MDFT Study: Cannabis Use in Adolescents

1. Andreas Gantner Dr Olivier Phan Therapieladen Institut Mutualiste Montsouris Delphi Unité INSERM U669 Berlin Paris INCANT coordinator : Pr Henk Rigter

2. Participants CHU Brugmann , Brussels Fondation Phenix Genève Parnassia Den Haag Therapieladen Berlin Institut Mutualiste Montsouris Paris

3. Current MDFT Treatment Development and Outcome Studies • Alternative to Residential Treatment Clinical Trial (NIDA) • Early Adolescent Clinical Trial (CSAT) • Transporting MDFT to Day Treatment Program (NIDA) • Brief Version of MDFT (NIDA) • Long Term Follow Up (NIDA) • Juvenile Drug Court (NIDA) • Dependency Drug Court (NIDA)

4. The INCANT study • RCT comparing MDFT to TAU • Cannabis action research plan • Multidimentional Family Therapy MDFT : Pr.Liddle, University of Miami • Two phases: • A pilot study 2004 2005 ( MDFT training , 25 pilot cases included) • Main study ( strated NOV 2006, 360 patients included)

5. Primary hypotheses: Cannabis use • Youth assigned to MDFT will decrease their use of cannabis more than youth in TAU between baseline and 6-months follow-up assessments. This difference will be maintained or grow bigger in the period between 6 and 12 months follow-up. • Youth assigned to MDFT will be less likely to meet diagnostic criteria of cannabis disorders from the 6 months to the 12 months follow-up assessments than youth in TAU.

6. Secondary hypotheses (1) : • Changes in the consumption of alcohol and illicit drugs other than cannabis will be measured. • MDFT will reduce internalizing and externalizing symptoms of mental health or behavioural disorder • MDFT will improve family functioning (interactions between adolescent and other family members) • MDFT will improve school performance (better grades, less truancy) and pro-social behaviour (positive social activities)

7. Secondary hypotheses (2): • MDFT will be more acceptable to adolescents and their parents than TAU as evidenced by better satisfaction ratings at all follow-up assessment points, and higher treatment retention and compliance rates. • MDFT therapists will more effectively engage and retain adolescents in treatment than TAU therapists.

8. Inclusion criteria • Age 13 through 18 years • Adolescent used 5 or more time cannabis in past year • At least 1 parent available Living close enough to allow for ambulatory treatment • Adolescent and at least 1 parent do master local language and do understand questions • Diagnosis of cannabis dependence or cannabis abuse in the past year • Evidence of ongoing use of cannabis • Informed consent by adolescent and at least 1 parent

9. Exclusion criteria • Inpatient or intensive residential treatment needed • Opiate substitution treatment (methadone, buprenorphine etc.) needed Screening, baseline • Adolescent participates in other drug/criminality research

10. Study Design Session with the researcher (Two reseachers one on each site) Screening Randomization Baseline assessment MDFT TAU-JUP TAUe France M3, M6 Assessment Six month treatment Additional six month follow-up M9, M12 Assessment

11. Psychometric scales • Cannabis consumption … and other • ADI-Light Intake Interview / TLFB / Urine analysis/ alcohol and other drugs • Socialbehaviour, co morbidity adolescent • CBCL / YSR / PEI / Live events / DSM IV • FamilialFunctioning • FES • Therapysatisfactionscale • SS • Parents • Parents intake interview

12. The therapeutic branches

13. MDFT team, supervision and assessment Two therapists One videotaped session For each patient included Read learn and apply MDFT Manual Videotaped session Supervision once a week Live supervision One supervisor Read learn And assess adherence Review the tapes Assess adherence Give feedback Give feedback MDFT Miami team Rate the tapes Assess mdft adherence

14. Multidimensional Family Therapy • MDFT is a family based outpatient treatment, developed for adolescents with substance use and behavioural problems • Tested in the USA since 1985 • Developers are at the Center for Treatment Research on Adolescent Drug Abuse (CTRADA), University of Miami. Director: Howard Liddle

15. Multidimensional Family Therapy – Roots, theory and focus Other therapeutic models: Rogers/CBT FamilyTherapy (Minuchin/Haley) Adolescent development MDFT Developmentalpsychopathology Risk and protective factors Ecology dimension

16. General Approach in MDFT • Substance use related problems of adolescents aremostly multidimensional, i.e., part of more general trouble • Multidimensional problems require multiple targets of change, witha varying set of interventions,ina variety ofcontexts andsettings.

17. Intervention Targets of MDFT MDFT is focusing on four ‘life domains’, or target areas. Some interventions are intrapersonal, others are interpersonal Adolescents Attitudes and Behaviour Parents Attitudes and Parenting practices Family Functioning, Relationships Ecological/Social context Extrafamiliar influences

18. Stages of Treatment • The “four corners” of MDFT are worked on in three stages: • Stage 1: Build the foundation: Alliance and Motivation • Stage 2: Requests For Change • Stage 3: Seal Changes and Exit • The therapist works the “four corners” through all stages of treatment.

19. Therapy Sessions and Settings Combination of individual sessions (adolescent, parent), family sessions and sessions with relevant persons outside the family. Sessions are conducted at the institute as well as at home or other places. No session time limits. Phone calls are important part of the interventions. Frequency and Duration of MDFT treatment 1 to 4 sessions/contacts weekly in varying settings, 4 to 6 months MDFT Principles/Requirements (1)

20. MDFT Principles/Requirements (2) • MDFT Forms Case Conceptualization Form, Therapist Session Planning Sheet, Treatment Contact Log • MDFT Supervision Weekly team supervision, individual supervision, live supervision, videotape reviews

21. German TAU is called „JUP“Youth Psychotherapy for Cannabis Clients • Not manualized! • Based on specific child and youth psychotherapy According to the law (KJHG ,SGBVIII)Psychotherapy is part of rehabilitation/help for education(Target group specific approach since 2000 in Therapieladen e.V. • Restraints on JUP in INCANTSetting: Individual therapy with additional counselling of parentsFrequency: 1 session weekly with youth, about 1 session monthly with parents.Duration: 8 to max. 10 months • Supervision/Intervision: weekly 2 hours

22. General approach of JUP Integrative Psychotherapy approach, • Client-centred Psychotherapy • Cognitive Behavioural Therapy (CBT) • Motivational Interviewing (MI) • drug- and addiction-specific oriented, including co-morbidity • based on developmental psychology • integrated in the pedagogic/educational context

23. Goal of the Explicit Treatment as usual (TAUe)Build by M.Lascaux, JP Couteron, P Bouthillon-Heitzmann, O.Phan • Have a standardized treatment • As representative as possible to what it’s done in French cannabis consultations • To have an homogeneous treatment in the two French sites (Emergence and CEDAT)

24. How we built the TAUe manual • From our own experience in the two sites of Emergence and CEDAT • From interviews with 8 skilled French therapists chosen on the basis of : • the size of the case flow they handle ( based on OFDT study), • on their reputation, • on their place of work ( 3 in Paris and suburbs, 5 in the province).

25. TAUe procedure • First session • with the therapist and the social worker • the family (parents and adolescent) is seen , then the adolescent alone, then all together again. • the therapist explains the treatment procedure to the parents and the adolescent all together • All the other sessions • The adolescent is seen alone • Once a week • No family or parental sessions ( information can be given on their requests) • These sessions can be performed by the therapist or the social worker • Medication is possible but not inpatient treatment or family therapy

26. The TAUe process Adolescent engagement Enter his world Create therapeutic alliance Phase 1 M1 Selfexamination enhancement Express and react on consumption and interaction with environment Enhance motivation Phase 2 M2 to M3 Work on consumption Coping strategies Work on adolescent problematics Own, familial and environmental ones Past and present Phase 3 M3 to M6

27. TAUe team, supervision and assessment Two therapists One videotaped session For each patient included Read learn and apply TAU e Manual Videotaped session Supervision once a week One supervisor Read learn And assess adherence Review the tapes Assess adherence Give feedback

28. Background of the TAUe • Phase 1 : This phase has much to do with empathic listening • Phase 2 : Inspiration of motivational strategies • Phase 3: is a combination of: • Cannabis use centered Cognitive sessions • Psychodynamical interviewing

29. Current INCANT Sampling n : 360 (nov 2008)

30. First preliminary results in Germany and France Status: 30.11.2008 • RecruitmentGermany : 100 • France : 81 • AgeG :Range 14 - 18 years, Ø 16,3years • F : Range 14-18 years, Ø 17,3years • GenderG :84% male, 16% female • F: 89% male, 11% female • ClinicalHigh co-morbidity, according to YSR,CBL, DSM IV

31. Comorbidity of INCANT-Population: YSR germany

32. Comorbidity INCANT-Population: CBCL germany

33. Referral n:75 France

34. Principal live events France

35. Treatment Retention Rate Germany (N=71)* Retention Rate: MDFT: 89% JUP: 69% * Stand 30.9.2008

36. Treatment Retention Rate France (N=72)* Retention Rate: MDFT: 88.5% TAUe: 73.9% TAU: 43.4% * Stand 30.11.2008

37. Reduction of Consumption Cannabis Time Line Follow Back (TLFB) Germany and France n: 85

38. Thank you for your attention Dr. Olivier Phan (Paris) Andreas Gantner (Berlin) www.incant.eu