Multidimensional Family Therapy for Adolescent Cannabis Users

244 Pages·2013·1.79 MB·English

Multidimensional Family Therapy
For Adolescent Cannabis Users
CCYYTT
Cannabis Youth Treatment Series
Volume 5
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
Multidimensional Family Therapy for
Adolescent Cannabis Users
Howard A. Liddle, Ed.D.
CYT
Cannabis Youth Treatment Series
Volume 5
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
Acknowledgments
Numerous people contributed to this document, which is part of the Cannabis
Youth Treatment (CYT) Project Cooperative Agreement. The document was written
by Howard A. Liddle, Ed.D. (University of Miami School of Medicine). The
Children’s Hospital of Philadelphia (CHOP) staff, University of Miami Center for
Treatment Research in Adolescent Drug Abuse staff, and the Steering Committee
(Thomas Babor, Michael Dennis, Guy Diamond, Jean Donaldson, Jim Herrell, Susan
H. Godley, Frank Tims, Charles Webb, and William White) provided valuable guidance
and support on this document. Significant contributions to the MDFT approach
have been made by Dana Becker, Gayle Dakof, Gary Diamond, Guy Diamond, Aaron
Hogue, Tanya Quille, and Cindy Rowe.
Disclaimer
This report was developed with support from the Center for Substance Abuse
Treatment (CSAT) to CHOP through Grant No. TI11323. The report was produced
by Johnson, Bassin & Shaw, Inc., under Contract No. 270–99–7072 with the
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services (DHHS). Karl D. White, Ed.D., served as
the CSAT Knowledge Application Program (KAP) Project Officer; Jean Donaldson,
M.A., as CSAT CYT Project Officer. The content of this publication does not
necessarily reflect the views or policies of CSAT, SAMHSA, or DHHS.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced
or copied without permission from SAMHSA or CSAT. Citation of the source is
appreciated. However, this publication may not be reproduced or distributed for a
fee without the specific, written authorization of the Office of Communications,
SAMHSA, DHHS.
Electronic Access and Copies of Publication
This publication can be accessed electronically through the following Internet
World Wide Web connection: www.samhsa.gov/. For additional copies of this document,
please call SAMHSA’s National Clearinghouse for Alcohol and Drug Information at
800–729–6686 or 800–487–4889 (TDD).
Recommended Citation
Liddle, H.A. Multidimensional Family Therapy for Adolescent Cannabis Users,
Cannabis Youth Treatment Series, Volume 5. DHHS Pub. No. 02–3660 Rockville, MD:
Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration, 2002.
Originating Office
Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration, 5600
Fishers Lane, Rockville, MD 20857.
DHHS Publication No. (SMA) 02–3660
Printed 2002
Cover images ©2000 Digital Stock.
Table of Contents
I. Background on the CYT Cooperative Agreement . . . . . . . . . . . . .1
Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Overview of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Expected Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
II. MDFT Approach to Cannabis Treatment . . . . . . . . . . . . . . . . . . . .3
Evolution of the MDFT Protocol . . . . . . . . . . . . . . . . . . . . . . . . . .3
Overview of the Treatment Model Intervention . . . . . . . . . . . . . . .4
Dimensions of Multidimensional Family Therapy . . . . . . . . . . . . . .5
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Problem Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Ecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Treatment Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Defining the Clinical Model in the CSAT–CYT Multisite Project . . .7
General Theoretical Assumptions and Approach . . . . . . . . . . . . . .7
Theory of Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Protective factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Adolescent development . . . . . . . . . . . . . . . . . . . . . . . . . .9
Theory of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Principles of Multidimensional Family Therapy . . . . . . . . . . . . . .14
Basic Requirements for Clinics Offering MDFT . . . . . . . . . . . . . .16
Treatment Locale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Treatment Duration and Intensity . . . . . . . . . . . . . . . . . . . . .17
Nature of Clinical Contact . . . . . . . . . . . . . . . . . . . . . . . . . .17
Staffing Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Clinical Supervision Requirements . . . . . . . . . . . . . . . . . . . .18
Overview: The Three Stages of the MDFT Treatment Program . . .18
Stage One: Build the Foundation . . . . . . . . . . . . . . . . . . . . . .18
Stage Two: Prompt Action and Change by Working the
Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Stage Three: Seal the Changes and Exit . . . . . . . . . . . . . . . .27
Modules Are Intervention Targets . . . . . . . . . . . . . . . . . . . . . . . .28
Whole and Part Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Multiple Domains of Simultaneous Intervention . . . . . . . . . . . . .29
Interventions With an Adolescent . . . . . . . . . . . . . . . . . . . . .30
Interventions With Parents and Other Family Members . . . . .31
Interventions with parents . . . . . . . . . . . . . . . . . . . . . . . .31
Interventions with other family members . . . . . . . . . . . . .31
Interventions To Change the Parent–Adolescent Interaction .32
Interventions With Systems External to the Family . . . . . . . .33
Therapeutic Case Management . . . . . . . . . . . . . . . . . . . . . . . . . .33
iiiiii
Multidimensional Family Therapy for Adolescent Cannabis Users
III. MDFT Sessions: Operational Features of the Approach . . . . . . . .39
The Three Stages of Treatment: An Indepth View . . . . . . . . . . . .39
Stage One: Build the Foundation . . . . . . . . . . . . . . . . . . . . . .39
Engaging the adolescent . . . . . . . . . . . . . . . . . . . . . . . . .39
Engaging parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Stage Two: Work the Themes . . . . . . . . . . . . . . . . . . . . . . . .45
Key themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
Therapist guidelines in working the themes . . . . . . . . . . .45
Dealing with the past in a present-centered therapy . . . . .46
Stage Three: Seal the Changes and Exit . . . . . . . . . . . . . . . .47
IV. Goals, Rationale, and Procedures of MDFT Interventions . . . . . .49
Key Concepts of MDFT Interventions . . . . . . . . . . . . . . . . . . . . .49
Multidimensionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Redefining Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Multiple Therapeutic Alliances . . . . . . . . . . . . . . . . . . . . . . .50
Linking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Whole–Part (Holon) Thinking . . . . . . . . . . . . . . . . . . . . . . . .51
Doing What It Takes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
“Parental Hell” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Working All Four Corners . . . . . . . . . . . . . . . . . . . . . . . . . . .52
What You Don’t Know CAN Hurt You . . . . . . . . . . . . . . . . . . .52
Organizing According to Modules and Stages . . . . . . . . . . . .53
Goals and Themes Emerge From the Interaction of the
Generic and the Idiosyncratic . . . . . . . . . . . . . . . . . . . . . . .53
Culturally Sensitive Treatment . . . . . . . . . . . . . . . . . . . . . . .54
The Adolescent Subsystem Module . . . . . . . . . . . . . . . . . . . . . . .54
Adolescent Engagement Interventions . . . . . . . . . . . . . . . . . .62
Case Example: There Is Something in This for You . . . . . . . . .65
Clinical Guidelines: Dealing With Drugs in MDFT . . . . . . . . . . . .70
MDFT, Drug Abuse, and Standard Family Therapy Practice . . .70
MDFT, Drug Abuse, and a Chemical Dependency Model . . . . .71
How To Deal With Drug Use and Abuse . . . . . . . . . . . . . . . . .72
In-Session Interventions Pertaining to Drug Use . . . . . . . . . .73
Practical Guidelines for the Use of Urinalysis in MDFT . . . . .77
Use of 12-Step Fellowships in MDFT . . . . . . . . . . . . . . . . . . .84
Case Example: Dealing With Drug Use Directly in Session . . .86
MDFT With Adolescent Girls . . . . . . . . . . . . . . . . . . . . . . . . .92
Cultural Theme Interventions . . . . . . . . . . . . . . . . . . . . . . . .93
Risky Sexual Behavior Interventions . . . . . . . . . . . . . . . . . . .97
Multimedia Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Psychiatric Consultation and Psychotropic
Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . .101
The Parents and Other Family Members Subsystem Module . . . .105
Parenting Relationship Interventions . . . . . . . . . . . . . . . . . .107
Parenting Styles and Practices Interventions . . . . . . . . . . . .110
Interventions With Other Family Members . . . . . . . . . . . . . .111
The Family Interaction Module . . . . . . . . . . . . . . . . . . . . . . . . .112
Case Example: I Want My Daughter Back . . . . . . . . . . . . . . .114
iivv
Table of Contents
Therapist Improvisation: Shifting Domains of Operation . . .114
Intentional and Unintentional Shifts in a Session . . . . . . . .116
Case Example: Building a Relationship Bridge . . . . . . . . . . .119
Extrafamilial Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
Interventions in Relation to the Peer Network:
The Ecomap Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
Interventions To Improve School Behavior and Academic
and Vocational Functioning . . . . . . . . . . . . . . . . . . . . . . . .136
Intervention Guidelines To Improve School Behavior and
Academic and Vocational Functioning of Drug-Involved
Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142
Decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
Collaborating With the Juvenile Justice System:
Probation Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
The interaction and interdependence of MDFT and
the juvenile justice system . . . . . . . . . . . . . . . . . . . . . .148
A collaborative, purposeful, youth-oriented alliance . . . .148
Additional Collaborations With the Juvenile Justice System:
The Important Subsystem of the Juvenile Court Judges . . .149
Repercussions of Lack of Involvement in Extrafamilial
Subsystems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152
V. Working the Model: The Interdependence of Emotions and
Cognitions in MDFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155
Negative Emotions and Problem Behaviors . . . . . . . . . . . . . . . .155
Emotions and Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . .156
Emotions and Dysfunctional Family Patterns . . . . . . . . . . . . . . .156
Case Example: Escalating Negative Emotion . . . . . . . . . . . . . . .157
Segment Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Segment One (Baseline): Negative Emotion in Action . . . . .158
Segment Two: Focus and Framing . . . . . . . . . . . . . . . . . . . .159
Segment Three: Emotions Inform Theme Development . . . .161
Segment Four: Working an Emotion-Related Theme and the
Interrelationship of Empathy and Constructivism . . . . . . .163
Segment Five: Using an Out-of-Session Crisis To Work a Core
Interpersonal Theme . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
Segment Six: In-Session Outcome . . . . . . . . . . . . . . . . . . . .169
VI. Procedural Steps: Implementing MDFT—Facilitating Key
Therapeutic Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Establishing Priorities and Making Decisions . . . . . . . . . . . . . .173
Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Linking as a Mechanism of Change . . . . . . . . . . . . . . . . . . . . . .174
Use of Self by the Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . .174
Incremental Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174
Therapist Improvisation: Shifting Domains of Operation . . . . . .174
Finding the Middle Ground . . . . . . . . . . . . . . . . . . . . . . . . . . .175
VII. Guidelines for Subsystem Sessions . . . . . . . . . . . . . . . . . . . . . .177
Guidelines for Seeing Parents or an Adolescent Alone . . . . . . . .177
Guidelines for Seeing Parents and an Adolescent Together . . . .179
vv
Multidimensional Family Therapy for Adolescent Cannabis Users
VIII. Appendixes
Appendix A. Key Terms and Abbreviations . . . . . . . . . . . . . . . . . . .181
Organizing Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181
Theory-Related Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
Clinically Related Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
Appendix B. Administrative Issues in Implementing
MDFT in CYT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Therapist Training, Supervision, and Protocol
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Roles of clinical coordinator and supervisor . . . . . . . . . . . .187
Supervision goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Supervision schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Cross-site standardization . . . . . . . . . . . . . . . . . . . . . . . . .187
Therapist training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
Quality Assurance of Treatment . . . . . . . . . . . . . . . . . . . . . . .188
Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188
Treatment adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
Written documentation . . . . . . . . . . . . . . . . . . . . . . . . . . .189
Chart review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
Project Clinical Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . .190
Common Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .190
Missed sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190
Lateness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190
Participants showing up high . . . . . . . . . . . . . . . . . . . . . . .190
Threat of harm to oneself or others . . . . . . . . . . . . . . . . . .190
Participants receiving collateral services . . . . . . . . . . . . . .191
Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
Dropped cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
Data Storage and Staff Access . . . . . . . . . . . . . . . . . . . . . . . . .191
Audiotape and Videotape Storage and Access . . . . . . . . . . . . .192
Participant ID Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
Crisis Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
Assessing Suicidality and Threat of Harm to Others . . . . . . . . .192
If the participant commits to safety . . . . . . . . . . . . . . . . . .193
If the participant does not commit to safety . . . . . . . . . . .193
If a patient refuses inpatient admission . . . . . . . . . . . . . . .193
Phone Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193
If the participant commits to safety . . . . . . . . . . . . . . . . . .193
If the participant does not commit to safety . . . . . . . . . . .193
If there is a threat of violence . . . . . . . . . . . . . . . . . . . . . .194
If the participant has contraband (e.g., weapons
and drugs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
Deciding on a Higher Level of Care . . . . . . . . . . . . . . . . . . . . . .194
Appendix C. Videotape Analysis Outline/Format . . . . . . . . . . . . . .195
Activity Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
Goals of the Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
vvii
Table of Contents
Appendix D. Summary of the MDFT Research Program . . . . . . . . .197
Randomized, Controlled Trials and Studies of MDFT . . . . . . . . . .199
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200
Appendix E. Clinical Management of a Multisite Field Trial of Five
Outpatient Treatments for Adolescent Substance Abuse . . . . . . .207
IX.References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
vviiii
I. Background on the CYT Cooperative Agreement
Goals and Objectives
The purpose of the Substance Abuse and Mental Health Services
Administration’s (SAMHSA’s) Center for Substance Abuse Treatment’s
(CSAT’s) Cannabis Youth Treatment (CYT) Project Cooperative Agreement was
to test the relative effectiveness and cost-effectiveness of a variety of interven-
tions designed to eliminate marijuana use and associated problems in adoles-
cents and to provide validatedmodels of these interventions to the treatment
field. The target population was adolescents with cannabis use disorders of
abuse or dependence, as defined by the American Psychiatric Association
(1994), who were assessed as appropriate for treatment in outpatient
settings.
Overview of the Study
The study was conducted in collaboration with staff from Chestnut Health
Systems (CHS–MC) in Bloomington and Madison County, Illinois; University
of Connecticut Health Center (UCHC) in Farmington, Connecticut;
Operation Parental Awareness and Responsibility (PAR) in St. Petersburg,
Florida; and Children’s Hospital of Philadelphia (CHOP). It involved five
manual-based, expert-supported treatment conditions:
• Motivational Enhancement Therapy/Cognitive Behavioral
Therapy (MET/CBT5)—This is a five-session treatment composed
of two individual sessions of motivational enhancement therapy
and three group sessions of cognitive behavioral therapy. The MET
sessions focus on factors that motivate clients to change. In the
CBT sessions, clients learn skills to cope with problems and meet
needs in ways that do not involve marijuana or alcohol.
• MET/CBT5 + CBT7—This treatment is composed of the complete
MET/CBT5 treatment combined with seven additional group
sessions of CBT. The primary difference between this and
MET/CBT treatment is the provision of more CBT sessions over
a longer (12-week) period.
• Family Support Network (FSN)—The family support network
treatment includes the MET/CBT5 + CBT7 treatment, with the
provision of additional support for families (home visits, parent
education meetings, parent support group), aftercare, and case
management.
• Adolescent Community Reinforcement Approach (ACRA)—The
adolescent community reinforcement approach is composed of 12
individual sessions with an adolescent and/or the adolescent’s
“concerned other.” It focuses on teaching alternative skills to
cope with problems and meet needs, with an emphasis on the
adolescent’s environment. Concerted effort is made to change the
11
Multidimensional Family Therapy for Adolescent Cannabis Users
environmental contingencies—both positive and negative—
related to continued substance use.
• Multidimensional Family Therapy (MDFT)—Multidimensional
family therapy is the multisystemic family-focused treatment
described in this manual for experienced family therapists that
includes 12 weeks of in-clinic and telephone sessions working
with individual adolescents and their families. MDFT targets the
psychosocial functioning of individual family members, the family
members’ relationships, and influential social systems outside the
family.
These treatments vary by mode. The first three are combinations of individual
and group approaches, and the last two combine individual and family or
significant-other treatment approaches. Further, the MET/CBT and ACRA
interventions are based on behavioral treatment approaches, whereas the
FSN and MDFT interventions are based on family treatment approaches.
Third, they vary in terms of resource intensity and cost when the final analyses
are completed.
At each site, approximately 150 adolescents were randomly assigned to
one of three conditions. At UCHC and PAR, they were assigned to the brief
MET/CBT5 or one of the two other individual/group combinations of
MET/CBT5 + CBT7 or FSN. At CHS–MC and CHOP, adolescents were
randomly assigned to the MET/CBT5 treatment or one of the two individual/
family approaches of ACRA or MDFT. All conditions were replicated at two
or more sites and were manual driven with expert work groups supporting
them. All clients were assessed at intake and at 3, 6, and 9 months. To
validate clients’ responses, urine tests and collateral assessments were done
at intake and at 3 and 6 months.
Expected Products
The 3-year study began in October 1997. Starting in spring 1998, adolescents
with marijuana abuse or dependence problems who were appropriate for
outpatient treatment were assigned to one of the treatment conditions.
The recruitment and treatment phase of the study lasted 12 to 15 months.
Clients were followed up on a flow basis from 9 months after their intake
through spring 2000, and analyses were conducted during the project on
baseline needs, costs, outcomes, and cost-effectiveness.
The study has produced a series of research and treatment manuals that
can be used by other providers and evaluators, as well as scientific findings
on the characteristics of adolescents entering outpatient treatment, the
effectiveness of the five treatment approaches, and estimates of their costs
and cost-effectiveness. These materials and findings will be distributed
through a variety of channels, including professional conferences, journal
articles, annuals, and the project’s Web site (www.chestnut.org/).
22