Bipolar Disorder – How Can Therapists Support Clients and Their Families?: An interview with Dr. David J. Miklowitz, PhD
Curt and Katie interview Dr. David Miklowitz about his work with people with Bipolar Disorder and their families. We look at what therapists can often get wrong when working with patients presenting with this disorder. We explore differential diagnosis, treatment options, lifestyle coping strategies, and family support. We also talk about how to walk the line between self-responsibility and accommodation.
Click here to scroll to the podcast transcript.Transcript
An Interview with Dr. David J. Miklowitz, PhD
Dr. Miklowitz is Distinguished Professor of Psychiatry and Director of the Child and Adolescent Mood Disorders Program at the UCLA Semel Institute. He is also Visiting Professor of Psychiatry at Oxford University in the UK. His research and clinical work focuses on family environmental factors and family interventions for kids and adults with mood or psychotic disorders. His work has helped establish the effectiveness of psychosocial interventions as adjuncts to medication for bipolar disorder across age ranges. Dr. Miklowitz has received numerous awards for his research, including: • Young Investigator Awards from the International Congress on Schizophrenia Research (1987) and the National Alliance for Research on Schizophrenia and Depression (NARSAD) (1987) • a Distinguished Investigator Award from NARSAD (2001) • the 2005 Mogens Schou Award from the International Society for Bipolar Disorders • the 2009 Gerald Klerman Senior Research Investigator Award from the Depressive and Bipolar Support Alliance, • the 2011 Bipolar Mood Disorder Research Award from the Brain and Behavior Research Foundation. • In 2017, the Distinguished Scientist Award from the Society for the Science of Clinical Psychology • in 2020, the Mood Disorders Research Award from the American College of Psychiatrists, one of only two psychologists to have done so. He has received multiple research grants from the National Institute of Mental Health and 10 private foundations. Dr. Miklowitz has published over 400 research articles and 8 books, including “Bipolar Disorder: A Family-Focused Treatment Approach” and “The Bipolar Disorder Survival Guide,” an international bestseller with over 350,000 copies in print and translated into 8 languages. His latest book, due out in September, is called “Living well with bipolar disorder: Practical strategies for improving your daily life.”
In this podcast episode, we interview an expert on Bipolar Disorder
Many clinicians can miss or over-diagnose bipolar disorder. We wanted to make sure that our modern therapists have enough of the basics to identify if it is coming in their offices. We also talked with our guest about non-medication options to supporting bipolar clients and their family members.
What makes it hard to diagnose bipolar disorder?
“Depending upon how familiar…a clinician is with the disorder, they may either see it in cases where it’s not really there, or they may miss it in cases where it is. And the biggest, I think, confusion is: is this just depression, or is it actually bipolar disorder? Does a person really have the highs as well as the lows?” – Dr. David J. Miklowitz, PhD
- Therapists need to get adequate information, which is often self-report or family history
- There are a number of rule outs and comorbidities such as depression (unipolar), anxiety, trauma, personality disorders, substance use
- If someone is inaccurately dx, it can lead to the wrong treatments, including the wrong medications
- It is challenging to differentiate normal adolescent behavior from bipolar, so careful assessment is needed.
What can get in the way of treatment compliance for bipolar disorder?
- Desire to be more creative or feel all of ones emotions can lead to lack of meds compliance
- Perceptions about productivity during hypomania
- Substance use and abuse can cause a lack of compliance or efficacy with medications, substances can also lead to exacerbation of symptoms
- Medication side effects can be challenging, which requires active communication with psychiatrist to adjust dosages
“The issue, of course, is if somebody is truly bipolar and they go off their medications, they could end up in the hospital with a long aftercare period and a depression to follow, and can really set their life back.” – Dr. David J. Miklowitz, PhD
What role can the family and loved ones play in supporting someone with bipolar?
- Family-Focused Therapy (FFT) is a protocol that can be helpful
- Family members can provide accommodation for client
- There is a balance to be struck between family support, medication, and personal responsibility
- Boundaries are very important
Resources for Modern Therapists mentioned in this Podcast Episode:
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
Dante Cicchetti | Institute of Child Development
Kay Redfield Jamison – Wikipedia article
Living Well with Bipolar Disorder: Practical Strategies for Improving Your Daily Life by Dr. David J. Miklowitz, PhD
CHAMP | Semel Institute for Neuroscience and Human Behavior
David Miklowitz | UCLA Profiles
Dr. David J. Miklowitz, PhD | UCLAHealth.org
Relevant Episodes of MTSG Podcast:
How to Understand and Treat Psychosis: An interview with Maggie Mullen, LCSW
Risk Factors for Suicide: What therapists should know when treating teens and adults
Psychiatric Crises in the Emergency Room, An Interview with Kesy Yoon, LMHC and James McMahill, LMFT
Rage and Client Self-Harm: An Interview with Angela Caldwell, LMFT
What’s New in the DSM-5-TR? An Interview with Dr. Michael B. First, MD
What Therapists Should Know about the Rollout of 988
Two Years In: Is 988 Actually Helping People Facing Mental Health Crises?
Medical Assistance in Death (MAiD) in Canada: Mental Illness and Assisted Suicide
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
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Connect with the Modern Therapist Community:
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Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 0:15
Welcome back, modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy, and this is podcast for therapists about the things that go on in our profession, the things that we do in our practice, and sometimes the people that we serve. And it’s always fun when we get a new episode, a new topic that we haven’t really addressed before. And for as long as we’ve been doing this, I don’t think that we’ve ever done anything directly on working with clients with bipolar disorder, and always a wonderful place when it’s stuff that Katie and I don’t normally see in our practices either. So when we’re not experts on things, we like to bring people on who are and we are joined by Dr. David Miklowitz, and it’s got a lot of research and a lot of books about working with bipolar disorder, and we are happy to have other people like yourself share your expertise with us and our audience. So thank you very much for spending some time with us today.
Dr. David Miklowitz 1:17
Thanks, Curt and Katie. I’m very happy to be here.
Katie Vernoy 1:20
We’re excited to get into this conversation, but before we do, we’re going to ask you the question we ask all of our guests, which is, who are you and what are you putting out into the world?
Dr. David Miklowitz 1:29
Good question again, I’m David Miklowitz. I’m a Professor of Psychiatry in the UCLA psychiatry department in Los Angeles, what we call the Semel Institute, and I have been doing research in bipolar disorder now for close to 40 years. I’m embarrassed to say I started as a graduate student, and have been doing really pretty much that for most of my career. My focus is on families, how families cope with bipolar disorder, how people in families relate to their family members, and whether there’s anything you can do with psychological treatment to try to alter the course of a disorder like bipolar disorder, which is primarily treated with medications. So I am a professor. I run a clinic for children and adolescents with mood disorders, broadly defined, depression, bipolar disorder, and most of my time, I do research and write papers and write books and hopefully and see patients as well on on the side.
Curt Widhalm 2:36
One of the things that we start a lot of our episodes with is lot of mistakes can be made in working with clients with bipolar disorder, not from a shaming place, but if we can save some clinicians out there, maybe making some mistakes that other people have made. But what do we often see clinicians kind of do make errors with when initially working with clients coming with this diagnosis.
Dr. David Miklowitz 3:00
Some of these errors are not really the clinician’s fault. They’re sometimes the fault of the field and we the way we define disorders like bipolar disorder. Let me define it first. Really bipolar disorder is episodes of mania alternating with episodes of depression. And mania, of course, is when people get very activated, have elated or high moods or irritable moods, along with a decreased need for sleep. So they sleep very little. They feel full of energy and full of ideas. They talk very fast. They’re very distractible. They have lots of big ideas, what we call grandiose ideas, about what they’re going to accomplish and often do very impulsive and sometimes dangerous things in a manic episode. That alternates with periods of depression, where the person is very slowed down, fatigued, wants to sleep all the time, feels very sad, feels listless. Everything feels hopeless. Sometimes that person becomes suicidal, feels like their mind isn’t working anymore, or they lose their appetite. And people with bipolar disorder alternate between these two extremes. Now I’m kind of simplifying things, because in fact, people can have minor highs and major lows. They can be actually manic and depressed at the same time, some people are. But the core defining feature is a significant instability of mood. Now, where I think the biggest error comes in is diagnosing the disorder. You have to rely on the person’s self report. You have to rely on their history, hopefully, what history is available from their family members. And depending upon how familiar someone is, a clinician is with the disorder, they may either see it in cases where it’s not really there, or they may miss it in cases where it is. And the biggest I think, confusion is: is this just depression, or is it actually bipolar disorder? Does a person really have the highs as well as the lows? Many, many more people have just the lows. Depression is endemic to our society. It’s probably close to four to five times more common than bipolar disorder is. Almost, almost 20% of the population has had a major depressive episode at some point. Whereas Bipolar disorder is is probably only about 2% of the population, and it’s easy to over diagnose it, and it’s easy to miss. So that would be the biggest problem, I think. And then, of course, if you misdiagnose someone, you may give the wrong medications or the wrong psychological treatments. You may tell them that they’re suffering from one disorder when really they have others. So that’s really the big error I think clinicians make. There are many others, but I’ll stop there.
Katie Vernoy 5:53
When we’re looking at differential diagnosis or even comorbidities. What are the things that you would want to make sure to consider for bipolar disorder, and our audience is primarily non medical doctors. So there’s we’ve got master’s level clinicians as well as psychologists who typically listen. We have some psychiatrists and some medical doctors, but primarily we’re looking at master’s level clinicians who are listeners. So framing it that way, what are the things that we should be looking for to try to make sure that we’re ruling out and ruling in appropriately?
Dr. David Miklowitz 6:24
Sure. Well, one is, as I mentioned, depression, certainly you want to make sure that you’ve asked the questions, is there mania? Has there been a period of at least four days where someone is very activated and elated, and all those things that I just mentioned, ADHD is very Attention Deficit Hyperactivity Disorder, very easy to confuse with bipolar disorder, particularly in kids, because kids come in and they’re activated or very inattentive or distractible, and that can look like mania. The way to tell the difference, well, sometimes you have to see them multiple times to be able to tell the difference. But kids with ADHD don’t tend to get grandiose. They don’t tend to have a decreased need for sleep. They might have sleep disturbance, but they don’t say sleep four hours and then wake up raring to go the next day. That’s one distinction. Anxiety can look very much like depression and a person who, a kid who’s anxious but also impulsive and angry, sometimes that’s mistaken for a bipolar mood cycle. So you have to really be clear what what is the primary mood state, and are they really showing activation? Are they really moving fast, or is it really just anger and impulsivity. For a long time in the United States, there was a misdiagnosis of bipolar disorder and kids, kids were being called manic when really what we were seeing was irritability. And irritability is kind of like headaches. It hits all sorts of different disorders, and it can have irritability with almost any major psychiatric disorder, so it in itself, is not very diagnostic. So I would say anxiety, depression, ADHD and substance abuse. Also, if somebody comes in and they’re acting high, do we know if they’re really manic, or are they on cocaine? Are they taking meth? Are they using opiates in some way? Or if they’re slowed down, are they taking some sort of downer pill? So you have to know the person’s substance abuse history as well. But any of those disorders can go along, can co-travel with bipolar disorder.
Katie Vernoy 8:37
Some of the other things that I’ve seen, and I just want to get your thoughts on them, are folks with a lot of chronic Complex PTSD, or folks who have traditionally been diagnosed borderline personality disorder. It seems like there’s the dysregulation, there’s the potential impulsivity from trauma. There’s a lot of different things there, but it seems like some of those also could potentially be confused.
Dr. David Miklowitz 8:59
Yes, actually, PTSD and bipolar disorder often are comorbid with each other. Trauma is in the background of many people with bipolar disorder. That doesn’t necessarily mean the trauma is the causal factor, but they certainly it co occurs, and borderline personality disorder is very difficult to tell, sometimes from bipolar disorder. The difference is that first, a manic episode is not the same thing you see in borderline people. Borderline people tend to be explosive. They tend to have affective changes very quickly, particularly if something interpersonal happens, like a loss or a rejection. But it’s not the same as mania, with elated mood, grandiosity, decreased need for sleep, and the changes in mood in borderline tend to be very quick, quick onset, quick offset. They don’t tend to last weeks and weeks. That said, the two can go hand in hand, and actually are quite hard to treat when you have both.
Curt Widhalm 8:59
You had mentioned kids earlier, and I remember back when I first got licensed, and much earlier in Katie in my careers, it seemed like the the hot diagnosis for every teenager was juvenile bipolar disorder, and that seems to thankfully have kind of faded out in the last 15 years or so here. But how does it actually show up differently for teenagers than it might for adults?
Dr. David Miklowitz 10:26
Well, first, I think that confusion is understandable. The developmental psychopathologist Dante Cicchetti talked about adolescents having three core features. One is a desire for high risk activities, family conflict and mood instability that those are the big three of adolescents. Well, guess what? Bipolar disorder is all three of those things only multiplied 100 times, so you see plenty of mood instability and family conflict and risk taking behavior in adolescents, though you can see, could certainly see all the signs you do in adults. It really depends upon whether, for example, hyper sexuality, you may not see that in a pre teen, you might see it in a teenager, you wouldn’t necessarily see it in a pre teen. Or spending a lot of money. Well, if you’re a kid, you may not have access to the same amount of money that you have as an adult. But yet the same behaviors can co occur in either adults or children. One of the things we look for is, how fast is the cycling? Are there distinct episodes of mania and depression, or is it merely, is really kind of an up and down, up and down type, of course, with no real relief in between that that can really become a difficult distinction to make when you’re talking about teenagers, because they’re moody. They’re moody already. But what is actual bipolar disorder? Is there a dysfunction in their day to day life? Is the sleep disturbance there they have just kind of regular teenage stuff? Or are they going nights after night of not being able to sleep. Are they having trouble getting to school? Those are the things we look for to see if this is really bipolar disorder.
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Katie Vernoy 12:08
It seems like there’s a stereotype, maybe, that folks with bipolar disorder, especially when they’re in the the joy, the throes of mania, that there’s hyper productivity, there’s creativity, there’s a lot of stuff that’s especially in the hypomania, like before they get too far up the up the ladder there, it can seem like it’s an invitation to optimize yourself and to have such an amazing experience or create amazing things and and I’ve heard tell, I’ve not seen this personally in my with the clients that I’ve worked with, or the family members of the clients that I’ve worked with, that there’s a difficulty in committing to taking medication that stabilizes mood because they miss out on on that element, so they feel like they’re detached from themselves. So, so that’s one question is, is the the difficulty with truncating, that that effect and kind of the the practical implications of folks not wanting to comply with treatment. But before we get to that, I wanted to talk through this notion that folks in hypomania or people with bipolar are more productive and creative?
Dr. David Miklowitz 13:29
It’s a, I think, a very interesting question. There are books written about this. Person who’s written the most is Kay Jamison, a psychologist at Johns Hopkins, who actually was one of my mentors. Well, she’s run studies and written psychological histories of very famous people who probably had bipolar disorder. She recently wrote a book about Robert Lowell, the poet, had manic and depressive episodes. We think that Beethoven probably had them. Various dancers, we think maybe Ernest Hemingway had it. Johan Strauss and modern musicians and so forth, so. And she’d done some studies interviewing people who were, for example, first chair violinists in orchestras, and had actually found a higher rate of bipolar disorder and mood instability problems in people who have artistic careers. So I think there is a link there. But I think the issue is being bipolar doesn’t automatically translate into being more creative. There are people who have natural creativity and also have bipolar disorder, and during their manic episodes, they get the energy to produce a lot of of their artwork or their writing. It’s not always their best stuff. Sometimes when they get fully manic, they produce a lot of material, but then they throw it all out when they’re well, because they they don’t see it, think it’s up to snuff. I think the key point is what you made about hypomania versus mania, because during mania, people don’t tend to produce lots of good work. It’s during hypomania when they have more energy, more creative thinking. They sort of think beyond the box, using worn out expression during hypomania, and sometimes they can produce more work then, better work then. Now, of course, that does bring up the problem of, should people go off their medications? They I do get questions like, maybe I’m a famous musician, or maybe I would be if I if I had gone off my medication, maybe I’d be a Tchaikovsky or somebody like that. The issue, of course, is if somebody is truly bipolar and they go off their medications, they could end up in the hospital with a long aftercare period and a depression to follow, and can really set their life back. Now, and I think it’s kind of overstated, this idea that lithium or other drugs destroy creativity. They can blunt mood. There’s no question your mood can become feel feel more blunted. But whether it really erases creativity is not at all clear. What we usually encourage people to do is have a sit down with their psychiatrist where they can talk about dosage. Maybe the dosage of lithium could be dropped, or they could be maintained at a lower lithium level and still have the energy to do their artwork or their creative output. But that’s a kind of a risk benefit decision they have to make with their doctors.
Curt Widhalm 16:27
I think bipolar disorder tends to have one of the reputations as far as this is something that has to be treated medically first, and for clients out there, for the clinicians who are listening to this, what is it that the clinicians can help clients do if clients don’t want to do medication, if the medication is not being taken regularly, if it’s even something that the client doesn’t want to have as part of their treatment plan? What are the options for the therapists out there?
Dr. David Miklowitz 16:59
Okay, so if you’re encountering someone who has true bipolar one disorder, they’ve had manic episodes, you know, of the hospitalizable variety, or, you know, variety that would have gotten them in trouble with the police or destroyed relationships, and they’ve had depressions; first thing is, I think, have to tell them the primary treatment for this disorder is medications. What medication you take might differ. It might not have to be lithium. It might be an anti convulsant, it might be one of the other mood stabilizers or an anti psychotic medication. There are a lot of options in terms of which medication and which side effects you have to suffer suffer through. But some people say, I don’t want to do medication, no matter what. One I would tell them two things. One, develop a relationship with the psychiatrist first. Even if you’re not taking medications, have a psychiatrist who can treat you if you go into an episode, so if you’re showing the early warning signs of mania, that doctor can prescribe something for you so it doesn’t get fully out of hand. Secondly, use some lifestyle management techniques that help with bipolars who are like managing your sleep, wake cycle, going to bed at the same time, waking up the same time, the next day, if you’re able to sleep, hopefully, then you can if you keep your sleep wake cycle regulated, your mood is likely to follow and be more stable. Get exercise so you don’t fall into deep depression. Make sure you’re not making major life decisions when your mood is unstable. Don’t, you know, decide to move to Los Angeles to become a rock musician. When you’re right in the middle of a hypomanic episode or manic episode, or invest all your money all of a sudden. You have to be aware of your mood state. I encourage people to track their mood on a calendar, a mood chart, and keep track of you know, are they high or low or even keeled on any given day, how’s their sleep? And this kind of record keeping on yourself can be quite useful when your mood starts to change. So that’s what I would do, is make sure they have the backdrop of a psychiatrist so they can rely on that person when they’re getting worse.
Katie Vernoy 19:17
What I’ve seen with folks who have the have bipolar disorder, or, you know, members of their family. My clients have members of their family with bipolar disorder. When it’s my client, I can know whether or not they are actually complying with medication and those types of things, and when it’s a family member, I can only guess or know what my clients know. But what I’m finding is that even folks who are fairly consistent with their medication, you know, or completely consistent and committed to their their medication, there are still episodes that occur. And I think I was under the impression early on that if you take your bipolar medication consistently, you’re going to be fine, like you, you will stop having highs and lows, or they will be so muted that they will just feel like kind of normal life. And what I’ve really seen is that even when someone’s on their medication, there are possibilities that someone can go into a pretty high manic episode or be really stuck in kind of a depressive state. And so it seems like there’s, you know, and then obviously there’s different levels of, you know, kind of disorder, or however we want to talk about it. But for folks who are really struggling, where medication is helpful but potentially not sufficient, and, you know, they try some of these things, but those things can get harder. If depression starts, you know, kind of sliding in, or if mania starts sliding in, it can be hard to follow these lifestyle changes. How can someone actually improve their quality of life? How they can they have relationships with with the people that they care about, without kind of ruining those relationships in either a depressive romantic state like it, it feels like such a daunting diagnosis to really get a handle on. And so, so I guess I’m broadly asking, like, what do you do with somebody that’s really struggling and medication and even lifestyle changes are not totally sufficient.
Dr. David Miklowitz 21:13
One thing, and I probably should have mentioned this earlier, that I recommend for every bipolar person, is psychotherapy. There needs to be a an ongoing either individual or family or group therapy that you’re a part of. I, we particularly emphasize family therapy, particularly for these younger folks might be in their early 20s or late teens and are having their first episodes, or even, you know, middle aged or older people who are suffering from long term depressions, their spouse and their family members need to understand what this is and the fact that, where is it a depression? Where is it just a personality feature? When is the person getting worse? What can we do when they’re getting worse? Who can we call? That kind of family education, we’ve found, is very important for preventing recurrences and also bringing people out of depressions more rapidly, having the family support, being able to communicate clearly with their family members, for their family members to know how to respond when they feel suicidal, not to lay guilt trips on them, for example, or give bromides like, Hey, you only have One Life to Live, or God wants you to live this long. Or, you know, look at how badly your kids would suffer if you did that. You know, that’s not the way someone who’s suicidal wants to be, wants to hear. They want to hear empathy and validation. And we could teach families to do that. Likewise in psychotherapy, individual psychotherapy, person could learn what their warning signs are, what signs are that their mood is getting worse, and some of the strategies they can use to try to keep those symptoms from getting worse. Now, the medication, though, these are not perfect medications, and it is, you’re right. It’s inaccurate to say that if you take these drugs, you’ll always be episode free. We know you’ll have fewer episodes when we know the episodes won’t be as severe, but you may still have episodes and you may have also depression in between episodes. Now question is, are you on the right medications? Are you should you get a second opinion? What we encourage people to do all the time is, if you’re not benefiting from your medication, and your doctor is sort of throwing up their hands and saying, you know, I’ve done everything I can, I don’t know what else to do. Get a second opinion. Get somebody who’s an expert to do an evaluation. Nowadays, you can do this by telehealth, by zoom, or something like that, have somebody evaluate you and give us, you know, suggestions on other medications or other treatments to try. Ketamine, for example, is now being used for depression, mainly for unipolar depression, not Bipolar but I don’t think it’ll be long before we start hearing about it in bipolar disorder. There are other treatments, transcranial magnetic stimulation, that’s being used with bipolar depression. So there are other options other than just taking pills. I really think the ideal treatment protocol is one that combines psychotherapy with medications, so individual therapy or family therapy, or both, plus seeing a psychiatrist for medication management.
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Curt Widhalm 24:26
There seems to be a lot of comorbidity with substance abuse issues when it comes to folks diagnosed with bipolar disorder. Can we talk about how this shows up in a lot of different ways. I can make my guesses on how it might show up, but I’m going to leave this one to you.
Dr. David Miklowitz 24:47
You sure you don’t want even give me your guesses first?
Curt Widhalm 24:50
Well, my guess is, is that it’s both something that has the potential to be a self medication aspect, either to manage the depressive end of things, maybe things that help to bring about some of the good feelings of mania. But I’m also wondering if there’s some substances that end up triggering some of the episodes that happen in tier two.
Dr. David Miklowitz 25:16
Yes, absolutely. That’s right on what you just said. The comorbidity with alcoholism is very common. In some studies of adults, it’s 40 to 50% who’ve had a substance abuse problem at one point or another. Sometimes that’s alcohol. And of course, during depression, people drink a lot, and that does make their depression worse. It interferes with sleep, it causes weight gain, and, you know, impairment of functioning, and people think they’re drinking to make themselves feel better, but the the feeling better is usually very short lived, because the next day, of course, they feel worse. Marijuana is an interesting one. Cannabis is interesting one because people say they smoke weed or eat weed or whatever, vape it to alleviate anxiety and in the short term, yes, it can alleviate anxiety, but it also can contribute to anxiety in the long term. So if you look the next day, the person may be more anxious than they would have been that they hadn’t gotten high. It also can affect motivation to go out and do the kind of exercise you might need, or active activity, or social activity, may make people more likely to withdraw. So we encourage people to not if they can’t stay away from it, at least do some harm reduction. You know, don’t be don’t be drinking and getting high every day instead of taking medications, because the medications won’t work and the course of the illness is going to be worse. There are some drugs in addition that really do make bipolar much worse. Cocaine is in that category that can trigger a manic episode. Some of the hallucinogens, narcotics, even some of the prescription drugs, like taking too much Adderall can be, the stimulant for ADHD, can be trigger for a manic episode in some people. So you have to be very careful when you have this, this disorder. But then again, people use it because they say it makes them feel better at times when their medications aren’t working adequately.
Katie Vernoy 27:19
I think the other thing too, especially for marijuana and potentially even ketamine, I don’t know, but that it seems like there’s a desire to move away from some of these medications that have pretty gnarly side effects, and trying to find a more quote, unquote, natural way, or something that just, you know, we’re behind the times. These will get approved, kind of things, where they’re trying to find something different. I mean, what are the side effect profiles for some of the approved treatments for bipolar?
Dr. David Miklowitz 27:50
Sure, and that is true. Many of the medications can be tough to take, and first, as a caveat, you have to make sure you get the right dosage. You know, if you have very heavy side effects, it’s time for the discussion with your doctor about how that’s affecting you. Weight gain is one that people complain a lot about, particularly with antipsychotics like Abilify or Seroquel or some of those Risperidone, shaking of hands, drowsiness, dizziness, and for some people. With lithium, needing to urinate frequently is a side effect. Water retention in some teenagers actually, not even in only teenagers. Some young people, you see a lot of acne developing when they take lithium. But all these things first, many of these side effects are worse at the beginning, and they can be adjusted either with dosage adjustments or other medications that are meant to control those those side effects. Selenium and zinc, are used for hair loss with drugs like valproate. So there are, and Depakote, so there are, there are ways around it, but we have to acknowledge, yes, it is a cost benefit decision, but it’s not going to be solved by smoking weed. You know, it’s people can try to talk themselves into that, but there is no evidence that marijuana controls manic and depressive cycles, even if it makes you feel a little better in the short term.
Curt Widhalm 29:25
You had mentioned family therapy earlier, and I think that the very limited experience that I have in working with clients with bipolar disorder is there’s sometimes the acceptance of their own patterns over things, but especially for working in adulthood with clients, family members who might just be sick of all of the behaviors that go around bipolar disorder already kind of their own history with experiencing a lot of it. What do you find really helps to bridge bringing some of the family discussions around or helping to repair some relationships as it comes to understanding this from some of those folks.
Dr. David Miklowitz 30:06
When we see families and we have a protocol we call family focused therapy, or FFT, as we call it. It’s 12 sessions long, and it starts with family education about bipolar disorder. We bring in the person with a disorder and their immediate relatives, which might be mother, father, might be spouse, might be siblings. And one of the first things we do is ask the person with a disorder, what do you experience during a manic episode, and what do you experience during a depressive episode? Describe it to us. We have a handout. Which of these symptoms do you recognize? What’s it like to be depressed? What’s good about being manic? Why are you attracted to that state? Then we turn to the relatives and say, What have you seen when they have been depressed or manic? What’s, what’s disturbing to you about it? What have you tried to do to make them feel better? What’s worked and what hasn’t? Now, often the patient will chime in at that point and say, well, everything you’ve done doesn’t work because you scream at me to get out of bed. You tell me I’m lazy. Blah, blah, blah, and often, what comes out of that are some agreements on how the family should talk about this disorder. You know, let’s think about it as a biological disorder in the same way we might think of asthma or diabetes or a muscular disorder or something that the person has limited control over. What do they have control over? What do they not? The family tends to be very critical if they think the person is making decisions that makes life more difficult for everyone else. If they understand that some of this is not fully controllable, they tend to be more sympathetic and more empathetic. But to do that, you have to make clear to the person, where are you making decisions and what which of your behavior is really kind of feels like it’s driven by the illness. When families are on the same page about that stuff, and there’s a willingness to work together, I think family relationships work much better. It’s not, not easy.
Katie Vernoy 32:09
One of the things I’ve seen is when there is a place of empathy and there’s an understanding and a taking care of the individual with bipolar, there can be times when the dynamic kind of shifts to one of whether it’s infantilizing the person with bipolar or having the person with bipolar kind of assume that everyone else will cater to them, and not having the space or the empathy or the skill set to necessarily have compassion for a family member that’s having a bad day, right? It’s like, you know, I have an excuse. I have a disorder. You’re just being mean to me today, you know? And so what do healthy relationships look like? Because I I have a sense, I have asthma, I have some other things, so I know what it looks like when my loved ones need to work around whatever my disorders are. I don’t know what it looks like with bipolar, where it feels healthy, where it feels like it can get into this space of really a mutuality that we might expect in other types of relationships.
Dr. David Miklowitz 33:17
Yeah, and I would say that first families have to grow into that state. They don’t, they aren’t born knowing how to deal with someone with bipolar disorder. Nor does the person with bipolar disorder know how to deal with angry relatives. There’s been a construct that’s been around in psychological research for some time, expressed motion, which refers to how family members deal with a person with mental illness, and the two features of it are criticism and emotional overprotectiveness, and those two things actually can both contribute to recurrences. If there’s a family is very conflictual, very aggressive or blaming, or if they’re doing things for the person that the person could do for themselves. Neither one of those things are healthy, but to get to a low expressed emotion environment, person with a disorder has to take responsibility for their own behavior. They have to be willing to say, you know, I could fill my medications myself. My mom doesn’t need to do it. I don’t need to be told when to go to bed. I don’t need to have someone pull me out of bed in the morning. These are things I could take responsibility for myself and make life a little easier for my family members. But that requires acknowledging you’ve got the disorder and that you want to have independence from your family. You want to be able and this is particularly a sensitive issue for people in their early 20s, they say, I want to be away from my family. I want to live independently. But yet, they’re doing your laundry, your laundry for you, for you, you’re, they’re filling your medications. They’re reminding you to take them. They’re reminding you when to eat. Which of those things can you do by yourself and relieve them of that responsibility. Now, will the family let them go? That’s another issue. Will the, will the parents say, I don’t think he’ll take his medications if I don’t remind him, so I’m going to keep reminding him, which then becomes a bone of contention. You see things I like, what I saw once with a family where an 18 year old was, his mother was really pestering him. Have you taken your lithium today? Every time you get upset, she would say, you sound like you’re getting manic again. Or if he’d laugh too loudly when he was watching a movie, take more lithium. He started leaving his tablets all over the house for her to find. He’d leave them on the counters behind the toilet, underneath her pillow, and she would, you know, she would say, I’m going to throw you out of the house if you’re not going to take these medications. They had to come to an agreement about taking, him taking the medicines, showing sharing his lithium level report with her, and her being willing to let him make his own mistakes. Very much like any developmental behavior.
Curt Widhalm 36:03
You have a book.
Dr. David Miklowitz 36:05
Yes.
Curt Widhalm 36:05
Could you tell us about it?
Dr. David Miklowitz 36:07
It’s called “Living Well with Bipolar Disorder: Practical Strategies for Improving Your Daily Life.” And what it is is it’s a book about how to live on a day to day basis with bipolar disorder. Really the things we’ve just been talking about. How do you deal with anxiety? How do you deal with chronic irritability, sleep disturbance? What are the workarounds? What can you do to prevent a manic episode? How do you anticipate it? What can you do when you’re depressed, other than just take medications? How do you get yourself up and working you know, out and about. What about the stigma of the illness? How do you deal with people’s attitudes if you want to go out on dates? How do you explain this to a person you’ve just met that you have bipolar disorder? Substance abuse, what role is that playing in your life? What problems do you run into in the working world with this disorder? How people treat you? That’s what the book is really about. Suicidality, how do you cope with suicidal thoughts or the desire to self cut or burn yourself when you’re in an episode? There are workarounds for all these things. None of them are fail safe. But what I’m trying to do with this book is convince people that there’s more you can do other than just taking medications to manage the disorder. So that’s, that’s the what the book is, is really meant for. It’s people with the disorder and their family members.
Curt Widhalm 37:29
And where can people find out more about you? And where that can they find your book?
Dr. David Miklowitz 37:34
Being published by Guilford press. You should be able to find it online again. It’s called Living Well with Bipolar Disorder. And if you want to know more about me, I have a website. Our clinic has a website. It’s Semel, S, E, M, E, L, dot, U, C, L, A.edu/champ, C, H, A, M, P, which is Child and Adolescent Mood Disorder Program: CHAMP. And that’s where all the information about our program and family focused therapy and books and so on can be found. You know, it’s a difficult disorder to live with, for families or for people who have it, but I do think one can be optimistic for a better future if you kind of grab hold of it and know as much as you can about how to live with it on a day to day basis.
Curt Widhalm 38:22
And we will include links to Dr Miklowitz’s book and to the Semel Institute on our show notes over at mtsgpodcast.com. Make sure that you follow us on our social media. Join our Facebook group, the Modern Therapist Group, to continue on these conversations, and until next time I’m Curt Widhalm with Katie Vernoy and Dr David Miklowitz.
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