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PROTOCOL: Brief Strategic Family Therapy (BSFT) for young people in treatment for non‐opioid drug use

2012; The Campbell Collaboration; Volume: 8; Issue: 1 Linguagem: Inglês

10.1002/cl2.97

1891-1803

Maia Lindstrøm, Pernille Skovbo Rasmussen, Krystyna Kowalski, Trine Filges, Anne‐Marie Klint Jørgensen,

Cannabis and Cannabinoid Research

Campbell Systematic ReviewsVolume 8, Issue 1 p. 1-64 PROTOCOLOpen Access PROTOCOL: Brief Strategic Family Therapy (BSFT) for young people in treatment for non-opioid drug use Maia Lindstrøm, Maia LindstrømSearch for more papers by this authorPernille Skovbo Rasmussen, Pernille Skovbo RasmussenSearch for more papers by this authorKrystyna Kowalski, Krystyna KowalskiSearch for more papers by this authorTrine Filges, Trine FilgesSearch for more papers by this authorAnne-Marie Klint Jørgensen, Anne-Marie Klint JørgensenSearch for more papers by this author Maia Lindstrøm, Maia LindstrømSearch for more papers by this authorPernille Skovbo Rasmussen, Pernille Skovbo RasmussenSearch for more papers by this authorKrystyna Kowalski, Krystyna KowalskiSearch for more papers by this authorTrine Filges, Trine FilgesSearch for more papers by this authorAnne-Marie Klint Jørgensen, Anne-Marie Klint JørgensenSearch for more papers by this author First published: 16 January 2012 https://doi.org/10.1002/CL2.97Citations: 2 Linked article: Systematic review. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat 1 Background 1.1 DESCRIPTION OF THE CONDITION Youth drug use1 that persists beyond curious experimentation is a severe problem worldwide (United Nations Office of Drugs and Crime (UNODC), 2010). Use of non-opioids drugs such as cannabis, amphetamine and cocaine is strongly associated with a range of health and social problems, including delinquency, poor scholastic attainment, fatal automobile accidents, suicide and other individual and public calamities (Deas & Thomas, 2001; Essau, 2006; Rowe & Liddle, 2006; Office of National Drug Control Policy (ONDCP), 2000; Shelton, Taylor, Bonner & van den Bree, 2009). More than 20 million of the 12 to 25 year-olds in the US, and more than 11 million of the 12 to 34 year-olds in Europe have used illicit2 drugs during the month prior to survey interviews in 2009 (Substance Abuse and Mental Health Services Administration (SAMSHA), 2010; European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2010). Seven percent of Australian 12-17 year olds have used some kind of drug during the month prior to survey interviews in 2008 (White & Smith, 2009). In Canada 26 percent of 15-24 year olds had used any illicit drugs during the past year (Health Canada, 2010). Not all young drug users progress to severe dependence, however some do and may therefore require treatment (for further reading, see e.g. Liddle et al., 2004; Crowley, Macdonald, Whitmore & Mikulich, 1998). For example, 8.4 percent of 18 to 25 year-olds in the US are classified as needing treatment for illicit drug use, but less than one tenth of these young people actually receive treatment (National Survey on Drug Use and Health (NSDUH), 2007). Likewise among young people aged 12 to 17, 4.5 percent were estimated to be in need of treatment for a drug use problem, but only one tenth in this group actually received any (SAMSHA, 2010). Research calls attention to the significant gap between young people classified in need of treatment and young people actually receiving treatment (SAMSHA, 2010; NSDUH, 2007). There is a growing public concern regarding the effectiveness and high costs of available treatments for young people, and by the high rates of treatment dropout and post-treatment relapse to drug use (Austin, Macgowan & Wagner, 2005; Najavits & Weiss, 1994; Stanton & Shadish, 1997). Accordingly, treatment to help young drug users should be as engaging as possible in order to avoid dropout and relapse (Simmons et al., 2008; National Institute on Drug Abuse, 2009), and services provided should be empirically supported in order to increase the likelihood that 1. Treatment will be successful, and 2. Public spending supports the interventions with the most effect. Researchers point to the fact that many research projects have empirically validated different kinds of treatment approaches for young drug users as effective (e.g. Rowe & Liddle, 2006; Waldron, Turner & Ozechowski, 2006; Williams, Chang & Addiction Centre Adolescent Research Group, 2000; Austin et al., 2005). The current dilemma in the field of youth substance abuse treatment is that it is not clear what works best as the research suggest that most interventions lead to reduced drug use. While there are some promising individually based cognitive and motivational therapies, i. e. Cognitive Behavioral Therapy (CBT) (Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001; Galanter & Kleber, 2008), family-based approaches may also show some promise. Family therapy covers a range of different interventions, based on different manuals and varying theoretical sources such as behavioral and cognitive behavioral theory, structural and strategic family theory, and family systems theory (Williams et al., 2000; Austin et al., 2005). Some reviews suggest that these family-based therapies are superior to individual-based programs in reducing youth drug use (Williams et al., 2000: Lipsey et al., 2010; Waldron, 1997) Young people with persistent drug use have unique needs due to their particular cognitive and psychosocial development. Young people are specifically sensitive to social influence, with family and peer groups being highly influential. Youth drug treatments facilitating positive parental and peer involvement, and integrating other systems in which the young person participates (such as schools, social services, justice authorities) are key to youth drug reduction (National Institute on Drug Abuse, 2009). A number of studies and reviews show positive results for family therapies in general, but there is a need to synthesize individual study results for specific family therapies to determine whether and to what extent specific family therapy interventions work for young drug users (Williams et al., 2000; Austin et al., 2005; Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001). This review will specifically explore the family-based intervention Brief Strategic Family Therapy (BSFT) (Szapocznik, Hervis & Schwartz, 2003; Robbins & Szapocznik, 2000) as aggregated evidence for BSFT's effects is needed. The review seeks to clarify the effects of the BSFT program for relevant groups of young people age 11-21. The review focus on young people enrolled in treatment for drug use, independent of how their problem is labeled. Enrolment in treatment means that the severity of the young person's drug use has caused a significant adult close to the young person (teacher, parent, social services, school counselor, etc.) to require treatment. The intervention (BSFT) is delivered in outpatient treatment settings3 to young people age 11-21 living with their family. The review will focus primarily on non-opioid drugs use4, and will consider poly-drug use if relevant. This review will be one in a series of reviews on manual-based family therapy interventions for young people in treatment for non-opioid drug use5. 1.2 DESCRIPTION OF THE INTERVENTION BSFT is a manual-based family-oriented prevention and treatment intervention for young people's drug use. BSFT is a problem focused family therapy, aiming at creating changes in interactions relevant to the identified problems within families, and in individual family members resisting changes. BSFT is one of many family therapy forms that meet the general characteristics of manual-based family therapies as it targets young people and their families as a system throughout treatment, and thereby recognizes the important role of the family system in the development and treatment of young people's drug use problems (Liddle et al., 2001, Muck et al. 2001). BSFT was developed at the Centre for Family Studies, University of Miami. The program was developed in the 1970s as an intervention targeting Hispanic minority young people, primarily immigrants from Cuba (Robbins & Szaspocznik, 2000). BSFT was developed to be culturally sensitive, originally in relation to Cuban immigrants in Miami, but has since been revised and is now a broadly applied intervention for young people, primarily with problematic behavior and drug use problems (Robbins & Szaspocznik, 2000). BSFT is adaptable and incorporates relevant issues depending on the population served and is supposedly sensitive to different cultural and ethnic groups as well as rural versus inner-city conditions (Robbins, Szapocznik & Horigian, 2009). 1.2.1 Theoretical background BSFT is a family systems approach that relies on both structural family theory and strategic family theory (Robbins & Szapocznik, 2000; Szapocznik et al., 2003). BSFT along with other family-systems based therapies builds on the assumption that families can be viewed as systems and as such each individual in the family is important for the family system as a whole (Poulsen, 2006). In family systems theory the family is perceived as a unique system consisting of interdependent and interrelated members. The family members are influenced by each other's actions and are strongly related to each other, and as such they can be viewed as a unique and changeable system. The behavior of each family member must be understood in relation to the family context. Young family member's problematic behavior is associated with maladaptive social interaction patterns in the family, and therefore interventions must be implemented at family level. The family itself is part of a larger social system, and as young people are influenced by their families, the family is influenced by the larger social (and cultural) systems in which they exist (Poulsen, 2006; Doherty & McDaniel, 2010; O'Farrell & Fals-Steward, 2008; Kaminer & Slesnick, 2005; Austin et al., 2005). Family therapies are concerned with the wider social context in which the individual and the family is embedded. The structural family theory is based on the idea that subsystems, structures and hierarchies within families influence or determine individual family members' actions (Goldenberg & Goldenberg, 2008; Minuchin, 1985). In structural family theory social interactions are understood structurally, as repetitive patterns of interaction. The family structure can range from a supportive structure to a maladaptive structure. Either way the structure of interactions affects the family members and could play a pivotal part in maintaining positive as well as problem behavior (Poulsen, 2006; Doherty & McDaniel, 2010; O'Farrell & Fals-Steward, 2008; Kaminer & Slesnick, 2005; Austin et al., 2005; Madanes & Haley, 1977). BSFT is a strategic approach whereby components are planned, practical and problem-focused. Intervention components are tailored to the young person and family. Components are selected based on the components' likelihood of targeting the identified core problems and positively affecting the young person and their family in a desired direction (e.g., reduced drug use, improved family interactions). The components are problem-focused in the sense that only the interactions that most directly affect the young person's drug use problems are targeted. The intervention components are well planned in the sense that the therapist determines which interactions are directly linked to the symptomatic behavior of the young person and determines which of these will be targeted. The therapist creates a tailored plan to help the family develop more appropriate patterns of interaction (Szapocznik et al., 2003; Horigian, Robbins & Szapocznik, 2004; Szapocznik & Williams, 2000; Robbins & Szapocznik, 2000). 1.2.2 BSFT components BSFT contains three major components: 'joining', 'diagnosing' and 'restructuring' (Szapocznik et al., 2003; Horigian et al., 2004; Szapocznik & Williams, 2000; Robbins & Szapocznik, 2000). Joining 'Joining' refers to engaging young people and family members in treatment through the establishment of a good therapeutic relationship. Joining occurs at the individual level (the therapist establishes a relationship with each family member) and at the family level (the therapist joins with the family system to create a new therapeutic system by becoming a temporary member of the family). Through recognizing, respecting and maintaining the family's characteristic interactional patterns the therapist attempts to establish an alliance with the individual family members and the family as a whole (Szapocznik et al., 2003; Horigan et al., 2004; Szapocznik & Williams, 2000; Robbins & Szapocznik, 2000). Diagnosing BSFT focuses on identifying inappropriate family alliances and family boundaries, and maladaptive interaction patterns. Prior to the diagnosing, BSFT therapists must create a therapeutic context where family members are free to interact in their typical style. These "enactments" permit the therapist to directly observe how the family behaves, and on this basis diagnose (Horigian et al., 2004). The 'diagnosis' of alliances, boundaries and patterns will reveal how the characteristics of family interactions contribute to the family's difficulties to meet the objective of eliminating or reducing the young person's drug problems. The therapist will analyze family interactions on five interactional dimensions: structure, resonance, developmental stage, identified patient, and conflict resolution (Robbins & Szapocznik, 2000; Horigian et al., 2004; Szapocznik et al., 2003). Diagnosing includes seeing the patterns of family interaction and their influence on the young person's problems in context (e.g. the young person's network and social setting). Individual and social risk and protective factors will therefore be taken into consideration by the therapist when evaluating the impact of family interactions on the young person's drug problems (Szapocznik et al., 2003). The diagnosing component allows for the BSFT program to be flexible and adaptable to different social settings, family structures and cultures, and co-occurring conditions, e.g. juvenile justice system issues, co-morbid mental health conditions. Restructuring The goal for 'restructuring' will be to change maladaptive family interaction patterns related to the young drug users problems to more adaptive and successful ways of interacting (Horigian et al., 2004; Robbins & Szapocznik, 2000; Szapocznik et al., 2003). Key restructuring components are 'working in the present', 'reframing' and 'working with boundaries and alliances' (Horigian et al., 2004; Robbins & Szapocznik, 2000; Szapocznik et al., 2003). Working in the present. BSFT focuses primarily on the current interaction among family members, and distinguishes between process and content. The main focus during therapy sessions is on interaction processes between family members. Reframing. The aim of reframing is to disrupt maladaptive interaction patterns and create a new context for family interactions. Reframing offers positive alternatives to the family, i.e., by shifting the family members' view of the young drug user from a 'troubled young person' to e.g., a 'vulnerable young person in pain'. Highly gendered interaction patterns in the family may also be adjusted in the reframing process. Working with boundaries and alliances. According to BSFT families with drug using young people need strong parental leadership, meaning a strong alliance between parents, with the power to make executive decisions together. For single parents there is a need for a strong parental position. The therapist will work to restore the parent alliance in families with weak or disrupted parent alliances. For single parents the therapist will work to establish and/or reinforce a strong parental position. In BSFT the therapist will also aim to set clear boundaries between family members, thereby allowing all members some privacy and independence within the family. Boundaries and alliances may vary according to e.g. gender and age, and can be attended to in this process. Intervention components in BSFT are tailored to the young person and his/her family needs and are based on the components' likelihood of positively affecting the young drug user and family in a desired direction (e.g., reduced drug use, improved family interactions). Therefore, BSFT intervention varies in distribution of components to suit the needs of family members. The tailoring of the BSFT program and the focus on family system and family functioning potentially catalyze side effects such as improved overall family functioning, improved educational outcome for the young person in treatment and siblings affected by better family functioning, and other related outcomes. 1.2.3 Duration and setting The average length of BSFT intervention is 12-16 sessions6, however the program is flexible and can be tailored to individual needs (Robbins, Bachrach & Szapocznik, 2002). Likewise BSFT is flexible in its implementation and can be delivered in a variety of settings including clinical or community facilities or in the family home (Robbins et al., 2002). 1.3 HOW THE INTERVENTION MIGHT WORK BSFT has two primary objectives: 1) to eliminate or reduce young people's drug use, and 2) to change the family interactions associated with young people's drug use. Randomized controlled trials and systematic reviews show that BSFT reduces drug use in participants and contributes to reduction in conduct problems and delinquency (Robbins et al., 2002; Santisteban et al., 2003; Waldron & Turner, 2008; Austin et al., 2005). The program outcomes may be affected by participant characteristics and program mechanisms. Participant characteristics that have been found to predict program drug use reduction or abstinence are history and severity of drug use pretreatment, general peer and parental support, particularly in relation to non-drug use, and higher levels of school attendance and functioning pretreatment (Williams et al., 2000). Practitioners need knowledge on highly relevant participant characteristics such as age, gender, minority background, family composition (e.g., single parents) and co-occurring conditions. These participant characteristics are potential predictors of treatment outcome and practitioners need to be able to assess the programs relevance for any particular type of client. 1.3.1 Intervention mechanisms Treatment variables with positive impacts on treatment outcomes have been identified across reviews of a range of treatments for youth drug use (Waldron & Turner, 2008; Williams et al., 2000). Treatment completion is the variable with most consistent relationship to drug use reduction (Williams et al., 2000; Waldron & Turner, 2008). Early alliance building predicts the likelihood that adolescent complete treatment and that they reduce drug use (Waldron & Turner, 2008). It remains unclear if this is a direct treatment impact, or an indicator for treatment motivation, which is another key to positive treatment outcome. Either way, these findings points to the importance of the BSFT component 'joining' as a key mechanism, influencing treatment compliance and attendance. Studies show that BSFT positively affects engagement and retention of young people and families (Santisteban et al., 2003; Coatsworth et al., 2001; Santisteban et al., 1996), which can be linked directly to the joining effort. In BSFT, joining has two aspects: joining is the steps a therapist takes to prepare the family for change, and joining occurs when a therapist gains a position of leadership within the family. A number of techniques can be used to prepare the family to accept therapy and to accept the therapist as a leader of change. For example the therapist can present him/herself as an ally, appealing to family members with the greatest dominance over the family unit, and attempting to fit in with the family by adopting the family's manner of speaking and behaving. These techniques are adaptable to the needs of various clients groups. Motivation, being key to positive treatment outcome (Williams et al., 2000), is also linked to the support and influence of the family system. The family systems ability to influence the young person to a non-drug-using lifestyle is a possible mechanism of change related to the family systems focus of BSFT. Studies find that BSFT positively influences family interaction changes, family functioning, and contributes to the reduction in young people's drug use (Santisteban et al., 2003; Robbins et al., 2002). For example, Robbins et.al., (2009) find that parent participants in the BSFT intervention gain from the parenting training and education in youth and family struggles, leading to reduction in the young person's drug use. According to Robbins et.al. (2009) parent participants in the BSFT intervention have been found to display improved ability to identify signs of for instance youth gang participation, improved ability to communicate with the young person about gang issues and drug issues, and improved knowledge about parent's responsibility related to youth gang and drug participation. In addition, BSFT participating parents also display improved knowledge about the negative health and legal consequences of substance use. The young person's participating in BSFT also display positive behavior improvements over the course of the treatment intervention, such as improved conflict resolution skills, improved self-concept and sense of personal resources, and reduced gang and drug identification (Robbins et.al., 2009). Improvements are gained through the reframing phase, during which the therapist work with both the young person and family members, to change their ways of behavior towards a more constructive behavior (Robbins et al., 2009). The therapist coaches the young person and family members on constructive interaction methods, and ensures that new interaction patterns are practiced at home in naturally occurring situations (e.g., when setting a curfew or when eating meals together) (Szapocznik et al., 2003). The quality of the therapeutic alliance predicts the family's engagement, retention and gains from therapy (Robbins et al., 1998). Robbins et al. (2004) have demonstrated how unbalanced alliances between therapist and young person and/or family in early BSFT session were associated with program dropout. In BSFT, one of the most useful strategies a therapist can employ in joining is to support the existing family power structure. Szapocznik et al., (2003) concludes that The BSFT counselor supports those family members who are in power by showing respect for them. This is done because they are the ones with the power to accept the counselor into the family; they have the power to place the counselor in a leadership role, and they have the power to take the family out of counseling. In most families, the most powerful member needs to agree to a change in the family, including changing himself or herself. For that reason, the counselor's strongest alliance must initially be with the most powerful family member. (Szapocznik et al., 2003:26). The family systems focus and the joining effort in BSFT are both key ingredients in BSFT, and influence family functioning and facilitate changes in young people's drug problems. 1.4 WHY IT IS IMPORTANT TO DO THIS REVIEW Persistent drug use among young people is a significant social problem, and treatment of young people's drug use is challenging and costly, not least because the treatments for young people's drug use problems is plagued by high dropout rates and post-treatment relapse to drug use. Research suggests that nearly half of the young drug users never complete drug use treatment (SAMSHA, 2008). There is a need to identify effective treatments for addressing young people's drug use problems, and to reduce treatment dropout and post-treatment relapse. Furthermore, the growing interest among policy makers in increasing funding for empirically supported interventions is a strong motivation to add to the evidence base with a systematic review on a promising treatment for young drug users. There are a number of studies indicating that BSFT is a promising treatment for young people with non-opioid drug use. By aggregating individual studies' results on BSFT, this review will contribute to the knowledge about treatment of young drug-users and their families. The review will inform practice by exploring the effects of BSFT for relevant client groups. 2 Objective of the review The aim of this review is to evaluate the current evidence on the effects of BSFT on drug use reduction for young people in treatment for non-opioid drug use. A further objective of this review is, if possible, to examine mediators of drug use reduction effects, specifically analyzing whether BSFT works better for particular types of participants. 3 Methods 3.1 CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW 3.1.1 Types of studies The study designs included in the review will be: • Controlled trials7 (all parts of the study are prospective, i.e. recruitment of participants, assessment of baseline, allocation to intervention, selection of outcomes and generation of hypotheses, see Higgins & Green, 2008): ○ RCT - randomized controlled trials ○ QRCT - quasi-randomized controlled trials (i.e. participants are allocated by means such as alternate allocation, person's birth date, the date of the week or month, case number or alphabetical order) ○ NRCT - non-randomized controlled trial (i.e. participants are allocated by other actions controlled by the researcher such as location difference or time difference). We will include study designs that use a well-defined control group. Comparison will be no intervention, wait list control, TAU and alternative active intervention. Studies using single group pre-post comparison will not be included. The rationale for including NRCTs is as follows: The aim of this review is to evaluate the current evidence and synthesize all of the potentially high quality international evidence in this topic area. If only RCTs are included, studies from countries that do not have a tradition for conducting RCTs in the area of youth drug use (at the time this protocol was written) would be excluded8. There is a long tradition for doing randomized controlled trials on social interventions in North America. However this is not the case in Europe. 3.1.2 Types of participants The population included in this review will be young people aged 11-21 years enrolled in manual based BSFT drug treatment for non-opioid drug use (e.g., cannabis, amphetamine, ecstasy or cocaine). Definitions of young people, and the age in which a person is considered a young person and may be entitled special services, such as drug treatment varies internationally (United Nations, 2011). Age group distinctions for young people are unclear as the boundaries are fluid and culturally specific (Weller, 2006). Furthermore young people start experimenting with illegal drugs at different ages in different countries (Hibell et al., 2009). Patterns of young people's independence from parents and independent living patterns likewise vary internationally. In order to capture international differences we have set the age range from 11 to 21 (Hibell et al., 2009; United Nations, 2011; SAMHSA, 2010; Danish Youth Council, 2011). In addition, only out-patient interventions are included in order to evaluate effects of BSFT on youth living with their family, since family interactions are cardinal in BSFT. No universal international consensus exists concerning what categories to use when classifying drug users9, and different assessment tools and ways of classifying the severity of drug use are applied in different research studies (American Psychiatric Association, 2000; World Health Organization (WHO), 2011; Nordegren, 2002). We include participants regardless of formal drug use diagnosis. The main criteria for inclusion is the fact that the young person is enrolled to participate in treatment (i.e. intervention or comparison condition). Referral and enrolment in drug use treatment requires a level of drug use such that a significant other, or authority (or the young person) finds it necessary to solicit or require treatment. We define the population as young people referred to or in treatment for using non-opioid drugs. We will include poly drug users, as long as the majority of drug users in a study are non-opioid drug users. Psychosocial interventions for youth opioid dependence has been evaluated in Cochrane reviews (Amato et al., 2011; Minozzi et al., 2010), and we wish to avoid duplication of effort. Populations who exclusively use alcohol will be excluded. 3.1.3 Types of interventions The review will include outpatient manual based BSFT interventions of any duration delivered to young people and their families (see 1.2 Description of the intervention). The BSFT intervention must be an outpatient intervention that does not include overnight stays in a hospital or other treatment facility. The BSFT intervention can take place in the home, at community centers, in a therapist's office or at outpatient facilities. Interventions in restrictive environments, such as prisons or other locked institutions10 (e.g., detention centers, institutions for sentence-serving juvenile delinquents) will be excluded. BSFT is a family intervention requiring the active participation of the young drug user and his or her family, and with the aim of improving family functioning. In c