Ruby is a 16-year-old girl with bipolar disorder (BD) treated with lithium and low-dose quetiapine. The treatment has stabilized her mood and dissipated her anger. However, her sleep remains disrupted, her relationships with her parents are strained, and she reports continued suicidal ideation.

Family involvement is essential to treatment for youth with mood disorders. While some patients do well on medication alone, family conflict predicts suicidal ideation during depressive episodes in children, making family functioning a primary treatment target (Brent DA et al, Am J Psychiatry 2009;166(4):418–426). In pediatric BD, family-based psychosocial treatments reduce relapse rates and suicidality. Evidence-based family-inclusive treatments include family-focused therapy for adolescents (FFT-A) and dialectical behavior therapy for adolescents (DBT-A). Both demonstrate significant reductions in suicidal ideation in this population (Bahji A et al, JAMA Netw Open 2021;4(4):e216614). This article reviews family-based psychotherapy and how to help families access it.

Why psychotherapy?

Family-based psychotherapies improve core family functions (attachment, communication, cohesiveness, shared problem solving), reducing relapse and suicide risk. We explain to parents that addressing family factors is as important as medication and individual therapy. FFT-A targets familial and circadian disruptions in BD. DBT-A addresses emotional dysregulation and high-risk behaviors (eg, self-harm, suicidal ideation).

FFT-A

FFT-A is the most-studied family intervention for BD. It is conducted for 12 sessions over four months, and it covers psychoeducation, communication training, and problem-solving.

In an RCT with 127 participants, FFT-A demonstrated longer intervals between mood episodes and lower suicidal ideation over two years vs enhanced psychoeducation (Miklowitz DJ et al, J Affect Disord 2020;275:14–22). FFT-A has also been shown to halve relapse risk in at-risk kids (BD, depression) vs shorter psychoeducation, with strongest effects on depressive relapse (Miklowitz DJ et al, JAMA Psychiatry 2020;77(5):455–463). FFT-A also works to ease family conflict.

DBT-A

Lasting about four to six months, DBT-A is especially relevant for suicidal youth. In a randomized trial of 100 teens with bipolar spectrum disorder, DBT-A patients showed similar mood improvements compared with standard care, but had one-third the suicide attempts (Goldstein TR et al, JAMA Psychiatry 2024;81(1):15–24). The key skill patients learned was keeping their emotions from overwhelming them.

Shared elements of FFT-A and DBT-A

Both models:

• Teach parents to calm their child’s emotions in the moment. FFT-A does this in joint family sessions; DBT-A uses multi-family skills groups and individual parent coaching.
• Reduce blame, guilt, and stigma by teaching teens and caregivers that mood swings, irritability, and impulsivity reflect a brain-based vulnerability.
• Address environmental triggers, especially family conflicts.
• Help families validate teens’ emotions, communicate calmly, and keep the home environment supportive. This lowers relapse tied to “expressed emotion” (a home climate marked by criticism, hostility, or over-involvement).
• Build coping mechanisms through structured modules, behavioral rehearsal, role-playing, and homework.
• Prioritize symptom surveillance (eg, changes in sleep, speech, energy, or agitation) with plans to intervene before a full-blown episode.
• Help teens and families navigate ambivalence about psychotropic medication.

Sleep hygiene in FFT-A vs DBT-A

Sleep disruption is both a symptom and a trigger in BD.

FFT-A treats disrupted sleep as an early warning sign. Families chart mood and sleep, tracking decreased sleep need as prodromal for mania and hypersomnia for depression. They keep consistent bed, wake, and meal times; reduce screen time to stabilize circadian rhythms; and use communication skills to reduce bedtime conflicts.

DBT-A embeds sleep in its PLEASE process for reducing teen emotionality: treat PhysicaL illness, balance Eating, Avoid mood-altering substances, balance Sleep, and get Exercise.

When racing thoughts interfere with sleep, teens use distress-tolerance skills like TIPP (Temperature, Intense Exercise, Paced Breathing, Progressive muscle relaxation) and mindfulness techniques. They also track sleep via daily diary cards.

When school or social demands interfere with sleep, teens can use the DBT-A mnemonic DEAR MAN to advocate for a more workable sleep schedule: Describe the situation, Express concerns, Assert their perspective, Reinforce why their perspective is needed, Mindfully focus on the topic (without distraction), Appear confident, Negotiate.

Diet and exercise

Evidence for nutritional supplements in pediatric BD is limited and weak. A 2023 VA/DoD review found insufficient evidence to recommend for or against their use. Physical activity data are similarly thin, although too much or little exercise can destabilize mood (Stubbs B et al, JAMA Psychiatry 2026;83(5):535–542). Adult data suggest modest benefit from combined lifestyle interventions and stronger effects from sleep-focused approaches—which are built into FFT-A and DBT-A (Simjanoski M et al, Neurosci Biobehav Rev 2023;152:105257).

Choosing between FFT-A and DBT-A

While each patient and family is unique, consider FFT-A for family conflict and DBT-A for recent self-harm.

Since Ruby’s suicidal thinking comes in the context of family conflict, you refer the family for FFT-A.

Finding FFT-A and DBT-A therapists

Advise families to start with mood disorder clinics at academic medical centers. Directories include the Behavioral Tech Directory and DBT-Linehan Board of Certification for DBT-A, and a Psychology Today keyword search for “family-focused therapy” for FFT-A. The Depression and Bipolar Support Alliance, and the National Alliance on Mental Illness, can also surface vetted providers.

Families should ask potential therapists whether they were trained specifically in FFT-A. For DBT-A, they should ask whether the program includes multi-family skills groups and individual coaching, rather than just one-on-one sessions.

If FFT-A or DBT-A is unavailable, families can look for family or group psychoeducation with skill building for illness management. This is the best-supported and most accessible approach for depressive symptoms and suicidality, though the research focuses on borderline personality disorder, not BD (de Andrade D et al, J Clin Psychol 2024;80(10):2117–2133).

After six months of FFT-A, Ruby and her parents report improved communication, fewer conflicts, and reduced suicidality.

CARLAT VERDICT

Address family systems with pediatric BD. FFT-A has the strongest evidence for reducing relapse and suicidal ideation, while DBT-A is specific for reducing suicide attempts. Include sleep and routines as part of long-term management.