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Integrating Multi-Dimensional Family Therapy: Substance Abusing Adolescents in a Residential Treatment Setting

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Multi-dimensional Family Therapy (MDFT) is a well-researched, best-practice model for the outpatient treatment of adolescent substance use disorders (Liddle, 2008). The creator of MDFT, Dr. Howard Liddle of the University of Miami, credits the initial influences of the model to the work of Minuchin (1974) and Haley (1976) and refers to it as a structural-strategic family therapy (Liddle, 1985). MDFT has since evolved to be inclusive of principles familiar to contextually and systems-based practitioners. Simply put, the model approaches the treatment of the multidimensions of the teen’s life, emphasizing the teen’s internal world, relationship with their parents and peers, and the world of the parents themselves. Each aspect of the teen’s life is addressed in a manner consistent with the motivational interviewing principle of “rolling with resistance.” Clinicians roll right into the problem areas, viewing them all as opportunities to deliver developmentally and socially appropriate treatment.

Outpatient therapy settings have been the primary proving ground for MDFT, where it has been successful at delivering low-cost treatment (Liddle, 2002). MDFT employs a harm reductionist approach, which is often not the preferred method of treatment for adolescents, particularly in residential treatment.

The National Institute of Drug Abuse (NIDA) reported that some of the most important recovery factors in the prevention and treatment of adolescent substance abuse disorders are: strong bond with family, and experience of parental monitoring with clear rules of conduct within the family unit and involvement of parent in the lives of their children.

 Success in school performance. Addiction can seriously disrupt the adolescent’s school performance. Oftentimes student peers, as well as the parents’ medicine cabinets, are often the adolescent’s primary source of drugs. Therefore, selection of the treatment aftercare school environment is crucial. Often the families are called upon to consider a drug-free therapeutic school at time of discharge from a primary care treatment setting.

 Strong bonds with pro-social institutions such as family, school and religious organizations. It is imperative that families become familiar with Young People 12-step meetings (YPAA) and Al-Anon in the community upon the adolescent’s re-entry following residential treatment.

According to NIDA, MDFT for adolescent drug abuse offers broad and lasting benefits compared with cognitive behavioral therapy (CBT). The therapeutic approach that integrates individual family and community interventions described as MDFT had a better one-year success rate with fewer drug-related problems, and improved health compared to those treated with standard counseling based on CBT. In MDFT, adolescent drug abuse is viewed as a complex phenomenon in which personal issues, interpersonal relationships, overall family functioning and social forces must all be addressed to effect enduring change. This article addresses how the interventions of the MDFT model can be successfully incorporated into a residential treatment setting with adolescents.

Stage One: Build the Foundation

The initial phone call to the treatment program, followed by a screening, assessment and/or tour of the facility, is the first step of this phase of treatment. Setting expectations, such as intense parent and family participation, needs to be established from the beginning. Admission to treatment is in itself symbolic of a therapeutic alliance with the parents and eventually with the teen as well. Any conflict or stress in the admission process is an opportunity for the clinician to focus on the developmental challenges of adolescence and build relationships with both parents and teens.

Once the teen is admitted into treatment and prior to the commencement of family therapy, creating a space for parents and teens to share their narrative is crucial. Teens need to be assured that they will have that opportunity through individual and group therapy sessions scheduled throughout the week. For parents, a full day is recommended, typically during that first week, as an opportunity for them to share their story and express their range of emotions in a safe, supportive environment. Referred to as the Parent Intensive, this one-day parent only meeting with clinicians at the treatment center is also an opportunity for the multi-disciplinary team to provide their clinical impressions as well as share treatment planning with therapeutic, recovery and academic goals. A multi-generational family genogram developed by the teen is shared with and edited by the parents. Generational patterns of addiction, mental health and family dynamics are identified to be revisited with the entire family. During the Parent Intensive, parents are oriented to the expectations of the family program as well as introduced to key concepts in family systems and 12 Step fellowships, such as Al-Anon. Parents are also introduced to the general program guidelines, program rules and expectations.

MDFT targets four treatment domains: the individual adolescent; parents and other family members; the family’s transactional patterns; and family members’ interactions with extrafamilial systems (Liddle, 1985). The Parent Intensive often involves other families who recently admitted their teen into treatment as well. This begins the parents’ interaction with extra-familial systems which continues with the weekly family program and Al-Anon participation. The Parent Intensive builds the foundation to address the multitude of issues within all four treatment domains.

Within the MDFT model, residential treatment has advantages over an outpatient setting. Due to the concentration of multiple disciplines, the varied dimensions can be approached consistently with high levels of support, generating a path of change that can continue throughout the second stage of the MDFT model.

Summary of MDFT Interventions in a Residential Setting
(based on Newport Academy™ Family Program and minimum 45-day residential stay)

Week One–Parent Intensive – Initial 8-hour meeting for parents only to share their story, be introduced to the treatment team, receive clinical impressions and be oriented to the expectations of the family program as well as 12 Step fellowships. Parents are introduced to family systems through their own multi-generational genogram developed by their adolescent. Parents are given books and articles to read as well as make a commitment to attend three Al-Anon meetings per week in addition to their own individual couples therapy.

Weeks Two through Four –Weekly individual family therapy and participation in a weekly fullday Family Program that includes psychoeducational presentation, multi-family process group and attendance at Al-Anon meeting.

Week Five – Family Intensive – 2-1/2 day individual family intensive that includes all family members. Equine individual family therapy, process groups, cognitive behavioral assignments, etc. Family intensive is comprehensive and individualized so that it may include family sculpting, art therapy, psychodrama as well as individual, couples, siblings and family group therapy.

Week Six – Continued weekly individual family therapy refining exit plan and home contract and weekly participation in Family Program that includes psycho-educational presentation, multi-family process group and attendance at Al-Anon meeting.

Stage Two: Prompt Action and Change by Working the Themes

With the foundation firmly established, the therapist, family and adolescent have identified several important themes that will be worked and reworked throughout the second stage of the model. The themes themselves will vary according to the family and its presenting problems. Where one family may be the most willing to address parent-adolescent interactions, another may avoid work in this dimension. The therapist will skillfully begin to address the areas the family can address while keeping other areas to be confronted at a later stage during the Family Intensive. As the therapeutic process unfolds and the family grows in self-efficacy and family esteem, they will gain access to the internal and external resources needed to focus on these issues. For example, a teen who gains insight to releasing ambivalence regarding substance abuse may become more willing to engage in the process of restructuring the family system.

Clinicians may experience challenges with the MDFT model during this stage. A combination of intensive clinical supervision and a thorough understanding of adolescent developmental stages are suggested to manage all the dimensions addressed by MDFT. For example, providing weekly group supervision sessions and individual supervision in addition to multi-disciplinary treatment planning meetings are necessary. The consequence of not providing opportunities for adequate supervision and therapist support when treating multiple dimensions can be family and adolescent regression into a chaotic state from which the therapist is illequipped to facilitate change.

Other expressions of MDFT during this state may include taking the teens into their environment for experiential therapies. No amount of talk therapy can take the place of supporting a bulimic teen through an all-you-caneat breakfast without binging and purging. Likewise, no speaker from a 12 Step group can convince an adolescent that attendance at a Young People’s AA dance is fun the way attending one with them will. Teens respond to the systems that are common in their everyday life. Taking a teen to a community college to walk the campus or to a pharmacy to process their anxiety around a compulsion to shoplift enhances the therapist’s ability to empathize with the teen. This builds trust in the therapist that translates directly into work in other dimensions such as parent-adolescent or peer conflicts.

Stage Three: Seal the Changes and Exit

One of the attributes of MDFT is the flexibility to match treatment options to the resources of the facility. MDFT has been proven to work in low-cost community-based settings and can be expanded to be implemented with higher resource programs as well. For the final stage of treatment, the model can be integrated into a multidimensionally focused Family Intensive.

By the final stage of treatment, the family has attended a Parent Intensive, weekly individual family therapy, multi-family psychoeducation and multi-family process groups with heavy participation in Al-Anon Family Groups and Young People’s AA for parents and teens, respectively. The teen has engaged in individualized treatment that was inclusive of medical stabilization and continued care, individual therapy and recovery therapy. Teens have begun to develop a new support group, and a new ecology for them to walk into post treatment has been facilitated and fostered.

The Family Intensive is a 2-1/2 day comprehensive individual family therapy module of treatment that cements the changes the teen, family and the extended family have undergone over the course of the preceding 45 to 90 days. This experience starts with an individual family equine-assisted therapy session which amplifies the dynamics of the family, while decreasing aggression on the teens (Kaiser & Smith, 2006). This is followed by five to six hours of therapy where the dynamics exhibited in the equine session are explored and often resolved. Several cognitive behavioral assignments completed by the adolescent related to their recovery are presented by the teen to the parents. This process continues and is adjusted throughout the weekend depending on the needs of the family. Multiple therapists are utilized during the intensive weekend, often simultaneously, when working with subsystems such as siblings, marital relationships or grandparents to resolve cross-generational conflicts that might not be appropriate for the teen to be present at, but are necessary for the family to reorganize into functional patterns.

The weekend is ultimately closed out with the development of a home contract. The home contract itself is multidimensional and addresses all of the areas and themes that were worked, reworked and resolved. This plan becomes the cement to seal the changes in the adolescent’s multidimensional world. It is the path that includes a discharge plan and rules of interaction that solidify structural changes in the family. This path encourages continued growth in all dimensions following formal treatment and is passed on to outpatient providers for follow-up. By completing this final stage of treatment within a week or two of discharge, the teen has time to refine the exit plan and allows the family systems to relax into the new patterns, seek support as needed and finish paving the road the family will walk down following residential treatment.

In conclusion, treatment of adolescent substance abuse at the residential level of care should provide teens with a safe and nurturing therapeutic environment where key elements can be addressed to ensure best possible outcomes. This can be accomplished through genderseparate treatment program settings that address the distinct needs of boys and girls; a comprehensive initial assessment with treatment matching; a highly qualified staff trained in adolescent development, co-occurring mental health disorders and substance abuse; a developmentally appropriate clinical program; a clinical climate that fosters trust between clinician, teen and family; and intensive family involvement throughout the teen’s residential stay. Within such a setting, MDFT can foster early engagement by the family and teen in the therapeutic process leading to better outcomes than standard counseling based on cognitive behavioral therapy. The family program at Newport Academy incorporates components of MDFT that have been traditionally used for adolescents with substance abuse disorders in outpatient familybased treatment. Integrating MDFT into a residential setting with adolescent substance-abusing teens at Newport Academy has demonstrated improvements including increased family involvement, a reduction in target symptoms, communication with peers and family and an overall improvement in problem behaviors.

Case Study: Angela, Age 17

Angela was admitted with poly-substance use with a secondary diagnosis of bulimia. At age 17, she already had multiple treatment episodes. While she was able to achieve abstinence from substances, as well as binging and purging in residential treatment, she was not able to maintain sobriety in her home environment.

Angela was the second born in a family of four children. Dad, a recovering addict, had an emotionally enmeshed relationship with his only daughter. Her mom was not in recovery and presented as disinterested and emotionally detached. Angela’s oldest brother was a high achiever with no previous drug use. Her second oldest brother had a THC addiction with ecstasy use and developing gaming addiction as well as in the early stages of bulimia. Her youngest brother was an emerging addict as he vacillated between the mascot and lost child.

The Parent Intensive offered the treatment team the opportunity to be exposed to the family dynamics in which Dad was insightful yet emotional in his expression, while Mom sat in silence, disconnected from her feelings. It was clear that dysfunctional communication and interactional patterns would be a focus in family therapy.

Throughout the course of treatment Angela’s parents had weekly face-to-face individual family therapy sessions which focused on Mom and Dad individually as a couple, as parents and the family as a whole. As a couple, they learned to identify their feelings and express their emotions appropriately to feel listened to and validated. As parents, they learned to join together as a unified front to take back their parental power. Weekly conference calls were also scheduled with the family, parents and/or siblings. These sessions focused on appropriate interactions between family members in the midst of a chaotic home environment. The parents also participated in the Family Program which included weekly participation in Al-Anon meetings, family psycho-educational sessions and multi-family process groups.

During the course of treatment Angela was taken into the community to experience some of those situations which created anxiety internally. She was able to process her feelings in safe and supportive environments. She also was able to experience food and bathroom challenges with her trigger food in a context with which she was familiar. These exercises allowed her to build her inner strength to develop a healthier self-esteem and more independent sense of self.

Working with an individual family in an intensive weekend allows for the treatment team to spontaneously develop therapeutic interventions that focus on the issues identified. With this particular family at the end of treatment, mom was able to assert herself while expressing love and affection while dad was able to engage in healthy detachment and set boundaries. The parents could begin to work on their relationship as a couple, and parents begin to regain the power and respect of the family.

The Family Intensive was an individual family experience which included parents, teen and siblings. Through the experiential process, family dynamics were identified, challenged and restructured. Equine family therapy and family sculpting was used to combat sibling resistance. For instance, the youngest brother provided insight into the family dynamics by sculpting the other family members. This exercise demonstrated the lack of cohesiveness and degrees of separation within the family system. Another example was the use of a coached family meal in which the Registered Dietician and Therapist had the entire family participate in where they processed triggers, messages and the meaning of food in their family. This exercise demonstrated the instability and chaos within the family system.

References

Haley, J. (1976). Problem solving therapy. San Francisco: Jossey-Bass.
Kaiser L., Smith K. A., Heleski C. R., Spence, L. J. Effects of a therapeutic riding program on at-risk and special education children. Journal
of the American Veterinary Medical Association
2006; 228(1): 46-52.
Liddle, H. A. (1985). Five factors of failure in structural-strategic family therapy: A contextual construction: In S. B. Coleman (Ed.), Failuresin family therapy. New York: Guilford.
Liddle, H. A. (2002). Multidimensional Family Therapy (MDFT) for adolescent cannabis users. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
Liddle, H. A., et al. Treating adolescent drug abuse: A randomized trial comparing Multidimensional Family Therapy and cognitive behavior
therapy. Addiction 103(10): 1660-1670, 2008.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press http://www.nida.nih.gov/NIDA_notes/NNvol23N3/Multidimensional.html.

 

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