Treating Adolescent Substance Abuse Using Family Behavior Therapy

A Step-by-Step Approach

Brad Donohue, Nathan H. Azrin

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470621929
• eBook ISBN: 9781118163948
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Praise for Treating Adolescent Substance Abuse Using Family Behavior Therapy

"This is an extremely positive and strength-focused text that provides therapists with a structure and the tools to implement interventions that have a long history of promoting the types of clinical changes desired by family members and community stakeholders."—From the Foreword by Scott W. Henggeler, PhD, Professor, Department of Psychiatry and Behavioral Sciences, and Director, Family Services Research Center, Medical University of South Carolina

"Kudos to Donohue and Azrin for writing a book that includes all the materials needed to implement FBT with adolescents, including prompting checklists, handouts, and worksheets."— Karol Kumpfer, PhD, Professor, Health Promotion & Education, and Chair, International Study Abroad Committee, College of Health, University of Utah, and former director, SAMHSA's Center for Substance Abuse Prevention

"Treating Adolescent Substance Abuse Using Family Behavior Therapy is an important resource for those who wish to provide an empirically supported, strengths-based, behavioral treatment for adolescents with substance-use problems and their parents." — Susan Harrington Godley, RhD, Senior Research Scientist and EBT Coordinating Center Director, and Mark D. Godley, PhD, Director, Research & Development, Chestnut Health Systems

"In my practice with adolescents, FBT has proven exceptionally effective in drawing families closer together and yielding improved outcomes. This remarkably supportive approach helps young people develop critical skills necessary to live a fulfilling and drug-free lifestyle. This book clearly illustrates how to implement the interventions with ease and exemplifies the deeply gratifying experience of FBT."— Stephen A. Culp, MEd, NCC, LPCC, Addiction Services Therapist, Comprehend, Inc., Maysville, KY

Listed in multiple national clearinghouses, including SAMHSA's National Registry of Evidence-based Programs and Practices and the CEBC, Family Behavior Therapy (FBT) is a scientifically supported treatment for adolescent substance abuse and its many associated problems. Written by Brad Donohue and Nathan Azrin—the premier researchers and practitioners of FBT—Treating Adolescent Substance Abuse Using Family Behavior Therapy is the first book of its kind to provide mental health professionals with the practical, step-by-step guidance needed to use this evidence-based treatment.

Filled with case studies, checklists, worksheets, and handouts, this essential guide features:

• Strategies to assist in effective goal-setting, treatment plans, and family management
  
  

• Motivational enhancement exercises to encourage youth into a problem-free lifestyle
  
  

• Methods to effectively address contextual issues such as noncompliance and culture
  
  

• Standardized treatments to assist in eliminating problems that coexist with substance abuse, including unemployment, depression, behavioral misconduct, and family dysfunction
  
  

• An accompanying CD-ROM contains all the book's record-keeping forms, checklists, assignments, progress notes, agendas, and worksheets in a customizable format.
  
  

CHAPTER 1

Introduction to Family Behavior Therapy

Overview

This chapter provides an overview of the application of Family Behavior Therapy (FBT) as applied to adolescents. First, the historical, theoretical, and empirical underpinnings of FBT are reviewed to assist in understanding its conceptualization and development during the past 20 years. We then describe youth and their families who are most likely to benefit from FBT, and offer recommendations in determining a method of assessment to assist in treatment planning. Although content of each of the FBT intervention components is extensively reviewed in Chapters 4 through 13, a summary of each intervention component is provided in this chapter. The method of using our relatively novel prompting checklists to guide treatment providers (TPs) in intervention implementation is reviewed, and procedures involved in the assessment of treatment integrity are underscored.

Chapter at a Glance

• Historical, theoretical, and empirical background of FBT
• Clinical populations and therapeutic contexts appropriate for FBT
• General structure of FBT
• Maintenance and assessment of FBT intervention integrity

Historical and Theoretical Background

The FBT that is reviewed in this book was initiated in 1989 by the authors and their colleagues with support from the National Institute on Drug Abuse. During the time of FBT’s initial development, very few evidence-supported interventions were available to treat adolescent drug abuse. Behavioral treatment programs for preadolescent conduct disorders were comparatively advanced due to the pioneering work of Sidney Bijou, Don Baer, Todd Risley, Mont Wolf, and others. Two behavioral programs that stood out to us in their emphasis on positive reinforcement, standardized method, and effectiveness included Constance Hanf’s parent training program for noncompliant preadolescent children that was empirically validated in studies by Rex Forehand and his colleagues at the University of Georgia (see Forehand & McMahon, 1981); and Gerald Patterson’s social learning approach to family therapy (e.g., Patterson, Reid, Jones, & Conger, 1975) that continues to be enhanced by his colleagues at the Oregon Social Learning Center. The scientific work of these esteemed investigators validated our desire to enhance drug-incompatible skills in youth through family-based reinforcement, while rejecting punishment-based interventions that were shown to result in numerous negative side effects.

Consistent with behavioral theory, we conceptualized substance use to be a strong inherent reinforcer (i.e., pleasurable sensations, peer support, elimination of aversive emotions). Although negative consequences occur as a result of substance use, the severity of these consequences is often minimized or suppressed, or the full impact is not realized until well after the habitual processes of drug use has begun. To assist youth in gaining long-term abstinence from illicit drugs, we hypothesized that FBT would need to (a) reinforce the development of skills that are incompatible with drug use (e.g., recognizing antecedents or “triggers” to drug use, controlling drug cravings, utilizing communication skills to decrease arguments and other stressful antecedents to drug use), (b) modify the environment to facilitate reinforcement for time spent in drug-incompatible activities (e.g., enrollment in school or work, changing driving routes to avoid drug use triggers, creating a social network of nonaddicted friends), and (c) reward actions that are incompatible with drug use.

We decided to base the development of FBT on the Community Reinforcement Approach (CRA) due to its consistency with the aforementioned model and because CRA had been shown to successfully treat the related problem of alcohol abuse in adults (e.g., Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973; Sisson & Azrin, 1989). Communication skills training, a critical component in behavioral marital therapy (Stuart, 1969), had been successfully incorporated into Gerald Patterson’s program with parents of conduct-disordered youth when marital problems were evidenced. Therefore, it made good sense to incorporate methods of facilitating family activities and communication skills training into FBT that were similar to CRA. As can be seen in Chapters 8 and 9, we made very few changes to the original CRA communication skills therapy protocols other than to emphasize youth/parent relationships.

To assist in managing youth who refused to go to school we modified another CRA component, the Job Club intervention for adults (Azrin, Flores, & Kaplan, 1975), to be developmentally appropriate in youth (see Chapter 12). For instance, shortly after we initiated our first controlled trial, it became apparent to us that, relative to adults, we needed to spend additional time motivating youth to wear appropriate clothing to job interviews, arranging transportation for them to attend interviews, and teaching them to speak respectfully during their job interviews. They also demonstrated relatively greater difficulties responding to questions that are commonly asked in job interviews. Therefore, the Job Club intervention was modified to train youth in these important areas.

It was initially anticipated that many adolescents would be unmotivated to desire abstinence from illicit drugs, and likely evidence frequent lapses in drug use throughout treatment. Therefore, relapse prevention strategies similar to those of Alan Marlatt (1985), and concepts of motivational interviewing methods similar to those formalized by William Miller (1983), were utilized to shape clinical style and general approach to therapy (see Chapters 3 and 5). The youth who were treated in our clinical trials were extremely responsive to these supportive methods, and our TPs found them to be consistent with their conceptualization to the addictions and enjoyable to implement. Relapse prevention strategies were also embedded within a newly developed stimulus control method in which youth learned to identify antecedents (“triggers”) to drug use and non–drug use, and to implement skills to assist in managing these antecedent stimuli (see Chapters 10 and 11). We theorized that youth and parent motivation would be enhanced with external reinforcement through contingency contracting. We decided to establish a point system in which youth would be rewarded for behaviors that were incompatible with substance use. About the time we were developing this contracting procedure, Stephen Higgins and his colleagues (1991) had demonstrated the efficacy of CRA and voucher-based contingency management in reducing drug abuse. The latter study demonstrated the importance of using objective methods of assessing drug abuse (i.e., urinalysis testing) in contingency management. Similar to their work, we made all rewards contingent on no signs of drug use through urinalysis and reports from others. The developed system included standardized methods of quickly determining target responses, and rewards from the participants’ social ecology. The point system appeared to be relatively effective in our first randomized controlled trial with youth (Azrin, Donohue, Besalel, Kogan, & Acierno, 1994). However, some parents evidenced difficulties managing earned points, and it seemed more complicated than necessary. Therefore, in a subsequent trial (Azrin et al., 2001), this point system was replaced with a much easier to implement level system (Chapter 6). The developed level system was similar to those that are often utilized in state-of-the-art residential youth programs. However, the contingencies were managed by parents rather than staff.

One of the interventions we developed in our first trial of FBT was an Urge Control (Self-Control) intervention (see Chapter 11) to reduce drug cravings/urges. This intervention was based on Joseph Cautela’s (1967) Covert Sensitization therapy. In Covert Sensitization, the person with the addiction is instructed to think of aversive stimuli just as alcohol use is about to occur during imagery trials. After repeated pairings of aversive and alcohol-related thoughts, desire for alcohol use diminishes. However, in our earlier pilot trials, youth were often resistant to extended imagination of aversive thoughts. Moreover, Covert Sensitization does not teach skills relevant to managing substance use. Therefore, we developed an Urge Control (or Self-Control) intervention to assist youth in identifying the earliest thought of drug use and very briefly imagining aversive stimuli when the urge is relatively low. This change permitted cravings and desires for drug use to be overshadowed easily and quickly by aversive thoughts and images. Once the urge was terminated in the imagined trial, youth were taught to engage in a series of skill sets culminating in a brief problem-solving exercise to identify drug-incompatible behaviors, and imagine escape from the drug use situation. The latter skill-based modifications were unique to the previous Covert Sensitization procedure. Because youth reported that they had a difficult time imagining themselves doing the non-drug-associated actions that were brainstormed, we had them verbally describe themselves doing responses that were incompatible with problem behavior. That is, they were prompted to complete “practice” trials by describing themselves doing the desired behavioral sets aloud, and were subsequently praised for their efforts. Adolescents reported great satisfaction with these trials, probably because of the abundant encouragement and praise they received throughout.

Thus, FBT is consistent with the CRA and other behavioral therapies, but does differ in meaningful ways. Since our initial trial 2 decades ago, FBT has undergone continued enhancement. Standardized quality assurance programs specific to FBT have been originated to assist in managing infrastructural and administrative needs (see Donohue et al., 2009; Chapter 2), and the method of assessing treatment integrity that is described later in this chapter has been favorably evaluated in a community setting (Sheidow, Donohue, Hill, Henggeler, & Ford, 2008). Easy-to-follow prompting checklists that are described at the end of this chapter have been developed to guide TPs in efficient and effective administration of therapies during sessions (included at the end of each of Chapters 4 through 13), and standardized telephone therapies aimed at improving session attendance have been favorably examined in controlled trials involving youth to complement FBT (Donohue et al., 1998). Standardized agendas have also been developed to assist TPs in transitioning between treatment sessions (see Chapter 4), interventions have been tied directly to standardized treatment plans (see Chapter 7), and the treatment termination process is now clear and specific to future goal preparation (see Chapter 13). Relevant to dissemination, other standardized procedures have been developed to assist in determining readiness for FBT adoption in community agencies, and prompting checklists have been developed to guide trainers when implementing FBT workshops and ongoing training sessions (freely available from the first author).

Empirical Background

Relevant to outcome support, FBT is one of the few evidence-based treatments to demonstrate efficacy in controlled clinical trials involving both adults and adolescents who have been identified to abuse illicit drugs (see reviews, for example, by Bukstein & Horner, 2010; Carroll & Onken, 2005; Dutra et al., 2008; Macgowan & Engle, 2010). In the first randomized controlled trial of FBT (Azrin, McMahon, et al., 1994), adolescents and adults were randomly assigned to receive FBT (referred to as behavior therapy at that time) or a nondirective control group after completion of baseline data. Results indicated that, as compared with control group participants, the participants assigned to FBT demonstrated significantly greater improvements throughout the year following baseline in drug and alcohol use frequency, conduct problems, family functioning/satisfaction, work/school attendance, depression, and parental satisfaction with the youth. The results were maintained at 9 months’ follow-up (Azrin et al., 1996), with adolescents in FBT showing better outcomes than adults in FBT and adolescents and adults in the control group. Other randomized controlled trials that have explicitly examined dually diagnosed substance abusing adolescents and their parents (Azrin, Donohue, et al., 1994; Azrin et al., 2001) have shown similar positive effects. The studies of FBT have generally indicated favorable results regardless of gender, ethnicity, or type of substance used (i.e., alcohol, marijuana, hard drugs). Based on a meta-analysis of outcome studies conducted by an independent review group (Bender, Springer, & Kim, 2006), it was concluded that FBT was one of only two treatments to show large treatment effect sizes for dually diagnosed adolescents across substance use, and internalizing and externalizing behavior problems. Favorable substance abuse outcomes have also been indicated in the very similar Adolescent Community Reinforcement Approach (ACRA; Dennis et al., 2004; Godley, Godley, Dennis, Funk, & Passetti, 2007) and Community Reinforcement Approach in homeless adolescents (Slesnick, Prestopnik, Meyers, & Glassman, 2007). The dissemination of ACRA in 33 sites is particularly impressive (Godley, Garner, Smith, Meyers, & Godley, 2011). Relevant to family participation in FBT, we developed a brief telephone intervention that was shown to improve initial session attendance of youth and their parents by 29% in an outpatient setting (Donohue et al., 1998). More intensive CRA-like engagement programs, such as CRA Family Training (CRAFT) have been empirically developed by Bob Meyers and his colleagues (see review by Smith & Meyers, 2004). These programs have significantly enhanced family involvement in CRA (e.g., Meyers, Miller, Smith, & Tonigan, 2002; Miller, Meyers, & Tonigan, 1999).

These findings offer support for FBT in the treatment of adolescent substance abuse within community settings that are charged with the implementation of evidence-supported “best practices.” For instance, FBT is now listed in national clearinghouses as an evidence-based therapy (e.g., Substance Abuse and Mental Health Service Administration’s National Registry of Evidence-Based Practices, California Evidence-Based Clearinghouse for Child Welfare), and this treatment was one of the first behavioral programs reviewed in the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment (National Institute on Drug Abuse, 1998). In Module 10, published by the National Institutes of Alcoholism and Alcohol Abuse (2005), this behavioral approach was said to be an “emerging developmentally sensitive approach” for drug use problems.

Appropriate Intervention Settings and Referrals

Settings

Evidence-based treatments (EBTs) are experimentally evaluated in specified clinical settings, most often including inpatient and outpatient mental health facilities, hospitals, homes, and school environments. Since outcome studies of FBT in adolescent samples have been conducted in...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Foreword
• Preface
• Acknowledgements
• Chapter 1: Introduction to Family Behavior Therapy
• Chapter 2: Infrastructure
• Chapter 3: Therapeutic Style, Techniques, and Implementation Strategies
• Chapter 4: Establishing Effective Agendas for Treatment Sessions
• Chapter 5: Probing Negative and Positive Consequences to Determine Core Motivation
• Chapter 6: Establishing and Rewarding Goal Attainment With Family Support
• Chapter 7: Developing a Successful Treatment Plan
• Chapter 8: Reviewing Past Appreciations to Improve Current Relationships
• Chapter 9: Improving Communication With Positive Requests
• Chapter 10: Restructuring the Environment to Facilitate a Drug-Free Lifestyle
• Chapter 11: Using Self-Control to Manage Negative Behaviors, Thoughts, and Feelings
• Chapter 12: Gaining Employment
• Chapter 13: Concluding Treatment and Planning for Success
• References
• About the Authors
• Author Index
• Subject Index
• About the CD-ROM