Transporting an EmpiricallySupported FamilyBased Therapy into a Community Drug Treatment Program

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Transporting an Empirically-Supported
Family-Based Therapy into a Community Drug
Treatment Program Howard A. Liddle, Ed.D.,
Cynthia Rowe, PhD., Gayle A. Dakof, Ph.D., Craig
Henderson, Ph.D., Alina Gonzalez, Dana S.
Mills, Ph.D. Presented at the 2005 American
Psychological Association Meeting Washington, DC
August 19, 2005
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Topics and Themes
Empirically-supported treatments and the
research-practice divide
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The Times They Are A-Changin
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Developmental Status of a Changed and Changing
Specialty

• Renaissance of adolescent treatment
• New treatments and methods exist
• Feasibility and efficacy have been
  established
• Mechanisms are being investigated
• Treatment manuals are available
• Training models and materials exist
• Practice has influenced science
• Science is influencing practice and policy
• Generalizability has been addressed but not
  established on a widespread basis

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MDFT Research Program - Features Themes

• Defining and testing different versions - MDFT as
  treatment system
• Variations (versions) according to stage nature
  of dysfunction, age, gender, cultural / ethnic
  factors, clinical setting
• Research-based knowledge about development and
  dysfunction
• Own and others use delinquency school problems
• Therapeutic ingredients and processes
• Alliance, parenting, culture, in-session conflict
• Therapist competence and development
• Stages and methods of training, context factors
• Efficacy Rigorous treatment evaluation under
  ideal conditions
• Effectiveness Rigorous treatment evaluation in
  regular clinical settings
• Economic / cost studies
• Transportation studies

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Completed Treatment Outcome Studies

• MDFT, Group, Multi-Family Clinical Trial
• MDFT - Individual CBT Clinical Trial
• MDFP Prevention Trial
• MDFT-I Treatment Development
• CYT Multisite Clinical Trial
• MDFT - Group Early Adolescent Clinical Trial

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Current Treatment Development and Outcome Studies

• Alternative to Residential Treatment (NIDA)
• Transporting MDFT to Day Treatment (NIDA)
• Brief Version of MDFT (NIDA)
• Transportation and Training Outcomes (NIDA)
• Long Term Follow Up (NIDA)
• Economic / Cost Outcomes (NIDA)
• Juvenile Drug Court (NIDA)
• Dependency Drug Court (NIDA)
• CJ-DATS Research Center (NIDA)
• International Studies (NIDA, European Health
  Ministries)

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MDFT Outcomes 5 Completed Treatment RCTs, 1
Prevention RCT, 1 Technology Transfer Study
ps all lt.05 ds range from .27-.83 most effect
sizes in medium-large range
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Principles of MDFT Treatment Development
Mission Statement Develop an effective and
adoptable treatment for adolescent drug abuse

• Treatment development is the North Star
• Heterogeneity of studies
• Thematic
• Basic research guides intervention design and
  development
• Systems theory informs intervention development
• Therapist development, training and supervision
  are critical
• MDFT treatment is both structured and flexible
• Advances in the field inform the research program
• Synergy

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The Many Faces of Treatment Development
Crystal ball
Yardstick
Set of prescribed activities
Framework
Destination
Process
Research classification device
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Overview

• What did we do?
• How did we do it?
• How did it work?
• Whats next?

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Background
Liddle, H. A., Rowe, C. L., Quille, T. J., Dakof,
G. A., Mills, D. S., Sakran, E., Biaggi, H.
(2002). Transporting a research-based adolescent
drug treatment into practice. Journal of
Substance Abuse Treatment, 22, 231-243.
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What Did We Do?

• NIDA-funded study to bridge the gap
  (Bridging Study)
• Worked with providers at a representative
  adolescent day treatment program to adapt and
  transport MDFT
• 4 study phases Baseline, Training,
  Implementation, and Durability
• Tested whether MDFT was implemented and
  sustained in the treatment program

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Study Aims Outcome Domains

• Clinical Practices Determine whether providers
  implemented MDFT in the program
• Program Changes Determine whether the program
  could be transformed based on MDFT principles and
  interventions
• Client Changes Determine whether youths drug
  use and other outcomes improved
• Durability Determine whether these changes could
  be sustained without MDFT trainers

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Study Phases

• Phase I. Baseline Assessment of provider
  practices, program environment, and
  client outcomes
• Phase II. Training Work with all staff in day
  treatment program and larger system
• Phase III. Implementation Continue expert
  supervision and booster trainings as needed
• Assess impact of training
• Phase IV. Durability MDFT experts withdraw
• Assess sustainability of approach

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Adolescent Day Treatment Program Features

• Multicomponent program/multidisciplinary staff
• Behaviorally oriented levels approach
• School through alternative education program
• Group therapy daily and recreational activities
• Psychiatric evaluation and intervention
• Individual therapy weekly
• Family therapy as needed

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How Did We do It?

• Guiding principle Isomorphism between
  training approach and therapy model
• Collaboration/ Consultation approach
• Empowering clinical staff and defining roles
• Conceptualizing change at different levels
• Modeling, practice, and feedback
• Increasing staff accountability

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Known Barriers to Technology Transfer

• Treatment providers not ready for change
• Lack of organizational commitment to change
• Treatment technology not seen as credible
• Treatment too complex or unclear
• Insufficient incentives/resources
• Decay of new knowledge over time

 
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Addressing Barriers To Technology Transfer

• Start with what providers feel needs to change
•   Demonstrate outcomes in concrete ways
• Simplify the intervention with protocols
• Highlight the ways practices are consistent
• Be creative in providing incentives for
  change
•   Discuss and address obstacles openly

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How Did It Work?

• Program Directors Perspective on Training
• Its been a collaborative effort I think
  everybody was pretty good about understanding
  these are the parameters we work with and we are
  doing a good job.
• The staff just had to identify what they do
  already with the MDFT model. I think you
  abbreviated it and accommodated it within their
  setting.
• They saw it working so they were ok with doing
  it I think they did follow through with most of
  it and there was a certain amount of
  accountability there...
• I didnt see it as increased work. I saw it as
  good. Not only were they getting this one to one
  supervision from an expert, but the clinical
  meetings brought them to another level. I dont
  think it was a burden at allI think it made me
  get involved more which is good.

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Program Directors Perspective on Outcomes

• Weve sustained our census very nicely. All 12
  kids I think are coming on a daily basis, and
  thats a big deal.
• I think my sense of job satisfaction has
  improved incredibly since the study it helped me
  visualize the program, what it needed to be doing
  and how it needed to be doing it.
• The staff have better relationships with the
  kids. So they can request more from them. I think
  because of this, weve kept kids for a much
  longer period of time The whole concept of
  building the relationship before requesting
  change I think makes us more successful.
• Were making progress with the families The
  whole reason this study started and what
  attracted me was the multisystems and the family
  involvement.

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Program Directors View of Sustainability (18
mths later)

• I think that the clinical quality of the program
  has remained the same I think the learning has
  stayed.
• I think MDFT was more work for staff initially,
  but when they see the patients get better, they
  stick with it
• We still have the clinical meeting. At that
  meeting well rehash the very tough stuff and
  come up with program action plans and clinical
  action plans for the kids.
• I am holding them accountable about making sure
  the kids are coming in and they are urging
  involvement in family therapy The
  accountabilitys gotta be there.
• I think MDFT gave me structure a guide to where
  the weaknesses were, what we needed to work on,
  how to be proactive with the kids instead of
  reactive, focusing on their strengths, seeing the
  families, a context, and how to respond when a
  kid wasnt excelling.

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Therapists Perspective

• My practice changed totally. The way I viewed
  the kids changed, totally. By looking at the
  progress, and not feeling like I need to change
  them 110 by the time they leave here. If we can
  at least get them to start looking at things
  differently, to start coming here everyday, that
  was progress. So that made me start caring more
  about them and looking at the positives.
• I did have some fear. Its time consuming! But
  its worth it - when you start seeing those kind
  of changes and things happening, the kids being
  more willing to work with you than against you,
  you decide, hey I really need to make the time.
• When they know its not just them you are
  dealing with, you are also contacting their JPO,
  that started changing their behavior. And having
  more of a relationship with their parents. Their
  parents also have changed and they are dealing
  with the kid differently.

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Therapists Perspective (cont.)

• Most of the parents are very receptive because
  they like the changes. They see the changes in
  the kids and they know it is much better now. I
  have had parents where their parenting skills
  have totally changed, because of our interaction.
  We can do this, theres support out there for
  you. Dont give up, kind of thing, and thats
  all MDFT stuff right there.
• In school, you get the different theories and
  you kind of practice them as you go along as you
  see fit. But then being part of the study, you
  had to do this. You had to practice it. It made
  you really look at yourself and look at what was
  coming across and say, ok, am I using MDFT or
  what am I using? So prior to seeing a family, I
  would pull up the manual and I would go through
  the different domains that I had to touch.
• You know you get some sort of gratification from
  it when you see the kids, you see their changes,
  things in the home are changing. So why would we
  stop?

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How Did It Work?

• Clinical Practices
• Changes in sessions and contacts (parameters)
• Changes in session content (interventions)
• Program Changes
• Changes in program environment
• Client Changes
• Drug use and delinquency
• Externalizing/internalizing symptoms
• Placements in controlled settings

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Results Treatment Parameters

• Average number of weekly sessions/contacts
  compared across phases individual sessions,
  family sessions, DJJ contacts, and school
  contacts
• Baseline to Implementation all parameters
  increased significantly (plt.01)
• Baseline to Durability all parameters increased
  significantly (plt.01)
• Implementation to Durability
• Individual sessions and school contacts
  significantly increased
• DJJ contacts significantly decreased (plt.05)

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Increases in Contacts over Study Phases
More DJJ contacts in Implementation than Baseline
Slight decrease in DJJ contacts in Durability
More contacts with schools in Implementation and
Durability
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Results Session Content

• Therapy session notes coded for core MDFT themes
• Therapists focused more on drugs in Baseline
  phase than in Implementation and Durability
  (plt.05)
• Therapists focused on school and the adolescents
  thoughts and feelings about themselves more in
  the Implementation and Durability phases than in
  Baseline (pslt.01)
• Therapists in Implementation and Durability
  addressed more core MDFT content themes per
  session than in Baseline (plt.05)

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Results Program Environment

• Adolescents perceptions of the program were
  compared across study phases (COPES)
  Community-Oriented Programs Environment Scale
  (Moos, 1974, 1997)
• Implementation vs. Baseline
• increased Order and Organization (plt.05)
• Implementation and Durability vs. Baseline
• increased Practical Orientation (plt.05)
• increased Clarity (plt.05)
• decreased controlling behavior (plt.01)
• Durability vs. Baseline
• increased staff involvement (plt.05)

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Results Client Outcomes

• Implementation and Durability vs. Baseline
• Drug use decreased more significantly (plt.05)
• Durability vs. Baseline
• Delinquent behavior decreased more significantly
  (plt.05)
• Externalizing and internalizing symptoms
  decreased more significantly (plt.05) (adolescent
  and parent reports)
• Youth in Baseline were more likely to be placed
  in a controlled environment (37) compared with
  those in Implementation (8) or Durability (4)

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Change in Parent-Reported Externalizing Problems
Youth in Durability improved more rapidly than
youth in Baseline
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Change in Parent-Reported Internalizing Problems
Youth in Durability improved more rapidly than
youth in Baseline
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Percent in Controlled Environment at Follow-Up
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Summary of Findings

• Clinical Practices Therapists implemented MDFT
  in line with parameters and prescribed
  interventions
• Program Environment Program changed in line with
  MDFT principles (e.g., be therapeutic all the
  time)
• Client Outcomes Youths outcomes improved
  concurrently with staff/program changes
• Durability Staff continued to use MDFT and to
  have positive outcomes a year after MDFT experts
  withdrew
• Training created stable change in fundamental
  areas (provider, program, and client outcome)

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Whats next?

• New training studies focus on several unanswered
  questions
• Can training tools be developed that are user
  friendly and cost effective?
• Can new technologies enhance learning?
• How do trainers address unique provider and
  program level factors?
• What level of ongoing monitoring is needed from
  expert trainers to sustain learning?

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The Road Ahead

• Greatest current challenges are in effectiveness
  studies
• Developing a scientific basis for understanding
  the processes and ingredients of movement of ESTs
  into community treatment settings
• Parachuting therapies and manuals in regular
  clinics wont do
• Well designed systems of transportation / program
  change
• What has to change for these treatments to
  transport?
• Systems, policies, providers, training,
  organizations
• Sustainability sometimes ignored or characterized
  by naïve assumptions or plan
• The destination might be known but the territory
  is still murky
• Missing link politics and policy
• Evidence-informed policies for youth and
  adolescents

H. Liddle A. Frank (2005). The Road Ahead
Achievements and Challenges For Adolescent
Substance Abuse Treatment Research. Chapter 21 in
Liddle Rowe (Eds.) Treating Adolescent
Substance Abuse. Cambridge University Press 2005
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Change Research Base, Time, Process and
Circumstances
Governments don't often use research directly,
but research helps people reconsider issues, it
helps them think differently, it helps them
reconceptualize what the problem is and how
prevalent it is, it helps them discard some old
assumptions, it punctures old myths. It takes
time and reconceptualization before research
actually leads to a change in policy. In the
meantime lots of other things have happened. So
it's very hard to say that social science
triggered a change. There had to be a lot of
supporting and reinforcing conditions in place.
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Change Research Base, Time, Process and
Circumstances
For example, sociologists in the 1950s and 1960s
studied women in the professions, and showed that
women weren't being treated equally. They were
being held back, they weren't making partner in
law firms and so on. Research uncovered all of
these situations and the dynamics of the problem.
But it wasn't until the women's movement came
along and mobilized support for change that
something happened. Research alone didn't lead to
a change in policy. But research and activism
supported each other and resulted in change.
(Weiss, 1998)
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www.miami.edu\ctrada hliddle_at_med.miami.edu
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Acknowledgements Completion of this research was
supported by a grant from the National Institute
on Drug Abuse (Grant No. NIDA R01 DA13089). We
also thank Paul Greenbaum, Ph.D., as well as our
colleagues at Jackson Memorial Hospital for their
significant contributions to this
study. www.miami.edu/ctrada