, why would you think we’d be happier without you?

DOUGLAS: Oh, I don’t know. You wouldn’t have to be coming to these

therapy sessions and trying to figure out what’s wrong with me
all the time if I wasn’t here.

FATHER: You think I’m unhappy about coming to these meetings?

DOUGLAS: I know you’ve got better things to do. You never had to do this
kind of stuff because of Dave.

FATHER: Do you think I feel differently about you and Dave because of
that?

DOUGLAS: I guess not. I know you love us both. Sometimes it just seems
like I’m so screwed up that no one would want to be around me.
(To Dave) I know you don’t want me around you and your
friends.

DAVE: So you think I’d really rather have you gone for good? That’s
crazy. I’d hate it if you were gone. You’re my brother.

Although the parents in this family still had difficulty with just listening, the
communication skill format helped Douglas express feelings and thoughts he had been
unable to express previously. In so doing, he received feedback and support from his
family. They communicated clearly that they cared for him and valued his membership
in the family.

Addressing Suicidality Within the Problem-Solving Module

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There are at least two ways in which problem solving can be helpful for suicidal
ideation. One is to help the child and family generate a list of alternative behaviors
that the child can engage in when suicidal ideation becomes a problem. “Improving
the moment” strategies might include relaxing, praying, meditating, going for a walk,
taking a bath or a shower, talking to a friend or parent, fixing a meal, watching a
favorite video, or reading a book. If there are indications that the child’s potential for
attempting suicide is high, problem solving can also be used to develop a plan to keep
the child safe. This might involve the parents temporarily taking over responsibility for
functions the child generally handles. Examples include monitoring medication if the
suicide plan revolves around overdose of prescription drugs, or arranging
transportation for an adolescent if he or she is deemed unsafe to drive.

Think of suicidal behavior as a problem to be solved. Suicidal ideation and attempts

have antecedents and consequences. Determine if the child’s suicidal feelings are
reliably evoked by specific stimuli (e.g., arguments with certain family members, ups
and downs in a romantic relationship). Examine any self-statements that intervene
(e.g., “I’ll show him (boyfriend) that he can’t treat me that way”). A detailed discussion
of the chain of events, thoughts, feelings, and behaviors that led up to the last suicide
attempt may be quite helpful. The generation of solutions focuses on ways to alter this
chain of events (e.g., talking to supportive family members, journaling, listening to
music) to derail the self-destructive behavior.

Case example

Here is an example of using problem solving to respond to suicidal ideation in a 17-

year-old chronically depressed adolescent. Clare thought about suicide almost daily,
even when she wasn’t depressed, but her family was unaware of this. She had
actually made three somewhat ambivalent attempts, by overdosing on pain relievers
and other medications she had found around the house, but these attempts had never
come to the attention of her parents. Clare would get ill and vomit, or just sleep the
effects of the medication off, and go on as if nothing had happened.

During the psychoeducation portion of FFT-EOY, as suicidal ideation was being

discussed as a symptom of depression, the family was surprised to learn the extent of
Clare’s preoccupation with suicide. Her mother denied the danger of this thinking
pattern but her father, who had experienced his own father’s suicide, was quite
concerned. The problem was defined as, “How to keep Clare safe”. Clare’s suicidal
ideation was so habitual and ingrained that it seemed to have taken on a life of its own,
making it hard to identify antecedents. During the generation of possible solutions, the
clinician asked several key questions including:

1. Are you (Clare) willing to tell your parents if you become suicidal, and if so,
how will you tell them?
2. What kinds of responses from your parents will you experience as
supportive?
3. Is it safe for you to be alone when you are thinking this way? Is it safe for
you to go out? Is it safe for you to drive?
4. At what point must action be taken? When that point arrives, what needs to
happen and who is responsible for seeing that it happens?
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 5. At what point should the therapist, or physician, be called?
6. How else can your parents help? Where can you (the parents) get help if
you are feeling frightened or unsure of how to proceed?

The family was able to agree on a comprehensive plan that enabled the parents to be
more tuned in to when Clare was feeling unsafe, and to respond in ways that would
reduce the danger. Both parents worked during the day, and Clare, who had left high
school, was alone the majority of most days until 3:00pm, when her younger brother
got home from school. Clare agreed to try to contact one of her parents when the
suicidal thoughts were becoming excessively intrusive, i.e., when she could not put
them out of her mind and focus on something else, despite numerous attempts. It was
not always possible to reach either parent at work, so her father decided to start
carrying a pager. If Clare could not reach either parent, she agreed to page her dad
and he agreed to call her at home as soon as possible.

The hope was that brief, supportive contact with either parent would defuse the
situation and help Clare engage in something more constructive, like doing her home
schooling lessons or even watching TV. It was agreed that the plan would be re-
evaluated in two weeks, as it was unclear that Clare would actually initiate contact
when she needed to, and it also remained to be seen whether contact with a parent
would be enough to derail Clare’s suicidal obsessing. Nevertheless, Clare felt less
alone with her disturbing thoughts and more protected by her parents.

Self-Injury

Self-injury is a pattern of behavior that can include cutting oneself, burning oneself,
hitting or biting oneself, head-banging, interfering with the healing of wounds and even
more severe methods of self-harm. According to Conterio, Lader, and Bloom (1999),
this problem is appearing more frequently in childhood and adolescence. The self-
injurer does not intend to kill herself (most self-injurers are female), but has developed
this behavior as a method of coping. Some of the youth we have worked with exhibit
this behavior, so we present here some ideas (many of which are drawn from the book
just cited) about how to understand and work with this problem in the context of FFT-
EOY.

Self-injurers describe many reasons for their behavior. These generally fall into two
broad categories: 1) analgesic or palliative aims and 2) communicative aims. The first
category includes the common report that cutting helps the self-injurer feel calmer in
the face of overwhelming affect or to feel grounded or “real.” There is often a sense of
self-control that ensues. In this sense, self-injury is like an eating disorder. Although
everything in the youth’s environment may feel out of control, the eating or self-
mutilating behavior is something over which she has exclusive control. Some self-
injurers state that cutting helps them feel “cleansed,” as if they have released
something poisonous or contaminated from within themselves. A similar motive
involves the self-injurer who feels excessively guilty and uses self-harm to punish
herself for her imagined transgressions.

In terms of communication, many self-injurers say that by transforming their internal

pain into observable wounds, they hope to express to others how badly they hurt.
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Some people cut when they are very angry and have no constructive way to express it.
Some cut in the secret (or not so secret) hope of eliciting caring and concern from
others.

The significant majority of patients who self-injure come from dysfunctional family
systems where they experienced physical, sexual, or emotional abuse or neglect. In
these cases, in addition to the aims noted above, the self-injury may represent a
recreation of traumatic events from childhood. Nevertheless, it is important to keep in
mind that people do develop a pattern of self-injury in the absence of these conditions
and that not everyone who experienced a traumatic childhood will become a self-
injurer. Conterio et al. (1999) also note that in their work with self-injurers, many
patients come from families who “enforced strict and rigid codes of morality and
behavior, codes that usually allowed little room for the expression of normal human
emotions” (p.76).

There is some suggestion that self-injurers are more likely to be emotionally

hypersensitive than non-self-injurers (e.g., negative emotions are too overwhelming to
bear, certain sensations like noises or odors are experienced as extremely aversive).
In the treatment model described in Bodily Harm, however, self-injury is
conceptualized as neither a disease nor an addiction, but as a choice. In FFT-EOY,
the child is viewed as being challenged by a biologically-based condition that makes
self-regulation difficult, but the child must be presented with choices about whether to
use coping strategies that, although comfortable and familiar, ultimately do more harm
than good. In FFT-EOY, he or she can be acquainted with healthier methods of
coping with negative affect.

The treatment model described in Bodily Harm involves four key elements. Initially,
patients are required to sign a No-Harm Contract which spells out the expectations
and responsibilities of both patient and therapist and describes how behaviors that
threaten the treatment process will be handled. Designing the contract should be
collaborative, with the therapist and patient deciding together what is reasonable
behavior and what are fair consequences for stepping out of bounds. For example,
the therapist and patient may agree that self-injury on the day of a session is not
acceptable. Both parties should agree on consequences that are therapeutic rather
than punishing. In the example just mentioned, it may be agreed that if there is self-
injury on the day of a session, the patient foregoes the session. The contract should
not be so harsh that the treatment is terminated at the first violation, but the patient
may be asked to undergo a period of probation.

The second treatment component is the Impulse Control Log. Patients are asked to
keep a diary recording their self-harm urges. Each entry includes:
1. Self-injury thoughts
2. Time and date
3. Location
4. Situation
5. Feeling
6. What would be the result of self-injury?
7. What would I be trying to communicate?
8. Action taken
9. Outcome
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The third component is referred to as “The Five Alternatives.” This is simply a list of
safe alternatives to self-injury. These can be comforting activities or temporary
distractions. The fourth component is a series of writing assignments ranging from an
autobiography to writing about the emotions surrounding self-injury to writing about
“What I can’t stand about the people in my life.” Each assignment includes specific
questions to help focus the patient. Special writing assignments can be designed to
deal with specific situations. The authors make the point that, “any tool that helps you
slow down, redirect your thinking, channel your energies, and articulate thoughts and
feelings will help you navigate emotional distress more effectively” (p. 260). Please see
Conterio et al. (1999) for more details on these techniques.

Addressing Self-Harm Within the Education Module

The FFT-EOY clinician can use many of the above strategies in the education module.
For example, the Impulse Control Log can be incorporated into the mood chart either
with a separate line on the chart designated for self-injury or self-injury thoughts.
Alternatively, the child can complete the Impulse Control Log in a separate space on
the mood chart and then represent when those urges occurred by using an initial (i.e.,
S-I) on the chart with the mood state that the urges accompanied. When the clinician
checks the mood chart he or she can also review any instances of self-injurious
thoughts or behaviors. If the self-injurious thoughts are more likely to accompany
certain moods then prevention plans can be put in place. “The Five Alternatives” can
be generated during a discussion of coping strategies that the child can use when
struggling with self-injury impulses. Given that a lot of kids report self-injuring after a
fight or conflict with family members a discussion of how family members can help with
self-injury can be added to the discussion of Handout 10, How Can Your Family
Help with mood problems. Finally, self-injury appears to have a relapse remission
course so developing a specific relapse plan for self-injury will hopefully be a helpful
addition to mood episode prevention planning.

Addressing Self-Harm Within the Communication Module

Although young self-injurers often harm themselves in an attempt to engage with

others (e.g., to express anger or to invite rescue), their behavior often has the opposite
effect on other people. Friends and family members are frequently repulsed by the
self-mutilation, and may feel frustrated and helpless, with resulting withdrawal from the
youth rather than engagement. Clearly, the family needs to play a central role in
addressing self-injurious behavior in the child. Parents will need guidance from you in
determining what is and isn’t helpful.

For example, many parents try to keep the child safe by taking away all potential
instruments of self-harm. This can be counterproductive with adolescents. It sends
the message that the parents are in charge of controlling the maladaptive behavior and
it may exacerbate struggles for control that are already going on between the parents
and the adolescent.

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Encourage the use of communication skills to help the child talk to her family about her
experience of self-injury, including typical triggers, ways in which the behavior feels
reinforcing to the child and in particular, ways in which the act is an attempt to
communicate distress to others. One of the goals of treatment should be to help the
child get beyond self-injury as a mode of communication and to use words to express
her thoughts and feelings. Here is an example of an adolescent trying to explain to her
family the emotional turmoil she experiences prior to cutting herself. Her parents were
asked to use listening skills.

Joyce: When I’m angry, I feel like I’m out of control. It builds up
inside me and when I can’t hold it any more, it explodes like
a soda can when you shake it up and open it. All the
pressure comes out. I feel like I want to kill the person I’m
angry at. When I cut myself, it relieves all that. I’m not
angry anymore.

Mother: But doesn’t it hurt?

Joyce: Not really. I know that sounds weird, but it really doesn’t.

Father: So it seems like a better alternative than killing someone.

Joyce: Well, that’s what I think.

Father: But you wouldn’t really kill anyone. And what do you get so
angry about anyway?

Joyce: I get angry about lots of things. I just don’t talk about it. I
don’t want to lose control.

Addressing Self-Harm Within the Problem-Solving Module

Problem-solving skills can be used to help clarify “who takes responsibility for what” in
the family’s attempts to prevent self-injury. As noted earlier, only the self-harmer can
be accountable for the choice to self-harm or not, and the tools suggested by Conterio
et al. may be useful in the solution-generation portion of problem solving. Because
these tools are designed for the individual therapy context, the FFT-EOY therapist may
elect to schedule some individual sessions with the child to familiarize him/her with
their use. The family, however, will also need guidance about how to respond to a
cutting episode. In the case where the self-injury is an attempt to communicate, the
family may elect to hold a family meeting after each self-injury episode, so that the
child can be gently encouraged to express in words the message represented by the
cutting.

Following is a vignette involving a 16-year-old girl with mild depression and ADHD,
Alyson, who lived with her mother, her older brother and her mother’s boyfriend.
Alyson has recently had her first cutting experience and the family is describing it in a
family session. Curt (mother’s boyfriend) did not attend the session.

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 Mother: We had just had a big blow-up about Alyson going over to
Jason’s [Alyson’s boyfriend]. It was 10:00 on a school night and
Alyson wanted to go over to Jason’s house and I said no.
Alyson refused to take no for an answer and said she was going
anyway. We started arguing and then Curt and Mike (Alyson’s
brother) chimed in too. We were all pretty much telling Alyson
that she couldn’t go and that it wasn’t OK for her to be so
headstrong or disobedient or whatever. It got pretty heated.
Alyson charged up the stairs and into her room and I guess
that’s when she started cutting herself.

Clinician: Alyson, what do you remember about that night?

Alyson: Everybody was yelling at me and basically telling me I was a

bad kid. When I went up to my room to try to get away from it,
Mike had to grab me in the hall and make it worse. He asked
me how I could do that to Mom and said she was too stressed
out already without me making it worse. When I went in my
room, I was really angry but also feeling guilty. I felt so upset,
like I couldn’t calm down. I kept pacing around. I felt like
jumping out the window, like it might feel better to get really hurt
and break my bones. I saw the scissors lying on my desk and I
got the idea to cut myself. It hurt at first, but when I saw the
blood coming out, it was calming or relaxing or something.

Mike: So you’re going to blame it on me, because of what I said.

Clinician: Is that what you’re saying Alyson?

Alyson: No, I guess not, although that comment didn’t help.

Clinician: I guess my belief is that you were having a lot of intense feelings
following the argument, and that would be hard for anyone to
handle, and especially someone with a mood disorder. But you
still have choices about how to handle intense feelings. If you
had a chance to replay this scene, what could everyone, not just
Alyson, have done differently?

The family went on to explore how things could have gone differently that night. They
used that discussion to work through a problem-solving exercise focused on how to
prevent future episodes of self-harm. Two solutions were chosen for trial. The
therapist invited Alyson to call or e-mail if she felt another urge to cut, as a way to give
more time to consider other options besides cutting. The family decided that after an
intense argument, they would allow for a brief (half-hour) cooling-off period, and then
have a family meeting to try to “debrief” after the argument. During the debriefing,
everyone would get a chance to talk about how they were feeling as a result of the
argument, but the issue that had prompted the argument would not be re-opened. If
Alyson was feeling agitated, angry, upset or guilty after an argument, it would be better
for her to communicate her feelings to her family than to try to dissociate from those
feelings or to act them out in an indirect way like self-harm. Everyone agreed on this in
145
principle, but whether the plan would work in practice still needed to be assessed. A
date was set to re-evaluate the solutions.

The therapist did not opt for individual sessions with Alyson at this point to try to
address the self-harm, because this was the first incident and a habitual pattern had not
been established. Alyson herself was dismayed at what she had done and was
motivated to use healthier coping strategies, so it was hoped that these solutions might
address a developing problem.

Conclusion

Suicidality is, unfortunately, not unusual in the treatment of youth at risk for bipolar
disorder. You must be knowledgeable about the appropriate questions to ask and what
actions to take based on the answers to those questions. If you can obtain a suicide
contract, you can proceed to implement some of the outpatient strategies outlined
above, utilizing communication skills training and problem solving to deal with the acute
crisis. Not all self-destructive behaviors are motivated by a true intent to die. In those
cases, it is most helpful to uncover the child’s true intent: what he/she hopes to
accomplish or communicate by the self-injury. Nevertheless, all suicidal ideation and
self-injurious behaviors must be taken seriously.

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 References

Brent, D. A.,& Poling, K. (1997). Cognitive therapy treatment manual for depressed
and suicidal youth. Pittsburgh, PA: STAR Center Publications, University of
Pittsburgh.

Conterio, K., Lader, W., Bloom, J. K. (1999). Bodily Harm: The breakthrough healing
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