Bridging the research-practice gap in adolescent substance abuse treatment: the case of brief strategic family therapy

Journal of Substance Abuse Treatment 23 (2002) 123 – 132

Regular article

Bridging the research-practice gap in adolescent substance abuse treatment: the case of brief strategic family therapy Michael S. Robbins, Ph.D.a,*, Ken Bachrach, Ph.D.b, Jose´ Szapocznik, Ph.D.a a

Center for Family Studies, Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, Miami, FL 33136, USA b Tarzana Treatment Centers, 18646 Oxnard Street, Tarzana, CA 91356, USA Received 20 March 2002; received in revised form 17 May 2002; accepted 29 May 2002

Abstract This article presents an empirically validated intervention, Brief Strategic Family Therapy (BSFT), for the treatment of adolescent drug abusers. The BSFT intervention steps and program format are presented. Challenges to implementation in community treatment settings are discussed to identify factors that may facilitate or block the integration of BSFT into community practice settings. In particular, this discussion explores how 3 critical aspects of community treatment programs — program philosophy, program structure, and cost/funding — influence the blending of BSFT into community treatment practice. D 2002 Elsevier Science Inc. All rights reserved. Keywords: Adolescent; Substance abuse; Family therapy; Research-practice

1. Introduction This article explores some of the practical issues in blending a research-proven family based intervention for adolescent substance abusers, Brief Strategic Family Therapy (BSFT; Szapocznik, Hervis, & Schwartz, 2001; Szapocznik & Kurtines, 1989) into current community treatment practices. Efforts to blend research-proven interventions in community treatment settings may have a significant impact on the day-to-day activities of both practitioners and researchers. Yet, there is relatively little research or experience on the blending of empirically supported treatments for adolescent substance abusers with community treatment practice. The work presented in this article is based on collaborative relationships developed through the Clinical Trials Network of the National Institutes on Drug Abuse. This article brings together the experiences of community treatment providers and university-based researchers to discuss bridging the research-practice gap around BSFT for adolescent drug abusers. This collaboration reflects our guiding assumption that the best way to build an

* Corresponding author. Tel.: +1-305-243-4592; fax: +1-305-243-4417. E-mail address: [email protected] (M.S. Robbins).

effective research-practice bridge is to involve both clinicians and researchers as full partners. Through this partnership, we have identified critical challenges and potential solutions for initiating efforts to blend BSFT with community practice. The information in this article is presented in two sections. In the first section, we present a brief description of BSFT intervention and relevant outcome results. This information provides an understanding of the clinical aspects of BSFT as well as selected outcome research findings. The second section presents issues involved in blending BSFT with community treatment practice. Specifically, this section includes key questions and challenges to be addressed in blending research with practice, and offers some potential recommendations for facilitating this process. Throughout this section, we highlight issues that are particularly salient for blending research-proven interventions for adolescent substance abusers with adolescent community treatment services.

2. Brief strategic family therapy (BSFT) This section is organized into two parts: (1) a brief description of the clinical approach; and (2) relevant research findings.

0740-5472/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 2 ) 0 0 2 6 5 - 9

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2.1. The role of context BSFT is a family-based intervention designed to help children and adolescents with conduct, delinquent, and other behavior problems, including alcohol and substance abuse. BSFT is based on the fundamental assumption that the family is the ‘‘bedrock’’ of child development; the closest and most influential context influencing children’s development and behavior. Therefore, the family is viewed as the primary context in which children learn to think, feel, and behave. To improve a youth’s behavior problems, BSFT targets the family interactions that are related to the youth’s behavior problems. Interactions refer to the family’s characteristic manner of relating with one another. BSFT is particularly focused on repetitive patterns of family interactions that persist despite the fact that these interactions fail to meet the needs of the family or its individual members. Family relations are thus believed to play a pivotal role in the evolution of behavior problems, and consequently are a primary target for intervention. BSFT recognizes that the family itself is part of a larger social system and, as children are influenced by their families, the family is influenced by the larger social system in which it exists (Bronfenbrenner, 1979, 1986; Szapocznik & Coatsworth, 1999). This sensitivity to social context begins with an understanding of the important direct influence of peers, school, and the neighborhood on the development of children’s behavioral problems. In BSFT, this concern with social context also includes a concern for parents’ relationships with their children’s peers, schools, and neighborhoods as well as a focus on the unique relationships that parents have with individuals and support systems outside of the family (e.g., work, Alcoholics Anonymous). It should be clarified that families come in many different forms, and in fact, often the person who functions in the role of a family member may not be a biologically linked family member. For that reason, in BSFT, work with families is conducted with any set of individuals that functions as a ‘‘family’’; that is, the individuals who live with the adolescent, who provide for him or her, who are concerned for the adolescent, and who have the interest or capacity to collaborate with the adolescent in setting rules and consequences for misbehaviors. Sometimes families have been defined as ‘‘networks of mutual commitment’’ comprised of the persons who carry out the functions that are expected by legal or traditional standards from family members (Pequegnat & Szapocznik, 2000). A fundamental assumption in BSFT is that families enter treatment with their own informal, natural systemic networks. The most common examples of these natural networks include friends, extended family members, schools, and work. BSFT therapists are expected to examine these networks to identify potential problems or areas of strength on which to capitalize in therapy. Thus, rather than placing its highest emphasis on connecting family members with

surrogate formal systems, like social services, that tend to be transient in nature, BSFT gives its highest priority to improving those links that are naturally occurring. Similar to the philosophy of decentralization, the idea is that the family is more likely to maintain positive changes if the changes involve systems that will continue to interact when the therapist (or social services) are no longer involved with the family. This is not to say that therapists do not utilize formal social services in BSFT. This philosophy merely reflects the reality that such services often fail to have a lasting impact on the family because they tend to address the family’s immediate problems in living, and do not prepare the family to handle problems on their own. Hence social services are used for what they do best, provide short-term support. BSFT is used to create short-term as well as longterm changes. Obtaining the collaboration of whole families has always been a major obstacle to provision of family therapy services (Szapocznik et al., 1988). For that reason, a specific module has been developed in BSFT to bring families into treatment and to blend treatment and family life. In BSFT, therapists are very active in working to engage reluctant family members, particularly during the early phase of therapy. The basic philosophy is that therapists will be able to better understand a family’s problems and treat the youth’s behavior problems more effectively if they are able to view directly the family’s maladaptive, repetitive patterns of interaction. For that reason, specialized techniques have been developed to engage families in treatment. This work is based on the simple assumption that the same relational problems that may be obstacles to removing the adolescent’s problem behaviors (e.g., parent and adolescent view themselves as enemies), might also keep whole families from coming into treatment. The specialized engagement techniques help to temporarily overcome these problematic family interactions, long enough to bring the family into treatment, where these problematic family interactions can be properly treated. The concern with social context in BSFT also extends to the recognition of the influence of cultural factors in the development and maintenance of behavior problems (Szapocznik, Kurtines, & Santisteban, 1994). For example, when parents experience discrimination it may affect their parenting, and when children experience discrimination, it may affect their appraisal of their parents as ‘‘protective figures’’ if they are unable to protect the child from discrimination. With Hispanic immigrant families, a cultural process that is often addressed by BSFT therapists is the differences in attitudes, beliefs, values, and behaviors that develop between parents and children, when children rapidly acculturate to a culture that is foreign to the parents (Szapocznik & Kurtines, 1993). 2.2. The role of the therapist BSFT redefines a youth’s behaviors in terms of the social context that influences him/her. There is special emphasis

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on the influence of families on their children because families have the potential for the greatest influence on their children (Resnick et al., 1997). For that reason, the therapist targets those family interactions that appear to have the greatest influence on the adolescent’s symptoms. This ‘‘targeting’’ is done by working directly with the entire family. For example, a youth may have gotten involved with delinquent, drug-using friends. As a result, parents are angry and there is much fighting at home. As long as the adolescent perceives the parent as an adversary, the parent is unlikely to be able to influence the adolescent. Hence, in the presence of the adolescence and parent, the therapist may redefine the parents’ anger as ‘caring’. For example, the therapist may say to the adolescent, ‘‘. . .Did you know that your father cared for you so passionately?’’ This change in the family relations may create the opportunity for the parent to get in touch not just with their anger, but with their underlying concern for the youth, and in the youth it may create a greater openness to the parent. Therapists are expected to encourage family members to interact among themselves to permit the therapist to identify maladaptive interactions, and, when these maladaptive patterns are revealed, to then attempt to change these interactions within the treatment session, as in the prior example. The goal of BSFT is to change those patterns of interaction that are directly related to the youth’s behavior problems, or that impede a more effective interaction that will facilitate change in the youth’s behavior problems. Although therapists are active and directive as in the example above, a feature of BSFT is that the therapist never does for the family (or a family member) what the family members can do for themselves. The goal is to move in and out of family interactions, making directive interventions that propel the family’s interactions in a new, more adaptive direction. Therapists are encouraged to remain decentralized in treatment because positive changes that occur in therapy are more likely to persist after treatment if the changes arise from and are accepted by the family rather than from the therapist. This philosophy is reflected in the attitude that therapists would like to work themselves out of a job with the family. That is, when the therapist leaves the system, the family can continue to respond adaptively to internal and external challenges. Exceptions, of course, are allowed when crises occur or when families are dramatically unskilled. But, even in these circumstances, the therapist moves briefly into a centralized role to help the family develop a new set of skills, and quickly moves out to permit the family to exercise their new skills with the therapist as a coach and supporter. 2.3. Steps of intervention BSFT is a structured, problem-focused, directive, and practical approach. As such, BSFT follows a prescribed process format. However, the family process format is flexible in that it is adapted to each family’s specific

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concerns. Sessions are intended to include all parent figures and the problem adolescent. As noted above, in BSFT, family is defined broadly, and includes the full range of family compositions, extended family members and individuals outside the family that serve in traditional family roles (e.g. emotional and financial support). Thus, sessions may include guardians, aunts and uncles, grandparents, cousins, and close friends. The decision for who to include is based on the therapist’s determination of the most relevant people in the life context of the adolescent and family members. Typically, therapists should begin by working with all of the members of the adolescent’s current household, and then extend or reduce the number of participants in subsequent sessions based on their observation of different family member’s involvement in patterns of interaction linked to the problem behavior. The first step in BSFT, ‘Joining’, is to establish a therapeutic alliance with each family member and with the family as a whole. This requires that the counselor accept and show respect for not only each individual family member, but also the way in which the family as a whole is organized. The therapist in this initial step accepts and respects individual family members’ beliefs and emotions, as well as their power position in the family. The purpose of this step is to have the family accept the therapist as a person who can be trusted and who can lead the family through change. Step 2 involves identifying the problem symptoms and the family relations surrounding those symptoms. This is done by encouraging and permitting the family to behave as it would usually behave if the counselor were not present; that is, encouraging family members to speak with each other about the concerns that bring them to therapy, or anything else they may want to talk about (in contrast to encouraging family members to tell the counselor their concerns). When family members speak with each other, they are likely to do so in their usual way of behaving/relating. From the observations in Step 2, the therapist is able to proceed with Steps 3 and 4 to diagnose both family strengths and problematic relations. Emphasis is given to the family’s problematic relations that are linked to the youth’s problem behaviors, or that interfere with the parent’s (or parent figures’) ability to correct the youth’s problem behaviors. For example, family members may not speak directly with each other, or when they speak their communications may be so vague that it would be difficult for other family members to know exactly what is being requested. Other examples of family problem relations that are assessed include: alliances of one parent or parent figure with the ‘‘problem youth’’ against another parent or parent figure; appropriate and inappropriate involvement of parent figures with the problem youth; effective and ineffective conflict resolution styles (conflict denial, avoidance, diffusion, discussion, and resolution); the extent to which family problems are perceived as shared vs. lodged in a

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single individual (e.g., child may misbehave, but mother may be depressed, father may get drunk, thereby interfering with the parents’ effective behavior management); and developmental appropriateness of family roles (do children have too much or too little responsibility; do parents abdicate parental responsibility). Step 5 is to develop a treatment plan that systematically addresses the problems that are directly linked to the youth’s problem behaviors. The treatment plan is strategic in that the most relevant problems that are identified in Step 4 are the primary targets of intervention. In addition, the treatment plan strategically addresses problems that are relatively easier to change in early sessions to create positive therapeutic experiences for family members. All interventions are planned to capitalize on the unique strengths of each family and individual family member, identified in Step 3. Step 6, ‘Restructuring’, involves the implementation of those change strategies needed to transform family relations from problematic to effective and mutually supportive. In this work the therapist is problem-focused, direction-oriented (i.e., transforming interactions from problematic to competent), and practical. Change strategies used include transforming the meaning of interactions through cognitive restructuring interventions called reframes. Reframes are intended to modify the negative affect of frustrating family interactions into more positive affect that improves communication and increase competence. Other change interventions include: (a) directing, redirecting, or blocking communication; (b) shifting family alliances; (c) placing parents in charge; (d) helping families to develop conflict resolution skills; (e) developing effective behavior management skills; and (f) fostering parenting and parental leadership skills. 2.4. Aspects of the treatment program 2.4.1. Target population BSFT targets children and adolescents who are displaying or are at risk for developing behavior problems, including substance abuse, delinquency, conduct problems, oppositional defiant behavior, among others. BSFT has been used with children between the ages of 6 and 17. In addition, BSFT has been tailored to work with inner city, minority families (including both African American and Hispanic families). BSFT has been implemented as a preventive and early intervention as well as with severe delinquent and substance abusing adolescents. 2.4.2. Length of treatment BSFT is a short-term, problem-focused intervention. The average length of treatment is approximately 12– 16 sessions, and lasts approximately 3 to 4 months. For more severe cases, the average number of sessions may increase. It is important to note, however, that BSFT is not a fixed, inflexible ‘‘package.’’ Treatment continues until the thera-

pist has evidence (observation of interactions and reduction in adolescent problems) that the family has achieved the level of changes identified in the therapist’s treatment plan. That is, termination occurs when the family has achieved changes in behavioral criteria rather than when they have received a pre-determined number of sessions. 2.4.3. Location of treatment In the research studies, most of the clinical work with early intervention populations occurred in the office. However, with more severe cases such as adolescent substance abusers (typically also delinquent), we have found that it is often necessary to conduct sessions in the home or community to overcome a variety of obstacles that keep families from coming to the clinic. Although home/communitybased treatment is not always necessary, it may be required when working with more severe cases. The underlying BSFT philosophy is that therapists should never allow location of treatment (e.g., home, office, school yard) to become an obstacle in treatment. 2.5. Research findings on BSFT Family therapy has been shown to be highly successful in reducing adolescent substance abuse and co-occurring behavior problems (for reviews see Alexander, Holtzworth-Munroe, & Jameson, 1994; Liddle & Dakof, 1995a,b; Stanton & Shadish, 1997). With respect to BSFT in particular, BSFT has been shown to be effective in engagement and retention, as well as adolescent substance use and related behavior problems. 2.5.1. Engagement and retention Previous research has demonstrated that a very large proportion of families who seek treatment for drug abusing adolescents are never engaged into therapy (cf. Szapocznik et al., 1988). As noted above, in response to this problem, a set of specialized engagement procedures was developed (Szapocznik & Kurtines, 1989; Szapocznik, Perez-Vidal, Hervis, Brickman, & Kurtines, 1990). Based on BSFT principles, this approach conceptualizes treatment ‘‘resistance’’ as interactional; therefore, failure to engage in therapy is best understood by identifying the same maladaptive family interaction patterns that also maintain the symptom in the family. As a result, BSFT includes specialized engagement strategies designed to modify these maladaptive interactions and bring the family into treatment. Examples of engagement strategies include allying with the adolescent (if the adolescent is the primary source of the ‘‘resistance’’), asking the mother (or whoever else makes the initial call) for permission to talk to the other family members, and/or coaching the caller on how to bring the family into treatment. The effectiveness of BSFT in engaging adolescents and family members into treatment has been tested in three separate studies (respectively, Szapocznik et al., 1988;

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Santisteban et al., 1996; Coatsworth, Santisteban, McBride, & Szapocznik, 2001). In the first study (Szapocznik et al.), 108 Hispanic families with behavior problem adolescents (i.e. those who were suspected of, or were observed, using drugs) were randomly assigned to one of two conditions: Engagement as Usual (i.e., BSFT with no specialized engagement procedures, the control condition) and BSFT with Specialized Engagement (i.e., the experimental condition). Results showed that 42% of the families in the Engagement as Usual condition were engaged into treatment, compared to 93% of the families in the BSFT with Specialized Engagement condition. For all cases randomized, 25% in the Engagement as Usual condition and 77% in the BSFT with Specialized Engagement condition were successfully terminated. In the second study (Santisteban et al., 1996), 193 Hispanic families were randomly assigned to one experimental and two control conditions. The experimental condition was BSFT with Specialized Engagement, while the control conditions were BSFT with Engagement as Usual and group counseling with Engagement as Usual. Engagement as Usual involved no specialized engagement strategies. Results demonstrated that BSFT with Specialized Engagement was more effective in engaging adolescents and family members (81%) compared to the two engagement control conditions combined (60%). The third study (Coatsworth et al., 2001) compared engagement and retention rates for 104 adolescents and their families assigned to BSFT with Specialized Engagement or community control. Results showed that BSFT with Specialized Engagement was significantly more successful in engaging cases (81%) than the community control (61%). In the BSFT condition 58% of randomized cases completed treatment compared to 25% in the community control condition. A risk ratio analysis revealed that families randomized into BSFT with Specialized Engagement were 2.3 times more likely both to engage and to retain than families randomized to community control. 2.5.2. Adolescent substance use and related behavior problems Several studies have examined the impact of BSFT on adolescent drug abuse and related behavior problems. These studies are briefly reviewed below. The first study (Santisteban et al., 2002) examined drug use and behavioral outcomes for 79 adolescents and their families who were randomly assigned and completed either BSFT or a Group Control Condition. Marijuana and alcohol were the two most commonly reported substances and are the focus of analyses. Results showed that BSFT was significantly more effective than the Group Control in reducing marijuana use, but that there were no differences between the two groups on alcohol use. Analyses of clinically meaningful changes in marijuana use showed that among cases assigned to BSFT, 75% showed reliable improvement (with 56% classified as recovered) and 25%

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showed reliable deterioration. In the Group Control Condition, 14% showed reliable improvement and were classified as recovered, and 43% showed reliable deterioration in marijuana use. With respect to behavior problems, results indicated that participants in BSFT showed significantly greater reductions in conduct problems and delinquency in the company of peers than those participants who were assigned to the Group Controls. Analyses of Clinical Significance in conduct problems showed that in the BSFT condition: 44% showed reliable improvement, 26% were classified as recovered, and 5% showed reliable deterioration. In the Group Control Condition, 11% showed reliable deterioration and no case was classified as reliably improved or recovered. A similar pattern was seen for delinquency in the company of peers. In the second study (also discussed in Engagement and retention section), Szapocznik and colleagues (1988) randomly assigned 108 adolescents to BSFT with Specialized Engagement or BSFT as usual. Youths were included in this study if there was direct evidence of drug use (observation of use or self-report) and/or if there was evidence of problems in four domains of functioning (e.g., school, work, peers, family). Drug use self-reports and parent reports obtained during this interview showed that 93% of these adolescents were using drugs at admission. Of the 108 families participating in this study, 74 were successfully engaged and were present at an intake interview. For these cases, marijuana was the drug of choice (82.5%), and cocaine was frequently listed as the youth’s secondary drug of choice (80%). The frequency of primary drug use was several times per week for 47.2%. Forty-one percent reported restricting their primary drug use to one time per week or less. Results showed that youth in both BSFT conditions (with or without specialized engagement interventions) showed a significant pretreatment to post-treatment improvement in adolescent drug use. There were no differences between conditions. In the third study (Szapocznik, Kurtines, Foote, PerezVidal, & Hervis, 1986), 37 Hispanic families with drug abusing adolescents were randomly assigned to receive either conjoint (full family) or one-person family therapy. The One Person BSFT modality was an adaptation of the original BSFT approach. Results indicated that both the conjoint and one-person BSFT treatments were successful in reducing adolescent drug abuse, conduct problems, delinquency in the company of peers, and impulse control problems. There were no significant differences between the two BSFT conditions (conjoint and one-person). In the fourth study (Santisteban et al., 1997) 122 atrisk young adolescents (ages 12– 14) who received BSFT demonstrated significant reductions in conduct problems, delinquency in the company of peers, and anxiety. Moreover, reductions in behavior problems were associated with reduced likelihood of substance use initiation nine months post-therapy.

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2.6. Issues in blending BSFT with community treatment practice Establishing efficacy is helpful in identifying promising interventions for the ‘‘real world.’’ However, for even these promising interventions to be useful in community treatment settings, it is critical to explore the common challenges to blending the research and practice of BSFT. Three challenges that we explore now in this article are: philosophy of the community treatment agency, the program structure of the agency, and cost/funding. These blending issues are not intended to be an exhaustive list of the potential issues involved in the blending process; rather, they are the three issues that have come up in our conversations on BSFT among the research and practice-based authors. 2.7. Relationship between the philosophy of the community treatment agency and BSFT One of the most important sets of questions in blending BSFT and community practice involves understanding similarities and differences between the philosophical orientation of the community agency (and individual therapists) and the orientation that is the basis of BSFT. Our discussion has identified three broad philosophical areas that are critical to address in the blending process: (1) the relevance of research-proven interventions to community practitioners; (2) the relevance of the intervention in question; and (3) the relative effectiveness of the research-based approach compared to the current practices within the agency. 2.8. Relevance of research-proven interventions to community practitioners A concern that is often raised by community treatment providers is that research-based interventions have not been developed and tested with ‘‘real’’ patients. In this case ‘‘real’’ refers to youth with severe drug use problems and co-morbid conditions, including delinquent youth referred by the juvenile justice system. The skepticism raised by community providers is captured by the question ‘‘Sure, it has been shown to work in a University-run research study, but will it work with the kids in our program?’’. This question also raises doubts about whether BSFT is going to be effective with other problems that are common across treatment programs, such as youth from homes in which the child has been exposed to abuse, neglect, or parental drug use as well as youth with other problems such conduct problems, oppositional defiant behavior, or depression. A strength of BSFT is that it has been conducted with ‘‘real’’ youths (e.g., co-morbid, delinquent, ethnically diverse, and representing a wide range of socioeconomic status) in ‘‘real’’ settings (e.g., home, community) by ‘‘real’’ therapists (practicing professionals with diverse training backgrounds). For example, in our most recent study

(Robbins et al., 2002), 89% of the youth referred for drug abuse counseling also presented with at least one additional psychiatric disorder, and approximately 35% of the sample presented with four or more co-morbid disorders (the most common disorders were attention deficit with hyperactivity, conduct disorder, oppositional defiant disorder, and major depression). Moreover, the studies on BSFT have included families in which there were serious family problems (such as abuse and neglect or drug use) and individual psychopathology in one or more parents or other family members. With respect to clinical work with adolescents, the work done in BSFT is attractive to many providers because: (1) clinicians in inner-city communities are interested in research with inner-city minority youth; and (2) clinicians who work with adolescents (in any setting) recognize the importance of involving family members in the adolescent’s treatment process. Moreover, the practical and specific guidelines about how to engage reluctant youth and their families are very attractive to community treatment providers who often receive little support or information in this area. Finally, BSFT is appealing because it is adaptable to a variety of approaches/philosophies, including abstinencebased, harm reduction, and 12-step-based. 2.9. Relevance and effectiveness of BSFT Treatment centers may already include complex intervention packages designed to address the multi-faceted nature of adolescent substance abuse. Individual therapy, group therapy, and case management are common components in many community programs. Given the diverse array of services that is provided, this question must be addressed in the blending process: ‘‘Is BSFT going to be added to individual or group therapy services, or is BSFT supposed to replace these services?’’ One of the most interesting questions is whether BSFT should be provided as an alternative strategy or as an ‘‘add on’’ to existing substance abuse treatment services. A major concern with providing BSFT as an ‘‘add on’’ service is the increased treatment costs associated with providing an additional intensive psychotherapy. For example, most community treatment providers currently provide weekly therapy sessions. Adding another psychotherapy to existing treatment packages substantially increases treatment costs. The increased costs may limit the ability of community agencies to integrate BSFT into current services. Moreover, adolescents and family members may simply be overextended with psychosocial services. An interesting area where BSFT collides with current practice patterns occurs in circumstances where the standard service involves the utilization of outpatient group counseling/therapy sessions. For BSFT, these services are problematic for several reasons. First, as an empiricallybased intervention, BSFT recognizes that existing research documents the potential negative impact of group interventions for behavior problem youth (c.f., Dishion,

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McCord, & Poulin, 1999). Second, group interventions are inconsistent with BSFT intervention philosophy and practice guidelines that recommend connecting youth to prosocial peer networks (Szapocznik et al., 2001). Obviously, adding BSFT to group services in practice settings creates a philosophical conflict. 2.10. Program structure 2.10.1. Staffing with therapists Questions are often raised with regard to staffing, e.g., ‘‘How do therapists in research protocols compare to counselors/therapists in the community agency?’’ ‘‘What is the educational/training level required for BSFT to be implemented in community settings?’’ ‘‘Does this agency have staff that can deliver BSFT?’’ In our experience implementing BSFT, master’s level providers who have some experience working with families or some training in understanding systems (such as Master’s in Social Work) make excellent candidates to be trained in BSFT. Likewise, we have found that some bachelor’s level counselors have the skills needed to participate in BSFT training and successfully implement it. Thus, education alone is not a specific requirement of BSFT. Also, while clinical experience with families is helpful, not just any clinical experience is a good prerequisite for training and implementing BSFT. For example, 15 years of conducting individual therapy may not be as important as the ability to conceptualize problems in relational terms (e.g., son runs away when father threatens to leave home). BSFT requires specific training and skills. Based on prior experience, individuals with academic and clinical experience with systems (i.e., social work, counseling psychology) have been the quickest to grasp the complex concepts and requirements of BSFT. In contrast, individuals strongly rooted in individual (particularly psychodynamic) approaches have been the most difficult to train in the implementation of BSFT. One critical step in blending BSFT in a community treatment agency is the initial process of identifying clinical staff within the agency that have the requisite skills for participating in the BSFT training process. The success of this process can only be achieved through extensive dialogue between the community agency leadership and the BSFT Trainers. The process of identifying staff involves interviewing agency supervisors, directors, and clinical staff as well as reviewing videotapes of therapists conducting sessions with families. The specific skills that we search for at this level include the clinician’s: (1) general interpersonal skills; (2) openness to learning new information and responding to feedback; (3) openness to recognizing the role of relationships in influencing behavior; and (4) directness and clarity of communication. With respect to videotapes of clinical work, we are interested in examining the extent to which the therapist is able to: (1) convey understanding, acceptance, and respect to all family members;

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(2) speak with families in a manner that is comfortable and familiar; (3) reflect family members’ comments without being challenging or critical; (4) obtain information from each family member; and (5) stimulate dialogue between family members. The entire issue in selecting or identifying therapists is subsumed by the broader issue of ‘‘raising the bar’’ for adolescent (and adult) substance abuse treatment. The bottom line is that if the primary goal is to provide high quality treatment then there must be high quality staff available to provide these services. The field needs to move beyond simply stating that funds are not available to support quality staff. As a field, both community providers and researchers must advocate for creating a system that fosters and supports qualified/competent providers. Otherwise, we will be unable to attract competent practitioners who can earn a decent living and have respect and status within the mental health field. 2.10.2. Training and supervision In addition to staffing, other central aspects of BSFT must be considered. For example, ‘‘What are the training and supervision requirements for BSFT?’’ ‘‘What supervision requirements must be maintained to ensure the sustained effectiveness of BSFT?’’ ‘‘Will these resources be internal or external to the agency?’’ In BSFT, training involves four 3-day workshops conducted over a 3-month period. Each workshop consists of didactic presentations, review of videotape, and live supervision. Later workshops also include review and planning of therapist’s pilot cases. Workshops are conducted at community treatment agencies by a trained BSFT therapist/ supervisor. Training should be accompanied with ongoing weekly supervision of active cases. After training, the implementation of BSFT also includes regular supervision with a BSFT therapist/supervisor. Supervision sessions may occur via telephone calls; however, these meetings should always include the review of videotapes. Intensive training and supervision is critical for developing core skills in a complex intervention such as BSFT. Although therapists are adept at working with individuals (alone or in group counseling sessions), they tend to have less experience with understanding and changing systems that have a long history and well-established pattern of relating with one another. Moreover, the fact that therapists in community agencies recognize the importance of involving family members in treatment, they often adopt a child advocate position that results in fostering an adversarial relationship with authority figures in the child’s life (e.g., parents or parent figures). At present, the research team at the Center for Family Studies at the University of Miami School of Medicine has the only qualified trainers and supervisors for BSFT. Our experience is that, although initial training can be conducted at the Center for Family Studies, the last two training sessions, whenever possible, should be conducted at the

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treatment agency, using each agency’s own cases to organize the training experience. We have also had considerable success conducting weekly supervision sessions via weekly telephone calls. The supervision process is facilitated by having therapists videotape their sessions, make a copy of these videotapes, and send these tapes to the clinical supervisor. The supervisor reviews selected (both random and specific) to track therapist’s performance and to make recommendations. The Center for Family Studies is working on streamlining the supervision process. To facilitate supervision, the Center for Family Studies is working on developing a webbased program for tracking clinical notes and contact logs. A primary goal of this system is to further increase the effectiveness of supervision by having all important clinical materials available in real time to supervisors. Clearly, the effectiveness of BSFT in engagement and retention as well as in decreasing adolescent substance abuse and related behavior problems is attractive to community agencies. However, the costs and availability (only one site currently provides training) of training may detract from community providers’ willingness to participate in BSFT training. More work needs to be done in marketing BSFT to community providers, which includes facilitating additional University-based research at other universities as well as establishing multiple sites across the nation that may better serve the training and supervision needs of community agencies. 2.11. Program support Practical questions also must be considered, such as ‘‘Is BSFT intended to be delivered in patients’ homes?’’ and ‘‘How should it be handled if an individual family member is in need of specific services, such as psychiatric consultation or medication?’’ The specific manner in which these questions are addressed will vary substantially across agencies. However, at their core, these questions speak to the issue of how agencies are structured (or may have to be restructured) to assist therapists in delivering BSFT. For example, if an implementation goal is to maintain the BSFT philosophy that location of treatment should not become an obstacle to delivery of services, agencies must have in place resources to address therapist safety (mobile phone), transportation costs, and travel time. Outreach programs such as this one are typical among many drug abuse treatment programs. Community treatment providers ‘‘buy in’’ to the concept of home/community-based service delivery. However, agencies may have to reconsider alternative strategies for drug users that do not reside in the surrounding community. For example, in many residential/inpatient programs it is common for participating adolescents to come from a variety of neighborhoods, counties, or states. Clearly this issue has implications for conducting family therapy with family members that live in another state. However, even when

an outpatient program serves a relatively small geographic area (e.g., a 20-mile radius from the clinic), there are practical challenges to home-based delivery of services. Therapists often spend considerable time in their vehicle and conduct sessions in sometimes very dangerous communities. Both situations contribute to burnout. Also, completing case notes and storing notes in a secure location is difficult for therapists who may complete a session late in the evening and do not wish to go back to the office before going home. We recommend providing the therapist with a lockbox and recommend that the lockbox be kept with the therapist or in a locked room in the therapist’s home at all times, until the case notes are taken to the office. An issue to consider when conducting family therapy is the realistic concern that involving additional family members results in considerable more difficulty in scheduling sessions. Adding one or two parents or other adults that work during the day means that sessions may need to be conducted during evenings or on the weekends. For clinic-based delivery, extending hours into evenings and weekends may increase operating and administrative support costs, and home-based delivery may be a more attractive alternative. Perhaps the most salient concern about cost is the fact that home-based delivery may result in 2 – 4 hr of staff time for a single billing session. This reality may represent the biggest stumbling block in blending BSFT’s location of treatment philosophy in community treatment agencies. On the one hand, research has shown that a clinic-based BSFT is effective; but, on the other hand, our research has also shown that the more difficult adolescents and families may be more difficult to engage in a traditional, clinic-based intervention. Although an argument can be made that the positive impact of BSFT on adolescent behavior problems may result in an ultimate cost savings, irrespective of whether services are delivered in the clinic or in client’s homes, third-party providers (or the clients themselves) may not be willing to fund transportation costs to and from treatment sessions. With respect to psychiatric medications, because the family is the client, BSFT identifies the psychiatric needs of adolescents as well as the other family members. Often the treatment agency may not provide the psychiatric services. When psychiatric consultation is not available at a community treatment agency, BSFT therapists are required to work with family members to identify and access psychiatric services. This practice is similar to therapists working in private practice settings. In prior research studies on BSFT, psychiatric consultation was not provided within the clinic where the studies were conducted. Thus, BSFT therapists had to work directly with the family and community providers to find affordable and readily available psychiatric services when they were needed. In our experience implementing BSFT with low income, non-insured families, we have found that therapists are very successful in linking families to psychiatric services when they aggressively work with the family to facilitate these consultations.

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Community agencies are structured in many ways and agencies differ in their philosophy about the utilization of psychiatric services. Although providers are increasingly supporting psychiatric medication for co-morbid psychiatric conditions and even substance abuse itself, there are still many agencies that view the use of psychiatric medication in a negative light. In this regard, the philosophy of the treatment agency will be adopted in the delivery of BSFT. 2.11.1. Cost and funding An important decision that will dramatically affect cost is whether BSFT will be added onto existing services or whether it may replace some of the existing therapy services. Adding family therapy onto existing services will be considerably more expensive than replacing another therapy with family therapy. In either case, agencies must assess how family services will be paid. ‘‘Are family services covered by third-party providers?’’ ‘‘How many sessions?’’ ‘‘Who pays for transportation to and from sessions?’’ If BSFT is added to existing services, ‘‘Will it be covered under existing packages?’’ These types of questions become even more salient when family therapy may replace group interventions in which billing may occur separately for each client in a session. 2.11.2. Training and supervision A major consideration in the blending of any empirically-based intervention has to do with training requirements. In BSFT, training is very intensive and costly. The current training program for BSFT costs $32,000 (travel is additional). This includes four 3-day on-site trainings plus 26 weeks of weekly phone supervisory sessions. The training is provided for up to eight therapists at one time. Clearly, a major factor that may limit the widespread adoption of BSFT is the resources available to pay for such intensive training. To facilitate the dissemination of BSFT, we have encouraged agencies to combine efforts to raise the funds at a rate of $4,000 per therapist to be trained, for up to eight therapists per training. This means that two or three agencies can send therapists to a single training, each paying $4,000 per therapist for the full complement of eight therapists per training. In these instances, training may be conducted at a site that is convenient to both agencies or the 3-day on-site trainings may be alternated from agency to agency. The Center for Family Studies has also worked closely with dozens of agencies from around the country to support them in their efforts to raise funds to receive BSFT training to certification. This includes working with agencies around the country applying for Center for Substance Abuse Prevention’s Family Strengthening funds and the Center for Substance Abuse Treatment’s treatment expansion funds. In these efforts we have made boilerplate language available to agencies on the approach, the supporting evidence, a possible evaluation of BSFT to include in their

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grant applications, and the parameters of the training program. Moreover, we have worked with agencies that have sought philanthropic support to fund the BSFT training program, and to re-organize their programs to enable a family therapy focus. Funding training and supervision activities requires considerable creativity and effort, and many community treatment agencies have considerable skill in securing these types of funds. This process may be facilitated by many state and federal initiatives (like the one mentioned above) that provide funding for training and (even) implementation. Beyond funding constraints, additional training issues must be considered. For example, ‘‘Given high rates of staff turnover, how can training be streamlined into existing agency practices to minimize re-training costs?’’ ‘‘Can experts be trained at agencies to ensure that future training will be conducted internally rather than externally?’’ This latter question also applies to supervision and supervision costs. For example, ‘‘Can an expert be trained at the agency to provide regular monitoring and supervision of BSFT therapists?’’ At present, the Center for Family Studies is working on a number of strategies to make training more available. The most important of these is a recently funded project that is designed to: (1) package the BSFT training program into an audiovisual curriculum, making it easier for future generations of trainers to train on BSFT; and (2) to train 18 trainers in community agencies around the country and have these trainers test the usefulness of the BSFT audiovisual curriculum. Such projects reflect the fact that dissemination is a long process that involves adaptively responding to and developing solutions for critical challenges that emerge. One of the most important strategies that we currently recommend for minimizing the impact of turnover on community agencies is strategically selecting staff for training and rewarding staff for achieving certification in BSFT. For example, agencies may want to select staff that they perceive as having a long-term commitment to the agency. Although such procedures might create problems for conducting an effectiveness study, they represent a potential strategy for minimizing the likelihood that staff may have to be retrained.

3. Conclusions and recommendations Bridging the research-practice gap is a complex process that requires attention to the philosophy and parameters of the intervention as well as the philosophy and organizational structure of the practice settings. Issues of cost/funding are of course present, and BSFT poses unique challenges in this area. Although this article presents many questions and offers only a few suggestions, it provides an example of the types of questions that must be considered when attempting to successfully blend research-based interventions with community

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treatment programs. One of the primary issues this article brings up is that future research must examine strategies for effectively negotiating this process. With respect to BSFT, for example, research should be conducted to determine if BSFT is effective in provider settings. Once this basic question is addressed, further research can examine: (1) what aspects of BSFT can be most easily transferred; (2) can a ‘‘train-thetrainer’’ model be successfully implemented; and (3) if clinic based delivery of BSFT is as effective as home-based delivery? This list of effectiveness research questions is not complete, but it does shed light on important next steps in the evaluation and dissemination process. The challenges of transportation underscore the need for increasing the dialogue between researchers and practitioners. This dialogue should be continuous, shaping both the nature of the research that is conducted as well as the models that are tested. The existing tension and emerging collaborations between researchers and practitioners should be capitalized on to facilitate the development of innovative strategies for bridging the research to practice gap. Researchers and practitioners must achieve a level of understanding and respect for the critical role that each group plays in the effective treatment of substance abusing populations.

Acknowledgments This work is supported by funding from the National Institute on Drug Abuse to Jose´ Szapocznik, Principal Investigator (1U10DA13720 and DA 10574), and to Michael Robbins, Principal Investigator (DA 14297). The information contained in this presentation was originally presented by Jose´ Szapocznik and Ken Bachrach at the National Institute on Drug Abuse, Clinical Trials Networks ‘‘All Hands Meeting’’ in Los Angeles, CA, October, 2000.

References Alexander, J. F., Holtzworth-Munroe, A., & Jameson, P. B. (1994). Research on the process and outcome of marriage and family therapy. In A. E. Bergin, & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (4th ed.). New York: John Wiley & Sons. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press. Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22, 723 – 742. Coatsworth, J. D., Santisteban, D. A., McBride, C. K., & Szapocznik, J. (2001). Brief strategic family therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent symptom severity. Family Process, 40, 313 – 332. Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54, 755 – 764. Liddle, H. A., & Dakof, G. A. (1995a). Efficacy of family therapy for drug abuse: Promising but not definitive. Journal of Marital and Family Therapy, 21, 511 – 543.

Liddle, H. A., & Dakof, G. A. (1995b). Family-based treatment for adolescent drug use: State of the science. In E. Rahdert, & D. Czechowicz (Eds.), Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions ( pp. 218 – 254). Rockville, MD: National Institute on Drug Abuse. Pequegnat, W., & Szapocznik, J. (2000). Working with families in the era of HIV/AIDS. Thousand Oaks, CA: Sage. Resnick, M. D., Bearman, P. S., Blum, R. W., Bauman, K. E., Harris, K. M., Jones, J., Tabor, J., Beuhring, T., Sieving, R. E., Shew, M., Ireland, M., Bearinger, L. H., & Udry, J. R. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823 – 832. Robbins, M. S., Kumar, S., Walker-Barnes, C., Feaster, D., Briones, E., & Szapocznik, J. (2002). Ethnic differences in psychiatric comorbidity among substance abusing adolescents referred to outpatient therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 394 – 401. Santisteban, D. A., Coatsworth, D., Perez-Vidal, A., Kurtines, W. M., Schwartz, S. J., & Szapocznik, J. (2002). The efficacy of brief strategic family therapy in modifying adolescent behavior problems and substance use (Manuscript submitted for publication). Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Mitrani, V., JeanGilles, M., & Szapocznik, J. (1997). Brief structural/strategic family therapy with African-American and Hispanic high risk youth. Journal of Community Psychology, 25, 453 – 471. Santisteban, D. A., Szapocznik, J., Perez-Vidal, A., Kurtines, W. M., Murray, E. J., & LaPerriere, A. (1996). Efficacy of intervention for engaging youth and families into treatment and some variables that may contribute to differential effectiveness. Journal of Family Psychology, 10, 35 – 44. Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition, and family-couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, 170 – 191. Szapocznik, J., & Coatsworth, J. D. (1999). An ecodevelopmental framework for organizing the influences on drug abuse: A developmental model of risk and protection. In M. D. Glantz, & C. R. Hartel (Eds.), Drug abuse: origins and interventions ( pp. 331 – 366). Bethesda, MD: NIDA, Division of Epidemiology and Prevention Research. Szapocznik, J., Hervis, O., & Schwartz, S. (2001). Brief Strategic Family Therapy Manual [NIDA Treatment Manual Series]. Rockville, MD: National Institute on Drug Abuse. Szapocznik, J., & Kurtines, W. M. (1989). Breakthroughs in family therapy with drug abusing problem youth. New York: Springer Publishing Company. Szapocznik, J., & Kurtines, W. M. (1993). Family psychology and cultural diversity: Opportunities for theory, research, and application. American Psychologist, 48, 400 – 407. Szapocznik, J., Kurtines, W. M., Foote, F., Perez-Vidal, A., & Hervis, O. (1986). Conjoint versus one person family therapy: Further evidence for the effectiveness of conducting family therapy through one person. Journal of Behavioral Sciences, 6, 303 – 330. Szapocznik, J., Kurtines, W. M., & Santisteban, D. A. (1994). The interplay of advances among theory, research, and application in family therapy for Hispanic behavior problem youth. In R. G. Malgady, & O. Rodriguez (Eds.), Theoretical and conceptual issues in Hispanic mental health (pp. 156 – 180). Malabar, FL: Krieger Publishing Company. Szapocznik, J., Perez-Vidal, A., Brickman, A., Foote, F. H., Santisteban, D., & Hervis, O. E. (1988). Engaging adolescent drug abusers and their families into treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology, 56, 552 – 557 [Reprinted in Annual Review of Addictions Research & Treatment, 1991, 331 – 336.]. Szapocznik, J., Perez-Vidal, A., Hervis, O. E., Brickman, A., & Kurtines, W. (1990). Innovations in family therapy: Strategies for overcoming resistance to treatment. In R. A. Wells, & V. J. Giannetti (Eds.), Handbook of brief psychotherapies. Applied clinical psychology ( pp. 93 – 114). New York: Plenum Press.