PROTOCOL: Multidimensional Family Therapy (MDFT) for young people in treatment for non‐opioid drug use

Abstract

Youth drug use1 that persists beyond curious experimentation is a severe problem worldwide (UNODC, 2010). Drug use such as cannabis, amphetamine and cocaine, referred to in this review as non-opioids, amongst other drugs are 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; 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 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 drugs during the past year (Health Canada, 2010). Not all young drug users progress to severe dependence, however, some may be at risk and therefore require treatment (see e.g. Liddle et al., 2004; Labouive & White, 2002) For example, 8.4 percent of 18 to 25 year-olds in the US are classified as needing treatment for drug use, but less than one tenth of these young people actually receive treatment (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). There is growing public concern regarding the effectiveness and high costs of available treatments for young people, and with 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 dropouts and relapse (Simmons et al., 2008; National Institute on Drug Abuse, 2009). Researchers point to the fact that many research projects have empirically validated different kinds of treatment approaches for young drug users (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 use treatment is that it is not clear what works best and for whom and the research suggests that a number ofinterventions led to reduced drug use (Waldron & Turner, 2008). Treatments identified as promising are individually based cognitive and motivational therapies including Cognitive Behavioral Therapy, Multisystemic Therapy, and Family therapies (Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001; Galanter & Kleber, 2008). Family therapy covers a range of different interventions, based on different manuals and varying theoretical sources, i.e., behavioral and cognitive behavioral theory, structural and strategic family theory, and family systems theory (Williams et al., 2000; Austin et al., 2005). Promising family based interventions for the treatment of young drug users include Multidimensional Family Therapy, Brief Strategic Family Therapy and Family Behavior Therapy (Waldron & Turner, 2008; Austin et al., 2005; Rowe & Liddle, 2006; Waldron et al., 2006; Williams et al., 2000). Some reviews suggest that these family based therapies are superior 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 developmental stage. Young people are also specifically sensitive to social influences, and family and peer groups are highly influential. Youth drug treatments facilitating positive parental and peer involvement that integrate other systems in which the young person participates (such as schools, social services, justice authorities) are important keys to reducing youth drug use (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 Multidimensional Family Therapy (MDFT) (Liddle, 2002; Liddle et al., 2001; Liddle, Rowe, Dakof, Henderson & Greenbaum, 2009) as aggregated evidence for MDFT's effects is needed. The review seeks to clarify the effects of the MDFT program for relevant groups of young people age 11-21 living with their family. The review focus is on young people enrolled in treatment for drug use, independent of how their problem is labeled. Enrolment in treatment indicates that the severity of the young person's drug use has caused a significant adult close to the young person (teacher, parent, social services worker, school counselor, etc.), or the young person themself to seek treatment. The intervention in focus is MDFT delivered as outpatient treatment2 and the review will focus primarily on non-opioid drugs use3, but will consider poly-drug use if relevant. This review will be one in a series of reviews on different manual-based family therapy interventions for young people in treatment for drug use4. Multidimensional Family Therapy (MDFT) has evolved over the last twenty years and is a manual-based, family-oriented treatment, designed to eliminate drug use and associated problems in young people (Liddle, 1999; Liddle, 2002; Liddle et al., 2009). MDFT is one of many Family Therapy forms that meet the general characteristics of manual-based Family Therapies as it deals with 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). MDFT is designed to take multiple risk and protective factors into account and it acknowledges that young people's drug use is linked to multiple dimensions: home life, friends, school and community (Liddle et al., 2004). As such it advocates that a multi-dimensional approach is needed to resolve the young person's problematic drug use, and therefore aims to modify multiple domains of functioning by intervening with the young person, family members, and other members of the young person's support network (Austin et al., 2005). This also means that MDFT is based on multiple therapeutic alliances, with the young drug-using person, parents and other family members and eventually school and juvenile justice officials. While some young people have only a single parent and few significant others relevant to therapy, others might have even two sets of parents and many significant others relevant to therapy, which is a challenge the therapist must deal with. Treatment focuses on individual characteristics of the young person, the parents, and other key individuals in the young persons' life, as well as on the relational patterns contributing to the drug use and other problem behaviors. A variety of therapeutic techniques are used to accomplish this, and to improve the young person and the family's behaviors, attitudes, and functioning across the variety of domains (Liddle, 1999). MDFT aims to reorient the young person and family toward a more functional developmental trajectory on the basis of some key principles, including: 1) Individual biological, social, cognitive, personality, interpersonal, familial, developmental, and social ecological aspects can all contribute to the development, continuation, worsening and chronicity of drug problems. 2) The relationship with parent(s), siblings and other family members are a fundamental area of assessment and change. 3) Change is multifaceted, multi-determined and stage-oriented. 4) Motivation is not assumed, but is malleable and motivating the young person and family members about treatment participation and change is a fundamental therapeutic task. 5) Multiple therapeutic alliances are required to create a foundation for change. 6) Therapist responsibility and attitude is fundamental to success (Liddle, 2010). Besides addressing drug problems, MDFT may lead to reductions in delinquent behavior and affiliation with delinquent peers (Rowe, 2010; Liddle et al, 2008a; Hogue et al, 2002; Liddle et al, 2002). MDFT may also improve school behaviors and grades (Liddle et al, 2009), and youths receiving MDFT may engage in fewer unprotected sex acts (Rowe, 2010; Liddle et al, 2008a; Marvel et al, 2009; Liddle et al, 2001; Liddle et al, 2009)). Finally, MDFT has also shown reduction in internalized distress, including depression and anxiety symptoms (Rowe, 2010; Liddle et al, 2004; Liddle et al, 2009; Liddle et al, 2008a). MDFT combines aspects of several theoretical frameworks, including family systems theory and developmental psychology (Bronfenbrenner, 1979; Minuchin, 1985; Stroufe & Rutter, 1984), ecosystems theory and the risk and protective model of adolescent substance abuse (Hogue & Liddle, 1999; Liddle & Hogue, 2000; Austin et al., 2005). The influence of ecological and developmental theory is reflected in MDFT as the intervention takes into account the changing environments and multidimensional systems in which young drug users reside (Liddle, 2002; Liddle et al., 2001). MDFT is based on the idea of subsystems, structures and hierarchies within the family that influence family members' actions. MDFT along with other family-systems based therapies build 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 the 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 also concerned with the wider social context in which the individual and the family are embedded. The focal areas of MDFT (family, peers, networks) are each considered to be a ‘holon’. The term holon, which is specific to MDFT, refers to simultaneously being a whole and a part. In this sense the family is (Liddle, 2002; Minuchin & Fishman, 1981; Koestler, 1978), both a whole (e.g., each family member is an independent entity) as well as “parts” of other systems (e.g., families, school or work, peer systems, communities, and ethnic or racial group systems). The multiple ecologies in which young people reside are both wholes and parts, and both systems and subsystems. A therapist's job is to understand the workings of each system or ecology as both a whole and a part and to devise interventions that fit the individual and the systems he/she is part of. For example, relationships with parents and/or peers must be included in therapy as part of leaving the drug-using life-style. Whole and part thinking is identified as a core element in the MDFT-intervention (Liddle, 2002). MDFT, a change in parenting or in the parent(s)-young person interaction is not necessarily sufficient for a change in the young person's drug use. The fundamental idea behind MDFT is that only by working with both internal family factors (family patterns and rituals, perceptions of each other and oneself), as well as with external systemic factors (peer relations, school and other pro-social institutions), the young person's drug-using lifestyle can be addressed. Liddle (2002) state that within MDFT: “.. 1) the family is the primary context of healthy identity formation and development, 2) peer influence operates in relation to the family's buffering effect against the deviant peer subculture, and 3) adolescents need to develop an interdependent rather than an emotionally separated relationship with their parents.” (p.11) Therefore, MDFT aims at reducing symptoms and enhancing pro-social and normative developmental functions in problem youths, by targeting the family as the foundation for intervention and simultaneously facilitating curative processes in several domains (systems) of the young persons' lives. Particular behaviors, emotions and thinking patterns related to problem formation and continuation are replaced by new behaviors, emotions, and thinking patterns associated with appropriate intrapersonal and familial development (Liddle, 2002; Liddle, Cecero, Hogue, Dauber & Stambaugh, 2006). MDFT is manual-based but flexible regarding duration, settings and to some extent also therapeutic methods (Liddle, 2002). MDFT has been developed over time and has been used by both experienced family therapists and clinicians with no family therapy experience, but ideally (according to the MDFT manual by Liddle, 2002), the therapists as well as their supervisors should have a background in family therapy and/or child development. The MDFT approach has been developed and tested since 1985. Since 1991, this work has been performed through the Center for Treatment Research on Adolescent Drug Abuse, Miami USA. The latest version of the MDFT manual was published in 2002 (Liddle, 2002). MDFT is organized into phases, based upon knowledge of what is considered normal cognitive and emotional development for young people. Each phase represents one of several targets for assessment, intervention, and change, and the therapist will not progress to the next phase until the therapy has been through the current phase. The phases generally structuring MDFT aim to (Liddle, 2002): Engaging both the young person and family is one of the main emphases in the first phase of MDFT (Liddle et al., 2001). Engagement strategies include the formulation of therapeutic alliances with the adolescent, family members, and other extra familial support systems. Liddle (2002) concludes in the MDFT manual, that the first phase is important and includes ‘presenting therapy as a collaborative process’, ‘defining therapeutic goals that are meaningful to the young person, ‘generating hope’ and ‘attending to the young person's experience’. The focus is on individualizing treatment for each of the family members involved. This is accomplished through the development of personal and individualized treatment objectives for each participant. The use of culturally specific themes is also cited as a useful tool for engaging diverse youths and families (Liddle, 1999). The first phase will typically last for three weeks and is oriented at motivating and preparing the family for therapy, explaining to the family about the therapy, creating expectations, and the therapist will meet persons relevant to the family. In some cases siblings and relatives count as relevant persons, in other cases friends or for instance a social worker are relevant depending on with whom the young drug user spend time. The beginning of first phase is crucial and it can be a challenging task to engage the family positively; especially as the young person can be resistant, will often deny his/her drug use, and lack cooperation. The first phase forming therapeutic alliances allows for the MDFT program to be flexible and adaptable to different social settings, family structures and cultures, e.g., single parents, different ethnic groups, and co-occurring conditions, e.g., juvenile justice system issues, co-morbid mental health conditions. In the second phase the therapist will take action by mobilizing the young people and family network, by working with the different systems (school, peers, family, community workers), and by the practice and training of the family members' stress and communication handling skills as well as preventing or preparing for detours. The second phase is more behaviorally focused and includes efforts to increase the young person's pro-social behaviors, positive social networks, and antidrug behaviors and attitudes. There is also an emphasis on developmental issues, including a focus on increasing developmentally appropriate family interactions. Teaching problem-solving and decision-making skills and modifying defeating parenting beliefs and behaviors through a process called enactment are the primary techniques used by MDFT clinicians during phase two. The therapist will work with the young person and the parents individually and both together as a family to see how they communicate and treat each other. The therapist assesses different aspects of the young person's life and to start the process of change, the therapist asks, ‘what are the missing aspects of the young person's and family's lives? What set of circumstances and what specific day-to-day activities and intrapersonal and interpersonal processes could reverse the current development-destroying circumstances?‘ (Liddle, 2002) In the third phase the therapist will maintain the changes in the behaviors, emotions and thinking patterns of the family members. This is also the phase where the therapist will prepare for the ending of the MDFT sessions. In this last phase the therapist works with the young person and family to generalize the newly acquired skills and behaviors for future situations to maintain the positive changes. MDFT does not include an aftercare component. The three phases are implemented through four types of treatment sessions (Liddle, Dakof, Turner, Henderson & Greenbaum, 2008; Liddle et al., 2006, Liddle, 2002): Within these sessions, the therapist will present therapy as a collaborative process and define therapeutic goals that are meaningful to the young person. Also the therapist will generate hope for the young person and his/her family, by focusing on the young person's internal locus of control and by presenting themselves as an ally. Finally, within this component the therapist will closely attend to the young person's experiences and needs. During these sessions, the therapist will help the young person to learn more about their feelings and thinking patterns and how to control their anger and impulses and thereby communicate more effectively with their parents and others. MDFT has a stepwise way of reaching parents that is parallel to the way the young persons are reached in the first phase of therapy. Parenting relationship sessions are designed to close the emotional distance between parents and young people, by enhancing parents' individual functioning and their willingness to try new parenting strategies and develop new kinds of relationships. The ultimate aim is to increase parents' commitment and involvement with the young person (Liddle, 2002; Liddle, 2006). MDFT recognizes that other family members, for example siblings, adult friends of parents or extended family members, often play key roles in the development and/or maintenance of drug taking and generally maladaptive behavior patterns of young people. Individuals who play key roles in the young people's lives will be invited to participate in family and individual sessions and usually their cooperation to such requests is achieved by stressing the serious circumstances. Also individuals external to the family could take part in therapy if the parent(s) is (are) overwhelmed and need support. Themes in this component are: 1) problems in the parent-young person-relationship that began as developmental struggles (e.g. increasing independence for the young person), 2) problems that have grown or evolved over time (e.g. school problems, legal problems, family disengagement and despair), and 3) events such as family crises (chronic or acute) or traumas (e.g. parental drug use, physical or sexual abuse, physical abandonment). Therapists work on basic communication skills and patterns, by focusing for instance on whether the parent(s) and the young person state their respective points of views in their communications, and if they are able to listen and indicate that they have heard the other's point of view. Any discussion creates a context and over time, new experiences of the other individuals and of the self, will contribute to new relational outcomes. An early marker of progress in the parent and young person's relationship is how discussions are handled. The therapist will work according to a ‘first things first’ philosophy, meaning that the problems must be considered in relevant order. In this ‘first things first’ philosophy, the therapist works on basic communication skills and patterns (Liddle, 2002). For instance, can the parents and adolescents state their points of view? Can they listen and indicate that they heard the other's point of view? Within the overall frame of MDFT, the MDFT components can be practiced in slightly different ways according to the clinical needs of the young person and his or her family (Rowe & Liddle, 2003; Liddle, 2002). MDFT has been developed and tested in different forms or versions, making it a uniquely flexible intervention. For example, an intensive outpatient version consists of 25 sessions over six months, and a less intensive version consists of 12 sessions over three months (Liddle, 2002). The frequency of sessions will depend on the needs of the family. Sessions could take place in clinical and/or home settings. MDFT has three primary objectives for the young person: 1) to reduce drug use and ultimately change drug-using lifestyle into a non-drug-using lifestyle, 2) to improve the general functioning in domains such as positive peer relations, healthy identity formation, school and other pro-social institutions and 3) to improve the parent-young-person-relationship and create a balance between autonomy and emotional connection (Liddle et al., 2001; Rowe & Liddle, 2003). The objectives for the parent(s) include 1) facilitating parental commitment and investment as well as improving the overall relationship and daily communication between the parent(s) and the young person, and 2) increasing knowledge about and changes in parenting practices such as limit-setting, appropriate autonomy granting etc. (Liddle, 2002). Studies show that MDFT reduces drug use as well as behavioral problems in young people, (Liddle et.al., 2001; Liddle et al., 2006; Williams et al., 2000; Austin et al., 2005; Waldron, 1997). The effectiveness of MDFT on drug reduction outcomes may be influenced by participant characteristics and program mechanisms. Participant characteristics that have been found to predict program drug use reduction or abstinence are pretreatment history and severity of drug use, general peer and parental support, particularly in relation to non-drug use, and high levels of school attendance and functioning (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 and tailor the program to particular types of young drug users. MDFT may affect the young drug users through different mechanisms. One mechanism, that affects the young drug user positively, is the family systems focus (Rowe, 2010; Liddle, 2002). That is the family's ability to support and influence the young person to positive behavior changes, which in this case is equal to a non-drug-using lifestyle. Improvements in family relations and family behavior are related to the MDFT interventions focus on training family communication and social support (Rowe, 2010; Liddle, 2002; Liddle et al., 2001). Liddle (2010) states that “MDFT offers a unique clinical focus in how it establishes individual relationships with parent and teen, works with each alone in individual sessions and targets family interactional changes ...” (Liddle, 2010: 146). Another feature of the MDFT model that is hypothesized to increase the success of MDFT with young people experiencing multiple problems is the comprehensive multidimensional assessment. Assessment in MDFT provides a therapeutic map, directing therapists where to intervene in the multiple domains of the young person's life. The process involves not only the identification of different problem areas, symptoms, and co-occurring disorders, but also risk and protective factors in all relevant domains, so that these factors can be targeted for change. Through a series of individual and family interviews, meetings with school, court, and other mental health professionals, and observations of directed family interactions, the therapist seeks to answer critical questions about functioning in each area. Assessment is an ongoing process throughout therapy, continually integrated with interventions to calibrate treatment planning and solving. Second, guided by this multidimensional assessment, the model addresses common root factors underlying a range of emotional and behavioral symptoms that co-occur with young persons' drug use. An important mechanism relates to the multidimensional focus, and concerns the therapist's engagement in all relevant dimensions of the young person's life, including family relations, peer relations and school/work dimension, but also other dimensions (relations to social workers, extra familial relations) could be relevant mechanisms for promoting change. MDFT is based on the therapist's acknowledgement of “what you don't know can hurt you” (Liddle, 2002: 52) where it is the therapist's job to gain insight in all dimensions. Thus it is vital for the therapist to make comprehensive assessments of all spheres including local resources, court hearings, proceedings and school regulations, alternative school options etc. (Liddle, 2002). Yet another active mechanism in MDFT is related to the ‘holon‘-thinking. This includes the therapist's approach to the young person and the systems in which the young person interacts, as being both independent systems with their own logics respectively, and parts of other systems and thereby subsystems interfering with each other (Liddle, 2002). Liddle (2002) states in the MDFT manual, that: “..Systems, both intrapersonal and interpersonal, are interconnected and mutually influencing. An important job for the therapist is to acquire an understanding of how each system works as both a whole and a part and to devise appropriate interventions.” (p.51) According to Liddle (Liddle, 1999; Liddle et al., 2006), MDFT is successful in changing family interactions, improving family functioning, and reducing young people's drug use because: Furthermore, Liddle (2002) suggests that MDFT works by focusing on parent-young person's relationships. On the basis of both individual and family sessions, the therapist effectuates changes to the communication and the mutual respect between the young person in treatment and parent(s), and thereby the problem with drug-use can be reached. MDFT has shown great potential to reduce adolescent drug use. Between 64 percent and 93 percent of adolescents receiving MDFT reported abstinence from substance use at one year follow-up (Liddle et al., 2008; Rowe, 2010). Furthermore, MDFT has shown positive effects on school functioning and has shown decrease in delinquent behavior and affiliation with delinquent peers (Rowe, 2010; Liddle, 2010). Several studies show that treatment engagement and successful outcomes can be more difficult to achieve with adolescents who have co-occurring drug use and psychiatric disorders (Rowe, 2010). This is important to bear in mind, since the majority of untreated young people with a substance abuse disorder are likely to have a comorbid psychological disorder as well as a history of physical, emotional, or sexual victimization (Waldron & Turner 2008). Kaminer and Waldron (2006) noted that these co-occurring conditions may influence the onset, identification, course, and treatment of drug use problems. Drug using youths who also display conduct disorders are at increased risk of not completing treatment and have lower participation rates, both of which are linked to poorer treatment response. Persistent drug use among young people is a significant social problem around the world, and treatment of young people's drug use is challenging and costly, not least because 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 (Substance Abuse and Mental Health Services Administration, 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 evidence-based 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 MDFT is a promising treatment fo