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Behavioral Therapies Development Program - Effective Drug Abuse Treatment Approaches

Multidimensional Family Therapy (MDFT)

Multidimensional Family Therapy (MDFT) for Adolescents is an outpatient family-based drug abuse treatment for teenage substance abusers (Liddle, 1992; Liddle, in press). From the perspective of MDFT, adolescent drug use is understood in terms of a network of influences (i.e., individual, family, peer, community). This multidimensional approach suggests that reductions in target symptoms and increases in prosocial target behaviors occur via multiple pathways, in differing contexts and through different mechanisms. The therapeutic process is thought of as retracking the adolescent*s development in the multiple ecologies of his or her life. The therapy is phasically organized, and it relies on success in one phase of the therapy before moving onto the next. Knowledge of normal development and developmental psychopathology guides the overall therapeutic strategy and specific interventions. The approach has been tested in three major randomized trials (two treatment and one prevention/early intervention), and in several process studies. A treatment manual (Liddle, 1998) and adherence scales have been developed (Hogue, Liddle & Rowe, 1996; Hogue et al., 1997). Current tests of this outpatient family therapy approach include its comparison against a residential treatment program and a twelve week version of the model that is the only family therapy approach being tested in the CSAT Cannabis Youth Treatment Multisite Collaborative Study.

The MDFT treatment format includes individual and family sessions, and sessions with various family and extrafamilial sessions. Sessions are held in the clinic, in the home, or with family members at the family court, school or other relevant community locations. Change for the adolescents and parents is intrapersonal and interpersonal, with neither more important than the other. The therapist helps to organize treatment by introducing several generic themes. These are different for the parents (e.g., feeling abused and without ways to influence their child) and adolescents (e.g., feeling disconnected and angry with their parents). The therapist uses these themes of parent-child conflict as assessment tools and as a way to identify workable content in the sessions.

During individual sessions, the therapist and adolescent work on important developmental tasks such as decision-making and mastery. The teenager is helped to acquire skills in communicating his or her thoughts and feelings. Also taught are problem solving skills to better deal with life stressors. Job skills and vocational training are also part of treatment. Parallel to these individual sessions with the adolescent is work with the parents. Certain parenting styles and belief systems as they pertain to children have been shown to be related to adolescent drug abuse and, as such, are the target for intervention. The parents are helped to examine their particular parenting style, to distinguish influence from control, and to accept that not everything can or should be changed in order that they have a developmentally appropriate positive influence on their child (Liddle et al, 1998).

In one of the controlled trials to determine the efficacy of MDFT in terms of reducing drug use and associated problem behaviors while improving academic performance, MDFT was compared to two alternative models of drug abuse treatment: peer group therapy and multifamily educational group therapy. Results indicate that overall improvement was made among youths in all three treatment groups, with adolescents receiving MDFT showing the most improvement. This finding contributes to the growing number of studies which demonstrate that family-based therapy is an effective approach to treating adolescent drug abuse.

Summary of process results. Several studies have addressed the mechanisms and nature of change in family based treatment of adolescent drug abusers. For example, an investigation of the mechanisms of change within the family therapy treatment revealed a significant relationship between improvement in parenting, one of the primary target outcomes in MDFT, and reduction of adolescent symptomatology (Schmidt, Liddle & Dakof, 1996). A second therapy process study identified therapist behaviors and family interactions necessary to resolve therapeutic resistance. An active, directive yet supportive stance on the therapist's part -techniques that block or divert negativity and facilitate new interactions between parents and teenagers in sessions we found to be related to changes in in-session process on the target behaviors. Additionally, the therapist's individual sessions with different family members, which addressed individual family member needs and also prepared them for sessions in which new interactions were promoted, also were related to the achievement of positive in-session interactional outcomes (G. S. Diamond & Liddle, 1996; in press). A third study examined the impact of MDFT Adolescent Engagement Interventions (AEI) on improving an initially poor therapist-adolescent alliance. We found that in those cases in which alliance improved, the therapist continues to work on goal formation, presents himself or herself as an ally, and attends to the adolescent*s experience while simultaneously decreasing efforts to teach the youth about the nature of therapy (i.e., too much orienting about therapy without moving to the development of a personally meaningful therapeutic agenda is unproductive, and does not permit the alliance to develop through its initial stage; G.M. Diamond, Liddle, Hogue & Dakof, 1997). Finally, a fifth study asked whether the exploration of particular, empirically-and theoretically-derived cultural themes would enhance adolescent engagement and participation in therapy among African American boys referred for treatment. We found that therapeutic discussions about anger and rage, alienation, and the journey from boyhood to manhood were associated with increased participation and less negativity in the very next therapy session, suggesting that the focusing therapy on certain culturally relevant themes can facilitate the adolescent's participation. Moreover, the more youth participated fully in a therapy session, the mor likely that such engagement would take the form of conversation with the therapist of what it means to become a man (cultural theme of journey from boyhood to manhood) in the next session (Jackson-Guilfort, Liddle & Dakof, 1998).

CSAT (Center for Substance Abuse Treatment) (1998). Adolescent substance abuse: Assessment and treatment (Treatment Improvement Protocol Series [TIPS]). Rockville, MD: Author.

Diamond, G.S., & Liddle, H.A. (1996). Resolving a therapeutic impasse between parents and adolescents in Multidimensional Family Therapy. Journal of Consulting and Clinical Psychology, 64(3), 481-488.

Diamond, G.S. & Liddle, H.A. (In press). Resolving impasses in family treatment of adolescents: A process study. Family Process.

Diamond, G. M., Liddle, H. A., Hogue, A., & Dakof, G. A. (1997). Therapist alliance building techniques with adolescents in multidimensional family therapy. Paper presented at the 1998 North American Society for Psychotherapy Research, Santa Fe, NM. Submitted for publication.

Hogue, A., Liddle, H.A., & Rowe, C. (1996). Treatment adherence process research in family therapy: A rationale and some practical guidelines. Psychotherapy: Theory, Research, Practice, & Training, 33(2), 332-345.

Hogue, A., Liddle, H.A., Rowe, C., Turner, R.M., Dakof, G.A. & LaPann, K. (1997). Treatment adherence and differentiation in individual versus family therapy. Journal of Counseling Psychology, 45(1), 104-114.

Jackson-Gilfort, A., Liddle, H. A., & Dakof, G. A. (1998). The relationship of cultural theme discussion to engagement with acting out, African American male adolescents in family therapy. Paper presented at the 1998 Society for Psychotherapy Research Meeting, Santa Fe, NM, and submitted for publication.

Liddle, H. A. (1992). Family therapy techniques for adolescents with drug and alcohol problems. In W. Snyder and T. Ooms (Eds), Empowering families (ADAMHA Monograph from the First National Conference on the Treatment of Adolescent Drug, Alcohol and Mental Health Problems). Washington, D.C.: United States Public Health Service, U. S. Government Printing Office.

Liddle, H.A. (1998). Multidimensional family therapy treatment manual. Center for Treatment Research on Adolescent Drug Abuse, University of Miami School of Medicine.

Liddle, H.A. (In press). Holistic treatment development: Theory-practice-research connections in a family-focused intervention for adolescent drug abuse. Journal of Child Clinical Psychology.

Liddle, H.A., Rowe, C.L., Dakof, G.A., & Lyke, J. (1998). Translating parenting research into clinical interventions. Clinical Child Psychology and Psychiatry (Special Issue: Parenting interventions), 3, 419-442.

Schmidt, S.E., Liddle, H.A., & Dakof, G.A. (1996). Effects of multidimensional family therapy: Relationship of changes in parenting practices to symptom reduction in adolescent substance abuse. Journal of Family Psychology, 10 (1), 1-16.

For more information contact:
Howard Liddle, Ed.D., Professor and Director,
Center for Treatment Research on Adolescent Drug Abuse,
Department of Psychiatry and Behavioral Sciences,
University of Miami School of Medicine,
1425 NW 10th Avenue,
Miami, Florida 33136.

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