Family Systems and Motivational Interviewing: A Systemic-Motivational Model for Treatment of Alcohol and Other Drug Problems

SUMMARY

Despite growing evidence of the impact of substance abuse disorders on families and the effectiveness of family-based treatment approaches for these disorders, family therapy remains an underutilized modality for these conditions. One reason may be the relative paucity of treatment models combining family systems concepts with current advances in substance abuse treatment. This paper describes one such approach, called the Systemic Motivational Model, a treatment model that has as its goal the integration of the empirically-grounded family systems model of alcoholism treatment first developed in the 1980s (the Family Life History model) with the core ideas encompassed in Motivational Enhancement Therapy.     

Dual and multiple diagnosis among substance using runaway youth

Although research on runaway and homeless youth is increasing, relatively little is known about the diagnostic profile of runaway adolescents. The current study examined patterns of psychiatric dual and multiple diagnosis among a sample (N=226) of treatment-engaged substance-abusing youth (ages 13 to 17) who were residing at a runaway shelter. As part of a larger treatment outcome study, the youths' psychiatric status was assessed using the DSM-IV based computerized diagnostic interview schedule for children [CDISC; (1)]. The majority of the youth in our sample met criteria for dual or multiple diagnosis (60%) with many having more than one substance-use diagnosis (56%). The severity of mental-health and substance-use problems in this sample of substance-abusing runaways suggests the need for continued development of comprehensive services. The range and intensity of diagnoses seen indicates a need for greater focus on treatment development and strategies to address their multiple areas of risk.     

End-of-life care in black and white: race matters for medical care of dying patients and their families

OBJECTIVES: To compare the end-of-life medical care experienced by African-American and white decedents and their families. DESIGN: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design. SETTING: Hospitals, nursing homes, and home-based medical services across the United States. PARTICIPANTS: Surrogates (N=1,447; primarily family members) for decedents from 22 states. MEASUREMENTS: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact. RESULTS: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care. CONCLUSION: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.     

Adolescent premarital sex and health outcomes among Taiwanese youth: perception of best friends' sexual behavior and the contextual effect

This study explores premarital sex among adolescents and its health outcomes in a typical East Asian society, Taiwan. As a collective society in terms of cultural heritage, a particular target of this study was perceived peer pressure and its contextual influence. The data were taken from the Taiwan Youth Project, 2004 and 2007, and never married youth aged 20 years constituted our sample (N=3530). Best friends' sexual behavior and other context-related factors, such as school attendance and community participation, are presumed to influence adolescent premarital sex as well as their health status. Logistic regression models show a positive and significant association between the perception of friends' sexual behavior and the likelihood of adolescent premarital sex engagement, after adjusting for the youth's own sex-related experience and attitudes, individual characteristics, and family background. The analysis also confirms that school attendance and community participation are significantly associated with a lower likelihood of having premarital sex. Furthermore, adolescent premarital sex was found to be linked to the perceived health status of the youth (self-rated health, smoking, and drinking), as expected. These findings demonstrate the importance of peers and social context, which suggests that HIV prevention and health promotion programs for youth need to take friendship networks and social context into consideration.     

Family Response to Adolescence,Youth and Alcohol

SUMMARY

This review highlights three aspects of adolescent alcohol use and misuse that have ramifications for families: (a) adolescent disinhibition, (b) substance-specific parenting factors, and (c) non-substance-specific parenting factors. Although there are a great number of adolescent treatment models currently utilized across the country, this review focuses on three integrated family-based treatment models with proven efficacy: (a) Multisystemic Therapy (MST; Henggeler, Schoenwald, Borduin, Rawland, & Cunningham, 1998), (b) Brief Strategic Family Therapy (BSFT; Szapocznik, Hervis, & Schwartz, 2003), and (c) Multidimensional Family Therapy (MDFT; Liddle, 2004; Center for Substance Abuse Treatment [CSAT], 2004). These family-based therapies focus on accurately assessing multiple influences and targeting effective intervention strategies designed to support changes throughout a number of systems that affect and serve to reinforce or support the adolescent's problem behaviors.     

Employing Complier Average Causal Effect Analytic Methods to Examine Effects of Randomized Encouragement Trials

Aims: This article details the application of Complier Average Causal Effect (CACE) analysis to the examination of youth outcomes from adaptive substance use prevention trials. Methods: CACE analysis is illustrated using youth-reports of tobacco-use from ages 11 to 22, from the Adolescent Transitions Program, a family-focused randomized encouragement trial designed for delivery in the school setting Results: Female gender and early peer deviance predicted family engagement with active intervention components. Further, long-term reductions in youth tobacco use from age 11 to age 22 were found for families that engaged with treatment. Conclusions: CACE modeling techniques enable researchers to examine factors that predict engagement with core intervention components and to examine intervention effects specifically for youth who engaged with those components.     

Systemic Integration of IFS Therapy and 12-Step Facilitation for Substance Use: A Theoretical Discussion

Substance use disorders (SUDs) are a major problem in the United States that have reverberating effects within families, communities, and society. Marriage and family therapists (MFTs) are uniquely positioned to be leaders in addressing SUDs through a systemic relational context. Internal Family Systems Therapy (IFS) is an evidence-based practice that has the potential to be an excellent fit for individuals, couples, and families struggling with SUDs. In addition, 12-Step facilitation provides a supportive network for individuals dealing with substance use issues. This article uses a systemic approach to integrating IFS and 12-Step facilitation for use with the emerging adult population. A case study example is provided to illustrate the integrated model.     

The Use of Timelines in Illustrating the Permanency Planning Process for Families Infected/Affected by HIV/AIDS

ABSTRACT

The Family Ties Project (FTP) is a multi-agency, collaborative, federally funded demonstration project whose mission is to promote and preserve the well-being of District of Columbia (DC) children, youth, and families affected by HIV/AIDS by working with parents and caregivers to plan for the future care of their children. FTP was first funded in 1996 through the federal Administration for Children, Youth and Families (ACYF) as part of a national grant program to reduce the burden of infants and children abandoned or orphaned as the result of AIDS related illnesses. This article demonstrates the use of timelines in clinical practice. Timelines of the permanency planning process of three families who experienced a maternal death are presented to help illustrate the similarities and differences in the process for each of these families. Additionally, the authors discuss the implications for social work practice as they relate to client/family engagement, length of intervention, interdisciplinary collaboration within the HIV/AIDS service delivery system, and the use of timelines as a clinical tool.     

Social recovery model: an 8-year investigation of adolescent 12-step group involvement following inpatient treatment

Background:  Despite widespread use of 12-step treatment approaches and referrals to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) by youth providers, little is known about the significance of these organizations in youth addiction recovery. Furthermore, existing evidence is based mostly on short-term follow-up and is limited methodologically.
Methods:  Adolescent inpatients ( n =  160; mean age = 16, 40% female) were followed at 6-months, and at 1, 2, 4, 6, and 8 years posttreatment. Time-lagged, generalized estimating equations modeled treatment outcome in relation to AA/NA attendance controlling for static and time-varying covariates. Robust regression (locally weighted scatterplot smoothing) explored dose–response thresholds of AA/NA attendance on outcome.
Results:  The AA/NA attendance was common and intensive early posttreatment, but declined sharply and steadily over the 8-year period. Patients with greater addiction severity and those who believed that they could not use substances in moderation were more likely to attend. Despite declining attendance, the effects related to AA/NA remained significant and consistent. Greater early participation was associated with better long-term outcomes.
Conclusions:  Even though many youth discontinue AA/NA over time, attendees appear to benefit, and more severely substance-involved youth attend most. Successful early posttreatment engagement of youth in abstinence-supportive social contexts, such as AA/NA, may have long-term implications for alcohol and drug involvement into young adulthood.     

Social Work Training for Mental Health Services to the Elderly Within a Multigenerational Context

The Multigenerational Family Project at the University of Washington School of Social Work aims to respond to practice gaps in both mental health and aging services. Given the growth in the number of multigenerational families and the increased employment of middle aged women who have been the traditional family caregivers, it is critical that geriatric social workers in mental health settings take account of the effect of multigenerational dynamics on the delivery of services. A multigenerational approach recognizes the dynamic interplay between the family's resources to provide care and the older person's needs as well as how the family caregiver's well-being interacts with that of the older person. This paper reviews the practice-based rationale for a multigenerational approach in social work education, and then presents curriculum implications. A multigenerational framework is viewed as one way to integrate content on aging with foundation courses in practice, policy, and human behavior with the field practicum. It also allows for the integration of content from other population-focused concentrations (e.g., children, family, and youth) or problem-focused specialization (e.g., health and mental health). Examples of multigenerational content to be integrated in core courses, a course on the multigenerational family, and a procedure to evaluate this curriculum change are discussed.     

A family retreat as a comprehensive intervention for children with arthritis and their families

Objective . Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. Methods . Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. Results . Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. Conclusions . Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.     

Improving treatment engagement and outcomes for cocaine-using methadone patients

A task-based behavioral contingency-the "treatment reinforcement plan" (TRP)-was implemented with cocaine-using methadone patients to increase treatment engagement and retention. Subjects (N = 57) were rewarded up to $15 per week in travel/food/entertainment vouchers for the completion of tasks related to their individual treatment needs. Eighteen types of tasks were contracted and completed with varying frequency. The largest categories of tasks were related to therapy attendance (N = 272; 58% completed), obtaining public entitlements (N = 165; 61% completed), medical/psychiatric appointments (N = 155; 70% completed), and obtaining Medicaid (N = 96; 54% completed). The highest proportion of tasks completed were related to human immunodeficiency virus (HIV) testing/education (N = 19; 100% completed), managing money (N = 17, 94% completed), and legal matters (N = 16, 88% completed). Successful TRP involvement during months 1-2 predicted longer retention in methadone treatment, greater therapy attendance during months 3-6, and lower proportion of cocaine-positive urines at 6-month follow-up. This research supports recent findings that early treatment engagement is associated with improved therapeutic relationships, increased retention, and reduced cocaine use. Behavioral counseling techniques may be especially helpful in addressing the complex needs of high-risk methadone patients, which in turn may facilitate treatment process and positive outcomes.     

The HIV testing experiences of adolescents in Ndola, Zambia: do families and friends matter?

This study explored how adolescents involve their families, friends and sex partners when making decisions about seeking HIV voluntary counseling and testing (VCT) and disclosing their HIV-status. The study is based on 40 qualitative in-depth interviews with 16 to 19 year olds who knew their HIV status in Ndola, Zambia. The findings show that: a) almost half of the youth turned to family members for advice or approval prior to seeking VCT; b) a disapproving reaction from family members or friends often discouraged youth from attending VCTuntil they found someone supportive; c) informants often attended VCTalone or with a friend, but rarely with a family member; and d) disclosure was common to family and friends, infrequent to sex partners, and not linked to accessing care and support services. Family members need access to information on VCT so they can support young peoples' decisions to test for HIV and to disclose their HIV status. These results reinforce the need to provide confidential VCT services for adolescents and the need to develop and test innovative strategies to reach adolescents, their families and sex partners with VCT information and services.     

An efficient tool for screening for maladaptive family functioning in adolescent drug abusers: the Problem Oriented Screening Instrument for Teenagers.

The assessment of maladaptive family functioning among adolescent drug abusers is particularly important because maladaptive family functioning has been linked to adolescent drug abuse/delinquent behaviors, and there are now highly effective family interventions available for treating these family dysfunctions. The purpose of the study reported in this article was to investigate the degree to which the Problem Oriented Screening Instrument for Teenagers screen for the family domain provides useful information regarding family functioning when used with clinic-referred youths with behavior problems. Participants in this study were 135 Hispanic and African-American youth referred for the treatment of severe behavior problems, including drug use. Our findings provide support for the usefulness of the 11-item POSIT family functioning screen. Data supporting the criterion validity of the POSIT Family screen, its ability to classify families correctly in terms of their family functioning, and its significant loading on the latent variable resulting from a confirmatory factor analysis all lend support to the usefulness of this screen of family functioning. In addition, analyses designed to explore the relationships between gender and race/ethnicity and the POSIT Family subscale showed that differences in scores by gender and race/ethnicity are not unique to the POSIT, but rather reflect similar differences in family functioning reported by the adolescent on more extensive family measures.     

An Efficient Tool for Screening for Maladaptive Family Functioning in Adolescent Drug Abusers: The Problem Oriented Screening Instrument for Teenagers

The assessment of maladaptive family functioning among adolescent drug abusers is particularly important because maladaptive family functioning has been linked to adolescent drug abuse/delinquent behaviors, and there are now highly effective family interventions available for treating these family dysfunctions. The purpose of the study reported in this article was to investigate the degree to which the Problem Oriented Screening Instrument for Teenagers screen for the family domain provides useful information regarding family functioning when used with clinic-referred youths with behavior problems. Participants in this study were 135 Hispanic and African-American youth referred for the treatment of severe behavior problems, including drug use. Our findings provide support for the usefulness of the 11-item POSIT family functioning screen. Data supporting the criterion validity of the POSIT Family screen, its ability to classify families correctly in terms of their family functioning, and its significant loading on the latent variable resulting from a confirmatory factor analysis all lend support to the usefulness of this screen of family functioning. In addition, analyses designed to explore the relationships between gender and race/ethnicity and the POSIT Family subscale showed that differences in scores by gender and race/ethnicity are not unique to the POSIT, but rather reflect similar differences in family functioning reported by the adolescent on more extensive family measures.     

A pilot home-based geriatric health screening project in primary care

Regular multidimensional screening of the elderly for undetected health problems has the potential for delaying functional deterioration and improving the quality of life, but has not been evaluated rigorously. This pilot study examined the amount and type of unmet health care need discovered by home-based screening of 100 family practice patients aged 75 and over. Although 96 per cent of patients had some health problems, only 71 per cent had problems that needed further intervention. Of these, the majority were problems in the area of psychosocial function, independence, and lifestyle. Age, sex, and frequency of attendance at the practice in the previous year were not found to be useful markers for targeting screening efforts. Although it is potentially beneficial for detecting unmet need, home-based screening is resource-intensive and requires further examination in randomized trials in the North American context.     

A culturally responsive,family-enhanced intervention model

The Multicultural Interventions for Adolescent Substance Use, referred to as The Shadow Project, was a 3-year, NIAAA-funded pilot study involving 60 American Indian families who had a youth entering alcohol and drug inpatient treatment. Participation was voluntary and involved comparison of two different treatment modalities: treatment as usual and a brief family-enhanced intervention. In adapting this family-based intervention specifically for American Indian families, a cultural approach to assessment and intervention was integrated into the process, with the intervention focusing on building support around the youth to attain abstinence and assuring the youth that their family, community, and substance abuse counselor were motivating influences. Five areas were assessed in the family observation tasks: relationship building, positive reinforcement, limit setting, monitoring, problem solving, and communication. Cultural adaptation was made for two of the five tasks. Two legends were used to assess the families' skill level in relationship building, problem solving, and communication as a family unit. By incorporating Indian stories, families were encouraged to respond in a culturally appropriate manner. Preliminary findings show that these stories were linked to child prosocial behavior and the percentage of days abstinent from individual drug use. This pilot project also adapted culturally responsive instruments, tasks, and validity to this population. The first year required adaptation of recruitment methods, tribal and treatment center agreements, referral contacts, and implementation of intervention and follow-up with adolescents and their families. The second year was composed of intervention implementation and follow-up assessments. To determine the intervention program's long-term effect on reducing adolescent alcohol and other drug use, all families were followed up and assessed 11 months after they left treatment. The third and final year of the study included follow-up, data entry, and data analysis.     

Barriers and facilitators to initial and continued attendance at community‐based lifestyle programmes among families of overweight and obese children: a systematic review

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community‐based lifestyle programmes among families of overweight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed‐method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.     

The Relationship Between Substance Abuse Performance Measures and Mutual-Help Group Participation after Treatment

The authors examined the relationship between treatment quality, using during-treatment process measures, and mutual-help group (e.g., Alcoholics Anonymous) attendance after outpatient substance use disorder (SUD) treatment for 739 clients in the Alcohol and Drug Services Study. Logistic regression models estimated any and regular mutual-help attendance after treatment. Clients referred to mutual-help groups were significantly more likely to attend any mutual help after treatment. Results were mixed for facility offered mutual-help groups; treatment engagement and retention were not significant. These findings offer treatment providers further evidence of the importance of referring clients to post-treatment mutual-help groups, an effective, low-cost option.     

An Overview of Marital and Family Treatments with Substance Abusing Populations

A selective literature overview of marital and family treatments with substance abusing populations is provided. Theoretical issues are presented and research is categorized into four main areas: Marital Therapy, Multicouple Therapy, Family Therapy, and Multifamily Therapy. Implications and suggestions for future research are provided.