Multidimensional Family Therapy for Adolescent Drug Abuse & Delinquency

1. Multidimensional Family Therapy for Adolescent Drug Abuse & DelinquencyReclaiming FuturesTreatment Improvement Institute28 January 2005 Howard A. Liddle, Ed.D., ABPP Professor, Epidemiology & Public Health and Psychology, and Director, Center for Treatment Research on Adolescent Drug Abuse University of Miami School of Medicine www.miami.edu/ctrada

2. Miami, FloridaDowntown Brickell

3. Miami, FloridaDowntown Harbor

4. Miami, FloridaSouth Beach

7. University of MiamiCoral Gables Campus

8. University of MiamiMedical Campus

9. University of MiamiMedical Campus

10. University of MiamiMedical Campus Quad

14. MDFT for Adolescent Drug Abuse and Delinquency • Multidimensional Family Therapy • Adolescent substance abuse specialty • Related problems • Family-based treatment system • Diversity of studies • Sample findings • Clinical thinking & features

15. MDFT Fact Sheet • Background • Variety of studies • Sample findings • Website • Contact information

21. Developmental Stage • Renaissance of adolescent treatment • New treatments and methods exist • Feasibility and efficacy has been established • Mechanisms are being investigated • Generalizability has been addressed • Treatment manuals are available • Training models and materials exist • Full generalizability has not been established

22. New Generation of Interventions • Integrative • Connected to basic research on development and dysfunction • Diverse approaches • Expanded in scope: Multiple systems of assessment & intervention • Brief interventions as well • Context of service delivery • Well specified protocols

23. Features and Themes of the MDFT Research Program • Research-based knowledge about development and dysfunction • Therapeutic ingredients and processes • Therapist competence and development • Efficacy: Rigorous treatment evaluation under controlled conditions • Effectiveness: Rigorous treatment evaluation in regular clinical settings

24. Research Program (2) • Transporting and disseminating • Training studies • Refining and adapting • Defining and testing different versions • Continued exploration of key components and processes

25. Diverse Client Populations • Urban and inner-city ethnic minority youth and families - many with serious economic disadvantage • Co-occurring mental health problems • Juvenile justice involved teens • Parents with mental health, criminal justice, or substance abuse problems

26. Completed Treatment Outcome Studies • MDFT, Group, Multi-Family Clinical Trial • MDFT - Individual CBT Clinical Trial • MDFP Prevention Trial • MDFT-I Treatment Development • CYT Multisite Clinical Trial • MDFT - Group Early Adolescent Clinical Trial

27. Current Treatment Development and Outcome Studies • Alternative to Residential Treatment (NIDA) • Transporting MDFT to Day Treatment (NIDA) • Brief Version of MDFT (NIDA) • Training Outcomes (NIDA) • Long Term Follow Up (NIDA) • Cost Outcomes (NIDA) • Juvenile Drug Court (NIDA) • Dependency Drug Court (NIDA) • CJ-DATS Research Center (NIDA) • International Studies (NIDA, 6 European Health Ministries)

28. Treatment Development • ASUD – multidimensional phenomenon • Multidimensional clinical phenomena require parallel understanding, intervention and research • Clinical Model – MDFT as a treatment system • Research strategy is multidimensional • Variety of variables and dimensions of research interest • Study variety: Outcome and process studies • Focus on setting issues • Treatment development strategy is multidimensional

29. Multidimensional Family Therapy • Promising approach for transportation or adaptation • Superior outcomes in comparison to several state-of-the-art, widely used treatments • Capacity to impact a wide array of risk factors associated with adolescent drug abuse • Capacity to engage teens and families in treatment and motivate them to complete the program

30. Lower cost than standard outpatient or residential treatment • Demonstrated success in treating a range of teens and families (e.g., different ethnicities, genders, ages, severity of problems) • Empirically based knowledge about mechanisms of action • Flexibility in adapting to existing program factors and providers’ resources and needs • Success in improving client, therapist, and program outcomes in community-based “transportation” studies

31. Substance Use Outcomes • MDFT has demonstrated better results than several state-of-the-art treatments • Family group therapy, peer group treatment, individual cognitive behavioral therapy, and residential treatment • Substance use is significantly reduced in MDFT to a greater extent than all comparison treatments previously tested • 41% to 66% reduction from intake to discharge

32. Substance Use Outcomes • Effect sizes have consistently been in the medium-large (d=.6; Liddle, 2002; Liddle, Dakof, & Henderson, 2002) to large range (d=.7; Liddle et al., 2001, 2004) • Treatment gains are enhanced in MDFT after treatment discharge • Youth continue to decrease drug use up to 1 year following treatment entry • Comparison treatments have increased drug use

33. Change in Substance Use Frequency 43% Reduction from Intake to 6-Month Follow-Up 41% Reduction from Intake to 12-Month Follow-Up Reductions at 12 Month Follow-Up maintained through 30 months

34. Change in Number of Substance Use Related Problems Reductions at 12 Month Follow-Up maintained through 30 months

35. Reduction in Average Cost to Society Cost savings to society continue to decrease through 30 months

36. Outcomes on Associated Risk Factors • MH symptoms show greater reductions during treatment in MDFT • Range of 35% to 80% within treatment reduction • MDFT clients continue to improve following discharge • Affiliation with delinquent peers decreases more rapidly in MDFT

37. Impact on Associated Risk Factors • School functioning improves more dramatically in MDFT • Youth return to school, receive passing grades at higher rates, and are less disruptive in the classroom • Family functioning improves to a greater extent in MDFT

38. Process Studies IlluminateTreatment Mechanisms • Outlined within-treatment process of improving family interactions • Demonstrated how therapists successfully build therapeutic relationships with teens (Diamond & Liddle, 1996) • Parenting practices are systematically improved during therapy and that these changes are linked to reductions in adolescents’ symptoms (Schmidt, Liddle, & Dakof, 1996)

39. Process Studies • Specified the links between exploring important cultural themes and increasing teens’ participation in treatment (Jackson-Gilfort et al., 2001) • Identified parent and adolescent factors critical to treatment engagement (Dakof, Tejeda, & Liddle, 2001)

40. Change in Parenting and Change in Adolescent Drug Use Schmidt, Liddle & Dakof, J. Family Psychology, 1996 60% Tandem change 20% Adolescent only change 10% Parent only change 10% Neither parent or adolescent change

41. Family Functioning Before, During, and After the Therapeutic Impasse Diamond & Liddle, 1996, J Consulting & Clinical Psychology After successfully addressing impasse, family functioning improves Family functioning remains poor after unsuccessful impasse resolution attempt

42. Three WorldsM. C. Escher 1955

43. MDFT: Part of a New Generation of Interventions • Connected to basic research on development and dysfunction • Expanded in scope • Multisystemic assessment & intervention • Context of service delivery • Clinician contributions to outcomes • Treatment development emphasis

44. Conceptual Framework:Current Key Elements • Risk and protective factors • Normative development • Developmental psychopathology • Ecological perspective

45. Intervention Targets • Adolescent: Self, son/daughter, peer system • Parent: Self and parenting • Family Interaction and Family Relationships • Extrafamilial

46. Adolescent development Community connection School / academic Treatment Foci Family relations Job/vocational Cultural identity Peer network Drug use / drug taking contexts Liddle, H. (2002). Multidimensional Family Therapy for Adolescent Substance Abuse. CSAT CYT Manual Series.

47. Outcome Treatment Parameters Process Multiple Dimensions of MDFT Family Therapy Development Psychotherapy Problem Behaviors Ecology

48. Key Features and Processes • Facilitation of development • Working the four corners • Therapeutic alliances • Concrete alternatives for a better life • Adolescent – self, school, peers, family • Parent – self, stress, parental subsystem conflict, parenting practices • Changing family environment • Therapist attitude and behavior

49. Principles of Multidimensional Family Therapy • Current symptoms of adolescent or other family members as assessment & intervention opportunities 2) Change is multidetermined and multifaceted 3) Motivation to change is not assumed to be present with adolescents or their parent(s)

50. Principles of Multidimensional Family Therapy • Practically-oriented , outcome-focused working relationships between therapist and family members/extrafamilial influences • Failure & crises are intervention opportunities • Planning and flexibility are critical components • 8) Therapists think in terms of stages of work and modules