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Family Based Therapy for Adolescents with Problematic Substance Use
Substance use disorder is a medical condition where substance use leads to clinically significant impairment or distress[1]. Problematic substance use
among adolescents presents a unique situation that must be addressed as soon as possible. See substance use disorder.
Family-based approaches to treating substance use developed out of a link between family variables and adolescent behavior problems[2]. Family based therapy (FBT) is one such way of addressing adolescent substance use, as families and communities are an important part of treatment[3]. These are system-oriented approaches aimed at changing family patterns that may contribute to adolescent substance use.
FBT is considered an efficacious model for adolescent substance abuse[4]. Treatment focuses on communication and conflict management between parents and adolescents and parenting skills as well as helping adolescents better integrate into their communities[5]. FBT has some limitations, as it was developed in the United States, with most studies done in the United States[6]. FBT also has high costs associated with it, limiting access for people to treatment[7].
In 2018, around 3.7% of adolescents (ages 12-17) in the U.S. had a past year substance use disorder (SUD). This means that 1 in 27 adolescents had a SUD in the past year. This prevalence is similar to that in 2017, but lower than the percentages in 2015 and 2016. See the figure to visualize SUD rates over time for different age groups[8].
This figure shows substance use disorder rates over time by age group.
Multidimensional family therapy (MDFT) is a version of family therapy that targets the surrounding social systems of at-risk youths[9]. The intervention involves outpatient therapy with the adolescent and their family with the focus being on changing individual behavior as well as within-family interactions and interactions among relevant social systems[10]. In general, studies on MDFT have demonstrated improvement through significant declines in drug use and acting-out behaviors among adolescents[11]. In a randomized study, MFDT was found to have a positive impact on problem behaviors, including drug use, as well as the capacity to promote positive gains[12].
Multiple studies have found positive results from MDFT. Some specific outcomes include significant reductions in substance abuse with some relapse within a year[13]. MDFT was associated with the most improvement compared to adolescent group therapy (AGT) and multifamily educational intervention (MEI), as well as greater improvement compared to individual cognitive behavioral therapy (CBT-I)[14][15]. Based on these outcomes, MDFT has been widely regarded as a well-established treatment[16]. In a randomized control trial comparing MDFT and peer group therapy, MDFT was significantly more effective in reducing risk and promoting protective processes in the individual, family, peer, and school domains. MDFT also resulted in a reduction of substance abuse over the course of the treatment[17].
This diagram shows the three stages of Brief Strategic Family Therapy.
Brief strategic family therapy (BSFT) is a manualized, empirically validated family-based intervention meant to address components of family functioning connected to adolescent substance use[18]. It is very structured, with a prescribed process format that is directive problem-focused, and practical. Steps include Joining, Diagnosis, and Restructuring. Therapists aim to change family patterns of interactions[19]. One of the main change strategies is using cognitive restructuring via reframing, transforming negative affect due to frustrating family interactions to positive affect. BSFT is 12-16 sessions over 4 months involving multiple family members, with 8 optional booster sessions and flexibility depending on the needs of the family[20].
BSFT was evaluated by two systematic reviews. Austin, Macgowan, and Wagner (2005) found that BSFT, along with Multidimensional Family Therapy, are the most effective among family-based interventions, rated probably efficacious[21]. Waldron and Turner (2008) found it to be probably efficacious, but needing independent replication[22]. BSFT has been found to provide more engagement in therapy and increased family functioning as well as to reduce socialized aggression, conduct problems, and substance use[23].
Multisystemic Therapy (MST) is a family-based, ecological treatment model for adolescents, which focuses on an individual’s social systems and its relations with clinical problems like substance use and delinquency[24]. This approach is marked by rigorous home-based services, therapist availability, less burden caseload (for the therapist), skill provision, and assurance of proper treatment standard. Its allows for meetings between the adolescent and therapist; however, family involvement is preferred. MST focuses more on antisocial behaviors and its connections with the functioning of the adolescent's family[25]. This approach provides high promise for treatment of substance use disorders, efficacy in keeping families in treatment, and room for variability in how therapists practice[26]. That said, other studies have noted the need for independent replication[27].
Ecological family-based treatment (FBT-E)/Ecologically Based Family Therapy (EBFT)
Ecologically-Based Family Treatment (EBFT) is a home-based family therapy that targets runaway adolescents with substance abuse problems. EBFT is modeled after the Homebuilders family preservation model in which services are initiated by a family crisis. More specifically, EBFT is initiated when an adolescent runs away from home. The goal of EBFT is to reconnect families and target family distress so runaway adolescents can go back home[28]. This therapy was developed with the following assumptions in mind: services must address the needs and priorities of each family, with respect to their limited amounts of time and that most children are better off with their own families than elsewhere.
In a systematic review by Hogue et al. (2014), EBFT was found to reduce substance use more than treatment as usual[29]. The home-based EBFT model also resulted in better rates of treatment participation than office-based treatments. When compared to motivational interviewing and cognitive behavioral treatment on an individual basis, EBFT was associated with slower changes but also slower relapse, indicating a greater reward overall. All three treatments were equally effective in reduced alcohol substance use, but EBFT appeared to have the greatest latency. Hogue et al. (2014) deemed EBFT to be well-established and later in 2018, probability efficacious[30].
A limitation of ecologically-based family therapies (FBT-E) is that they consist of intensive and comprehensive therapeutic services that must fit into familial needs and time constraints. Especially since adolescents are best taken care of by their own family, therapy must fit into a limited amount of sessions so runaway adolescents can be reconnected with their families sooner rather than later[31].
Multisystemic Therapy (MST) and Functional Family Therapy (FFT) are similar interventions with overlapping treatment goals and target populations[32]. By intervening in the family and environmental system of 12–18 year old adolescents, both therapies have proven to effectively reduce externalizing behavioral problems, with a specific focus on antisocial behavior and delinquency[33]. Nonetheless, the two differ on the grounds that MST is typically used to treat more severe cases of behavior disorders. In comparison, FFT is more cost-effective and has been embraced nationwide as a valid treatment for substance abuse and juvenile outcomes[34].
FFT offers weekly sessions for up to 6 months, and involves two distinct phases, primarily designed to improve supportiveness and family communication, while also reducing the dysfunctional behavior patterns and negativity that cause or maintain adolescent recidivism or substance abuse[35]. The first phase introduces families to the process, committing them to the treatment process, and promoting their motivation to change. The second phase seeks to reshape the family dynamic to produce new patterns of interaction which emphasize better communication, behavioral modification, and advocacy outside the context of home[36].
Primary Objective: Improve functioning in adolescent, parents, family interactions, and extra-familial relationships; targets the surrounding social systems of at-risk youths[39]
Structure: 3 stages; Stage 1: Building a Foundation for Change; Stage 2: Facilitating Individual and Family Change; and Stage 3: Solidifying Changes[40]
Need for long-term follow up and sample size calculations[47]
Brief strategic family therapy (BSFT)
Delivery: Flexible to work with any family members[48]; very structured, with a prescribed process format that is directive problem-focused, and practical[49]
Duration: 12-16 sessions over 4 months involving multiple family members, with 8 optional booster sessions and flexibility depending on the needs of the family[50]
Primary Objective: Treat substance use in adolescents[51] by focusing on 4 things: 1) joining with the family, 2) assessing problematic interactions, 3) creating a context for change, and 4) restructuring family interactions[52][53]
Structure: 3 steps: Joining, Diagnosis, and Restructuring[54]
Engages family, reduces drug abuse, improves family relationships[55]
↑Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004).The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. J Subst Abuse.2004;27:197-213.2004-20575-00410.1016/j.jsat.2003.09.00515501373. http://dx.doi.org/10.1016/j.jsat.2003.09.005 .
↑Liddle, H. A. (2015). Multidimensional family therapy. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy. New York: Routledge.
↑Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004).The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. J Subst
↑Liddle, Howard A.; Rowe, Cynthia L.; Dakof, Gayle A.; Ungaro, Rocio A.; Henderson, Craig E. (2004-03). "Early Intervention for Adolescent Substance Abuse: Pretreatment to Posttreatment Outcomes of a Randomized Clinical Trial Comparing Multidimensional Family Therapy and Peer Group Treatment". Journal of Psychoactive Drugs 36 (1): 49–63. doi:10.1080/02791072.2004.10399723. ISSN 0279-1072.
↑Liddle, Howard A.; Rowe, Cynthia L.; Dakof, Gayle A.; Ungaro, Rocio A.; Henderson, Craig E. (2004-03). "Early Intervention for Adolescent Substance Abuse: Pretreatment to Posttreatment Outcomes of a Randomized Clinical Trial Comparing Multidimensional Family Therapy and Peer Group Treatment". Journal of Psychoactive Drugs 36 (1): 49–63. doi:10.1080/02791072.2004.10399723. ISSN 0279-1072.
↑Robbins, M. S., Horigian, V. E., & Szapocznik, J. (2008). Brief strategic family therapy: An empirically-validated intervention for reducing adolescent behavior problems. Praxis der Kinderpsychologie und Kinderpsychiatrie, 57(5), 381–400.
↑Santiseban, S., Suarez-Morales, L., Robbins, M., & Szapocznik, J. (2006). Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process, 45, 259–271.
↑Santiseban, S., Suarez-Morales, L., Robbins, M., & Szapocznik, J. (2006). Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process, 45, 259–271.
↑Stouwe, Van der T., Asscher, J. J., Stams, G. J. J. M., Dekovic, M., & van der Laan, P. H. (2014). The effectiveness of multisystemic therapy (MST): A meta-analysis. Clinical Psychology Review, 34, 468–481.
↑Stratton, P. (2016). The Evidence Base of Family Therapy and Systemic Practice.
↑Henggeler, S., & Lee, S. (2003). Multisystemic treatment of serious clinical problems. In A. Kazdin & J. Weisz (Eds.), Evidence based psychotherapies for children and adolescents (pp. 301–324). New York: Guilford.
↑Curtis, N. M., Ronan, K. R., & Borduin, C. M. (2004). Multisystemic treatment: A meta-analysis of outcome studies. Journal of Family Psychology, 18, 411–419.
↑Stouwe, Van der T., Asscher, J. J., Stams, G. J. J. M., Dekovic, M., & van der Laan, P. H. (2014). The effectiveness of multisystemic therapy (MST): A meta-analysis. Clinical Psychology Review, 34, 468–481.
↑Stouwe, Van der T., Asscher, J. J., Stams, G. J. J. M., Dekovic, M., & van der Laan, P. H. (2014). The effectiveness of multisystemic therapy (MST): A meta-analysis. Clinical Psychology Review, 34, 468–481.
↑Sundell, K., Hansson, K., Andrée Löfholm, C., Olsson, T., Gustle, L.-H. and Kadesjö, K. (2008) ‘The transportability of multisystemic therapy to Sweden: short-term results from a randomized trial of conduct-disordered youths’, Journal of Family Psychology, vol 22, no 4, pp 550–60.
