People with bipolar disorder need support systems. Most of time, family is a large part of that support system. Spouses can remind them to take their medication or take them to doctor’s appointments. Mothers provide emotional support. Siblings make sure they leave the house when they’re depressed. It’s a vital part of maintenance treatment and recovery. However, sometimes the family support system breaks down. Instead of helping patients recover, they may actually be making symptoms worse.
Family dynamics are important to all families. They determine how family members relate to one another and interact with each other. World-views and self-image are shaped by these relationships. Strong family dynamics foster communication and understanding. Major factors that contribute to family dynamics are family size, socioeconomic status, cultural beliefs and customs, the quality of the parents’ relationship, and individuals’ personalities.
When a mental illness is diagnosed, it can throw off the family dynamic. It can help explain the behavior of a parent, child or spouse. Sometimes the diagnosis may foster empathy and understanding. It may also lead to a negative family dynamic. Partners or children become caretakers, adding to their stress load. Animosity may arise when family members don’t believe the person with the mental illness is trying hard enough to control it.
Psychologists refer to this dynamic – how families interact with and talk about their family member with mental illness – as expressed emotion. It’s made up of three factors: hostility, criticism, and emotional over-involvement.
In bipolar disorder, when expressed emotion is high it can cause a patient to relapse, even if the person is sufficiently medically treated.
Hostility and criticism seem like obvious stressors. When someone is constantly blamed for having a mental illness or not controlling it properly, the large amount of stress can cause significant anxiety and depression, which may lead to a full-blown mood episode.
Emotional over-involvement is the tricky part of expressed emotion. It is not blatantly negative. In fact, it can stem from loving intentions. Family members fault themselves for the mental illness. They consider a setback or symptoms a sign of their inadequacy as caregivers. Fixing a mental illness becomes the top priority. This family member may start to overreach boundaries and become controlling. Pity becomes a primary motivation for interactions.
Being the subject of pity, and feeling like a problem that needs to be fixed, takes away a patient’s personhood. The patient is no longer a human with personality, emotions, desires and gifts, but a problem. A burden. Mental illness is not accepted as a part of the person, but consumes the rest. When patients are only seen as their mental illness, it’s depressing. It’s overwhelming. It’s enough to trigger a full-blown episode.
The most effective way to prevent high expressed emotion is family-focused treatment. The patient and one or more family members attend regularly scheduled therapy sessions over nine months. The goals of family-focused treatment are:
Educating the patient and his or her family member about bipolar disorder
Family members are taught to recognize the symptoms of bipolar disorder, what can trigger symptoms and episodes, how to prevent those triggers, and the importance of adhering to treatment plans.
Enhancing communication skills
Patients and family members are taught listening and speaking skills to help prevent or defuse conflict.
Brainstorming potential problems and solutions can help families prepare for symptoms, mood episodes, treatment refusal, and any other aspect of bipolar disorder. From that they can develop action plans for different scenarios.
Family-focused treatment has been found effective in reducing patients’ symptoms and increasing healthy behavior, especially in families with high expressed emotion. It also positively affects the mental health of the caregiver. It can even be more effective in recovery than cognitive behavioral therapy.
Families should consider having their level of expressed emotion evaluated before beginning any family-based treatment to see which type of treatment will work best for their family dynamic.
Image credit: Evil Erin