Transcript Brief Strategic Family Therapy: Research

Holly Barrett Waldron, Janet L. Brody, & Michael S. Robbins
Funding: National Institute on Alcohol Abuse and Alcoholism - R01AA12183
National Institute on Drug Abuse - R01AA12183; R01DA09422; R01DA13350;
R01DA13354; R01DA021357; R01DA023568; R01DA15762
Other than HIV/AIDS, social, behavioral, and
environmental factors are the primary causes
of adolescent mortality worldwide
Blum, 2006
Unintentional
Injury
Homicide
Suicide
Cancer
Heart Disease
CDC 2006
Behavioral Correlates of
Adolescent Substance Use
 School: Attendance, academic performance, or
behavioral problems
 Family: Conflict with or withdrawal from family
 Social: Inappropriate social/ sexual behavior, change in
peer group
 Activities: Decreased participation, unproductive use of
time, high risk behaviors, work problems
 Health: Accidents, injury, loss of motivation, co-morbid
diagnoses (e.g., depression)
 Legal: Illegal behaviors, juvenile justice involvement
What makes these youth unique?
 Pharmacological and physiological addictive
effects of alcohol and drugs have specific
treatment implications
 Availability of substances
 Immediate social influences
 Peer, sibling and parental use
 Indirect societal Influences
 Tobacco and alcohol taxes, law enforcement)
 Use is often covert
What is adolescent
drug abuse?
Adolescent Illicit Drug Use in the U.S.
Rates in Past 30 Days
National Survey on
Drug Use and Health:
SAMSHA, 2009
Adolescent Alcohol Use in the U.S.
Rates in Past 30 Days
National Survey on
Drug Use and Health:
SAMSHA, 2009
ALCOHOL
ABUSE
Experimental Use
DRUG DEPENDENCE
Unwanted teen
pregnancy
Accidental death
Crime
HIV risk behaviors
School failure
Emergency room
admissions
Homicide and
suicide
Co-Occurrence of Substance Use and
Psychiatric Disorders
African Hispanic White, non Significance
American
Hispanic
Youth Report
Conduct Disorder
33.6%
43.2%
39.2%
.401
Oppositional Defiant
31.0%
39.4%
50%
.021
ADHD
19.1%
25.3%
37.2%
.006
58.2%
65.6%
70.3%
.253
74%
84.0%
87.2%
.031
64.5%
68.1%
67.6%
.934
Parent Report
Conduct Disorder
Oppositional Defiant
ADHD
Co-Occurrence of Substance Use and
Psychiatric Disorders
Hispanic
Simple Phobia
African
American
9.1%
Significance
12.7%
White,
Non Hispanic
12.2%
Social Phobia
15.4%
14.5%
25.7%
.045
Agoraphobia
9.0%
7.0%
8.1%
.413
Panic Disorder
5.4%
8.4%
Generalized Anxiety
5.4%
6.1%
14.2%
14.2%
.056
.028
Major Depression
6.4%
8.9%
20.3%
.002
Parent reports of depression: 23.6%, 42%, 52% (p < .0001)
.811
Risk and Protective Factors
Risk
Factors
Domains
Protective
Factors
Early Aggressive
Behavior
Individual
Self Control
Lack of Parental
Supervision
Family
Parental Involvement
Parent
Substance Abuse
Peer
Academic Competence
Drug Availability
School
Anti-drug Use Policies
Poverty
Community
Strong Neighborhood
Attachment
Cellular to Social Context
Adapted from NIH Publication No. 04-4212(A) Second Edition
October 2003
Family Influences on Drug Use
 Parent or sibling use
 Positive parental attitudes toward use
 Lack of attachment or bonding
 Poor parenting practices
 Family conflict, negative affect
 Maladaptive communication patterns
 Lack of warmth or supportiveness
 Marital discord
Culture
Friend’s Family
Family’s Jobs
Family Support
Networks
Health & Social
Services
Laws
FFT:AD
Functional Family Therapy
for Alcohol and Drug Involved
Youth and Families
What is FFT:AD?
• Has enhanced features designed to
treat adolescents with alcohol
and/drug use involvement
• Developed through direct clinical
experience
• Well established evidence-based
practice evaluated in numerous
clinical trials conducted over the
past 15 years
THE FFT CLINICAL MODEL:
Phases of FFT
Engagement Behavior Change Generalization
Goals
Relational Assessment
E & M Relationally based
Interventions
Skills
Motivation
Early
Goals
Goals
Behavioral Assessment
Multisystems Assessment
Behavior Change
Interventions
Skills
Behavior Change
Middle
Ecosystemic
Case Management
Skills
Generalization
Late
Pre-Treatment Assessment Issues
• Is the adolescent appropriate for outpatient
treatment?
• Understand different classes of drugs:
• physiological effects on the body/brain
• signs of intoxication and withdrawal
• potential for psychological and physical addiction
• Assess need for detoxification or need for
concomitant medication management
• Recognize potential for dual diagnosis
• With depression, assess for suicidal ideation
• Understand community criteria for residential
treatment admission
Engagement Issues
• Alcohol and drug use is often a covert behavior
– Parent unaware of extent of problem
– Family may be in crisis when present for treatment
• Families have widely differing views on
importance of treatment
• “Traditional “ community treatment approaches
emphasize medical model
– May create resistance to family-based treatment
• May be other drug users at home
– Parents/siblings with serious drug problems may live at home and
not be motivated/willing to participate
– Sometimes parents have most control over youngest/least drug
involved child in family
Characteristics of Families
• Wide range of responses to substance use
as a problem behavior
• Beliefs about the “meaning” of drug and
alcohol use affect motivation and
engagement in treatment
• A range of responses is also seen within
individual family members
• Parental views on substance use tend to
drive family variability in treatment motivation
• These views are generally tied to the
parents’ prior experiences with alcohol and
drugs
Common Parental Responses
• Drug use is normal
• “I was a user in high school. I don’t care, just don’t get in trouble”
• “We use together…I buy my pot from him”
• “My use doesn’t affect him”
• “I only drink alcohol and it’s legal for adults”
• “This isn’t about me – I’m the parent (I can do what I want)”
• Fear (especially if family drug/alcohol history)
•
•
•
•
“He’s just like my brother who died of an overdose”
“His drug use shows “disrespect for my feelings”
“I searched his room because I’m always afraid for him”
Parent makes frequent references to prior history
• “My son is an addict”
• Individual problem focus; resists relationship focus
• High level of blaming and negativity
• “It’s my fault”
Techniques for Motivating Families
Create a “Family” Frame for Problem
Behaviors
Technique: Relationship Focus
Minimize, Contain Hostile Interactions
Technique:
Relabeling/Reframing
Relationship Focus
Jump into escalating hostility ASAP –
somehow…just do it!
Assessment of Relationship Functions
High
Midpointing
Separation
(Distance)
Low
High
Merging
(Contact)
Menu of Behavior Change Strategies
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Communication Training
Problem-Solving Skills
Contingency Management Strategies
Positive Family Activities
Anger Management
Depression and Negative Mood Management
Job Skills
Functional Analysis of Use & Non-use Behavior
Coping with Urges and Cravings
Sobriety Challenge
Substance Refusal Skills
Prosocial & leisure skills (competing behaviors)
Seemingly Irrelevant Decisions
Relapse Prevention
Functional Analysis of Use
• Antecedents of use - External triggers
•
•
•
•
What sets the person up to use or drink?
Who is the person with?
Where is the person?
When does the use or drinking occur?
• Antecedents of use - Internal triggers
• What is the person thinking?
• What is the person feeling (physically and emotionally)?
• Description of use behavior
• What does the person do before, during, and after an episode?
• What and how much does the person use over what time period?
• How much money is spent?
• Positive & negative consequences of use
• What positive things happened before, during, and after the episode?
• What negative things happened before, during, and after the
episode?
Self-Monitoring Record
TRIGGER THOUGHTS/
FEELINGS
What sets
me up to
use?
What was I
thinking?
What was I
feeling?
BEHAVIOR POSITIVE NEGATIVE
OUTCOME OUTCOME
What did I
do then?
What good
thing
happened?
What bad
thing
happened?
Personal Triggers:
Many people develop regular habits about when and where they use
drugs and also when they don’t use drugs. Common drug use situations
include when you first wake up, before, during or after school/work, when
with a particular friend, and at parties. When are you least likely and most
likely to use?
Times you are LEAST likely to use:
SITUATION/ACTIVITY
1. Treatment at CFAR
2. _______________
3. _______________
4. _______________
DAY
Tues.
____
____
____
TIME
5:00 pm
______
______
______
DAY
____
____
____
____
TIME
______
______
______
______
Times you are MOST likely to use:
SITUATION/ACTIVITY
1. _______________
2. _______________
3. _______________
4. _______________
Coping with Thoughts about Using
•
•
•
•
•
•
Challenge them
List and recall benefits of not using
Distractions
Self-reinforcement
Talk it through
Decision delay (“urge surfing”)
Alternatives to Using Drugs/Alcohol
I might be tempted to use in
these circumstances:
Things I can do instead of
using:
1. _____________________
___________________
2. _____________________
___________________
3. _____________________
___________________
4. _____________________
___________________
1a)
1b)
2a)
2b)
3a)
3b)
4a)
4b)
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
Menu of Behavior Change Strategies
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Communication Training
Problem-Solving Skills
Contingency Management Strategies
Positive Family Activities
Anger Management
Depression and Negative Mood Management
Job Skills
Functional Analysis of Substance Use Behavior
Coping with Urges and Cravings
Sobriety Challenge
Substance Refusal Skills
Prosocial leisure skills (competing behaviors)
Seemingly Irrelevant Decisions
Relapse Prevention
Indicators that Families are Ready
for Treatment to End…
•
•
•
•
•
•
•
Family solves problems more independently at home
Conflict is diminished
Positive interactions occurring spontaneously
Improved extended family and social networks
Family better navigates school, legal systems
Adolescent is abstinent or has reduced use
Adolescent using time productively
…schedule follow-up booster sessions as needed
FFT: AD Contact Information
Holly Barrett Waldron, Ph.D.
1715 Franklin Blvd.
Eugene, OR 97403
541-484-2123 Ext. 2303
[email protected]
Janet L. Brody, Ph.D.
707 Broadway NE, Suite 402
Albuquerque, NM 87102
505-842-8932
[email protected]
Michael S. Robbins, Ph.D.
1251 NW Elford Drive
Seattle, WA 98177
954-552-0779
[email protected]