Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use.

This study investigated the efficacy of brief strategic family therapy (BSFT) with Hispanic behavior problem and drug using youth, an underrepresented population in the family therapy research literature. One hundred twenty-six Hispanic families with a behavior problem adolescent were randomly assigned to 1 of 2 conditions: BSFT or group treatment control (GC). Results showed that, compared to GC cases, BSFT cases showed significantly greater pre- to post-intervention improvement in parent reports of adolescent conduct problems and delinquency, adolescent reports of marijuana use, and observer ratings and self reports of family functioning. These results extend prior findings on the efficacy of family interventions to a difficult to treat Hispanic adolescent sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: Report from two randomized controlled trials.

Objective: We used growth mixture modeling to examine heterogeneity in treatment response in a secondary analysis of 2 randomized controlled trials testing multidimensional family therapy (MDFT), an established evidence-based therapy for adolescent drug abuse and delinquency. Method: The first study compared 2 evidence-based adolescent substance abuse treatments: individually focused cognitive–behavioral therapy and MDFT in a sample of 224 urban, low-income, ethnic minority youths (average age = 15 years, 81% male, 72% African American). The second compared a cross-systems version of MDFT (MDFT—detention to community) with enhanced services as usual for 154 youths, also primarily urban and ethnic minority (average age = 15 years, 83% male, 61% African American, 22% Latino), who were incarcerated in detention facilities. Results: In both studies, the analyses supported the distinctiveness of 2 classes of substance use severity, characterized primarily by adolescents with higher and lower initial severity; the higher severity class also had greater psychiatric comorbidity. In each study, the 2 treatments showed similar effects in the classes with lower severity/frequency of substance use and fewer comorbid diagnoses. Further, in both studies, MDFT was more effective for the classes with greater overall substance use severity and frequency and more comorbid diagnoses. Conclusions: Results indicate that for youths with more severe drug use and greater psychiatric comorbidity, MDFT produced superior treatment outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Examination of ethnicity in controlled treatment outcome studies involving adolescent substance abusers: A comprehensive literature review.

The extent to which adolescent drug treatment outcome studies address ethnicity was systematically examined. Reliability coefficients were calculated for both the search methodology used to obtain these outcome studies and the extent to which ethnicity was addressed along several dimensions. The resulting coefficients were highly reliable. Findings indicated that although investigators of 94% of the outcome studies considered ethnicity to some extent, only 28% of these studies incorporated ethnicity into their design, and only 6% of studies involved statistical analyses to examine differential response to treatment or moderating effects of ethnicity with a sufficient number of ethnic minority participants. Overall, results indicated that there is much work to do regarding the examination of ethnicity in controlled treatment outcome studies involving adolescent substance abusers. Indeed, modifications were rarely made to the treatment components to accommodate ethnicity-related variables. Future recommendations are presented in light of these findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment techniques and outcomes in multidimensional family therapy for adolescent behavior problems.

The link between treatment techniques and long-term treatment outcome was examined in an empirically supported family-based treatment for adolescent drug abuse. Observational ratings of therapist interventions were used to predict outcomes at 6 and 12 months posttreatment for 63 families receiving multidimensional family therapy. Greater use of in-session family-focused techniques predicted reduction in internalizing symptoms and improvement in family cohesion. Greater use of family-focused techniques also predicted reduced externalizing symptoms and family conflict, but only when adolescent focus was also high. In addition, greater use of adolescent-focused techniques predicted improvement in family cohesion and family conflict. Results suggest that both individual and multiperson interventions can exert an influential role in family-based therapy for clinically referred adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Statewide adoption and initial implementation of contingency management for substance-abusing adolescents.

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary results for an adaptive family treatment for drug abuse in Hispanic youth.

A small randomized trial investigated a new family-based intervention for Hispanic adolescents who met DSM–IV criteria for substance abuse disorder. The Culturally Informed and Flexible Family-Based Treatment for Adolescents (CIFFTA) is a tailored/adaptive intervention that includes a flexible treatment manual and multiple treatment components. The study used an “add on” design to isolate the effects on substance abuse, behavior problems, and parenting practices attributable to the newly developed components. Twenty-eight Hispanic adolescents and their families were randomized either to the experimental treatment or to traditional family therapy (TFT) and were assessed at baseline and 8-month follow-up. Despite the small sample, results revealed statistically significant time × treatment effects on both self-reported drug use (marijuana + cocaine), F(1, 22) = 10.59, p     

Family therapy, substance abuse, and adolescents: Moving from isolated cultures to related components.

Reviews the books The family context of adolescent drug abuse, by R. H. Coombs (1988); Practical approaches in treating adolescent chemical dependency: A guide to clinical intervention and assessment, by P. B. Henry (1989); Consequences of adolescent drug abuse, by M. D. Newcomb and P. M. Bentler (1989); Adolescent drug abuse: Analyses of treatment research, by E. R. Rahdert and J. Grabowski (1988); Breakthroughs in family therapy with drug-abusing and problem youth, by J. I. Szapocznik and W. M. Kurtines (see record 1989-98115-000); and Family therapy approaches with adolescent substance abusers, by T. C. Todd and M. Selekman (in press). This spate of books includes representatives of three "cultures" interested in family therapy with substance-abusing adolescents: developmentally oriented research on substance abuse (Combs; Newcomb & Bentler; Rahdert & Grabowski), family therapy applied to substance abuse (Szapocznik et al.; Todd & Selekman), and the addiction/self-help approach (Henry). The coincidental publication of this large number of writings on families and adolescent substance abuse is encouraging. It suggests that all three cultures are vital and contributing. There are important well-written contributions in volumes from each culture. The disjointed status of the field may be a prelude to a significant integrative shift from the isolated cultures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems.

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist adherence in brief strategic family therapy for adolescent drug abusers.

Objective: Therapist adherence has been shown to predict clinical outcomes in family therapy. In prior studies, adherence has been represented broadly by core principles and a consistent family (vs. individual) focus. To date, these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinically relevant outcomes over the course of treatment. In this study, the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents who received brief strategic family therapy within a multisite effectiveness study. Method: Participants were 480 adolescents (age 12–17) and their family members, who were randomized to the Brief Strategic Family Therapist treatment condition (J. Szapocznik, U. Hervis, & S. Schwartz, 2003) or treatment as usual. The adolescents were mostly male (377 vs. 103 female) and Hispanic (213), whereas 148 were White, and 110 were Black. Therapists were also randomly assigned to treatment condition within agencies. Results: Results supported the proposed factor structure of the adherence measure, providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy. Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinically relevant ways and that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning, and reductions in adolescent drug use. Conclusions: Clinical implications and future research directions are discussed, including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adolescent and Parent Alliance and Treatment Outcome in Multidimensional Family Therapy.

In this study, the authors examined the relation between adolescent and parent therapeutic alliances and treatment outcome among 65 substance-abusing adolescents receiving multidimensional family therapy. Observer ratings of parent alliance predicted premature termination from treatment. Observer ratings, but not self-report, of adolescent alliance predicted adolescents' substance abuse and dependency symptoms at posttreatment, as well as days of cannabis use at 3-month follow-up. The association between adolescent alliance and substance abuse and dependency symptoms at posttreatment was moderated by the strength of the parent alliance. Results reveal the unique and interactive effects of the 2 alliances on treatment outcome and emphasize the need for a systemic and well-articulated approach to developing and maintaining the multiple alliances inherent to family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Developmental factors in the treatment on adolescents.

Most empirically supported interventions for adolescent mental health problems are either downward adaptations of adult treatments or upward adaptations of child treatments. Although these treatments show respectable effects with teens, a review of the outcome research reveals significant gaps, both in coverage of adolescent conditions and problems (e.g., eating disorders, suicidality) and in attention to the biological, psychological, and social dimensions of adolescent development. The authors critique the field, propose a biopsychosocial framework for the development of dysfunction and intervention, and discuss ways the developmental literature can and cannot inform intervention and research. A long-term goal is an array of developmentally tailored treatments that are effective with clinically referred teens and an enriched understanding of when, how, and why the treatments work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Associations between family structure, family functioning, and substance use among Hispanic/Latino adolescents.

This study examined the role of family structure and functioning in predicting substance use among Hispanic/Latino adolescents, surveyed in 9th and 10th grade. The sample (N = 1433) was half female, mostly of Mexican descent, and the majority was born in the United States. Living with a single father was associated with less parental monitoring and less family cohesion (γ = ?0.07, ?0.06, respectively). Living with a single mother was associated with less parental monitoring (γ = ?0.10). Living with neither parent was associated with less communication (γ = ?0.08), less parental monitoring (γ = ?0.09), more family conflict (γ = 0.06), and less family cohesion (γ = ?0.06). Less monitoring was associated with substance use at follow-up (β = ?0.17). Low rates of parental monitoring appear to mediate the association between parental family structure and substance use. Results suggest that improving basic parenting skills and offering additional social support and resources to assist parents in monitoring adolescents may help prevent substance use. These interventions may be particularly beneficial for single parents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in adolescent substance abuse treatment: A one-with-many analysis.

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment.

Married or cohabiting female drug-abusing patients (N=75) were randomly assigned to either a behavioral couples therapy condition (BCT, n=37), which consisted of group, individual, and behavioral couples therapy sessions, or to an equally intensive individual-based treatment condition (IBT; n=38), which consisted of group and individual counseling. During most of the 1-yr follow-up, compared with participants who received IBT, those who received BCT reported (1) fewer days of substance use, (2) longer periods of continuous abstinence, (3) lower levels of alcohol, drug, and family problems, and (4) higher relationship satisfaction. However, differences in relationship satisfaction and number of days of substance use dissipated over the course of the posttreatment follow-up period and were not significantly different by the end of 1 yr. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review.

Results from 23 studies examining associations between therapeutic relationship variables and treatment outcomes in child and adolescent therapy were reviewed with meta-analytic procedures. Results indicated that the overall strength of the relationship-outcome associations was modest and quite similar to results obtained with adults. This modest association was moderated by 1 substantive factor, type of patient problem, and 5 methodological factors, timing and source of relationship measurement, type and source of outcome, and shared versus cross-source measurement of relationship and outcome variables. Type, mode, structure, and context of treatment did not moderate associations between relationship variables and outcomes. Findings indicated that the association between the therapeutic relationship and treatment outcome was consistent across developmental levels and across diverse types and contexts of child and adolescent therapy. Recommendations for future process research on the therapeutic relationship in child psychotherapy are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents.

Many family therapies for adolescent drug use include ecological interventions. The purpose of this randomized clinical trial was to establish whether ecological interventions contribute to the impact of family therapy above and beyond the contributions of family process-only interventions. A family-based ecological approach, structural ecosystems therapy (SET), was compared with family process-only condition (FAM) and community services control (CS). One hundred ninety substance-abusing or dependent African American and Hispanic adolescents were randomized to SET, FAM, or CS. Follow-up assessments were conducted at 3, 6, 12, and 18 months postrandomization. SET was significantly more efficacious than FAM and CS in reducing adolescent drug use. However, these improvements were limited to Hispanic adolescents. The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treating paternal alcoholism with learning sobriety together: Effects on adolescents versus preadolescents.

The purpose of this study was to determine whether Learning Sobriety Together, a treatment for substance abuse that combines behavioral couples therapy and individual counseling, had comparable secondary benefits on the internalizing and externalizing behaviors of adolescent versus preadolescent siblings living in homes with their alcoholic fathers (N = 131) and their non-substance-abusing mothers. During a 17-month assessment period, the association between parents' functioning (i.e., fathers' drinking as determined by percentage of days abstinent and parents' dyadic adjustment) and children's adjustment (as rated by mothers, fathers, and children's teachers) was stronger for preadolescents than for their adolescent siblings, particularly in terms of children's externalizing behaviors. Interventions that reduce paternal drinking and improve couple functioning may serve as an important preventative intervention for preadolescents in these homes, whereas adolescents may need more intensive interventions to address internalizing and externalizing symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)