Family Interventions in Substance Abuse

Current Best Practices

Oliver Morgan, Cheryl Lizke, Oliver J. Morgan, Cheryl H. Lizke

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317993681
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Leading clinicians discuss the latest evidence-based approaches to working with families that have an addicted or substance abusing member Family Intervention in Substance Abuse: Current Best Practices gathers together in one easy-to-read volume the most effective family-based clinical approaches to work with families and the difficult issues of substance abuse. The field's most respected and best known clinicians discuss the latest interventions that prove most effective and how to easily integrate them into clinical practice. This unique text is ideal for clinical trainers and professors working with students in the addictions and family therapy fields. Family Intervention in Substance Abuse: Current Best Practices provides students, practicing professionals, and educators with a range of clinical strategies from engaging resistant substance abusers into treatment, to therapy from a systemic viewpoint, to relapse prevention. This essential text comprehensively discusses nine of the most current and evidence-based approaches to working with families that have an addicted or substance abusing member. Each chapter contains basic theoretical descriptions, case applications, practical points for implementation, reviews of the outcome studies, and extensive bibliographies. Topics discussed in Family Intervention in Substance Abuse: Current Best Practices include:

• Family systems interventions
• Motivational Interviewing
• stages of family recovery from addiction
• integration of clinical work with Twelve Step programs
• strategies for engaging reluctant alcohol and other drug abusers
• working with adolescent alcohol and other drug abusers
• behavioral couples work for alcoholism and drug abuse
• and more!

Family Intervention in Substance Abuse: Current Best Practices is an invaluable resource for students, counselors, social workers, addiction specialists, marriage and family therapists, psychologists, psychiatrists, and professors and trainers in the fields of addiction and family therapy.

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EVIDENCE-BASED MODELS

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Brief Strategic Family Therapy: Engagement and Treatment

Ervin Briones, PhD
Michael S. Robbins, PhD
José Szapocznik, PhD

SUMMARY. An overview of Brief Strategic Family Therapy (BSFT), a family-based, empirically validated intervention designed to treat children and adolescents' problem behaviors is presented. In this article the theoretical underpinnings of BSFT are described using a clinical case to illustrate the basic BSFT tenets. A selected review of outcome evidence is presented as well as the considerable clinical development and research evidence on specialized BSFT Engagement. Clinical implementation is highlighted. doi:10.1300/J020v26n01_05 [Article copies available for a fee from The Haworth Document Delivery Sendee: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <htt­p:/­/ww­w.H­awo­rth­Pre­ss.­com­> © 2008 by The Haworth Press. All rights reserved.]

KEYWORDS. Family therapy, adolescent, alcohol-other drug abuse, engagement, strategic, structural

INTRODUCTION

The Espinozas, headed by a single Venezuelan-bom mother in her mid thirties, includes four offspring: 21 year old son serving time in prison, 19 year old daughter working full-time, a 14 year old son, Michael, currently on probation for burglary charges, and 16 year old, Juan, who was referred to treatment following a recent arrest. Juan is referred to by mother as “a cocaine baby” (i.e., she was using cocaine when Juan was in utero). At intake, Juan tested positive for marijuana, reported that he had dropped out of school and did not have a job. His mother reported that Juan did not help at home and spent the majority of his time with delinquent friends who used alcohol and other drugs and had problems at home. Ms. Espinoza reports that on two separate occasions she lost custody of her children due to her own drug use problems in the past. She reports being sober for 4 years and gainfully employed. Mother and children do not have a close relationship. In addition, mother is not successful in her attempts to manage her younger boys. Her parenting typically involves nagging her children, setting unrealistic goals, and sermonizing. The younger boys, particularly Juan, tend to withdraw when mother lectures. There is a lack of a positive affective relationship between mother and her younger boys. The younger boys are highly involved with each other, supporting each other's deviant behavior, including encouraging one another to disobey mother and court. Younger boys do not see that they have a problem and are reluctant to participate in treatment.

TARGET POPULATION

The example of the Espinoza family illustrates typical problems targeted by Brief Strategic Family Therapy (BSFT) and reflects the fact that BSFT was designed not only to treat adolescent drug use but also other behavioral problems that often accompany drug use (Jessor & Jessor, 1977; McGee & Newcomb, 1992), including lack of school bonding and underachievement, oppositional defiance, aggression, delinquency, sexually risky behavior, and disengagement from pro-social activities. Although the focus of BSFT is to address drug use and related behavior problems, therapists do this by working relationally with the entire family. That is, family relationships are targeted for change rather than individual problems. Specifically, BSFT addresses maladaptive patterns of interactions in the Espinoza family that are supporting the two younger boys' acting out behaviors within and outside the family. The initial treatment plan for the Espinoza family included several specific family goals: (1) decreasing anger and blaming toward the boys and in particular toward Juan, (2) restoring emotional connection between mother and children, (3) increasing mother's nurturance, (4) improving family members' ability to effectively negotiate and resolve differences of opinion, (5) elevating mother's hierarchy in the family (including helping her to be more effective in her parental management skills), and (6) establishing appropriate emotional boundaries between younger brothers. By impacting these aspects of family functioning, the two younger boys' behavior problems will decrease over the course of treatment if not disappear all together.

BRIEF STRATEGIC FAMILY THERAPY

Brief Strategic Family Therapy (BSFT) is a family-based, empirically validated intervention designed to treat children's and adolescents' problem behaviors. BSFT has evolved from more than thirty years of research and practice at the University of Miami Center for Family Studies. BSFT is an integrative approach dating back to the late 1970s, drawing on structural theory and techniques of Salvador Minuchin (e.g., Minuchin & Fishman, 1981), and the strategic thinking of Haley (1976) and Madanes (1981). In this article we describe: (a) the theoretical underpinnings of BSFT; (b) some of the evidence on BSFT; (c) the considerable clinical development and corresponding research on specialized BSFT Engagement techniques; and (d) the clinical implementation of BSFT.

The abbreviated BSFT manual for clinicians (Szapocznik, Hervis, & Schwartz, 2003) is available in hard copy, free of charge, from the National Institute on Drug Abuse (Ms. Gerry Murphy, Supervisor, National Clearinghouse for Alcohol & Drug Info, P.O. Box 2345, Rockville, Maryland 20847), or may be downloaded at htt­p:/­/ww­w.d­rug­abu­se.­gov­/TX­Man­ual­s/b­sft­/bs­fti­nde­x.h­tml­.

Basic Assumptions

BSFT is based on the fundamental assumption that the family is the most proximal and influential context for child development (Szapocznik & Coats worth, 1999). We view the family as the primary force shaping the way a child thinks, feels and behaves. Research demonstrates that family relations are predictors of drug abuse and related antisocial behaviors (cf. Szapocznik & Coatsworth, 1999). Research also shows, however, that adolescent drug abuse and behavior problems can change as a result of changes in family relations (Liddle & Dakof, 1995; Robbins, Alexander, & Turner, 2000). Family relations are thus believed to play a pivotal role in the evolution and/or maintenance of behavior problems including drug abuse, and consequently are a primary target for intervention.

BSFT recognizes that although the family is the primary context of human growth and development, the family itself is also part of a larger social system and-like a child is influenced by her/his family-the family is influenced by the larger social system in which it exists (Bronfenbrenner, 1979). This sensitivity to contextual or ecological factors begins with an understanding of the important influence of family but extends also to peers, school, and the neighborhood in creating protection or risk for behavior problems including drug abuse. BSFT also targets parents' relationships to their children's peers and schools, as well as the unique relationships that parents have with individuals (e.g., extended family members) and systems (e.g., work, support group) outside of the nuclear family. Hence, the target of BSFT is the family broadly defined to include the individuals who function in roles that are traditionally or legally assigned to family members.

Theoretical Underpinnings

BSFT is best articulated around three central constructs: system, structure/patterns of interactions, and strategy (Szapocznik & Kurtines, 1989).

System

The first construct is a systems approach. A system is an organized whole that is comprised of parts that are interdependent or interrelated. A family is a system that is comprised of individuals whose behaviors affect each other. Family members become accustomed to the behavior of other family members, because such behaviors have occurred thousands of times over many years. In the Espinoza family, one pattern that emerged over time involved the older sister taking on parental responsibilities for her younger brothers when the mother was separated from her children. Consequently, sister had developed a strong leadership position in the family that made it difficult for mother to gain a leadership role when she returned to the family. Also, because younger brothers were close in age and the older brother was immersed in deviant behaviors outside the home and was not physically or emotionally available, a special bond between younger siblings had taken place. These behaviors synergistically work together to organize the Espinoza family system.

Structure

The second construct is structure. A central characteristic of a system is that it is comprised of parts that interact with each other. The set of repetitive patterns of interactions that characterize a family is called the family's structure. A maladaptive family structure is characterized by repetitive family interactions such that family members repeatedly elicit the same unsatisfactory responses from other family members. In our example, as mother scolded Juan for misbehaving, Juan withdrew from mother and recruited his brother's support.

Strategy

The third fundamental concept of BSFT is strategy and is defined by interventions that are practical, problem-focused, and deliberate. Practical interventions are selected for their likelihood to move the family toward desired objectives. One important aspect of practical interventions is choosing to emphasize one aspect of a family's reality (e.g., mother nags because she cares for Juan's well-being) as a way to foster a parent-child connection, or another aspect (e.g., “this youth could get into serious problems at any moment”) in another family with passive or permissive parents to heighten their sense of urgency and encourage their involvement and setting rules and consequences quickly. Either strategy will be used depending on how the family is responding to a youth's problem.

As a problem-focused approach, BSFT targets family interaction patterns that are directly relevant to the youth's symptoms. For example, Ms. Espinoza's ineffective parenting approach (nagging) and Juan's typical withdrawing response is a pattern directly related to mother's reliance on this way of connecting with her son. Interventions simultaneously attempt to appropriately connect mother and her children by strategically highlighting positive aspects of their relationship, facilitating parental nurturance, and helping Ms. Espinoza and her children effectively to negotiate rules and consequences.

Our intervention strategies are very deliberate, meaning that the therapist determines the maladaptive interactions that, if changed, are most likely to lead to our desired outcomes (i.e., adolescent prosocial behavior) in a planned fashion. For instance, before working on mother's behavior management, one has to work on reestablishing positive emotional connection between mother and children so mother's attempt to manage children's behavior can be accepted as mother's expression of concern and love for them and thus less likely to be resisted.

RESEARCH ON BSFT: TREATMENT AND ENGAGEMENT

Rather than review all research on BSFT, because of space limitations, only one study on BSFT treatment efficacy and one on BSFT engagement efficacy are reviewed.

Treatment Outcome

The efficacy of BSFT has been established in several studies. For example, a clinical trial randomized 126 Hispanic families with a behavior problem adolescent to one of two conditions: BSFT or Group Treatment Control (Santisteban, Coatsworth et al., 2003). At intake 52% of participant adolescents reported use of either alcohol or other drugs during the past month and 94% scored in the clinical range on one or both of two behavior problem scales (conduct disorder and socialized aggression) from the Revised Behavior Problem Checklist (RBPC; Quay & Peterson, 1987).

Compared to Group Treatment, BSFT cases showed significantly greater pre to post-intervention improvement in parent reports of adolescent conduct problems and antisocial behavior in the company of peers, adolescent reports of marijuana use, and observer ratings and self reports of family functioning. More specifically, there was a 75% clinical reduction on marijuana use, 58% reduction in association with antisocial peers, and 42% improvement in acting-out behavioral problems in the BSFT condition, all of which were significantly greater than the group treatment (cf. Santisteban et al., 2003).

Engagement Outcome

Engaging and retaining families of drug using and problem behavior adolescents is one of the most difficult challenges faced by therapists. For example, only 27.1% of drug using adolescents stay in outpatient community treatments for the minimum expected time (Hser et al., 2001). In a study with drug using, delinquent adolescents it was noted that in an unmodified “usual services condition,” only 22% of the families received any substance abuse or mental health services (Henggeler, Pickrel, Brondino, & Crouch, 1996). These findings are particularly alarming because youth who drop out of treatment fare worse than treatment completers on measures of individual, school, home, and community functioning (Kazdin, Mazurick, & Seigel, 1994; Liddle & Dakof, 1995). In response to this problem, we developed a set of procedures based on BSFT principles to more effectively engage behavior problem, substance using youths and their families in treatment. This approach, which we call BSFT Engagement (Szapocznik & Kurtines, 1989), is based on the premise that resistance to entering treatment can be understood in family interactional terms.

The effectiveness of BSFT engagement has been established in several investigations. For example, a randomized clinical trial of BSFT Engagement vs. Engagement as Usual with drug using Hispanic adolescents and their families, demonstrated that 93% of families that received the BSFT Engagement were successfully engaged into treatment, compared to 42% of families that received Enga...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• About the Editors
• Introduction
• Family Systems Models
• Evidence-Based Models
• A Practitioner's Response
• Index