co-occurring disorders and fft with diverse populations funding: nida (r01da09422; r01da13350;...
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Co-Occurring Disorders and FFT with Diverse Populations
Funding: NIDA (R01DA09422; R01DA13350; R01DA13354)
NIAAA (R01AA12183)
Holly Barrett Waldron, Ph.D.
Oregon Research Institute
Development of Family Therapy
1940s 1950s 1960s 2000+
Family Intervention Science:
Mature Clinical Models of Practice
CyberneticsWeiner, 1942
Double-bind theory
of schizophrenia
Bateson et al., 1956
1980s
WWIIChanging women’s rolesFamily reunificationRise in divorceNeed for mental health services
General Systems Theory
von Bertalanffy, 1968
EarlyModel
Development:Ackerman
HaleyBowenSatir
Minuchin
Efficacy/Effectiveness
Trials of Treatment
Models
1990s1970s
Coercion Theory
Patterson, 1982
Evidence-Based Family Therapy Practices for Adolescent Problem Behaviors
Functional Family Therapy – (Alexander, Waldron, Robbins, Turner et al.)
Parent Training (Patterson)
Brief Strategic Family Therapy – (Szapocznik, Santisteban, Robbins et al.)
Multisystemic Therapy (Henggeler et al.)
Multidimensional Family Therapy (Liddle et al.)
Behavioral Family Therapy (Azrin, Bry, Kazdin)
Multidimensional Treatment Foster Care (Chamberlain)
Integrative Behavioral & Family Therapies – (Barrett; Brent; Rohde & Waldron)
Family Therapy
BFT (Behavioral Family Therapy) Azrin et al., 1994; 2001; Krinsley & Bry, 1995
MDFT (Multidimensional Family Therapy) Dennis et al., 2004; Liddle et al., 2001; 2003; 2004
FFT (Functional Family Therapy) Friedman, 1989; Hops et al., 2007; Waldron et al., 2001; 2005; 2007
These Three are “Well Established” for Adolescent Substance Use Disorders
Controlled Clinical Trials for Adolescent Substance Use
Disorders:
Functional Family TherapyIntegrative Behavioral and Family Therapy
Group Cognitive Behavioral TherapyIndividual Cognitive Behavioral Therapy
Team of InvestigatorsHolly Barrett Waldron Hyman Hops Charles W. Turner Manuel Barrera
Timothy J. Ozechowski Janet L. Brody
Findings from Three Controlled Clinical Trials Evaluating FFT and CBT
for Adolescent Substance Abuse and Dependence
Study Participants Living at home, parent willing to participate
DSM diagnosis Substance Use Disorder
Appropriate for outpatient treatment
No evidence of psychosis
Not receiving other mental health treatment
English language
Referral SourcesJuvenile Justice System: 43%
Schools: 31%
Newspaper Ads / Flyers: 11%
Self Referred: 10%
Other Treatment Agency: 5%
Drug Use CharacteristicsDrug % Using % Days
UsedMarijuana 99 57Alcohol 95 10Tobacco 84 64Hallucinogens 50 2Cocaine 33 3Stimulants 22 2Opiates 10 <1Sedatives/Tranquilizers 4 <1Inhalants 2 <1Other Drugs 9 <1
Common Design Features of Three Randomized Clinical Trials
12-14 sessions of treatment Four assessments conducted at:
Intake … 3 mon … 7-9 mon … 15-19 mon Substance Use Measures
– Time-Line Follow-Back Adolescent Interview– Time-Line Follow-Back Parent Collateral
Report– Urine Drug Screening
Therapy Sessions Completed
0
10
20
30
40
50
60
70
80
90
GROUP FFT CBT FFT+CBT
% S
essi
on
s C
om
ple
ted
Treatment Group
Skills-Based Group Interventionn = 30
Cognitive-Behavior Therapyn = 30
Functional Fam ily Therapyn = 30
Com bined (FFT and CBT)n = 30
19 Month Follow-up
7 Month Follow-up
4 Month Follow-up
Random Assignm ent:
Pretreatm ent Assessm ent
Randomized Trial for Marijuana Abuse (DAYS Project)
Adolescent Marijuana Use at Pre- and Post-Treatment Follow-Up
10
20
30
40
50
60
70
80
PreTx 4 Mo F/U 7 Mo F/U 19 MoF/U
FFT CBT FFT+CBT GROUP
Mea
n P
erce
nt
Day
s o
f U
se
(Waldron et al., 2001; 2008)
Proportion of Adolescents Abstinent or Using at Minimal Levels (<10% of days)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
PreTx 4 Mo F/U 7 Mo F/U 19 MoF/U
FFT CBT FFT+CBT GROUP
Pro
po
rtio
n o
f A
do
lesc
ents
(Waldron et al., 2001; 2008)
Randomized Trial for Alcohol Abuse (CEDAR Project)
Skills-Based Group Therapyn = 40
Cognitive-Behavior Therapyn = 40
Functional Fam ily Therapyn = 40
Integrative Behavioral &Fam ily Therapy
n = 40
19 Month Follow-up
8 Month Follow-up
5 Month Follow-up
Random Assignm ent:
Pretreatm ent Assessm ent
Adolescent Alcohol Use by Treatment Condition: Pre-Treatment to Follow-Up
0
5
10
15
20
PreTx 4 Mo F/U 7 Mo F/U 19 MoF/U
FFT CBT IBFT GROUP
Mea
n P
erce
nt
Day
s o
f U
se
Summary of Outcomes Family therapy produces significant pre- to post-
treatment improvement for conduct disorder, substance use disorders, anxiety (also, adult schizophrenia, adult alcohol and drug use disorders)
Family therapy is a “treatment of choice” for adolescents with conduct and substance use disorders
No evidence that one family therapy model is superior to any other for any disorder or co-occurring problems
Re-occurrence of symptoms (e.g., relapse, recidivism) presents major challenges to treatment and booster care or continuing care for a portion of treated youth may be required
Research on Mental Health Services for Hispanic Clients
At higher risk for mental illness (due to discrimination, poverty) compared to individuals in dominant culture
Underutilize mental health services Higher premature drop out rates Higher likelihood of inappropriate or ineffective services Benefit less from services than clients of majority culture Referred to substance abuse treatment at higher rates
than youth in majority culture Experience higher rates of “unsatisfactory releases from
treatment”
Shillington & Clapp, 2003 Sue, 1977; Sue et al., 1991; Vera et al., 1998)
IBFT(n=30)
CBT(n=30)
New MexicoHispanic-American
IBFT(n=30)
CBT(n=30)
New ly Im migratedM exican-American
IBFT(n=30)
CBT(n=30)
Anglo-Am erican
N ew M exico S ite
IBFT(n=30)
CBT(n=30)
New ly Im migratedM exican-American
IBFT(n=30)
CBT(n=30)
Anglo-Am erican
O regon S ite
Two-Site Randomized Trial for Drug-Abusing Hispanic and Anglo Youth
(VISTA Project)
Figure C.1. Effects of CBT and IBFT on Marijuana Use (% days) in the Hispanic Sample.
30
35
40
45
50
55
60
65
0 3 6 9 12 15 18
Assessment Point (months)
Ma
riju
an
a U
se
(%
da
ys)
CBT IBFT
Note: The individual points represent self-reported days of marijuana use (percent of days) during the past 90 days on the TLFB interview.
Figure C.2. Effects of CBT and IBFT on Marijuana Use (% days) in the Non Hispanic Sample.
20
25
30
35
40
45
50
55
60
0 5 10 15 20
Assessment Point (months)
Mar
ijuan
a U
se
(%
day
s)
CBT IBFT
Note: The individual points represent self-reported days of marijuana use (percent of days) during the past 90 days on the TLFB interview.
Therapist-Client Ethnic Matching and
Family Therapy Outcome
Source: Flicker, Waldron, Turner, Brody, & Hops (2008) Journal of Family Psychology
Rationale for Research on Ethnic Matching of Therapists and Clients
Better communication in primary language and understanding of client’s cultural background (Flaskerud, 1986).
Better therapeutic alliance due to common experience of therapist and client (Sue, 1988)
Less frequent miscommunication and misdiagnosis (Sue, 1988; Sue & Sundberg, 1996)
Therapeutic goals similarly conceptualized by the client and therapist
Similarity positively influences liking, persuasion, and credibility, processes important to treatment success (Simons et al., 1970)
Better identification of the impact of cultural issues on problem Preference of clients for working with culturally-similar
therapist (Atkinson & Lowe, 1995)
Sample
89 substance-abusing adolescents in FFT 84% male; 13-19 years 1/2 Anglo, 1/2 New Mexican Hispanic 80% in Class 2 & 3 of Hollingshead Scale 40% 2-parent, 30% 1-parent, 25% blended 72% in legal system; 1/3 treatment mandate Mean sessions completed: 89%
Adolescent Marijuana Use by Ethnicity and Ethnic Match
0
10
20
30
40
50
60
70
Assessment Point
Mea
n C
han
ge
in U
se
Matched Hispanics
Nonmatched Hispanics
Matched Anglos
Nonmatched Anglos
Pretreatment Follow -Up 1 Follow -Up 2
General Ethnicity Findings
No significant differences between Anglos and Hispanics on treatment engagement or outcome
Hispanic adolescents had significantly lower treatment alliances in 1st session - perhaps Hispanic adolescents have different time course of alliance?
Ethnic Match Findings
No significant differences between ethnically matched Anglos and Hispanics on engagement or outcome
Ethnic match not related to attendance or treatment satisfaction
Non-matched Anglos had most balanced alliance
Ethnically matched Hispanics had greater decreases in drug use
Therapist Ethnicity Effects
Hispanic therapists had more balanced alliances with families than Anglo therapists
Hispanic therapists achieved better substance use outcomes with youth than Anglo therapists
Discussion Therapist-family ethnic matching effect
was found, despite highly acculturated Hispanic sample
Relationship between ethnic match and treatment outcome was unrelated to acculturation level
Therapeutic alliance was unrelated to relationship between ethnic match and change in drug use
Implications
Evidence that FFT is as or more effective with New Mexican Hispanic families
Ethnic match more important for Hispanic families than for Anglo families
Findings highlight the need for– ethnic diversity among therapists– better cross-cultural competence training
Treating Co-morbid Adolescent SUD and Depression
Treatments with the greatest efficacy for depression and anxiety (i.e., CBT) have not shown similar effects for SUD
In dually diagnosed youth, treating either depression or substance abuse alone is insufficient for both disorders
0.4
0.5
0.6
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0.8
0.9
1.0
1 2 3 4Time of Measure
Pro
port
ion
Hea
vy U
se
Family Low BDI
No Family Low BDI
FamilyHi BDI
No Family Hi BDI
Note: BDI > 9 = High BDI; Heavy Marijuana Use = >20% Days Use.
Effective Sequencing of Evidence-based Treatments for Co-Morbid Depression and Substance Use Disorders
Referral
Intake Assessment
Screen and Consent
Sequenced Tx. 2ACWD (10 weeks)
Integrated Tx. (20 weeks)Sequenced Tx. 1FFT (10 weeks)
Randomize to:
3-month Follow-up
6-month Follow-up
9-month Follow-up
Post-FFT assessment(Week 10)
Start ACWD (10 weeks)
Post-CWDA assessment(Week 10)
Start FFT (10 weeks)
Mid-Tx assessment(Week 9)
Post-ACWD assessment(Week 20)
Post-FFT assessment(Week 20)
Post-Tx assessment(Week 20)
Participant Flow through Each Stage of Study
Figure 5
Weeks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Sequenced Tx. 1
Sequenced Tx. 2
Integrated Tx.
F F F F F F F F F F
F F F F F
F F F F F
C C C C C
C C C C C
C C C C C
C C C C C F F F F F
C+ C+ C+ C+ C+ C+ C+ C+ C+ C+ C+ C+
F F F FFFF
Provision of Treatment in the Three Service Delivery Conditions
F F
C C F F
C C
F = FFT Sessions C = ACWD Sessions C+ = Augmented ACWD SessionsFigure 6
Directions for FFT Treatment Research
Clear need for improving outcomes for:– Heavy users, polydrug users– Co-morbid disorders
Better relapse prevention components – Booster treatment sessions; aftercare– Improved consolidation of treatment gains
New ways to approach treatment research– Evaluate adaptive, progressive interventions or
“stepped” care– Tailoring treatments to specific subgroups
Research evaluating effectiveness of dissemination– Supervision approaches– Training approaches