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              Family Functioning with Bipolar Disorder

By Alexa Martinez,  Office Intern, Clinical Psychology Associates of North Central Florida                          
all rights reserved.   Gainesville - Ocala
Clinical Psychology Associates of North Central Florida
2121 N. W. 40th Terrace, Suite B                                                                                           
Gainesville Florida 32605                                                                                                      
Ph: (352) 336-2888  Fax: (352) 371-1730   
Bipolar disorder (BD), a manic-depressive mood disorder, has an estimated lifetime prevalence of 3.9% and is known as one of the “most burdensome mental disorders” (Fiorillo et al., 2015, p.297). Bipolar disorder can be debilitating to the family environment through family conflicts or problems created by financial, healthcare, or other demands including acting-out, dangerous, or threatening behaviors.  Chang et al (2001) compared families who had a bipolar member to healthy families in the USA and found that there were high levels of conflict and low levels of cohesion and organization, Barron et al (2014) found that BD families in the United Kingdom experienced more conflict than families with no psychiatric history.  This suggests that providing assistance to the family support system could play an important part in treatment strategies for bipolar disorder.
Emotional Support, Involvement, and Overinvolvement
A healthy family environment is important in the recovery process for bipolar patients. Unfortunately, bipolar families more often face family financial difficulties, impairment in marital and parenting roles, and restrictions in social and leisure activities (Fiorillo et al., 2015, p. 292). Fredman et al (2015) followed 108 patients and their relatives for two years.  While emotional involvement was found to provide productive support, it was found that intrusive and overprotective behavior, exaggerated emotional responses, and excessive self-sacrificing can be damaging to the patient’s well-being (Fredman et al., 2015, p. 81). Fredman et al (2015) found that these types of overinvolved behaviors were associated with an increase in the number of manic episodes.  They found that appropriate supportive behaviors improved depressive behavior. In other words, appropriate involvement helped with depression, but over-involvement worsened manic symptoms. Excessive self-sacrifice, which is giving up excessive time, effort, and activities in order to take care of the bipolar disordered relative tended to be detrimental to the family relationship and tended to interfere with recovery from bipolar episodes.
Bipolar disorder can distress marital relationships.  Presence of a mood disorder is linked to martial distress, bouys in trees vermont  all rights reserved Ernest J. Bordini, Ph.D.  Clinical Psychology Associates of North Central Floridadecreasing marital satisfaction over time, an increased risk of divorce, and shorter marriage duration (Sherman et al., 2015, p.2).  With bipolar disorder, lower social support was correlated with more frequent depressive episodes and with longer recovery from depressive episodes.  Quality of the marital relationship and perceived availability were associated with frequency of relapse of depressive episodes. 
Children of Bipolar Parents
Parental mood disorders can impact on parenting, childrearing, response to parent-child conflicts, and on the quality of parent-child relationships.  Parents with bipolar disorder have reported more negative interactions with their children, likely contributing to risk of children developing psychosocial or behavioral problems.  Some studies have found maternal bipolar disorder (with a a 12-month prevalence of 1.6%) can have a greater impact on children than paternal bipolar disorder (Peay, Rosenstein, and Biesecker, 2014; Freed et al., 2015).  It was suggested that bipolar mothers may experience more stress in balancing roles and expectations with coping with their own mental illness.  They may experience guilt about perceived or actual parenting failures, and often experience fear and worry of genetic risks of their children developing bipolar disorder (Peay, Rosenstein, and Biesecker, 2014).
Child age and gender also interact with family conflict as moderators to children's vulnerability to parental bipolar disorder.  This magnifies young children's sense of distress and helplessness.  Female children, who may be more sensitive to interpersonal stress have been found to be more affected by family struggles than boys (Freed et al., 2015, p. 109) but boys are also vulnerable to family issues and violence when exposed to at a young age. 
Younger children have less developed coping strategies and cognitive schemes to deal with family conflict.  Higher frequency of family negative interactions, miscommunication, and less cohesion likely raises child anxiety and fears about what they might say or do could trigger dreaded manic or depressive reactions or episodes.  This can lead to inhibitions in communication about a child's own fears, conflicts or needs, and can inhibit open and honest communication by the child to the parent.  Since security and predictability are often critical to trust and a sense of attachment, this can also contribute to a sense of detachment or alienation in a child or teenager.  This can become all the more complicated when there are both parent(s) and children in a family which have bipolar disorder.  Child and adolescent mood or bipolar disorders can be a core cause of family stress (Freed et al., 2015).
A study by Muralidharan et al (2015) found young adults with bipolar disorder were “more vulnerable to emotional and cognitive responses to failure feedback. They displayed higher levels of self-criticism following failure feedback (p.397). There was an increase in negative affect in bipolar children after receiving criticism by their parents. Thus, a loop of criticism and negative affect partially fueled by parental mood disorder can exacerbate negative affect in children with mood disorder, escalating family conflict and family negative interactions.  This may ultimately contribute to more depressive or manic relapse episodes.
Healthy awareness and monitoring of children’s mental health was found to help bipolar parents feel less worried about risk of their child's risk of developing mood disorder and had a positive on perceived control (Peay, Rosenstein, and Biesecker, 2014, p. 198) . Learning and employing active coping strategies assists reducing guilt and worry and contribute to more positive family affect and communication, possibly reducing risk factors for relapse. Some active coping themes include:
·         Watchful awareness of the child’s psychological state and moods
·         Talking to the child about their moods
·         Making changes to the child’s environment
·         Maintaining open communication about mood disorders and the parent’s own illness
·         Being empathetic about the child’s moods and experiences
·         Seeking professional help and/or planning when to seek help
·         Teaching the child positive life lessons  
According to Fiorillo et al (2015), “living in a dysfunctional family is associated with more frequent relapses and hospitalizations, lack of compliance, and a worse social functioning” (p. 292).  Multifamily group therapy (MFG), family-focused therapy (FFT), and couples therapy represent treatment approaches to target such dysfunctional family or marital interactions.  Multimodal approaches may be required.  Couples therapy and FFT have been shown to result in fewer relapses, longer intervals between relapses, better communication and problem-solving skills, more social support, and better overall quality of life for couples experiencing marital distress and low perceived social support.
For families who are excessively supportive and overly protective, FFT combined with psychoeducation has been effective in improving family functioning. This intervention includes “individual and family assessment, psychoeducation on the characteristics and treatment of bipolar disorder, early warning signs, management of suicidal behaviors, and instruction on communication and problem-solving skills, and booster sessions” (Fiorillo et al., 2015, p. 293).  This approach teaches families to spot cues that may trigger or be associated with a manic or depressive episode and teaches appropriate responses (Freed et al., 2015, p. 144).  When overinvolved family members relinquish appropriate responsibility to the bipolar family member, caregiver burden is reduced, and the relationship often improves. 
The above demonstrates the importance of evaluating the family environment and designing appropriate interventions.  Peay, Rosenstein, and Biesecker (2014) suggest moving away from putting blame on parents with disorders to adopting treatment approaches which strengthen parenting and martial and family coping strategies.
High levels of disability and family instability (Fiorillo et al., 2014, p. 297) are important obstacles for families who have members with bipolar to overcome. Family functioning can be affected directly by symptoms and episodes of the disorder itself, but also by family conflict, lack of support, excessive support or codependency, and by family communication problems. Poor family functioning in families with a bipolar parent has a detrimental influence on children's psychosocial adjustment, but findings demonstrate positive family factors can exert protective effects” (Freed et al., 2015, p. 109).  It is important to conduct assessment of family functioning and consider interventions and education to encourage the family and individual recovery process.

Support Resources:
Barron, E., Sharma, A., Le Couteur, J., Rushton, S., Close, A., Kelly, T., … Le Couteur, A.
(2014). Family environment of bipolar families: A UK study. Journal of Affective Disorders, 152-154, 522-525.
Fiorillo, A., Del Vecchio, V., Luciano, M., Sampogna, G., De Rosa, C., Malangone, C., … Maj,
M. (2015). Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled, multicentric, real-world study. Journal of Affective Disorders, 172, 291-299.
Fredman, S. J., Baucom, D. H., Boeding, S. E., Miklowitz, D. J. (2015). Relatives’
emotional involvement moderates the effects of family therapy for bipolar disorder.
Journal of Consulting and Clinical Psychology, 83(1),81-91.
Freed, R. D., Thompson, M. C., Wang, C. H., Otto, M. W., Hirshfeld-Becker, D. R., Nierenberg,
A. A., Henin, A. (2015,). Family functioning in the context of parental bipolar disorder: Associations with offspring age, sex, and psychopathology. Journal of Family Psychology. 29(1),108-118.  
Muralidharan, A., Kotwicki, R. J., Cowperthwait, C., Craighead, W. E. (2015). Parental
relationships and behavioral approach system dysregulation in young adults with bipolar
disorder. Journal of Clinical Psychology, 71(4), 387-401.
Peay, H. L., Rosenstein, D. L., Biesecker, B. B. (2014). Parenting with bipolar disorder: Coping
with risk of mood disorders to children. Social Science & Medicine, 104, 194-200.
Sherman, M. D., Fischer, E. P., Owen, R. R., Jr., Lu, L., & Han, X. (2015). Multifamily
Group Treatment for Veterans with Mood Disorders: A Pilot Study. Couple and Family Psychology:Research and Practice. Advance online publication.
Submitted July 20, 2015, published November 2015  Ernest J. Bordini, Ph.D., editor,  further minor edits 7/31/23

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