Marissa was a 17-year-old with bipolar I disorder and comorbid attention deficit hyperactivity disorder, who lived with her mother, father, grandmother, and two brothers, one 19 and one 16. She was being treated with lithium 1200 mg and quetiapine 200 mg. She had had several instances of self-injurious behaviors (e.g., cutting). Her parents described the household as a "war zone" due to her frequent outbursts of rage. All family members agreed that Marissa's rages created huge problems for the family, but they disagreed on the causes of these episodes. Her mother described them as being "manic-like," with rapid speech, excessive movements, and flight of ideas. She was particularly worried about how Marissa would cope when she went off to college the following year; would she curse at her professors and alienate her roommates? Marissa claimed that her "attacks" were largely triggered by the highly critical, hostile, and insulting interactions she had with her brothers, who, she said, regularly called her "fat and stupid." When asked, her brothers used more colorful words to describe her behavior.
In the early sessions of FFT, the clinician encouraged Marissa, her parents, and her brothers to identify the triggers, early warning signs, and potential preventative strategies for her rage reactions. Her reactions were often precipitated by family arguments (e.g., certain looks from her brothers) or multiple requests from her parents that confused her. The clinician assisted her in developing a stress thermometer, which clarified the stages of her angry escalations. Marissa and her family members were then encouraged to use a set of emotional self-regulation techniques when her mood escalations began, including: disclosing to one another that "something isn't feeling right"; using calming self-talk "when we feel the heat rising"; mindful breathing; exiting the situation (e.g., going outside to cool down), or attempting to separate the warring members of the family.
With repeated practice, Marissa found that she could better control her outbursts with her parents, but was still repeatedly provoked by her brothers. When their interactions degenerated into back and forth yelling matches, she was especially likely to start self-cutting. The communication enhancement module focused on her relationships with her brothers and encouraging each of them to practice active listening (paraphrasing, asking clarifying questions, nodding one's head to show acknowledgment). The use of these skills was helpful to Marissa and her brothers in slowing down their volatile interactions. Being able to limit negative interchanges to a maximum of three "volleys" also helped to reverse these predictable sequences.
In the final segment of FFT, Marissa and her parents worked on problem solving to maximize her chances of making a successful adjustment to college. The sessions included how to manage her medications (i.e., filling her medication prescriptions and taking her pills without reminders), getting herself out of bed in the morning without continual intervention by her parents, and completing household tasks. They also involved emotional self-regulation techniques to use when she felt herself becoming angry with others (e.g., deep breathing, distraction).
By the end of treatment, Marissa still had impulsive, angry reactions brought on by negative interactions with her brothers. However, both Marissa and her parents reported that these episodes were becoming fewer and further between, did not last as long, and were not as destructive. She reported fewer suicidal thoughts and better overall mood states. Her brothers, although still angry with her, acknowledged that they had not understood the nature of her mood disorder, had on many occasions deliberately provoked her. She acknowledged, in turn, that they were becoming more patient with her. At termination, she continued with her ongoing pharmacotherapy appointments but did not seek additional therapy.