2. Family Therapy For Early Adolescent Substance Abuse .
Multidimensional Family Therapy for Early Adolescent Substance AbuseTreatment ManualSeptember 2003Howard A. Liddle, Ed.D.Professor and DirectorCenter for Treatment Research on Adolescent Drug AbuseDepartment of Epidemiology and Public HealthUniversity of Miami School of Medicine1400 NW 10th Avenue, Miami, Florida 33136(305) 243-6434 (phone) / (305) 243-3651 (fax)hliddle@med.miami.eduThis manual was prepared under funding provided by grant no. KD1 T1 11871(Howard Liddle,P.I.) from the Center for Substance Abuse Treatment (CSAT), Substance Abuse and MentalHealth Services Administration (SAMHSA). The model and approaches described in thisdocument are those of the authors and do not necessarily reflect views or policies of CSAT orSAMHSA.1
TABLE OF CONTENTSI. Background on the ATM Cooperative Agreement.6Goals and Objectives .6Overview of the Study .8II. MDFT Approach to Early Adolescent Drug Abuse Treatment .9Evolution of the MDFT Protocol.9Overview of the Treatment Model Intervention .11Dimensions of Multidimensional Family Therapy .11Outcome.12Process .12Development .12Problem Behaviors.13Ecology .13Psychotherapy .13Family Therapy.13Treatment Parameters .13Defining the Clinical Model in the ATM Study .14General Theoretical Assumptions and Approach .14Theory of Dysfunction.14Risk factors .15Protective factors .17Adolescent development.17Puberty and Early Adolescence .19Cognitive Development in Early Adolescents.20Emotional Expression .20Theory of Change .21Principles of Multidimensional Family Therapy .25Basic Requirements for Clinics Offering MDFT.27Treatment Locale .27Treatment Duration and Intensity .27Nature of Clinical Contact .27Staffing Requirements .27Clinical Supervision Requirements.28Overview: The Three Stages of the MDFT Treatment Program .28Stage One: Build the Foundation.28Stage Two: Prompt Action and Change by Working theThemes.32Stage Three: Seal the Changes and Exit .36Modules Are Intervention Targets .38Whole and Part Thinking .38Multiple Domains of Simultaneous Intervention.38Interventions With an Adolescent.392
Interventions With Parents and Other Family Members .40Interventions with parents.40Interventions with other family members .41Interventions To Change the Parent–Adolescent Interaction .41Interventions With Systems External to the Family .42Therapeutic case management .43III. MDFT Sessions: Operational Features of the Approach .46The Three Stages of Treatment: An Indepth View.46Stage One: Build the Foundation.46Engaging the adolescent .46Engaging parents.49Stage Two: Work the Themes .51Key themes.51Therapist guidelines in working the themes .52Dealing with the past in a present-centered therapy .53Stage Three: Seal the Changes and Exit .54IV. Goals, Rationale, and Procedures of MDFT Interventions.55Key Concepts of MDFT Interventions .55Multidimensionality.55Redefining Sessions .56Multiple Therapeutic Alliances.56Linking.56Continuity .57Whole–Part (Holon) Thinking .57Doing What It Takes.57“Parental Hell” .57Working All Four Corners .58What You Don’t Know CAN Hurt You .58Organizing According to Modules and Stages .58Goals and Themes Emerge From the Interaction of theGeneric and the Idiosyncratic .59Culturally Sensitive Treatment .59The Adolescent Subsystem Module.60The Self of the Early Adolescent and Clinical Implications.61Peer Relations in Early Adolescence and Clinical Implications.62Adolescent Engagement Interventions .71Case Example: There Is Something in This for You .74Clinical Guidelines: Dealing With Drugs in MDFT.79MDFT, Drug Abuse, and Standard Family Therapy Practice .80MDFT, Drug Abuse, and a Chemical Dependency Model.80How To Deal With Drug Use and Abuse .81In-Session Interventions Pertaining to Drug Use.83Practical Guidelines for the Use of Urinalysis in MDFT .86Case Example: Dealing With Drug Use Directly in Session.933
MDFT With Adolescent Girls .98Cultural Themes Intervention .100Risky Sexual Behavior Interventions.103Multimedia Interventions.104Spirituality.106The Parents and Other Family Members Subsystem Module .108Relationships with Parents During Early Adolescence and ClinicalImplications.109Parenting Styles and Practices Interventions .114Parenting Relationship Interventions.115Interventions With Other Family Members.118The Family Interaction Module .120Case Example: I Want My Daughter Back.122Therapist Improvisation: Shifting Domains of Operation .122Intentional and unintentional shifts in a session .124Case Example: “Building a Relationship Bridge” .127Extrafamilial Module .136Interventions in Relation to the Peer Network: The Ecomap Method.138Interventions To Improve School Behavior and Academicand Vocational Functioning.145Intervention Guidelines to Improve School Behavior and Academicand Vocational Functioning of Drug-Involved Youth.150Decision making .152Collaborating With the Juvenile Justice System: Probation Officers153The interaction and interdependence of MDFT and the juvenilejustice system .154A collaborative, purposeful, youth-oriented alliance.155Repercussions of Lack of Involvement in Extrafamilial Subsystems .156V. Working the Model: Transforming Negative Processes into Key Therapeutic Work.158Negative Emotions and Problem Behaviors .159Emotions and Problem Solving .160Emotions and Dysfunctional Family Patterns.160Case Example: Escalating Negative Emotion.161Segment Introduction.161Segment One (Baseline): Negative Emotion in Action .162Segment Two: Focus and Framing .163Segment Three: Emotions Inform Theme Development .166Segment Four: Working an Emotion-Related Theme and theInterrelationship of Empathy and Constructivism .167Segment Five: Using an Out-of-Session Crisis To Work a CoreInterpersonal Theme .168Segment Six: In-Session Outcome.173VI. Procedural Steps: Implementing MDFT—Facilitating Key Therapeutic Processes .176Establishing Priorities and Making Decisions .1764
Therapeutic Alliance.176Linking as a Mechanism of Change.177Use of Self by the Therapist.177Incremental Change .177Therapist Improvisation: Shifting Domains of Operation .178Finding the Middle Ground .178VII. Guidelines for Subsystem Sessions.178Guidelines for Seeing a Parent or Adolescent Alone.179Guidelines for Seeing a Parent and Adolescent Together .181VIII. AppendicesAppendix A. Research Summary.2115
I. Background on the ATM Cooperative Agreement6
I. Background on the ATM Cooperative AgreementGoals and Objectives of the ATM Cooperative AgreementSubstance abuse disorders among adolescents are a serious public health concern. As thenumber of adolescents presenting for treatment to the nation’s public treatment systemscontinues to increase, the need for effective substance abuse treatment models multiplies. Fewrigorous evaluation studies on the effectiveness of adolescent substance abuse treatment havebeen conducted. Those that have been conducted are limited by variation in programs and lackof definition of the approaches evaluated, along with problems related to small samples andmarginal follow-up rates. More importantly, the field lacks manualized treatment approachesthat can be easily disseminated to treatment providers who work with our nation’s substanceinvolved youth (Morral & Stevens, 2003).To address the need for evaluating, documenting, and disseminating effective substanceabuse treatment models, the Substance Abuse and Mental Health Services Administration’sCenter for Substance Abuse Treatment (CSAT) funded the Adolescent Treatment Models(ATM) program, in which ten exemplary adolescent treatment programs in the United Stateswere evaluated. The goals of the CSAT ATM Project Cooperative Agreement are listed below:1. Identify currently existing potentially exemplary models of adolescent substanceabuse treatment2. Collaborate with the treatment providers to formalize their models into disseminablemanuals that can be replicated by other programs3. Determine with whom the model has been tested and the amount of services theadolescents actually received4. Evaluate the effectiveness and cost associated with each model5. Collaborate on cross-site comparisons of these models with one anotehr and withother studies of adolescent substance abuse treatment6. Participate in professional activities to disseminate the resulting models and findings.The ATM project targeted substance abusing adolescents; however, the ATM treatmentmodels represent a wide range of levels of care, clinical approaches, provider organizations,geographic locations, and evaluators. As part of the ATM collaborative agreement, The Centerfor Treatment Research on Adolescent Drug Abuse (CTRADA) conducted a randomized clinicaltrial designed to target early adolescent substance abusers. The study was conducted incollaboration with staff from The Village of Miami, Florida and involved a comparison of twomanual-based treatment conditions for adolescent drug abuse: (a) an empirically supported,family-based treatment , Multidimensional Family Therapy (MDFT) and (b) adolescent grouptherapy. This treatment manual describes MDFT as it was delivered as part of the ATMcollaborative agreement. For this study, as described in this treatment manual, MDFT wasspecifically adapted for young adolescent substance abusers. As such, this manual presents oneversion of MDFT, which as a treatment system with flexible treatment parameters has beenmodified to treat a range of populations (e.g., outpatient, residential, and day treatment).7
Overview of the StudyThe early adolescent population has been identified as a group in need of specializedtreatments. Early adolescence is a developmental period that offers clinically important andintervention-rich opportunities (Loeber, 1990; Rowe, Parker-Sloat, Schwartz, & Liddle, 2003).Generally, the earlier youth begin to use drugs and experience related problems, the more seriousare the consequences (Tarter et al., 1999), and the more difficult it is to steer them on to apositive developmental course. As such, early adolescents were selected in this study as thetargeted population for these interventions. In addition, the study is noteworthy in that theinterventions were delivered by clinicians in a community-based drug treatment program. Assuch, the findings from this study are important due to the implications for treating earlyadolescent drug abuse, further specifying the boundary conditions of family-based treatment, aswell as establishing the generalizability of a representative empirically supported therapy to areal-world clinical setting.Multidimensional Family Therapy (MDFT)—Multidimensional family therapy is amultisystemic family-focused treatment that includes in-home, in-clinic, and telephone sessionsworking with adolescents and their families. MDFT targets the psychosocial functioning ofindividual family members, the family members’ relationships, and influential social systemsoutside the family. The comparison treatment employed in the study is a peer group-basedmodel. Group therapy was chosen as the comparison treatment primarily because it is among themost predominant treatments for adolescent drug abuse. Because we wanted to test MDFT in areal-world clinical setting, we compared it to standard treatment for early adolescent drug abuse.Group interventions focused on self-esteem enhancement, decision-making skills, stress/angermanagement, communication skills, health education, teen pregnancy prevention, andoccupational/career planning.Both treatments were delivered by Village therapists and involved 16 weeks of treatment,with three hours of weekly client contact. Approximately 85 adolescents were randomlyassigned to either MDFT or AGT. Both conditions were manual driven and carefully monitoredby expert supervisors. All clients were assessed at intake and at 6 weeks and 6 and 12 monthsfollowing intake on multiple dependent variables. To validate clients’ responses, urine tests andcollateral assessments were also conducted at intake and 6 and 12 month follow-up assessments.8
II. Multidimensional Family Therapy Approach toEarly Adolescent Substance Abuse TreatmentEvolution of the MDFT ProtocolMDFT is a family-based outpatient treatment developed for clinically referredadolescents with drug and behavioral problems (Liddle, 1992). The approach strives forconsistency and a coherent and logical connection among its theory, principles of intervention,and intervention strategies and methods. The intervention methods derive from target populationcharacteristics, and they are guided by research-based knowledge about dysfunctional andnormal adolescent and family development. Interventions work within the multiple ecologies ofadolescent development, and they target the processes known to produce and/or maintain drugtaking and related problem behaviors. Similar developmental challenges may be common to alladolescents and their families, and these are central assessment and treatment focuses (Liddle &Rowe, 2000). At the same time, considerable variation may be demonstrated in the expression ofthese generic developmental challenges. In MDFT therapists are sensitive to these individualadolescent and family variations. With each case, therapists seek to understand the uniquemanifestations of developmental problems.MDFT is not a narrowly focused treatment protocol but can be more accurately describedas a treatment system. The approach has been operational in different treatment applications.Different versions of this approach have been developed and tested according to several factors,including study population characteristics, the intent of the study at the time, and findings froman ongoing clinical research program on the MDFT model. The MDFT research program to dateis summarized elsewhere (Liddle & Hogue, 2001). The approach has varied in elements such astreatment length (e.g., in one study, 16 sessions over 5 months; in another, a flexible number ofsessions from 4 to 25), dosage or intensity (the amount of therapist contact per week),intervention locale (in-clinic or a combination of in-clinic/home-based locales), inclusion ofparticular therapeutic methods (e.g., clinical use of within-treatment drug screens and casemanagement), and formats (e.g., using a single therapist or a therapist and therapist’s assistant[case management assistant]). MDFT has been used effectively by both experienced familytherapists and line clinicians with no family therapy experience. Ideally, the person who trainsand/or supervises the implementation of MDFT should have a background in family therapyand/or adolescent development.The MDFT approach has been developed and tested since 1985 in four major, completedrandomized clinical trials, a randomized prevention trial, and several treatment development andprocess studies, which have illuminated core change-related aspects of the therapeutic process(Liddle & Hogue, 2001). Since 1991, this work has been performed at the Center for TreatmentResearch on Adolescent Drug Abuse (CTRADA). CTRADA was the first National Institutes ofHealth/National Institute on Drug Abuse (NIDA)-funded research center on adolescent substanceabuse. MDFT studies have been conducted at various urban locations in the United States,including Philadelphia, the San Francisco Bay area, central Illinois, and Miami. The study9
populations were ethnically diverse (and their problem severity varied as well), from high-risksubjects in early adolescence to multiproblem, juvenile justice-involved female and maleadolescent substance abusers with co-occurring disorders. This approach has been recognized asone of a new generation of comprehensive, multicomponent, theoretically derived, andempirically supported adolescent drug abuse treatments (Center for Substance Abuse Treatment,1999; Lebow & Gurman, 1995; National Institute on Drug Abuse, 1999; Nichols & Schwartz,1998; Selekman & Todd, 1990; Stanton & Shadish, 1997; Waldron, 1997; Weinberg et al., 1998;Winters, Latimer & Stinchfield, 1999). MDFT is included in NIDA’s list of empiricallysupported drug treatments (www.nida.nih.gov) and in the American Psychological Association’sDivision 50 issue on empirically supported drug therapies in The Addictions Newsletter (Liddle& Rowe, 2000). MDFT is also included in the Office of Juvenile Justice and DelinquencyPrevention’s Strengthening America’s Families—Exemplary Programs Initiative(www.strengtheningfamilies.org) with the Center for Substance Abuse Prevention. MDFT wasrecently profiled in the Drug Strategies Report on State of the Art Adolescent Drug AbuseTreatments (Drug Strategies, 2002). Awards recognizing the development of the approach havebeen presented to the model’s developer by the American Psychological Association (1991), theAmerican Family Therapy Academy (1995), the American Association for Marriage and FamilyTherapy (1996), and the Florida Association for Marriage and Family Therapy (2000).This manual describes the version of MDFT that was tested in the Adolescent TreatmentModels study funded by CSAT from 1998 to 2002 (Stevens & Morral, 2003). The version ofMDFT tested in CTRADA’s ATM study is a 12-16 week version of MDFT (delivered over 3-4months), specific for early adolescent drug abusers. Adolescents in this project were 12-15 yearsold and met ASAM criteria for outpatient drug abuse treatment. Because MDFT was beingtested as an early intervention model, youth with drug use or delinquency problems warrantingintensive outpatient services were not appropriate for this level of treatment. Thus, adolescentswith an extensive psychiatric and juvenile justice history were excluded from the program.Youths also had a family member willing to participate in therapy and research assessments.Most youths had between one and two arrests but very few had previous drug treatment. Thesample was approximately 48 percent African American and 44 percent Hispanic, with theremainder being from White Non-Hispanic and other ethnicities. Males made up slightly over70 percent of the sample. Adolescents reported using approximately twice per month, andmarijuana was the substance of choice for almost all youth in the study.MDFT is based on a developmental psychopathology framework and targets the multipleecological factors maintaining drug use and other problem behaviors (Liddle, 1999). In general,MDFT targets four treatment domains: (a) the individual adolescent, (b) parents and otherfamily members, (c) the family’s transactional patterns, and (d) family members’ interactionswith extrafamilial systems. Specific to the Miami study of the ATM cooperative, MDFT focuseson the same domains, but highlights developmentally relevant processes common with earlyadolescents including: (a) the adolescent’s developing sense of self, (2) peer relationships, and(3) relationships with parents. These domains represent arguably the most important spheres ofinfluence and change during early adolescence.10
Overview of the Treatment Model InterventionIt is important to have a sufficiently complex, multivariate framework to comprehend andact on what could be called the core clinical phenomena—the situations and processes thatdetermine poor developmental outcomes and that, therefore, should be targeted for change. Amultidimensional perspective on adolescent substance abuse and behavior problems, and thus amultidimensional framework, orients therapy and the therapist. This framework, made up ofempirically based knowledge about how adolescents develop and how development is derailed,drives the therapy.In research, design and statistical methods are tools to answer research queries. Similarly,in treatment, therapy techniques serve the overall approach. Techniques are tools; they are ameans to access and facilitate adaptive change. MDFT therapists are taught an overarchingconceptual framework that helps them appraise and respond to diverse clinical situations. TheMDFT framework focuses on several areas that are critical to a clinician’s understanding of howadolescent drug problems form, develop, and continue and how they can be replaced withadaptive and prosocial development and competence. Therapists are developmentalists in thesense of having a primary job of understanding how development has gone astray and devisingmeans to facilitate its retracking.Dimensions of Multidimensional Family TherapyMDFT is an integrative therapeutic philosophy and clinical approach. It relies on thecontemporary empirical knowledge base of risk and protective factors and known determinantsof adolescent substance abuse to assess and intervene in the lives of teenagers and their parents.Figure 1 answers the obvious and immediate question that comes from a first encounterwith MDFT: What are the dimensions of multidimensional family therapy? The followingsection gives a thumbnail sketch of each of these dimensions that reflect different aspects of themodel’s characteristics as well as the sources of influence on the MDFT approach over the years.11
OutcomeTreatmentParametersFamily TherapyProcessMultipleDi
Center for Substance Abuse Treatment (CSAT) funded the Adolescent Treatment Models (ATM) program, in which ten exemplary adolescent treatment programs in the United States were evaluated. The goals of the CSAT ATM Project Cooperative Agreement are listed below: 1. Identify currently existing potentially exemplary models of adolescent substance
Bruksanvisning för bilstereo . Bruksanvisning for bilstereo . Instrukcja obsługi samochodowego odtwarzacza stereo . Operating Instructions for Car Stereo . 610-104 . SV . Bruksanvisning i original
10 tips och tricks för att lyckas med ert sap-projekt 20 SAPSANYTT 2/2015 De flesta projektledare känner säkert till Cobb’s paradox. Martin Cobb verkade som CIO för sekretariatet för Treasury Board of Canada 1995 då han ställde frågan
service i Norge och Finland drivs inom ramen för ett enskilt företag (NRK. 1 och Yleisradio), fin ns det i Sverige tre: Ett för tv (Sveriges Television , SVT ), ett för radio (Sveriges Radio , SR ) och ett för utbildnings program (Sveriges Utbildningsradio, UR, vilket till följd av sin begränsade storlek inte återfinns bland de 25 största
Hotell För hotell anges de tre klasserna A/B, C och D. Det betyder att den "normala" standarden C är acceptabel men att motiven för en högre standard är starka. Ljudklass C motsvarar de tidigare normkraven för hotell, ljudklass A/B motsvarar kraven för moderna hotell med hög standard och ljudklass D kan användas vid
LÄS NOGGRANT FÖLJANDE VILLKOR FÖR APPLE DEVELOPER PROGRAM LICENCE . Apple Developer Program License Agreement Syfte Du vill använda Apple-mjukvara (enligt definitionen nedan) för att utveckla en eller flera Applikationer (enligt definitionen nedan) för Apple-märkta produkter. . Applikationer som utvecklas för iOS-produkter, Apple .
in the history of family therapy. They include Bowen Natural Systems Theory, contex-tual therapy, Virginia Satir’s Growth Model, brief therapy of the Mental Research Insti-tute, strategic family therapy, Milan Systemic Family Therapy, structural family therapy, solution-focused brief therapy, and narrative therapy.
Occupational Therapy Occupational Therapy Information 29 Occupational Therapy Programs 30 Occupational Therapy Articulation Agreements 31 Occupational Therapy Prerequisites 33 Physical Therapy Physical Therapy Information 35 Physical Therapy Programs and Prerequisites 36 Physical Therapy Articulation Agreements 37 Physical Therapy vs .
8.1. Introduction to Family Therapy Family therapy, also referred to as couple and family therapy, marriage and family therapy, family systems therapy, and family counseling, is a branch of psychotherapy that works
