Relatives' Emotional Involvement Moderates the Effects of Family Therapy for Bipolar Disorder

Objective: The "critical comments" dimension of the expressed emotion (EE) construct has been found to predict the illness course of patients with bipolar disorder, but less is known about the "emotional overinvolvement" component. The goal of this study was to evaluate whether relatives' observed appropriate and inappropriate emotional involvement (intrusiveness, self-sacrifice, and distress about patients' well-being) moderated the effectiveness of a family-based intervention for bipolar disorder. Method: 108 patients with bipolar disorder (mean age = 35.61 years, SD = 10.07; 57% female) and their relatives (62% spouses) from 2 clinical trials completed 10-min problem-solving interactions prior to being treated with pharmacotherapy plus family-based therapy (FBT) or brief psychoeducation (crisis management [CM]). Patients were interviewed every 3-6 months over 2 years to assess mood symptoms. Results: When relatives showed low levels of inappropriate self-sacrifice, CM and FBT were both associated with improvements in patients' manic symptoms over 2 years. When relatives showed high levels, patients in CM became more manic over time, whereas patients in FBT became less manic. Group differences in mania trajectories were also observed at high levels of inappropriate emotional response but not at low. When relatives showed high levels of appropriate self-sacrifice, patients in both groups became less depressed. At low levels of appropriate self-sacrifice, patients in CM did not improve, whereas patients in FBT became less depressed. Conclusions: Future studies of bipolar disorder should consider the prognostic value of the amount and appropriateness of relatives' emotional involvement with patients in addition to their critical behaviors.