Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial.
Liddle H.A, Rowe C.L., Dakof G.A. et al. Request reprint
Journal of Consulting and Clinical Psychology: 2009, 77(1), p. 12–25.
Holistic family therapy helped younger teens and their families get back on track before problems escalate, but was substance use really their focal problem?
Abstract Multidimensional Family Therapy addresses problem drug use and related problems among adolescents not through a set regimen, but by applying principles and a therapeutic framework to the individual young person situated within a particular set of environmental influences and constraints. It can be centre- or home-based or both, residential or non-residential, and can be delivered from one to three times a week over three to six months, depending on setting, problem severity, and family functioning. What distinguishes it from some other family therapies is that therapists see substance use as potentially a problem in its own right, and that the intervention extends beyond To address substance use and other problems, therapists intervene simultaneously across four interdependent domains They aim to engage the young person in treatment, to help them communicate, relate to parents and other adults, and to develop social competence and alternatives to drug use. A parallel attempt is made to engage parents in the therapy, to deepen their involvement with their child, and to improve parental monitoring and limit-setting. Family sessions with parents and children address interaction patterns, aiming to reduce conflict, strengthen emotional attachments, and improve communication and problem-solving. Lastly there is a focus on improving how the family relates to all the social systems in which the child is involved, such as school, the juvenile justice system, and recreational opportunities. Therapists work just with the adolescent, with the parent(s), or with both, depending on the problem being addressed. the child and family to all the social systems (school, juvenile justice, etc) in which the child is involved, according to the particular vulnerabilities and strengths of the child and their family.
Research on such approaches has mainly targeted teenagers around 16 years of age. The featured study extended this down to 11–15-year-olds referred (mainly by juvenile justice or schools) for outpatient substance use treatment at a treatment agency in Miami, whose problems were not so severe as to require intensive or inpatient care, and who lived with a parent or parent-figure who could participate in their treatment. The 83 children were mainly boys from poor African-American or Hispanic families whose substance use problems fell short of dependence; nearly half were on probation or awaiting a court hearing.
With family consent they were randomly assigned to Multidimensional Family Therapy or group therapy based on cognitive–behavioural principles. The latter differed from the family therapy by treating groups of four to six youngsters together and working exclusively with them rather than directly Though these were addressed indirectly as risk factors and through seeking to develop the youngsters’ self-esteem, values and identity, decision-making, personal control, and interpersonal communication. with their families and social environments. Both treatments were manual-guided, conducted by trained and supervised therapists from the treatment agency twice a week for 12–16 weeks, and supplemented case management services. Family therapy was conducted mainly in the home, group therapy at the clinic, and the family option involved about half an hour a week more contact time, a difference adjusted for in the analyses.
Nearly all the family therapy children completed treatment as did three quarters in group therapy, unusually high. Outcomes were assessed during treatment, at discharge, and six and 12 months after treatment started. Trends across this period consistently Not just across the different outcomes but also in that there were no significant signs that family therapy was more or less beneficial for boys or girls, different ages or racial groups, or children referred from different sources. favoured the family therapy children and tended to be sustained in the post-treatment period. Before treatment, 72% of children assigned to family therapy admitted substance use in the past month compared to 45% in group therapy. The number who abstained increased more rapidly in and after family therapy until 12 months later just 13% said they had used in the past month compared to 54% in group therapy. Among those who did use at some stage, The analysis was based on that used in another study (http://dx.doi.org/10.1037/a0014160) which explained that this so-called ‘continuous’ measure “represented the frequency of substance use, given that some use had taken place … substance nonuse within each time period was treated as missing data … Thus, students who reported nonuse of a particular substance throughout the study contributed little information to growth parameter estimates…; however, any and all information related to positive substance use was incorporated in the derivation of growth parameters.” frequency of use also declined faster among the family therapy children. These statistically significant differences were accompanied by a greater decline in children’s accounts of the frequency with which they experienced substance-related problems, associated with delinquent peers, Though in both groups this declined. or committed delinquent acts, Among those who did commit such acts the frequency fell in family therapy but increased in group therapy. confirmed by court records showing that over the 12 months of the follow-up, fewer family therapy children were arrested (23% v. 44%) or placed on probation (10% v. 30%). Family therapy children also improved more in psychological health and reported greater and sustained improvements in the quality of family interactions. Both more positive interactions and fewer negative. These improvements “include core relationship characteristics (such as parental involvement and acceptance) as well as parenting practices (such as monitoring and consistency in discipline and limit setting)”. Improvements were absent in the group therapy children. Finally, school records indicated that academic (but only slightly) and disciplinary grades improved in and after family therapy but declined in group therapy.
Another report on the same study concluded that better relations with parents gained during both treatments helped curb post-treatment substance use. What partly made the difference between them was that (to judge by the child’s accounts) during treatment, family therapy parents started to monitor their children more closely. This seemed to account for more of their children becoming or remaining abstinent than after group therapy.
This latest study extends a series of studies often demonstrating greater positive impacts from Multidimensional Family Therapy than from alternative treatments for teenage substance use problems. In general family-based therapies which (like the featured intervention) also intervene in the child’s life beyond the family have been relatively rigorously tested against alternatives and emerged with a good record, presumably and sometimes demonstrably because they alter critical aspects of the environment within which the child’s behaviour is generated, which on their own children are relatively powerless to alter. A bonus is that these alterations can in theory also improve the prospects for other children in the family. Though rarely studied, there is some evidence that this can happen in practice (1 2).
Multidimensional Family Therapy in particular has distinguished itself by the sustainability (and even the growth; for example, 1 2) of the gains made during treatment. Typically the reverse is the case in adolescent substance use treatment. A plausible explanation is that Multidimensional Family Therapy initiates a mutually reinforcing set of interactions between the child, their family and the wider environment.
Promising as it is, Multidimensional Family Therapy has not yet been subject to the searching independent analysis which questioned the effectiveness credentials of a closely allied therapy, nor has it always outperformed well structured alternatives. In one study, it was slightly (but not significantly) less effective at promoting recovery from substance use problems than two other therapies Motivational interviewing plus group cognitive-behavioural therapy and a family/individual therapy based on reinforcing pro-social behaviours incompatible with substance use and skills training related to relapse prevention and problem solving. and substantially less cost-effective. Unlike most other studies of the therapy including the featured study, this study was led by an executive team which did not involve its developers. Some other methodological issues relating to the featured study are detailed below.
Strengths of the study include random assignment, a very high follow-up rate, sophisticated analyses controlling for extraneous influences on outcomes, careful data collection from children and parents separately and by researchers unaware which treatment they had been assigned to, and the use of the clinic’s own therapists treating the usual run of normally referred cases. This last point is an important indication of ‘real-world’ applicability; an allied therapy was found far more effective when delivered by specially hired and closely supervised graduate students than in less controlled conditions. However, as the authors acknowledged, the study was conducted at a single clinic and among a very particular caseload of poor minority children selected not to have very severe 39 out of 130 referrals to the study were excluded because their problems warranted more intensive treatment. substance use problems – hence its designation as an ‘early intervention’ trial intended to forestall rather than treat serious problems. Again as the authors acknowledged, the study was not fully independent researchers but led by the researcher who developed In several social research areas (see http://dx.doi.org/10.1007/s11292-009-9071-y, http://dx.doi.org/10.1177/0193841X06287188, http://dx.doi.org/10.1093/clipsy.6.1.95), these and other forms of ‘allegiance’ have been found to favour more positive findings than fully independent research. the family intervention based at a centre which sells training and certification in the therapy. Proportionately, almost twice as many family therapy (22 out of 40 or 55%) as group therapy (12 out of 43 or 28%) children claimed not to have used substances over the month before starting treatment, a difference in their starting points which weakens confidence that later differences were entirely due to the treatment which followed. Also it is unclear whether adjustments were made for the multiple outcomes tested in the study to reduce the possibility of chance findings, and whether the way statistical significance was tested effectively doubled the chances of a positive finding by assuming that the featured therapy could not have negative impacts. The treatment which family therapy outperformed, though typical of much youth drug treatment, was perhaps a weak comparator. Group therapy for adolescent drug users has a poor record compared to other structured approaches. One concern is that grouping high-risk youngsters together tends to reinforce their delinquency. While this may not overwhelm a well constructed and skilfully implemented therapy, it may weaken its impacts when compared to therapies which do not involve such grouping. Compared to another non-group approach, Multidimensional Family Therapy has led to more persistent gains on some measures of substance use/problems (problem severity, overall minimal use levels, and use of drugs other than cannabis or alcohol) but not in drinking or cannabis use.
Such therapies require a high level of competence on the part of the therapist, who has to be able to exercise judgement and flexibility in working with highly stressed families and to intervene simultaneously in several aspects of the child’s life. In turn this mandates a high level of support in the form of training, supervision and opportunities for sharing experiences with other therapists. Though time-limited, the therapy is resource-intensive. Perhaps the biggest question mark over the featured study is whether such expenditure could be justified by the current substance use problems of the children and the risk that these might mushroom in to severe problems, when there are older/other children and families which already have severe problems. At intake, 47% of the participants met criteria for substance abuse but just 16% met criteria for substance dependence, leaving over a third without any such diagnosis. Most denied any substance use over the past month, and those who did use, did so on average just over once a week. Among 13–14-year-olds in their neighbourhoods, such behaviour may not have been exceptional. Their general trajectory of delinquency, trouble with criminal justice and other authorities, and poor educational progress within economically stressed (and usually single parent) families, may have been a more appropriate target for intervention by child and family social work teams. Importantly though, Multidimensional Family Therapy has the flexibility to place dealing with substance use on ice if other issues seem more pressing and pertinent, and the approach it takes has relevance for troubled teens in general, whether or not substance use is a prominent feature.
Recent caseloads involving children with problems seen as warranting substance use treatment are such that many British health areas could justify the kind of service investigated in the study. Family therapy providers and services for children with multiple needs would be the most appropriate base. Multidimensional family therapists engage systems which should already have been engaged by a coordinated multidisciplinary team, so the approach may have particular relevance where such coordination is imperfect and where a single person orchestrating the various systems may have more success. There seems considerable scope for developing this work, Though commending family work, an audit by the English National Treatment Agency for Substance Misuse found that family therapy is very much a minority Though many interventions were unspecified, just 3% were identified as involving family work. response to youth drug and alcohol problems. In Britain, Glasgow has been piloting the feasibility, acceptability and effectiveness of Multidimensional Family Therapy training in changing clinician practices and clinical outcomes in young people’s alcohol and drug services.
For more on Multidimensional Family Therapy see the research project’s own web site, the therapy’s entry in the US government’s directory of evidence-based therapies, or download the manual used in one of the US studies. For more on family therapy in general see this US expert consensus document.
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