Chapter 6 - Clinical Research Supporting Brief Stategic Family Therapy
This chapter describes past research on the effectiveness of BSFT
with drug-abusing adolescents with behavioral problems. BSFT has
been found to be effective in reducing adolescents' conduct problems,
drug use, and association with antisocial peers and in improving family
functioning. In addition, BSFT engagement has been found to increase
engagement and retention in therapy. Additional studies testing an
ecological version of BSFT with this population are currently underway.
As presented in this manual, BSFT's primary emphasis is on identifying
and modifying maladaptive patterns of family interaction that are
linked to the adolescent's symptoms. The ecological version of BSFT,
BSFT-ecological (Robbins et al. in press) applies this principle of
identifying and modifying maladaptive patterns of interaction to the
multiple social contexts in which the adolescent is embedded (cf.
Bronfenbrenner 1979). The principal social contexts that are targeted
in BSFT-ecological are family, family-peer relations, family-school
relations, family-juvenile justice relations, and parent support systems.
Joining, diagnosing, and restructuring, as developed in BSFT to use
within the family system, are applied to these other social contexts or
systems that influence the adolescent's behaviors. For instance, the
BSFT counselor assesses the maladaptive, repetitive patterns of interaction
that occur in each of these systems or domains. As an example,
the BSFT counselor would diagnose the family-school system in
the same way that he or she would diagnose the family system. In
diagnosing structure, the counselor would ask, "Do parents provide
effective leadership in their relationship with their child's teachers?"
In diagnosing resonance, the counselor would ask, "Are parents and
teachers disengaged?" In diagnosing conflict resolution, the counselor's
questions would be, "What is the conflict resolution style in the parentteacher
relationship? Might parents and teachers avoid conflict with
each other (by remaining disengaged) or diffuse conflicts by blaming
each other?" In BSFT-ecological, joining the teacher in the parentteacher
relationship employs the same joining techniques developed
for BSFT. Similarly, in BSFT-ecological, BSFT restructuring techniques
are used to modify the nature of the relationship between a parent
and his or her child's teacher.
Outpatient Brief Strategic Family Therapy Versus Outpatient Group Counseling
A recent study (Santisteban et al. in press) examined the efficacy of BSFT
in reducing an adolescent's behavioral problems, association with
antisocial peers, and marijuana use, and in improving family functioning.
In this study, outpatient BSFT was compared to an outpatient
group counseling control treatment. Participants were 79 Hispanic
families with a 12- to 18-year-old adolescent who was referred to
counseling for conduct and antisocial problems by either a school
counselor or a parent. Families were randomly assigned to either
BSFT or group counseling. Analyses of treatment integrity revealed
that interventions in both therapies adhered to treatment guidelines
and that the two therapies were clearly distinguishable.
Conduct disorder and association with antisocial peers were assessed
using the Revised Behavior Problem Checklist (RBPC) (Quay and
Peterson 1987), which is a measure of adolescent behavior problems
reported by parents. Conduct disorder was measured using 22 items,
and association with antisocial peers was measured using 17 items.
Each item asks the parent(s) to rate whether a specific aspect of the
adolescent's behavior (e.g., fighting, spending time with "bad" friends)
is no problem (0), a mild problem (1), or a severe problem (2).
Ratings for all items on each scale are then added together to derive
a total score.
The effects of BSFT on conduct disorder, association with antisocial
peers, and marijuana use were evaluated in two ways. First, analyses
of variance were conducted to examine whether BSFT reduced
conduct disorder, association with antisocial peers, and marijuana use
to a significantly greater extent than did group counseling. Second,
exploratory analyses were conducted on clinically significant changes
in conduct problems and association with antisocial peers. These
exploratory analyses used the twofold clinical significance criteria
recommended by Jacobson and Truax (1991). To be able to classify a
change in symptoms for a given participant as clinically significant, two
conditions have to occur. First, the magnitude of the change must be
large enough to be reliable--that is, to rule out random fluctuation as
a plausible explanation. Second, the participant must "recover" from
clinical to nonclinical levels, i.e., cross the diagnostic threshold.
Conduct Disorder. Analyses of variance indicated that conduct disorder
scores for adolescents in BSFT compared to those for adolescents in
group counseling were significantly reduced between pre- and posttreatment.
In the clinical significance analyses, a substantially larger
proportion of adolescents in BSFT than in group counseling demonstrated
clinically significant improvement. At intake, 70 percent of
adolescents in BSFT had conduct disorder scores that were above
clinical cutoffs. That is, they scored above the empirically established
threshold for clinical diagnoses of conduct disorder. At the end of treatment, 46 percent of these adolescents showed reliable improvement,
and 5 percent showed reliable deterioration. Among the 46 percent
who showed reliable improvement, 59 percent recovered to
nonclinical levels of conduct disorder. In contrast, at intake, 64 percent
of adolescents in group counseling had conduct disorder scores
above the clinical cutoff. Of these, none showed reliable improvement,
and 11 percent showed reliable deterioration. Therefore, while
adolescents in BSFT who entered treatment at clinical levels of conduct
disorder had a 66 percent likelihood of improving, none of the
adolescents in group counseling reliably improved.
Association With Antisocial Peers. Analyses of variance indicated that,
for adolescents in BSFT, scores for association with antisocial peers were
significantly reduced between pre- and post-treatment, compared to
those for adolescents in group counseling. In the clinical significance
analyses, 79 percent of adolescents in BSFT were above clinical cutoffs
for association with antisocial peers at intake. Among adolescents
in BSFT meeting clinical criteria for association with antisocial peers,
36 percent showed reliable improvement, and 2 percent showed
reliable deterioration. Of the 36 percent of adolescents in BSFT with
reliable improvement, 50 percent were classified as recovered. Among
adolescents in group counseling, 64 percent were above clinical cutoffs
for association with antisocial peers at intake. Among adolescents
in group counseling meeting these clinical criteria at intake, 11 percent
reliably improved, and none reliably deteriorated. Of the 11 percent of
adolescents in group counseling evidencing reliable improvement in
association with antisocial peers, 50 percent recovered to nonclinical
levels. Hence, adolescents in BSFT who entered treatment at clinical
levels of association with antisocial peers were 2.5 times more likely
to reliable improve than were adolescents in group treatment.
Marijuana Use. Analyses of variance revealed that BSFT was associated
with significantly greater reductions in self-reported marijuana use than
was group counseling. To investigate whether clinically meaningful 3
changes in marijuana use occurred, four use categories from the substance
use literature (e.g., Brooks et al.1998) were employed. These
categories are based on the number of days an individual uses marijuana
in the 30 days before the intake and termination assessments:
- abstainer - 0 days
- weekly user - 1 to 8 days
- frequent user - 9 to 16 days
- daily user - 17 or more days
In BSFT, 40 percent of participants reported using marijuana at intake
and/or termination. Of these, 25 percent did not show change, 60 percent
showed improvement in drug use, and 15 percent showed deterioration.
Of the individuals in BSFT who shifted into less severe categories,
75 percent were no longer using marijuana at termination. In group
counseling, 26 percent of participants reported using marijuana at
intake and/or termination. Of these, 33 percent showed no change,
17 percent showed improvement, and 50 percent deteriorated. The
17 percent of adolescents in group counseling cases that showed
improvement were no longer using marijuana at termination. Hence,
adolescents in BSFT were 3.5 times more likely than were adolescents
in group counseling to show improvement in marijuana use.
Treatments also were compared in terms of their influence on family
functioning. Family functioning was measured using the Structural
Family Systems Ratings (Szapocznik et al. 1991). This measure was
constructed to assess family functioning as defined in Chapter 3.
Based on their scores when they entered therapy, families were
separated by a median split into those who had good and those who
had poor family functioning. Within each group (i.e., those with good
and those with poor family functioning), a statistical test that compares
group means (analysis of variance) tested changes in family functioning
from before to after the intervention.
Among families who were admitted with poor family functioning, the
results showed that those assigned to BSFT had a significant improvement
in family functioning, while those families assigned to group
counseling did not improve significantly.
Among families who were admitted with good family functioning, the
results showed that those assigned to BSFT retained their good levels
of family functioning, while families assigned to group counseling
showed significant deterioration. These findings suggest that not all
families of drug-abusing youths begin counseling with poor family
functioning, but if the family is not given adequate help to cope with
the youth's problems, the family's functioning may deteriorate.
One Person Brief Strategic Family Therapy
With the advent of the adolescent drug epidemic of the 1970s, the
vast majority of counselors who worked with drug-using youths
reported that, although they preferred to use family therapy, they
were not able to bring whole families into treatment (Coleman and
Davis 1978). In response, a procedure was developed that would
achieve the goals of BSFT (to change maladaptive family interactions
and symptomatic adolescent behavior) without requiring the whole
family to attend treatment sessions. The procedure is an adaptation
of BSFT called "One Person" BSFT (Szapocznik et al. 1985;
Szapocznik and Kurtines 1989; Szapocznik et al. 1989a). One Person
BSFT capitalizes on the systemic concept of complementarity, which
suggests that when one family member changes, the rest of the system
responds by either restoring the family process to its old ways or
adapting to the new changes (Minuchin and Fishman 1981). The goal
of One Person BSFT is to change the drug-abusing adolescent's
participation in maladaptive family interactions that include him or
her. Occasionally, these changes create a family crisis as the family
attempts to return to its old ways. The counselor uses the opportunity
created by these crises to engage reluctant family members.
A clinical trial was conducted to compare the efficacy of One Person
BSFT to Conjoint (full family) BSFT (Szapocznik et al. 1983, 1986).
Hispanic families with a drug-abusing 12- to 17-year-old adolescent
were randomly assigned to the One Person or Conjoint BSFT modalities.
Both therapies were designed to use exactly the same BSFT
theory so that only one variable (one person vs. conjoint meetings)
would differ between the treatments. Analyses of treatment integrity
revealed that interventions in both therapies adhered to guidelines
and that the two therapies were clearly distinguishable. The results
showed that One Person was as efficacious as Conjoint BSFT in
significantly reducing adolescent drug use and behavior problems as
well as in improving family functioning at the end of therapy. These
results were maintained at the 6-month followup (Szapocznik et al.
One Person BSFT is not discussed in this manual because it is considered
a very advanced clinical technique. More information on One
Person BSFT is available in Szapocznik and Kurtines (1989).
Brief Strategic Family Therapy Engagement
As discussed in Chapter 5, in response to the problem of engaging
resistant families, a set of engagement procedures based on BSFT
principles was developed (Szapocznik and Kurtines 1989; Szapocznik
et al. 1989b). These procedures are based on the premise that resistance
to entering treatment can be understood in family interactional terms.
One Person BSFT techniques are useful in this initial phase. That's
because the person who contacts the counselor to request help may
become the one person through whom work is initially done to
restructure the maladaptive family interactions that are maintaining
the symptom of resistance. The success of the engagement process is
measured by the family's and the symptomatic youth's attendance in
family therapy. In part, success in engagement permits the counselor
to redefine the problem as a family problem in which all family members
have something to gain. Once the family is engaged in treatment,
the focus of the intervention is shifted from engagement to removing
the adolescent's presenting symptoms.
The efficacy of BSFT engagement has been tested in three studies with
Hispanic youths (Szapocznik et al. 1988; Santisteban et al. 1996;
Coatsworth et al. 2001). The first study (Szapocznik et al. 1988) included
mostly Cuban families with adolescents who had behavior problems
and who were suspected of or observed using drugs by their parents
or school counselors. Of those engaged, 93 percent actually reported
drug use. Families were randomly assigned to one of two therapies:
BSFT engagement or engagement as usual (the control therapy). The
engagement-as-usual therapy consisted of the typical engagement
methods used by community treatment agencies, which were identified
prior to the study using a community survey of outpatient agencies
serving drug-abusing adolescents. All families who were
successfully engaged received BSFT. In the experimental therapy,
families were engaged and retained using BSFT engagement techniques.
Successful engagement was defined as the conjoint family
(minimally the identified patient and his or her parents and siblings
living in the same household) attending the first BSFT session, which
was usually to assess the drug-using adolescent and his or her family.
Treatment integrity analyses revealed that interventions in both
engagement therapies adhered to prescribed guidelines using six
levels of engagement effort that were operationally defined and that
the therapies were clearly distinguishable by level of engagement effort
The six levels of engagement effort, as enumerated in Szapocznik et
al. (1988, p. 554), are:
- Level 0 - expressing polite concern, scheduling an intake
appointment, establishing that cases met criteria for inclusion
in the study, and making clear who must attend the intake
- Level 1 - attempting minimal joining, encouraging the caller
to involve the family, asking about the depth and breadth of
adolescent problems, and asking about family members;
- Level 2 - attempting more thorough joining; asking about family
interactions; seeking information about the problems, values,
and interests of family members; supporting and establishing an
alliance with the caller; beginning to establish leadership; and
asking whether all family members would be willing to attend
the intake appointment;
- Level 3 - restructuring for engagement through the caller, advising
the caller about negotiating and reframing, and following up
with family members (either over the phone or personally with the
caller at the therapist's office) to be sure that intake appointments
would be kept;
- Level 4 - conducting lower level ecological engagement interventions,
joining family members or conducting intrapersonal
restructuring (with family members other than the original caller)
over the phone or in the therapist's office, and contacting
significant others (by phone) to gather more information; and
- Level 5 - conducting higher level ecological interventions, making
out-of-office visits to family members or significant others, and
using significant others to help conduct restructuring.
Level 0-1 behaviors were permitted for both the BSFT engagement
and engagement-as-usual conditions. Level 2-5 behaviors were permitted
only for the BSFT engagement condition. Efficacy was measured in
rates of both family treatment entry as well as retention to treatment
The efficacy of the two methods of engagement was measured by the
percentage of families who entered treatment and the percentage of
families who completed the treatment. The results revealed that 42
percent of the families in the engagement-as-usual therapy and
93 percent of the families in the BSFT engagement therapy were
successfully engaged. In addition, 25 percent of engaged cases in the
engagement-as-usual treatment and 77 percent of engaged cases in
the BSFT engagement treatment successfully completed treatment.
These differences in engagement and retention between the two methods
of engagement were both statistically significant. Improvements in
adolescent symptoms occurred but were not significantly different
between the two methods of engagement. Thus, the critical distinction
between the treatments was in their different rates of engagement
and retention. Therefore, BSFT engagement had a positive impact on
more families than did engagement as usual.
In addition to replicating the previous engagement study, the second
study (Santisteban et al. 1996) also explored factors that might moderate
the efficacy of the engagement interventions. In contrast to the
previous engagement study, Santisteban et al. (1996) more stringently
defined the success of engagement as a minimum of two office visits:
the intake session and the first therapy session. The researchers randomly
assigned 193 Hispanic families to one experimental and two
control treatments. The experimental therapy was BSFT plus BSFT
engagement. The first control therapy was BSFT plus engagement as
usual, and the second was group counseling plus engagement as
usual. In both control treatments, engagement as usual involved no
specialized engagement strategies.
Results showed that 81 percent of families were successfully engaged
in the BSFT plus BSFT engagement experimental treatment. In contrast,
60 percent of the families in the two control therapies were successfully
engaged. These differences in engagement were statistically
significant. However, the efficacy of the experimental therapy procedures
was moderated by the cultural/ethnic identity of the Hispanic
families in the study. Among families assigned to BSFT engagement,
93 percent of the non-Cuban Hispanics (composed primarily of
Nicaraguan, Colombian, Puerto Rican, Peruvian, and Mexican families)
and 64 percent of the Cuban Hispanics were engaged. These findings
have led to further study of the mechanism by which culture/ethnicity
and other contextual factors may influence clinical processes related
to engagement (Santisteban et al. 1996; Santisteban et al. in press).
The results of the Szapocznik et al. (1988) and Santisteban et al.
(1996) studies strongly support the efficacy of BSFT engagement.
Further, the second study with its focus on cultural/ethnic identity
supports the widely held belief that therapeutic interactions must be
responsive to contextual changes in the treatment population (Sue et
al. 1994; Szapocznik and Kurtines 1993).
A third study (Coatsworth et al. 2001) compared BSFT to a community
control intervention in terms of its ability to engage and retain adolescents
and their families in treatment. An important aspect of this
study was that an outside treatment agency administered the control
intervention. Because of that, the control intervention (e.g., usual
engagement strategies) was less subject to the influence of the investigators.
Findings in this study, as in previous studies, showed that
BSFT was significantly more successful, at 81 percent, in engaging
adolescents and their families in treatment than was the community
control treatment, at 61 percent. Likewise, among those engaged in
treatment, a higher percentage of adolescents and their families in
BSFT, at 71 percent, were retained in treatment compared to those in
the community control intervention, at 42 percent. In BSFT, 58 percent
of adolescents and their families completed treatment compared
to 25 percent of those in the community control intervention.
Families in BSFT were 2.3 times more likely both to be engaged and
retained in treatment than were families randomized to the community
An additional finding of the Coatsworth et al. (2001) study warrants
special mention. In BSFT, families of adolescents with more severe
conduct problem symptoms were more likely to remain in treatment
than were families of adolescents whose conduct problem symptoms
were less severe. The opposite pattern was evident in the community
control intervention, with families that were retained in treatment
showing lower intake levels of conduct problems than did families
who dropped out. These findings are particularly important because
they suggest that adolescents who are most in need of services are
more likely to stay in BSFT than in traditional community treatments.