Christopher J Squillaro On The Benefits of Using a Family Approach for Treating Bipolar Disorder

Educate yourself. Don’t get all your information from your treatment team. There are tons of people who write about their experiences and something they say, that helped them, may resonate with you.

Bipolar Disorder, a condition that affects millions around the world, not only impacts the individual diagnosed but also their surrounding family. It’s becoming increasingly clear that the journey towards mental wellness is not solely an individual pursuit but a collective one. Incorporating family perspectives and integrating a family approach in treatment methodologies can be pivotal in achieving holistic healing and stability. As a part of this interview series, I had the pleasure of interviewing Dr. Christopher Squillaro.

Dr Christopher Squillaro is a Medical Director for Magellan Behavioral Health of Pennsylvania. He has 13 years of clinical experience working in community mental health and inpatient psychiatry. For the past two years, he has been working in managed care and does consulting for a Population Health company in Philadelphia.

Thank you so much for joining us in this interview series! Before we start, our readers would love to “get to know you” a bit better. Can you tell us a bit about your background and your childhood backstory?

I was raised in a suburb of Philadelphia, PA and am the oldest of 3 children. My father was a Periodontist and mom was a dental hygienist. Our Italian heritage was an important part of our family culture, so we were surrounded by lots of family and lots of food…really good food. Open communication was encouraged, and no subject was off limits for discussion around the family dinner table. The more challenging the better. Sometimes there were arguments, sometimes there were tears. But it always got worked out and it taught us the value of open and honest communication and how to approach difficult subjects.

My original plan was to become a lawyer. It was a plan I maintained through college until my senior year when I decided to pursue advertising/public relations. After a few jobs in that industry, I once again found myself starting from scratch with no idea what I wanted to do. I decided to marry two interests to find work and see where it took me. I had this desire to work with teenagers and loved the outdoors. I found a job working as a counselor at an outdoor experiential education camp in western Maryland, called New Dominion. The teens at New Dominion were court ordered and had a vastly different life than mine. This was really the first time I came to understand how fortunate I was. It opened my eyes to the effects that trauma, substance use, mental health and socioeconomic differences can play in a teen’s behavior. It’s a long a story, but essentially, my experiences there are what set me on the path to becoming a psychiatrist and gave me the strength to accomplish the goal.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“Things are never as good or as bad as they seem.” My dad would say this all the time and extended it to people. He was adept at finding the middle ground with anyone, no matter their personality style. The curiosity it takes to understand the perspective of the whole story or person, and to avoid defining events, information and people by extremes requires skill development. I failed more than I succeeded trying to emulate this. Getting beyond the superficial appearances and actions, including my own, was challenging to avoid letting emotions drive my immediate reactions. I started working on this in high school and found it fit well for resolving conflict and being a confidant to people who were struggling with the often-fluctuating feelings of a teenager. I was a non-judgmental sounding board for people, and it helped me develop strong relationships. I also began to appreciate being in that role and the seeds were laid for what would ultimately become my career, despite not seeing it that way at the time.

These are critical skills for a psychiatrist. People come to me with behaviors that they aren’t always proud of or feel they can control. They don’t want to feel that I judge them and can get past the behavior to look deeper. That’s hard to do when you’re not willing to take a piece of information that someone has defined as “bad” and ask the questions needed to understand it. Conversely, it’s difficult to challenge someone to do new things when they define their behavior as “good”, even when it is impacting their functioning. Exploring this with someone involves not seeing things as good or bad, but being neutral and seeing the things that impact what they want in life and the consequences of behavior that gets in the way.

Let’s now shift to the main part of our discussion. Can you tell us a bit about your background and your professional career treating patients with bipolar disorder diagnoses?

Like most physicians, my residency experiences have held a prominent influence on my career. Seeing medical conditions for the first time at varying degrees of acuity and severity stays with you, like any first experience does. The expert supervision and immediate support helped me develop the confidence and knowledge to manage these situations as a practicing physician. That being said, my most formative years of understanding bipolar disorder were founded at University of Maryland/Sheppard Pratt, where I trained. Treating the extremes of both affective poles and everything in between is critical to identifying emerging symptoms. If the symptoms get severe at either extreme, psychosis can develop and complicate treatment even further. I also saw some very stable people living with bipolar who managed their symptoms and life around the diagnosis. Understanding how to support someone in recovery is as important as knowing how to navigate it when they relapse. It was a great program to learn the full spectrum of interventions that can be used to treat.

During residency, I found throughout my career that bipolar had a range of presentations. Someone with severe mania or depression usually presented on the inpatient unit because they had stopped medications and stopped attending outpatient treatment. Seeing how the consequences of their mood +/- psychosis affected more than themselves was powerful. Families and friends suffered as much as their loved ones. The other side of that was how rewarding it was seeing some of those patients and families in an outpatient setting. I have worked in every type of psychiatric setting there is, including drug and alcohol and nursing homes. Identifying bipolar disorder has been relevant in every environment. Bipolar disorder needs to be on every psychiatrist’s mind since it can present in so many different ways.

When you work with patients, I understand that you often integrate family or friends into the treatment process. What do you consider the 3 primary benefits of including family?

The first would have to be the care that a family and good support system can offer someone in recovery from either a manic or depressed episode in the outpatient setting. Social connections that go out of their way to learn about the disease, encourage treatment, and contribute to the patient’s sense of who they are can be the motivation to manage bipolar the most effective way. That would be preventing relapse of symptoms.

Second, when there is a relapse of symptoms and they are severe or getting to be, involvement of family and friends can help patients understand the importance of restarting medications or initiating new treatments to minimize the impact. I once had a patient in an inpatient setting who was refusing medications and refusing to hear what I was saying. I called their mom, she showed up and said, “do it”, and the patient did. It’s not always that easy, but family and social connections can speak louder than any degree or years practicing.

Third, medications are only a piece of the treatment. If there are not people and things to make life enjoyable and worth living, the meds can only do so much in terms of fostering treatment adherence.

What are some of the challenges you run into when working with families? How do you balance responding to the needs of the family with the needs of the patient?

Families process pain, disappointment, and grief in different ways. They can project that pain onto others, and physicians are not immune from this. The family may want a definitive answer, quick fixes and results based on unrealistic expectations. They rapidly cycle through their grief, and it can come out onto the staff trying to help or the patient themselves. I can’t blame them. They feel out-of-control and are hurting. The challenge is, so are everyone else who is trying help and most importantly, so is the patient. But the most challenging families, by far, are the ones that never show up, but could.

I speak to patients the way I talk in general; directly, honestly and with the idea that people respond best to sincerity. If a family presents as a challenge, I say it to my patient, if not the family themselves. They or the patient either offers a perspective I don’t have, or it gives the patient permission to express their own feelings about it. If a family is amazing, I tell the them that I see it, appreciate it, and value that for them and their loved one. If a family is not coming through for whatever reason, I express my concerns. Bottom line is that I try to speak the truth when it is helpful and within professional boundaries to do so, even if it isn’t the easiest thing to hear. It cuts right to the chase and lets everyone know where the other stands.

Family dynamics can greatly vary depending on the sociocultural backgrounds of the individuals involved. How do you tailor your family approach to respect and incorporate different sociocultural perspectives and values?”

I recognize that I may unintentionally say or do something that can be construed as disrespectful or offensive to someone’s sociocultural background. If I sense a difference at the onset of a conversation, I start by explaining that I may not understand their family culture and will need some guidance from them on how to help their loved one that respects the differences. If I was not able to get a sense of those differences and happen to offend their sociocultural, perspectives and values, I address it directly.by assuring them that is not my intention and need their help and patience to understand the best way to communicate. Then I do everything in my power to respect their feedback and engage in a conversation. Establishing understanding when there are clear or unclear differences is the best pathway forward, and that may require some extra work to be done early in the relationship.

Likewise, inter-generational dynamics can sometimes play a significant role in the therapy process. Can you share any insights or experiences on how inter-generational understanding and communication facilitate the healing process?

I am Generation X. Growing up I heard a lot from Baby Boomers and The Greatest Generation about the fate of this country when people like me will be running it. As an adult I heard my generation say the same things about Milenials and Gen Z. There are a lot of assumptions that go into those kinds of blanket statements and thoughts. There is also a tremendous amount of criticism and implied disappointment as well. If there is conflict, I’d bet these sentiments are conveyed through attitudes, actions, and even words. There aren’t many relationships that can begin a healing process with this looming.

When including families where inter-generational dynamics are a barrier, I will do a lot of education around this. If families come together to help someone, regardless of generational differences, there is way more going on in that relationship that is positive and caring. This is not something that resolves quickly. It is important to look for common ground from which to take the first steps. Working to get the relationship to a firm spot from which to continue walking a journey together is a start.

Many mental health professionals don’t have training in working with families. How did you learn the techniques you use and what would you recommend to professionals that want to learn more about this approach?

Mental health providers are no different from any other medical provider. There are time crunches, productivity expectations and data driven indicators that are geared toward a population cohort. All of which makes individualizing treatment a little more strained. And that’s just in dealing with the patient. When layering in families, there are entirely new personalities and opinions that require extra effort to establish rapport and to learn effective communication, as we discussed above. In training, we learned how best to, and were expected to include families. In every clinical position I have had this was an expectation as well. The best way to do this is to accept that it needs to be done. Once you get into the mindset that this is crucial to help people, it adds extra assurance that you have access to the patient’s home resources and knowledge of the patient in their world from the family’s perspective. Then you can develop strategies for engaging the family better.

At the top of the list, is to never assume or judge. Just like I need to learn about the patient, I need to learn about the family unit and other supports. This helps establish them as an ally. The best way to learn is to ask direct questions in a neutral tone. When I feel like I have enough information, I formulate what I have heard so far in a summary and ask if that is accurate. Once I get their approval that I have demonstrated understanding, I switch tactics and begin to explain what I see are the next steps. Sometimes this involves clarification or further discussion. It may even involve prioritizing and triaging where the focus needs to be more immediately. I’ll often say to a family wanting to jump steps, “That’s an important point. For right now (I avoid using the word “but”) we need to accomplish x, y, & z before we know that. So that’s where I’m going to put the focus for now. We’ll come back to that after we get more information.” Then I summarize the immediate plan and see if there are questions. Having an outline and sticking to it will enable you to learn and tweak the approach, navigate bumps in the road and develop a consistent and efficient way to maximize time with families.

Caring for a family member with bipolar disorder can sometimes be challenging and might lead to caregiver burnout. How does your approach incorporate strategies for self-care and support for family members who are involved in the caregiving process?

Over the years, I have found there are a lot of similarities between caregiver burnout and people who are retiring from service-oriented careers (police, fire, military, etc.). Spending a life or large block of time in the service of others is inherently structured around the other person’s or people’s needs. It can be a time of singular focus with heavy emotional demands. It becomes their identity and eventually, there doesn’t feel like there is enough to give and guilt can creep in and drive behavior. When it is over, which is inevitable, that sense of structure and purpose is gone. In the process, the care giver may have lost their own priorities and sense of themselves.

I use the analogy of oxygen masks dropping from the ceiling in an airplane and ask if they understand why they would put it on themselves before a child. So far no one who is a caregiver has answered correctly because their first thought is always of the other person. Then I explain that people can go minutes without the oxygen mask. If yours is secured and you are getting oxygen you can spend the time placing it on them correctly, even if they fight you. Or, if you’re not wearing it as you begin to lose consciousness and see them remove theirs, there may be no one to help either of you. Helping yourself does not come at the expense of the person you are caring for; it contributes to both lives. For caregivers who are not taking care of themselves I predict out the difficulties, depression, and motivational struggles in trying to figure out who they are after such a long hiatus of paying attention to themselves. For care givers who account for this along the way, I check in to make sure that they are attuned to the value of it and assure them that it is also the best way to help the person they are caring for.

Preventive education is often seen as a powerful tool in managing bipolar disorder symptoms. How do you integrate education and awareness for family members within your family approach to treating bipolar disorder?

There are patterns that people have in general and then more specific ones that you can begin to identify when you get to know someone. For example, I caution patients and families that when symptoms stabilize there is a likelihood of vacillating adherence to the medications. This can be from either a false sense of security that they will never decompensate, fatigue from strict adherence, or a desire to feel the energy and euphoria of mania again, to mention a few. By predicting this for the person in treatment and alerting them to the possibility, they may be more inclined to alert me when these feelings come up. Family members who are aware of these patterns may see the signs when the patient does not and may be prompted to contact me so that we can develop a plan.

I also address some of the unintended consequences of treating bipolar disorder. I have heard from many patients that they have lost their creativity; they aren’t as proficient in their job and things just don’t seem as fun as they were when they were manic. Being manic is an extreme, but continued functioning at that extreme is time limited. Depression could be around the corner or the consequences to family and friends could be devastating to the same extreme. When you experience an elated mood to that degree, being within a “normal” range will not compare. It’s important to understand that a person’s behavior while in a manic state can have catastrophic consequences such as overuse of substances, overspending of financial savings, destruction of relationships and worse. The ability to manage the extremes of mania and depression while living and enjoying life in the middle of these two extremes is key. It’s important to live within that range and find enjoyment. The longer individuals with bipolar disorder live within that range, the more enjoyment they get from life without all the negative consequences of touching each affective pole. At a minimum, staying on the medication and communicating with the prescriber when things begin to change is essential. Quality of life and happiness increase when they seek to balance the psychological, social, and spiritual aspects of their lives.

What are 5 things you wish more people knew about people navigating life with bipolar disorder?

1 . It is treatable. Like any chronic health condition, it requires a mix of medications, lifestyle changes and supportive therapies as needed. Be informed, proactive, preventative, and diligent.

2 . Recovery from any illness is a journey with ups and downs. Don’t become overly confident when things are going well and don’t be too hard on yourself when they don’t.

3 . Educate yourself. Don’t get all your information from your treatment team. There are tons of people who write about their experiences and something they say, that helped them, may resonate with you.

4 . Talk to the people who care about you. This article is largely about family involvement. Patients tell me all the time that they don’t want to “burden” others with their problems. The burden is when you don’t tell them. They care no matter what. They can only help when they know.

5 . Unfortunately, it’s not going away. Everybody deals with something. This is your thing, take care of it. Avoiding it will only ensure that your energy will go to picking up the pieces of what life could have been.

There is a lot of misunderstanding when it comes to mental illnesses, especially involving psychosis. What do you wish more people were aware of either in the professional field or the general public?

The hesitation to understand mental illness, leads to a lack of feeling understood if you’re dealing with it in your own life. That cycle needs to be broken to get to a place of having safer conversations about it. We have come a long way towards that goal as it gets openly discussed in articles like this one, as people in the spotlight give testimonials, and as younger generations are taught to accept it as opposed to avoid it. Mental illness is a medical condition rooted in the same biological processes as other medical conditions that people share freely.

In terms of misunderstanding psychosis, this could be an article unto itself. The source of “understanding” of psychotic disorders is important. There is a lot of misinformation being consumed through some of the same sources that are helping destigmatize other mental health conditions. I do think it’s a scary prospect for most people to imagine a world where reality becomes something that cannot be trusted. It’s not a far leap to then imagine what someone who is responding to the internal stimulation of psychosis could be capable of doing. Psychosis is a lonely condition. People with psychotic disorders are not inclined to interact socially because they don’t know what can be trusted. Overwhelmingly, they are non-violent. And, when on medication, are trying to have all the things that anyone wants out of life.

If I had to some up what I’d want people to be aware of, it would be to have a curiosity about the experiences of someone struggling with a mental health condition and make them feel safe to talk about it. Take a chance to share your own experiences so that it is not something you feel needs to be private. Because, just like the individual must live with their diagnosis, as a society, we have to as well. Communication and acceptance can shift the power from something that causes anxiety to something that can be managed.

We are very blessed that some very prominent names in Business, VC funding, Sports, and Entertainment read this column. Is there a person in the world, or in the US with whom you would love to have a private breakfast or lunch, and why? He or she might just see this if we tag them. :-)

Selena Gomez. Her mental health struggles have been public. She has spoken about her recovery journey and seemed to include many facets of what we’ve talked about in this article. That journey can speak to others, especially younger people who are the most at-risk group since bipolar tends to present early. Bipolar disorder didn’t stop her career. She continues to have success in the film, music and business industries and has handled her public image with dignity. She communicates her struggles clearly and has demonstrated her sincere intentions to help others by her philanthropy and advocacy efforts. Going back to, “nothing is as good or as bad as it seems”, I would guess the public facing story is not a true reflection of the work, support and lessons learned behind the scenes.

How can our readers further follow your work online?

LinkedIn Profile: https://www.linkedin.com/in/chris-squillaro-do-02999720a/

Magellan Health Insights Profile: https://www.magellanhealthinsights.com/author/squillaroc/

Thank you for your time and thoughtful answers. I know many people will gain so much from hearing this.

About The Interviewer: Stephanie Greer, PhD is the Co-founder and CEO of Akin Mental Health — a company dedicated to guiding families on their journey supporting a loved one with mental health challenges like bipolar disorder, schizophrenia and severe depression. Stephanie is passionate about this topic from her own personal experience growing up with a mother who struggled with bipolar 1 disorder and found a path forward to overcome the obstacles and live well. Stephanie’s professional experience includes a doctorate in neuroscience as well as design research roles at Hopelab and Apple. Stephanie brings this personal passion together with her world-class science and technology background to support families across the US in their personal journeys supporting loved ones with mental illness. To learn more about Akin Mental Health and join our community, visit us at akinmh.com.