Multidimensional Family Therapy for Adolescent Drug Abuse

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Multidimensional Family Therapy for Adolescent
Drug Abuse DelinquencyReclaiming
FuturesTreatment Improvement Institute28
January 2005

• Howard A. Liddle, Ed.D., ABPP
• Professor, Epidemiology Public Health and
  Psychology,
• and Director, Center for Treatment Research on
  Adolescent Drug Abuse
• University of Miami School of Medicine
• www.miami.edu/ctrada

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Miami, FloridaDowntown Brickell
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Miami, FloridaDowntown Harbor
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Miami, FloridaSouth Beach
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University of MiamiCoral Gables Campus
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University of MiamiMedical Campus
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University of MiamiMedical Campus
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University of MiamiMedical Campus Quad
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MDFT for Adolescent Drug Abuse and Delinquency

• Multidimensional Family Therapy
• Adolescent substance abuse specialty
• Related problems
• Family-based treatment system
• Diversity of studies
• Sample findings
• Clinical thinking features

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MDFT Fact Sheet

• Background
• Variety of studies
• Sample findings
• Website
• Contact information

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Developmental Stage

• Renaissance of adolescent treatment
• New treatments and methods exist
• Feasibility and efficacy has been established
• Mechanisms are being investigated
• Generalizability has been addressed
• Treatment manuals are available
• Training models and materials exist
• Full generalizability has not been established

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New Generation of Interventions

• Integrative
• Connected to basic research on development
  and dysfunction
• Diverse approaches
• Expanded in scope Multiple systems of
  assessment intervention
• Brief interventions as well
• Context of service delivery
• Well specified protocols

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Features and Themes of the MDFT Research Program

• Research-based knowledge about development and
  dysfunction
• Therapeutic ingredients and processes
• Therapist competence and development
• Efficacy Rigorous treatment evaluation under
  controlled conditions
• Effectiveness Rigorous treatment evaluation in
  regular clinical settings

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Research Program (2)

• Transporting and disseminating
• Training studies
• Refining and adapting
• Defining and testing different versions
• Continued exploration of key components and
  processes

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Diverse Client Populations

• Urban and inner-city ethnic minority youth and
  families - many with serious economic
  disadvantage
• Co-occurring mental health problems
• Juvenile justice involved teens
• Parents with mental health, criminal justice, or
  substance abuse problems

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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)
• Training Outcomes (NIDA)
• Long Term Follow Up (NIDA)
• Cost Outcomes (NIDA)
• Juvenile Drug Court (NIDA)
• Dependency Drug Court (NIDA)
• CJ-DATS Research Center (NIDA)
• International Studies
• (NIDA, 6 European Health Ministries)

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Treatment Development

• ASUD multidimensional phenomenon
• Multidimensional clinical phenomena require
  parallel understanding, intervention and research
• Clinical Model MDFT as a treatment system
• Research strategy is multidimensional
• Variety of variables and dimensions of research
  interest
• Study variety Outcome and process studies
• Focus on setting issues
• Treatment development strategy is multidimensional

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Multidimensional Family Therapy

• Promising approach for transportation or
  adaptation
• Superior outcomes in comparison to several
  state-of-the-art, widely used treatments
• Capacity to impact a wide array of risk factors
  associated with adolescent drug abuse
• Capacity to engage teens and families in
  treatment and motivate them to complete the
  program

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• Lower cost than standard outpatient or
  residential treatment
• Demonstrated success in treating a range of teens
  and families (e.g., different ethnicities,
  genders, ages, severity of problems)
• Empirically based knowledge about mechanisms of
  action
• Flexibility in adapting to existing program
  factors and providers resources and needs
• Success in improving client, therapist, and
  program outcomes in community-based
  transportation studies

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Substance Use Outcomes

• MDFT has demonstrated better results than several
  state-of-the-art treatments
• Family group therapy, peer group treatment,
  individual cognitive behavioral therapy, and
  residential treatment
• Substance use is significantly reduced in MDFT to
  a greater extent than all comparison treatments
  previously tested
• 41 to 66 reduction from intake to discharge

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Substance Use Outcomes

• Effect sizes have consistently been in the
  medium-large (d.6 Liddle, 2002 Liddle, Dakof,
  Henderson, 2002) to large range (d.7 Liddle
  et al., 2001, 2004)
• Treatment gains are enhanced in MDFT after
  treatment discharge
• Youth continue to decrease drug use up to 1 year
  following treatment entry
• Comparison treatments have increased drug use

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Change in Substance Use Frequency
43 Reduction from Intake to 6-Month Follow-Up
41 Reduction from Intake to 12-Month Follow-Up
Reductions at 12 Month Follow-Up maintained
through 30 months
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Change in Number of Substance Use Related Problems
Reductions at 12 Month Follow-Up maintained
through 30 months
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Reduction in Average Cost to Society
Cost savings to society continue to decrease
through 30 months
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Outcomes on Associated Risk Factors

• MH symptoms show greater reductions during
  treatment in MDFT
• Range of 35 to 80 within treatment reduction
• MDFT clients continue to improve following
  discharge
• Affiliation with delinquent peers decreases more
  rapidly in MDFT

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Impact on Associated Risk Factors

• School functioning improves more dramatically in
  MDFT
• Youth return to school, receive passing grades at
  higher rates, and are less disruptive in the
  classroom
• Family functioning improves to a greater extent
  in MDFT

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Process Studies IlluminateTreatment Mechanisms

• Outlined within-treatment process of improving
  family interactions
• Demonstrated how therapists successfully build
  therapeutic relationships with teens (Diamond
  Liddle, 1996)
• Parenting practices are systematically improved
  during therapy and that these changes are linked
  to reductions in adolescents symptoms (Schmidt,
  Liddle, Dakof, 1996)

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Process Studies

• Specified the links between exploring important
  cultural themes and increasing teens
  participation in treatment (Jackson-Gilfort et
  al., 2001)
• Identified parent and adolescent factors critical
  to treatment engagement (Dakof, Tejeda, Liddle,
  2001)

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Change in Parenting and Change in Adolescent
Drug Use
Schmidt, Liddle Dakof, J. Family Psychology,
1996
60 Tandem change 20 Adolescent only change 10
Parent only change 10 Neither parent or
adolescent change
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Family Functioning Before, During, and After the
Therapeutic Impasse Diamond Liddle, 1996, J
Consulting Clinical Psychology
After successfully addressing impasse, family
functioning improves
Family functioning remains poor after
unsuccessful impasse resolution attempt
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Three WorldsM. C. Escher 1955
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MDFT Part of a New Generation of Interventions

• Connected to basic research on development and
  dysfunction
• Expanded in scope
• Multisystemic assessment intervention
• Context of service delivery
• Clinician contributions to outcomes
• Treatment development emphasis

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Conceptual FrameworkCurrent Key Elements

• Risk and protective factors
• Normative development
• Developmental psychopathology
• Ecological perspective

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Intervention Targets

• Adolescent Self, son/daughter, peer system
• Parent Self and parenting
• Family Interaction and Family Relationships
• Extrafamilial

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Adolescent development
Community connection
School / academic
Treatment Foci
Family relations
Job/vocational
Cultural identity
Peer network
Drug use / drug taking contexts
Liddle, H. (2002). Multidimensional Family
Therapy for Adolescent Substance Abuse. CSAT CYT
Manual Series.
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Outcome
Treatment Parameters
Process
Multiple Dimensions of MDFT
Family Therapy
Development
Psychotherapy
Problem Behaviors
Ecology
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Key Features and Processes

• Facilitation of development
• Working the four corners
• Therapeutic alliances
• Concrete alternatives for a better life
• Adolescent self, school, peers, family
• Parent self, stress, parental subsystem
  conflict, parenting practices
• Changing family environment
• Therapist attitude and behavior

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Principles of Multidimensional Family Therapy

• Current symptoms of adolescent or other family
  members as assessment intervention opportunities

2) Change is multidetermined and multifaceted
3) Motivation to change is not assumed to be
present with adolescents or their parent(s)
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Principles of Multidimensional Family Therapy

• Practically-oriented , outcome-focused working
  relationships between therapist and family
  members/extrafamilial influences
• Failure crises are intervention opportunities
• Planning and flexibility are critical components
• 8) Therapists think in terms of stages of work
  and modules

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Principles of Multidimensional Family Therapy

• Therapist attitude is fundamental to success
• Believer in Change
• Optimistic
• Respect and Admire Parent and Teen
• See Parent and Teen Better Than They See
  Themselves
• Systems thinking - seeing the case through a
  complex lens
• Knowledge of social systems and systems of care
• Navigation ability -- The Loop
  functioning-dysfunction-change processes-intervent
  ions-read feedback-track outcomes-recalibrate
• Practical, outcome orientation
• Comfortable working in close proximity. Not
  afraid to challenge.
• Do what it takes attitude.

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MDFT Theory of Change

• The family/parents are the key change agents
• Peer influence operates in relation to the
  buffering effects of families
• Adolescents need to develop an interdependent
  relationship with parents

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MDFT Theory of Change

• Symptom reduction and enhancement of prosocial
  and normative developmental functions occur by
• Targeting the family
• Facilitating curative processes in several
  domains of functioning across different systemic
  levels

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MDFT Theory of Change

• Targets adolescent functioning in six
  health-related domains
• Drug use
• Adolescent identity development and autonomy
• Peers and peer influence
• Bonding to prosocial institutions
• Racial and cultural issues
• Health and sexuality

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MDFT Theory of Change

• Attempt to stop the cascading momentum
  established by the interacting risk and
  development-derailing process

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MDFT Theory of Change

• Problem behavior can desist when meaningful,
  concrete alternatives are created, accepted,
  attempted and adopted
• If it has been multiple risk factors and a
  network of influences that have created and
  maintained adolescent drug abuse, then the same
  complex of interrelated influences must be
  systematically assessed and targeted for change

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MDFT Site Requirements

• At least one MDFT Team
• 2 therapists (masters level)
• 1 therapist assistant
• Supervision with a family therapy orientation
• Cell phones for all team members
• Urine test kits
• Reimbursement for team member travel
• Transportation for clients
• Camcorders to record sessions
• Discretionary funds for meals, movie tickets,
  books, movie rentals
• Caseload of 5-7 cases / therapist
• Treatment length 3-8 months

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MDFT Required Forms

• Case Conceptualization
• Therapist Session Planning and Implementation Log
• Supervision Weekly Contact Log

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Assessment Intervention Sequence
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Pieces of MDFT Approach
Developmental Psychopathology
Development
MDFT
Ecology
Risk and Protection
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Pieces of MDFT Approach
Developmental Psychopathology
Development
MDFT
Ecology
Risk and Protection
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Components and Logic of MDFT Approach

• Problems
• are multidimensional

• Multidimensional problems
• require multidimensional
• conceptualizations

Parent(s)
MDFT
Adolescent
Family
Extrafamilial

• Multidimensional
• conceptualizations yield
• multi-systems interventions

• MDFT assesses and intervenes
• into multiple systems of
• development and influence

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Pieces of MDFT Approach

• Self
• Family
• Peers

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Pieces of MDFT Approach

• Self
• Overall functioning
• Stress and burden
• Parent
• Love and commitment
• Guidance and limit setting

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Pieces of MDFT Approach

• Transactional
• patterns

Family
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Pieces of MDFT Approach

• School
• Neighborhood
• Legal (Juvenile Justice)
• Social
• Medical

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Pieces of MDFT Approach
Therapist - Parent
Therapist - Family
Therapist
Therapist - Adolescent
Therapist -Extrafamilial
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MDFT Case P05

• Mothers abstinence from alcohol
• Improve mothers parenting skills
• Engage and motivate mother to seek treatment for
  traumatic history and drug use
• Motivate parents to believe they are the medicine

• Abstinence from all drugs
• Improve adolescents anger management skills
• Build hope with adolescent
• Decrease involvement with negative peer
• Facilitate self-examination

4. Therapist - Family

• Improve adolescent and mothers relationship
• Help adolescent and mother communicate about past
  hurts

5. TherapistFamily-Extrafamilial

• Help the family to have successful
  interactions with agencies
• Contact the school to set-up a meeting
• Help Mom get assistance from court to stabilize
  adolescent

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Learning Complexity Components, Sequence,
Interrelationships, Staging

• Darins Keys

MDFT
2. Parent(s)
1. Dribbling
1. Adolescent
4. Defense
3. Family
4. Extrafamilial

• Foul Shots
• Jump Shots

5. Moving Without the Ball
6. Game Strategy
5. Stages
6. Orchestration
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Clinical Features

• Treatment protocol capable of being adapted and
  tested in different forms
• To date - outpatient and intensive outpatient
  variations
• Masters level therapists
• Initial training and ongoing supervision
• Use knowledge about known causes and correlates
  to assess and target dysfunction

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Clinical Features (cont.)

• Use knowledge about known buffers and protectors
  to assess and target strengths
• Principle-driven
• Flexible adaptation
• Multiple, simultaneous targets and activities in
  several realms of functioning
• Sequenced, multi-level, multi-person change
• Organization, planning and orchestration

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Clinician Characteristics

• Systems thinking - seeing the case through a
  complex lens
• Skill in family therapy facilitates development
• Knowledge of social systems and systems of care
• Comparable relationship and intervention skill
  with parent, adolescent, and extrafamilial
• Navigation ability -- The Loop
  functioning-dysfunction-change processes-intervent
  ions-read feedback-track outcomes-recalibrate
• Practical, outcome orientation
• Motivation - Wanting to work in this way
• Do what it takes attitude

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Practice Guidelines 1

• Complex conceptualization
• Think in terms of interaction and synergy
  among various social systems
• Dangers in too narrow or too broad a
  conceptualization
• Clinical phenomenon is multidimensional and
  involves multiple systems
• These systems vary in nature, process, role
  and function, access, malleability, and change
  difficulty

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Practice Guidelines 2

• Standardization and flexibility
• Treatment stages
• Stages within stages
• Core treatment components
• Core treatment processes

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Practice Guidelines 3

• Integration of drug and psychotherapy foci
• Integration of treatment and casework
• Integration of different service delivery
  orientations - clinic, home, community,
  school, court
• Flexibility of dose
• Focus on the research derived determinants
• Facilitate growth of the known protectors
  and buffers

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Practice Guidelines 4

• Need to acquire knowledge and skill in
  several areas- drugs, jj, schools, families,
  individuals, peer networks, residential care
• Orchestration and organization skills
• Mobilizing individual and social context
  forces to sustain gains

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Center for Treatment Research on Adolescent Drug
Abuse University of Miami School of
Medicine www.miami.edu/ctrada hliddle_at_med.miami
.edu
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Overview of Treatment Model/Intervention
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3 Stages of Treatment

• Stage 1 Build the Foundation/ Engagement
• Stage 2 Work the Themes /Request Change
• Stage 3 Seal the Changes and Exit

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Modules are intervention targets

• Four focal areas (primary developmental arenas)
• Adolescent
• Parent(s) and Parenting
• Family Relationships Interaction
• Extrafamilial systems of influence

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MDFT Interventions That Are Not Stage Specific

• Check in that client understands what therapist
  is talking about (Do you know what I mean? Do
  you know what it means?)
• Gently ask leading questions. Questions that you
  know the answer to for the point of making the
  point palpable to client. Can be simple
  questions. Therapist asks questions not to get
  information but to help client realize something
  important.
• Help youth and parents talk about (stay with, go
  to) emotions of sadness, pain, sensitivity.
  Instead of anger and acting out.
• Constantly check in about behavior in home and
  school, etc. How is it going? Is the change
  keeping? Are there problems?
• Encourage experience and expression of affect.
• Prepare participants individually for upcoming
  in-session interactions.

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MDFT Interventions That Are Not Stage Specific

• Arrange, coach, process multiparticipant
  interactions in sessions.
• Use the phone between sessions with both parent
  and youth.
• Use current crisis to mobilize action and create
  focus.
• Read client feedback and shifts focus, when
  necessary, to respond to clients needs and
  concerns.
• Be supportive, non judgmental (I understand what
  you are going through.) Communicate
  unconditional positive regard.

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MDFT Interventions That Are Not Stage Specific

• Look for most accessible area to make a change.
  It does not have to be the most important area.
  You just want the adolescent and parent to see
  you as an ally.
• Create positive expectations. They must believe
  that all this hard work and pain is worth it.
• Reinforce small steps, small changes, small
  accomplishments.

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Stage 1 Build the Foundation

• Treatment creates a new system
• Welcome the adolescent and family to a new life
  space
• Explain and orient to the program
• Develop a temporal orientation
• Intensive involvement

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Stage 1 Build the Foundation

• Use current crisis to mobilize positive forces
  and create focus. Distress is used to facilitate
  motivation
• Conduct family and individual sessions
• Create expectations
• Elicit and shape the stories

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Stage 1 Build the Foundation

• Work multisystemically
• Meet or talk with everybody familial and
  extrafamilial
• Build alliances
• Think development
• Work the phone

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Stage 1 Build the Foundation

• Craft themes Plant Seeds
• Visit the school and neighborhood
• Test different pathways and kinds of change

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Stage 2 Work the Themes

• Theme work launches from the foundation
• Increase action and change orientation
• Requires commitment, communication, belief, and
  consistent orientation
  
  
• Think successive approximations
• Work with the most accessible areas first

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Stage 2 Work the Themes

• Make theme development more rich
• Think and work in all modules
• Storyboard it out Thinking in stages. Session
  planning sheets.
• Crises, slips, and detours are opportunities

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Stage 2 Work the Themes

• Family enactment Dont be afraid, or Thats
  why theyre there
• Work the core sessions

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Stage 3 Seal the changes and exit

• Time is an important treatment dimension
• Honest appraisal of current status
• Accept rough around the edges outcomes
• Emphasize and make overt the changed in any and
  all domains our exit is their new beginning
• Assess next steps, future needs. Expect bumps in
  the road.

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Stage 1
Stage 1- Building the foundation (Engagement)
Adolescent Module
Adolescent Module

• Motivating the adolescent to engage in
  therapeutic process
• There is something in this for you.
• Articulating how the therapist and therapy will
  help adolescent get what he/she wants.
• But dont make false promises.
• Discuss with youth what they want to see changed
  in their family, with their parents.
• Discuss with youth what he/she wants to see
  changed in themselves, in their life.
• Communicate that you are their ally and advocate
  (I will help you get what you want.). This is a
  chance for therapist to show adolescent they care
  and will help.

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Stage 1- Building the foundation (Engagement)
Adolescent Module
Stage 1
Adolescent Module

• Encouraging a collaborative Process We are
  going to work together to formulate goals. What
  we do here is
• Communicating interest in knowing about youth and
  who he/she is. Getting to know them and their
  world His/her interests, what they like, music,
  sports, anything that is important to the
  adolescent. Therapist is very positive and
  encouraging. Completely nonjudgmental. No
  attempts are made to change youth. The point is
  to just get to know youth and to express that you
  like him/her, are interested in their thoughts,
  etc.

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Adolescent Module
Stage 1

• Get details of their life, day to day. How they
  spend their time. Peers. Girlfriends/boyfriends.
  Thoughts, feelings. So that their life is
  palpable to therapist
• Allow youth to voice their concerns, complaints
  about anything and everything.
• Encourage expression of hopes, dreams,
  competencies, strengths. Highlight these
  expressions, enlarge upon them. Discuss with
  youth who he/she wants to be.
• Assess for co-morbidity (depressions, anxiety).
  Refer to psychiatrists for psychiatric
  evaluations and medications if necessary.

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Stage 1- Building the foundation (Engagement)
Stage 1
Parent and Parenting Module

• Assess current and past stress and burden (I
  know this is hard on you. You have been through
  a lot.)
• Encourage parents to talk about all efforts in
  the past including treatment failures and
  success, parenting efforts, etc. Seek out
  competences and strengths in parent.
• Highlight how well they have done given difficult
  circumstances.
• Explore their childhoods- what type of parenting
  did they receive? Look for strengths to build
  upon. Look for accomplishments in this realm
  given poor role models.
• Enhance and strengthen feelings of love and
  commitment. (PRI- look at photo albums, help them
  go back to a time when they remember loving their
  adolescent when things were good between them.)

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Parent and Parenting Module
Stage 1

• Communicate to parents that this program is for
  them too. (I will be here to help you.)
  Therapist is an ally and advocate for parent.
• Motivating parents You are the medicine,
  parental influence. Help them state (put on the
  table for all to hear) that they will do whatever
  it takes to help their child.
• Motivating Parents No Regrets

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Stage 1- Building the foundation (Engagement)
Stage 1
Parent Relationship/Family Interaction Module

• Assess family interactions. What happened in the
  past? What went wrong up to now? (Is there
  conflict? How do they problem solve? How do
  they talk to each other? Is it superficial or do
  they talk about important issues? Who talks to
  who? How often do they talk to each other? How
  and how often do they communicate warmth and
  love?)
• Assess family history, family story. Look for
  themes of strength as well as past betrayals,
  neglect, abuse that will need to be talked about
  in Stage 2.
• Focus on the affective component of their
  relationship. Move to a level of love,
  commitment, connectedness, relationship and
  compassion.

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Stage 2- Work the Themes
Stage 2
Adolescent Module Remember Stage 1 interventions
are carried through and administered as necessary
in Stages 2 and 3.

• Prepare adolescent to tell his/her story to their
  parents. (Have adolescent tell parents about
  their world).
• Facilitate self examination. Help them examine
  the positives and negatives about their drug use,
  selling, high risk sexual behaviors, etc. If
  adolescent is still using and engaging in
  delinquent behaviors, help them talk about the
  positives (pleasure, esteem, money, etc) as well
  as the negatives (getting arrested, failing in
  school, never to get a decent job, disappointing
  parents, etc). If the adolescent is clean, this
  is a chance to allow the adolescent to talk about
  how they miss the drugs or the lifestyle, money,
  etc.

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Adolescent Module
Stage 2

• Examine barriers to change (youth may want to
  change but cant do it alone) and explore
  ambivalence about change.
• Help adolescent to articulate hopes and dreams
  for the immediate and long term. Create
  alternatives to current life (both short term and
  long term). Who you were, who you are, and who
  you want to become.
• Discuss with adolescent how they are going to get
  to where they want to be. Help them make a plan
  and take steps to realize the plan. This is a
  very problem-focused, behavioral intervention.
• Directly address drug abuse and other
  externalizing problems. (delinquency, high risk
  sex, school failure). Help adolescent deal with
  the truth about their behaviors and their
  thoughts about it. Help them explore
  consequences, risks, etc. (Your actions hurt
  others, hurt people you care about. -- What was
  going on with you when you did _______?

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Adolescent Module
Stage 2

• If depressed, work with psychiatrist if on meds.
  Regardless of medication, launch depression
  module.
• 7a. Education to parent and teen about depression
• 7b. Have youth keep daily activity log. Use in
  therapy sessions.
• 7c. Have youth keep automatic thought log. Use in
  therapy sessions.
• 7d. Regular consultation with psychiatrist if
  youth on meds.
• Refer teen to sex education and HIV prevention
  programs to address their high risk behavior.
  Discuss experience in therapy sessions.
• Use the drug screen in treatment. Use both
  positive and negative results in the session.
  Allow them to talk about all the details about
  their relapse or their abstinence.

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Adolescent Module
Stages 2

• Help youth form a new and more effective way of
  communicating with parents, teachers, other
  adults. Help them to see the negative
  consequences of certain types of communications
  (e.g., disrespectful and/or angry).
• Improve functioning in areas that get them into
  trouble anger management, impulse control,
  negative thoughts, self-esteem, hopelessness. (If
  the adolescent needs extra assistance with anger
  management and impulse control, refer them to
  anger management classes. If referred to anger
  management class, discuss experience in therapy)

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Stage 2- Work the Themes
Stage 2
Parent and Parenting Module Remember Stage 1
interventions are carried through and
administered as necessary in Stages 2 and 3.

• Help parent look at their own life and what they
  want for themselves. (Assess level of support- do
  they need any extra psychiatric services? If yes,
  make appropriate referral and follow up)
• Emphasize self-love, self care. You need to take
  care of yourself. Cant be good parent if you
  dont take care of self. Focus on parents needs.
  Who they are and who they want to be.
• Instill hope in parent (things can change, he/she
  can change, power of parental influence, etc).
  Create positive expectations.

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Parent and Parenting Module
Stage 2

• Address inter-parent conflict. Inspirational
  Help parents work as a team. Teamwork very
  important in parenting. Help them to realize that
  they must put aside their differences and come
  together for their child. Be very positive (you
  can do it).
• Address inter-parent conflicts. Behavioral Help
  parents work out a plan for how they will work as
  a team to parent child. Problem solve,
  collaborate with parents. Take an experimental
  framework (We will try it, and if it doesnt work
  we will try something else.)
• Prepare parent to hear the adolescent tell
  his/her story. If you want to have influence on
  your adolescent you have to know him/her. You
  may hear some things that are difficult and that
  you may not like. It is very important that you
  are able to hear about his/her world. Also,
  help parent not to flip out.

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Parent and Parenting Module
Stage 2

• Help parents examine their own behaviors,
  including drug use or other high risk behaviors.
  Encourage change in relevant areas.
• Encourage strong anti-drug stance and strong
  pro-school stance (Even if parent uses
  themselves, their stance to the adolescent is
  crucial).
• Psychoeducation about parenting adolescent
  development. (Sometimes you just need to tell
  them what to do. Some parents need more
  assistance than others with their parenting
  practices)
• Empower parents. Help them to be parental. Help
  them have influence and authority.

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Parent and Parenting Module
Stage 2

• Encourage age appropriate parenting skills
• Monitoring
• Limit setting
• Consequences (positive and negative)
• Follow through

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Parent and Parenting Module
Stage 2

• Assist parents in establishing extra support that
  will help them be successful with parenting their
  adolescent.
• Help parents to be emotionally available to
  child.
• Examine barriers to change (I cant. I
  wont.), and explore ambivalence about changing.

107
Stage 2- Work the Themes
Stage 2
Parent Relationship/Family Interaction
Module Remember Stage 1 interventions are
carried through and administered as necessary in
Stages 2 and 3. All the items below will be
addressed through enactments with the family.
Sometimes you will be meeting with adolescent
alone parents alone to prepare for these
enactments.

• Bring the conflict out in the open. Put it on the
  table so family can begin dealing with it.
• Help family resolve conflicts. Help them
  establish effective ways to problem solve.
  Improve conflict resolution skills. Help them
  learn to express self without fighting and
  blaming.
• Encourage age appropriate negotiation between
  adolescent and parent. Work together to set
  certain limits and consequences.

108
Parent Relationship/ Family Interaction Module
Stage 2

• Help family find ways to have positive
  interactions.
• Help adolescent to tell his/her story to their
  parents. (Have adolescent tell parents about
  their world). Keeping the parents from
  interrupting, disagreeing, or judging. Help
  parents respond in a constructive way, including
  apologizing if appropriate and explaining their
  stress and burden. Dialogue is the key.

109
Parent Relationship/ Family Interaction Module
Stage 2

• Help family talk about important issues.
  Increase communication between family members.
  Have them start with something small so that they
  can experience positive interactions. Have them
  work towards more important issues that are
  impacting their relationships (Through family
  interactions is where the adolescent will learn
  how to be healthy in the world. They will be able
  to have good communication with important adults,
  such as teachers, judges, police, employers, etc.)

110
Parent Relationship/ Family Interaction Module
Stage 2

• Focus on affective component of their
  relationship. Support and enhance family
  communication of warmth and love. Help them to
  recognize how important they are to each other.
  Their positive qualities, etc.
• Help family understand how important it is for
  them to establish positive supportive
  relationship. (parents need to show their love
  and warmth at the same time that they are making
  demands on the adolescent)
• Facilitate parent-adolescent discussion about the
  love, worry and concern behind parents limiting
  setting and discipline practices.
• If youth experienced past hurt, betrayals,
  neglect or abuse, facilitate discussion about the
  past. Dialogue is the key.

111
Stage 3- All Modules
Stage 3

• Seal changes- make all changes overt. Acknowledge
  the progress and changes. Acknowledge what is
  good.
• Assess progress make a plan to focus on workable
  goals during the last 6 weeks of treatment.
  Examine what you have accomplished, what is left
  to accomplish, and set priorities. Accept rough
  around the edges outcomes, if necessary.
• Talk about ending treatment. Explore clients
  thoughts and feelings. Seal changes- make all
  changes made overt.
• Discuss future potential, bumps in the road.

112
Extrafamilial ModuleTherapist will deal with
most accessible areas first. This will help
therapist engage with the family. All this work
is done throughout the three stages.

• School
• Get records
• Assess adolescent needs. Are they in appropriate
  placement?
• Schedule school meeting- introduce program and
  establish collaborative relationship.
• Facilitate placement is best possible
  school/educational situation.
• Closely monitor school/educational situation, and
  make adjustments as necessary.
• Teach parents how to assess school problems, and
  interact with systems to get the best for their
  child.
• At end of treatment, have youth stable in best
  possible educational situation.

113
Extrafamilial Module

• Court
• Get records.
• Attend court appearances.
• Advocate for adolescents.
• Establish good working relationship with
  probation officer and other juvenile justice and
  court officials.
• Closely monitor judicial situation, and make
  adjustments as necessary.
• Teach parents how to advocate for their child in
  court/juvenile system.
• Recreational Services for Youth
• Help adolescent get involved with prosocial,
  recreational activity (sports, art, music,
  community service, etc)

114
Extrafamilial Module

• Social Services for Family
• Assess needs and obtain services
• Financial assistance (DCF)
• Immigration
• Housing
• Food
• Health Care
• Mental Health Care (psychiatric or more intensive
  services for any family member.)
• Disability
• Social support for family