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%

Ethnicity

Anglo

Hispanic

NativeAmerican

Other/Mixed

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

Ethnicity and Treatment Outcome

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

FFT for Co-Occurring Adolescent SUD and

Depression

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

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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