Brief Strategic Family Therapy and Multidimensional Family Therapy
Peter is 15 year-old teenager who lives with his parents. His father is a mechanic whilst his mother does casual jobs. His father is a chronic alcoholic. Peter started drinking when he was 12. Most of his associates also drink. Peter has been arrested twice for stealing cash from groceries shops. Both times he had been taken to the court and ordered to do community service. He has never been sent to jail although he is under supervision by the juvenile system. He has been suspended from school severally and his grades are below average. He is being treated at the local community clinic. So far, he has been treated 3 times for his alcohol use problem but he relapses after every treatment. Most of his therapy consists of individual sessions with the therapist although his mother attends once in a while. He also attends group therapy sessions for alcoholic teenagers in his locality. His father has refused to participate in his treatment. Peter has no relationship with his father. His father physically abuses his mother and his younger siblings.
This fictitious case scenario presents a typical picture of many families affected by adolescent and adult substance abuse problems. Adolescent drug use is a pressing public health concern in many nations. It affects both male and female youths regardless of their racial or ethnic background. It is linked to immediate and long-term adverse consequences on users and their families such as school suspensions/drop-outs, emotional and behavioral problems, delinquent/criminal activities, early pregnancies, increased risks for sexually transmitted diseases, accidental injury, and death. Adolescent substance use is also costly for health care systems and the society at large (Robbins et al., 2011). In this paper, six articles related to two family therapy approaches, brief strategic family therapy (BSFT) and multidimensional family therapy (MDFT) will be reviewed. One of these treatment models will then be recommended for the management of the family in the presented case scenario.
Brief review of BSFT and MDFT
BSFT is a manualized mode of treatment that targets aspects of family functioning linked to substance abuse and behavioral problems amongst adolescents. It is a structured, directive, problem-focused, and practical approach that follows a prescribed process. The therapy is flexible in that it permits the contents of the treatment to be tailored to each family’s problems (Robbins et al., 2011). BSFT is provided in phases, each patient typically receives 12 to 16 sessions over a duration of 4 months. Booster doses of up to 8 sessions are also provided if deemed necessary.
Multi-dimensional family therapy (MDFT) is a multi-system, multi-dimensional, developmental-ecological, family-based treatment. It is a comprehensive, multicomponent, and phase-oriented therapy. It targets the individual attributes of the adolescent, parental, family, and peer factors that lead to the development, continuation, and exacerbation of substance use and related problem behaviors. The assumptions underlying MDFT include; adolescent substance abuse is a multicomponent phenomenon; family functioning is crucial in establishing new, developmentally congruent lifestyle alternatives for youths; problem situations are opportunities for assessment and treatment interventions; change is multidimensional, stage-oriented, and multidimensional; motivation is malleable but is should never be assumed; several therapeutic alliances are needed and all this alliances create a base for change; individualized interventions promote developmental competencies; treatment occurs in phases but continuity should be emphasized; the role of the therapist is emphasized; and finally, the attitude of the therapist is critical to success (Liddle et al., 2002). MDFT is provided on an outpatient basis, once a week over a period of 4-5 months.
Multidimensional Family Therapy
“Multidimensional family therapy (MDFT) for adolescent drug abuse: results of a randomized clinical trial” is an article that reports the findings of a study by Liddle et al. (2002). In this study, 182 adolescents abusing marijuana and alcohol were randomized to either MDFT, multifamily educational intervention (MEI), and adolescent group therapy (AGP). These treatments were provided once a week on an outpatient basis by community clinicians trained as therapists prior to the study and supervised throughout the duration of the clinical trial. Evaluation of the effectiveness of the three methods was done via a theory-based multimodal assessment. This strategy assessed symptom changes as well as improvements in prosocial functioning. Evaluations were done at the start, end, 6th and 12th months after the study had been terminated. The results showed improvements in participants in all three treatment groups. Participants in the MDFT group, however, had the greatest reduction in drug use improvements in prosocial functioning. Prosocial functioning was assessed using academic performance and behavioral ratings of family functioning. The findings support the efficacy of MDFT in the management of adolescent drug abuse. MDFT has several approaches. The approach utilized for this particular study is relevant to the management of Peter and his family. In the cited randomized clinical trial, it was found to be effective than IME and AGP. Additionally, it addresses the individual attributes, family factors, and other social factors such as peer pressure that contribute to the development and maintenance of substance use behaviors. These factors are present in Peter’s case. MDFT is also tailored to the individual and family’s therapeutic needs. Substance abuse is a universal problem but the treatment of individuals and families needs to be tailored to their problems. MDFT thus provides a framework within which treatment can be individualized to meet the needs of Peter and his family. The adolescent and family members are also actively involved in the therapy process for instance, in setting objectives for the treatment.
“Family-based therapies for adolescent alcohol and drug use: research contributions and future research needs” is a report of a randomized trial by Liddle et al. (2004). The study aimed at comparing the efficacy of MDFT vs. manualized peer group therapy. The study had 88 participants of Hispanic and African-American origin. The age of the participants enrolled from the study ranged from 11-15 years. The participants in this study were mainly male (74%). The therapeutic sessions were provided on an outpatient basis. Each patient/family received 1-3 sessions per week for a duration of 3-4 months. Evaluations were done at 6 weeks after intake and at termination. Follow-up assessments were done 6 and 12 months after intake. The findings of the study indicate that youths in the MDFT group displayed more improvements than those in the group therapy group on all outcomes. These improvements were on the following parameters substance abuse, affiliation with deviant peers, delinquency, internalizing distress, school and family functioning. The participants in the MDFT group were 2.3 times more likely to move from being substance abusers at intake to abstinence at the 12-month follow up (23% vs. 44%). They were also less likely to be put on probation (10% vs. 30%) and to report disruptive behaviors than their group therapy counterparts.
The findings of the study are significant to the presented case scenario. They suggest that MDFT is more effective than group therapy in reducing delinquent/criminal behaviors, substance abuse, and associations with deviant peers. They also suggest that MDFT enhances coping with life stressors. The patient in the fictitious scenario is grappling with these issues thus the treatment modality is pertinent to his care. Another important aspect about the findings of the study is that the changes were maintained at 1-year follow up. Peter has been in and out of therapy 3 times and has had relapses soon after completing each session. Therefore, MDFT may be beneficial for him because it seems to promote maintenance of learnt positive behaviors.
“A randomized controlled trial of intensive outpatient family based therapy vs, residential drug treatment for co-morbid adolescent drug abusers” is a research article by Liddle and Dakof (2002). The number of participants in the study were 113. Of these, 67% were males. The mean age of the youths in the study was 15. Majority of the participants were of Hispanic origin. 81% were involved with the juvenile justice system. The study compared the efficacy of MDFT vs. residential treatment. The therapeutic sessions were provided at home and on an out-patient basis 1-3 times a week for 4-6 months. Assessments of the efficacy of the 2 treatment modalities were done at the 4th, 12th, 18th, 24th, 36th, and 48th months. The attrition rate was lower for the MDFT group. The findings of the study were as follows: MDFT youths reported a more rapid decrease in severity of drug use problems, self-and-parent/guardian-reported aggressive behaviors, frequency of drug use, and delinquent activity than RT youths. The participants in the RT group spent more days, on average 60 days, in restricted environments like jails than MDFT youths. Follow ups done between 18 months and 4 years after the end of the study indicate that MDFT is better at maintaining treatment gains than RT. Drug use problems among RT youths had increased at the 18-month follow up. The HIV risk increased for RT youths at the end of 4 years. The treatment goals of the participants in this study that is, reduction in the severity and frequency of drug use, delinquent behaviors, aggression, and incarcerations are similar to those of Peter’s case. Therefore, the findings can be used as an evidence-base for Peter’s therapy. MDFT was also found to promote maintenance of positive changes. Maintenance of treatment gains is clearly an objective in Peter’s therapy considering that it is his fourth time seeking treatment for his alcohol problem. The strengths of MDFT in this realm can be capitalized on in Peter’s management.
Brief Strategic Family Therapy
“Brief strategic family therapy (BSTF) versus treatment as usual: results of a multisite randomized trial for substance abusing adolescents” is the report of a 2009 randomized clinical trial by Robbins et al. (2011). The objective of the trial was to determine the efficacy of BSTF vs. treatment as usual (TAU). The 2 treatments were provided on an outpatient basis in 8 community settings within the tenets of drug abuse programs. 471 adolescents of Hispanic, Caucasian, and African-American origin participated in the study and were randomized to one of the two treatments. The study was conducted at 8 community treatment agencies in the US. The 49 therapists who participated in the study were also randomized to either TAU or BSFT. The primary outcome for the study was adolescent drug use. The outcome was assessed every month via participant self-report and urinalysis for up to 12 months post randomization. The secondary outcomes for the study were treatment engagement, retention, and adolescent and family functioning at the 4th, 8th, and 12 months post randomization. The median number of self-reported drug use days was significantly higher for TAU than BSFT at 12 months post intake. BSFT was also more effective in engaging and retaining family members in treatment as well as improving family functioning than TAU.
The findings of this study have relevance to the presented fictitious case. In the study, Peter is an adolescent with alcohol use problems. His father is also an alcoholic and he has on previous occasions refused to participate in Peter’s rehabilitation. BSFT, therefore, offers a potential solution to the therapeutic needs identified in the case. Notably, majority of the adolescents who participated in the study were of Hispanic origin. This implies that the findings can be generalized to Peter’s family which is also of Hispanic origin. BSFT also focuses on family functioning and how dysfunctional ties in this system contribute to the development, continuation, and exacerbation of drug related problems amongst adolescents. The findings, therefore, have implications in the management of Peter because his family is grappling with similar issues.
“Principles for defining adverse events in behavioral intervention research: lessons from a family-focused adolescent drug abuse trial” is a review article by Horigian et al. (2010). The authors to this article reviewed the principles for defining adverse events as well as how they were applied in the BSFT vs. TAU effectiveness study by Robbins et al. (2011). The principles/procedures for identifying, monitoring, and reporting adverse events were adopted for the study were established during protocol development by experts in the study, ethicists, medical safety officers, and senior investigators. In total, five guiding principles were used to define adverse events in the BSFT vs. TAU trial. They entailed: adverse events must be validated and plausible, and monitoring systems must be systematic, able to evaluate relatedness, and are a shared responsibility for all participants in the therapeutic process.
The non-serious adverse events identified for the study were arrest, suspension and or dropping out of school, running away, violence, and being kicked out of home. The serious adverse events for this study included physical or sexual abuse, homicidal behavior, suicidal behavior, hospitalization, and death. These events were applicable to both the adolescent participants and members of their families. In the BSFT vs. TAU study, 57.5% of the participants experienced at least one adverse event during the course of the trial. The frequency of these events was less for family members (4.5%). Arrest (59.2%), school suspension/ drop-out (51.6%), and running away (28.5%) were the most common events for the adolescent group. The most common events amongst family members were violence (40.9%) and arrest (21.3%). Notably, the incidence of adverse events amongst family members in the BSFT group was higher than the TAU group (6.1% vs. 2.8%). Although the utility of these findings outside the trial are unknown, the principles identified for monitoring and tracking adverse events can be applied in Peter’s management. The events can in particular be used to assess the effectiveness of BSFT. In other words, the article articulates outcomes that can be applied to monitor the effectiveness of Peter’s therapy.
“Brief strategic family therapy: lessons learnt in efficacy research and challenges to blending research and practice” is a review article by Santisteban et al. (2006). The article presents the key lessons learnt from the BSTF vs. TAU study by Robbins et al. (2009) as well as those of 30-year research on BSTF. The authors posit that BSTF is effective in incorporating hesitant family members into treatment. Not all family members are usually eager about participating in the treatment of adolescent showing symptoms of drug use. Specialized strategies for reaching out to reluctant family members found effective in two randomized clinical trials include well-planned telephone conversations and home visits. These tactics are purposed to identify and address the reasons underlying the refusal to participate. Citing the findings of several studies, the authors contend that BSFT reduces the severity and frequency of drug use and improves family functioning. It also fosters the maintenance of treatment gains for periods of up to 1 year. The authors argue that maintenance of these changes occurs because BSFT targets the deviant behaviors of adolescents as well as family factors such as poor family functioning that contribute to substance abuse and conduct problems. The findings of this article have important implications in the management of Peter and his family. It provides strategies that can be utilized to engage Peter’s dad in the therapeutic process. It also articulates the importance of incorporating and addressing family factors in the management of substance abuse amongst adolescents. This is crucial because the past therapies Peter has received have mainly been focused on him. No explicit efforts have been made to address the familial factors such as his father’s alcoholism and violence that may be contributing to his problem.
Conclusion
The articles reviewed did not compare the efficacy of MDFT and BSFT directly. Therefore, conclusions cannot be made on which of the two treatment modalities is more effective. Their findings seem to suggest though that both treatment modalities are more efficacious when compared to TAU, group therapy amongst others. Abundant empirical evidence suggests that the factors that contribute to substance abuse among adolescents are multi-factorial, multi-dimensional, and they involve multiple systems. These factors include individual attributes, parent and familial interactions, and extrafamilial social systems. In peter’s case, parental, familial, and peer factors include poor parent relationship, parental alcoholism, domestic violence, poverty, and negative peer associations. MDFT focuses on all these factors whilst BSFT targets only family functioning. Therefore, MDFT is a better treatment model than BSFT for the presented scenario.
References
Horigian, V. E., Robbins, M. S., Domniquez, R., Ucha, J., & Rosa, C. L. (2010). Principles for defining adverse events in behavioral intervention research: Lessons learned from a family-focused adolescent drug abuse trial. Clinical Trials, 7(1), 58-68.
Liddle, H. A. (2004). Family-based therapies for adolescent alcohol and drug use: Research contributions and future research needs. Addiction, 99(2), 76-92.
Liddle, H. A., & Dakof, G. A. (2002). A randomized controlled trial of intensive outpatient family-based therapy vs. residential drug treatment for controlled adolescent drug abusers. Drug and Alcohol Dependence, 66, S103.
Liddle, H.A., Dakof, G.A., Parker, K., Diamond, G.S., Barrett, K., & Tejeda, M. (2002). Multidimensional family therapy for drug abuse: Results of a randomized clinical trial. Am. J. Drug Alcohol Abuse, 27(4), 651-688.
Robbins, M.S., Feaster, D.J., Horigian, V.E., Rohrbaugh, M., Shoham, V., Bachrach, K., Miller, M., Burlew, K.A., Hodgkins, C., Vandermark, N., Schindler, E., Werstlein, R., & Szapocznik, J. (2011). Brief strategic family therapy versus treatment as usual: Results of a multisite randomized trial for substance using adolescents. Journal of Consulting and Clinical Psychology, 79(6), 713-727.
Santisteban, D.A., Suarez-Morales, L., Robbins, M.S., & Szapocznik, J. (2006). Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Farm Process, 45 (2), 259- 271.
