Family therapy for drug abuse: review and updates 2003-2010

Just 15 years ago, Liddle and Dakof (Journal of Marital and Family Therapy, 1995; 21, 511) concluded, based on the available evidence, that family therapy represented a "promising, but not definitive" approach for the treatment of drug problems among adolescents and adults. Seven years later, Rowe and Liddle (2003) review described considerable progress in this specialty with encouraging findings on adolescent-focused models based on rigorous methodology, as well as advances with adult-focused family-based treatments. The current review brings the field up to date with highlights from research conducted in the intervening 7 years, cross-cutting issues, recommendations for new research, and practice implications of these findings. Adolescent-focused family-based models that attend to the ecology of the teen and family show the most consistent and strongest findings in recent studies. Adult-focused models based on behavioral and systems theories of change also show strong effects with drug abusers and their families. The overarching conclusion is that family-based models are not only a viable treatment alternative for the treatment of drug abuse, but are now consistently recognized among the most effective approaches for treating both adults and adolescents with drug problems.     

EFFICACY OF FAMILY THERAPY FOR DRUG ABUSE: PROMISING BUT NOT DEFINITIVE

Drug abuse is an enormous public health problem with consequences not only for individuals using drugs but also for families, communities, and society. Moreover, research evidence and clinical experience agree that drug abuse is one of the more difficult problems to treat. Despite considerable research on the connection between family factors and drug use, and the existence of family therapy models for drug abuse, comparatively few controlled efficacy studies have been conducted. This article presents a critical review of controlled treatment outcome research in the area of family therapy for drug abuse in both adults and adolescents. A number of studies from different clinical research groups demonstrate that different versions of family intevention can engage and retain drug users and their families in treatment, significantly reduce drug use and other related problem behaviors, and enhace particular domains of prosocial functioning. Moreover, a smaller number of comparative efficacy studies have shown family therapy to be more effective than nonfamily therapies. Family therapy of adolescent drug abuse is more developed at present than family therapy of adult drug abuse. Although the results of the reviewed studies are promising, a blanket confirmation of family therapy's efficacy for drug abuse cannot be made at this time because of the relatively small number of studies and the noted methodological limitations of the studies published to date. Nonetheless, substantial progress in this clinical research area has occurred, and if research and funding support continue or can expand, significant breakthroughs in the treamtment of drug abuse with family-based treatments are possible.     

The Evolution of Substance Abuse Treatment in Juvenile Justice

ABSTRACT

This paper discusses the scope of substance abuse and related problems among juvenile offenders, and describes three models of addressing the problem based on a review of current approaches, ranging from Treatment Alternatives to Street Crimes programs (TASC), to juvenile drug courts, to an integrated treatment network model. The relevant strengths and weaknesses of each in supporting lasting change in substance-abusing juvenile offenders and their families are presented, and a call to action is offered for communities wishing to aim their interventions innovatively and precisely in the direction of substance abuse among their delinquent youth.     

Risky alcohol use, peer and family relationships and legal involvement in adolescents with antisocial problems

The aim of the study was to examine risk and vulnerability factors contributing to problems with alcohol use in adolescence. Data relating to seven life areas (medical status, school status, social relationships, family background and relationships, psychological functioning, legal involvement, and alcohol use) was gathered using the ADAD (Adolescent Drug Abuse Diagnosis) interview. A total of 1163 Swedish adolescents (809 boys and 354 girls) between the ages of 12 and 20 years old were interviewed. All had antisocial problems and were detained at special youth homes. It was found that for those aged between 12 and 18 years, the general risk factors for alcohol use were leisure and peer problems, problems associated with family background and relationships, and criminal behavior. These results suggest that drug abuse treatment planning should focus on altering the predisposing factors that exist in these domains. It was also found that the ADAD problem areas seem to be most useful as prognostic indicators of treatment outcome for adolescents with antisocial problems who are under 18 years of age.     

A Life-course Perspective on the "Gateway Hypothesis"

Drawing on stress and life-course perspectives and using panel data from 1,286 south Florida young adults, we assess three critical questions regarding the role of marijuana in the "gateway hypothesis." First, does teen marijuana use independently (causally) affect subsequent use of more dangerous substances? Second, if so, does that effect apply to the abuse of other illicit substances, as defined by the DSM-IV, or only to the use of such substances? Finally, does any causal effect of teen marijuana use survive beyond adolescence, or is it a short-term effect that subsides as adolescents transition to adulthood? Our results indicate a moderate relation between early teen marijuana use and young adult abuse of other illicit substances; however, this association fades from statistical significance with adjustments for stress and life-course variables. Likewise, our findings show that any causal influence of teen marijuana use on other illicit substance use is contingent upon employment status and is short-term, subsiding entirely by the age of 21. In light of these findings, we urge U.S. drug control policymakers to consider stress and life-course approaches in their pursuit of solutions to the "drug problem."     

Getting reluctant substance abusers to engage in treatment/self-help: a review of outcomes and clinical options

This review examines the results from 19 outcome studies, involving 1,501 cases, within 10 different clinical approaches to getting alcohol or drug abusers to engage in treatment or self-help. Each approach is summarized and its "success rate(s)" presented. Comparisons are made across various subcategories, such as alcohol vs. drug abusers, adolescents vs. adults, and experimental conditions vs. controls. A distinction is drawn between "Dual-Purpose" approaches, which combine engagement with counseling of the concerned person who originally sought help for the substance abuser, and "Engagement-Primary" approaches, which generally confine their efforts (through working with family members and others) to getting the substance abuser into treatment/self-help. "Best bet" clinical options are presented in terms of which particular approach appears to have the edge with which kind of substance abuser.     

Educating adolescents on the dangers of premature childbearing and drug use: A focus on prevention

This article addresses the prevention of two social problems—premature parenthood and drug use among adolescents. A review of the salient literature on these problems as well as the literature on prevention suggests that a generic response is called for. Theories and perspectives such as social learning, cognitive behavioral, and ecological approaches, and knowledge of adolescent development are drawn upon to guide preventive efforts.     

Abstracts

Ahrons, C. R. Divorce: A crisis of family transition and change. Family Relations ,
Elmer, E. Child abuse and family stress. Journal of Social Issues .
McCubbin, H. I. Integrating coping behavior in family stress theory. Journal of Marriage and the Family ,
Reiss, D. & Oliveri, M. E. Family paradigm and family coping: A proposal for linking the family's intrinsic adaptive capacities to its responses to stress. Family Relations ,
Richman, J. The family therapy of attempted suicide. Family Process ,
Stanton, M. D. Family treatment approaches to drug abuse problems: A review. Family Process ,
Unger, D. G. and Powell, D. R. Supporting families under stress: The role of social networks. Family Relations ,
Wiseman, J. P. The "home treatment": The first steps in trying to cope with an alcoholic husband. Family Relations ,     

Utility Theory and Adolescent Drug Abusers in Hong Kong

Bauman (1980) showed that the perceived costs and benefits of drug abuse predicted adolescents' subsequent marijuana abuse. The purpose of this study was to replicate the Bauman study with Chinese adolescents in Hong Kong, adding further analysis of individual items of perceived costs and benefits of their drug usage. A total of 77 youth at risk (aged 12–21) were interviewed with a structured questionnaire and their attitudes toward drug abuse, stress level, coping strategies, and parents' marital status were obtained. Congruent with the utility theory, results indicated that the more positive their attitude toward drug abuse, the more likely their involvement in drugs and the higher the observed stages of abuse. However, there was no significant difference between the drug abusers and non-users in some antecedent variables including stress levels in most areas of the adolescent lives, in most stress coping strategies, and parents' marital status. Results are discussed in relation to prevention of adolescent drug abuse.     

Cost-effectiveness of family-based substance abuse treatment

In order to compete in a financially sensitive health care system, family systems-based treatments must demonstrate effective clinical results as well as cost-effectiveness. Cost-effectiveness research can demonstrate to health care insurers and policy makers which treatments are viable options for implementation. The present literature review identified eight cost-effectiveness family-based substance abuse treatment studies. The results suggest that certain family-based treatments are cost-effective and warrant consideration for inclusion in health care delivery systems.     

Military Combat Deployments and Substance Use: Review and Future Directions

Iraq and Afghanistan veterans experience extreme stressors and injuries during deployments, witnessing and participating in traumatic events. The military has organized prevention and treatment programs as a result of increasing suicides and posttraumatic stress disorder among troops; however, there is limited research on how to intervene with alcohol misuse and drug use that accompany these problems. This review presents statistics about post-deployment substance use problems and comorbidities, and discusses the military's dual role in 1) enforcing troop readiness with its alcohol and drug policies and resiliency-building programs, and 2) seeking to provide treatment to troops with combat-acquired problems including substance abuse.     

Sexual victimization and substance abuse in psychiatrically hospitalized adolescents

This article investigates the relationship between substance abuse and sexual abuse in a population of 260 psychiatrically hospitalized adolescents. Seven hypotheses are set forth to test a model that uses parental alcohol abuse, sexual abuse status, and gender as exogenous variables, perceived benefit of alcohol or drugs as an endogenous mediating variable, and substance abuse as the dependent variable. Using these variables, a path model was constructed and revised based on empirical testing. The revised model achieved an adjusted R2 of .38, thus explaining 38 percent of the variance in this sample's abuse of alcohol or drugs. The model suggests that within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as the degree to which adolescents perceive benefits from their alcohol or drug use.     

Physical abuse after child protective services investigation and adolescent substance use

The longitudinal pathways connecting physical abuse and substance use in child welfare-involved adolescents, a population with multiple risk factors for substance use problems, remain unclear. This study examined the relation between self-reported physical abuse among adolescents investigated by Child Protective Services (CPS) and later substance use, with a particular focus on exposure to physical abuse after CPS investigation as a potential contributing factor to this relation. Using data from the first National Survey of Child and Adolescent Well-being (NSCAW-I), a path analysis was conducted on a sample of 1079 adolescents aged 11–15 years who had recently been investigated by CPS. At baseline and 18-month follow-up, youths self-reported past-year physical abuse using the Parent-Child Conflicts Tactic Scale and past 30-day substance use frequency. At baseline, youths self-reported current internalizing and externalizing problems to the Youth Self Report. Path analysis revealed no significant relation between physical abuse at baseline and substance use at 18 months. Physical abuse at baseline was associated with higher levels of concurrent substance use and externalizing problems, which in turn predicted higher substance use at 18 months. Furthermore, physical abuse and externalizing problems at baseline predicted physical abuse at 18 months, which in turn was related to higher substance use at 18 months. The findings suggest that physical abuse after CPS investigation contributes to the development of adolescent substance use behaviors. Results indicate a need for innovative efforts to prevent physical abuse after CPS investigation, as well as assessment and treatment of substance use and externalizing problems at the point of investigation, to reduce future substance use in child welfare-involved adolescents.     

Alcoholism and Drug Abuse in Gay and Lesbian Persons:

This review article examines the incidence of alcoholism, and insofar a possible, other forms of drug abuse, among gays and lesbians in the United States and one European society. The consensus is that about 25% of such persons suffer from definitive drug and alcohol abuse problems, while an additional percentage experience “suggestive or problematic” abuse patterns.     

School Violence and Adolescent Mental Health in South Africa: Implications for School Health Programs

This study examines the perceptions of high-school adolescents about gang violence in a periurban community near Cape Town and the implications for school health in South Africa. Using the qualitative focus group discussion (FGD) guide, data were collected from 60 high-school adolescents, between 10 and 20 years of age. Trained moderators conducted nine FGDs with small groups of six to eight students. The constant comparative ethnographic method was used to analyze the data. Results indicate that gang violence is very common among high-school adolescents living on the Cape Flat. Gangs, perceived by many as part of the rite of passage among adolescents, are a major threat to the public health, mental well-being, general welfare, happiness, and development of high-school populations on the Cape Flat. Gang activity interlock with many other social problems, including drug and alcohol abuse, school unrest and violence, and the increasing prevalence of sexually transmitted diseases, especially HIV and AIDS. These findings suggest an urgent need for concerted efforts to develop mechanism to protect school pupils from gangs and develop healthier social alternatives to gang-related activites. Ties among government, school, parents, and community education and participation are urgently necessary to implement a school-based approach to adolescent health promotion.     

Cost/effectiveness analysis of alcoholism and drug abuse treatment programs: the relevance of recidivism and resource absorption.

Cost/effectiveness measures are increasingly being applied to alcoholism and drug abuse treatment programs. Program evaluators usually regard readmissions as inadequate for assessing outcome, and resource absorption is rarely examined; this paper presents the argument that increased attention to recidivism and resource absorption is integral to the program evaluation process. Readmissions formed 53% of admissions to U.S. drug abuse programs, and in alcoholism treatment centers, 4% of the patients accounted for 24% of the detoxications. Problems with assessing cost/effectiveness are associated with duration of treatment, average cost, time span of analyses, quasi-experimental designs, multiple episodes of treatment, "silting up", and extrapolation. Five approaches to dealing with these problems are suggested: analyzing existing program data bases for recidivism and resource absorption, considering recidivism when evaluating programs, tempering clinical enthusiasm with skepticism, matching patients with levels of care appropriate to previous treatment history, and assessing additional benefit derived from increasing amounts of care per patient as part of cost/effectiveness analysis.     

Examination of the Role of Therapeutic Alliance,Treatment Dose,and Treatment Completion in the Effectiveness of The Seven Challenges

Adolescent alcohol and illicit drug (AOD) use is a major public health concern. This longitudinal study examines the effectiveness of The Seven Challenges in reducing adolescent substance use and mental health problems, as well as the process by which it is effective. Participants were 89 adolescents (72 male, 17 female) enrolled in a 3 month intensive outpatient adolescent substance abuse treatment program using The Seven Challenges and who provided self-report data at pre- and post-treatment. Results indicated that The Seven Challenges was effective at increasing the number of days refrained from using AOD, reducing use of tetrahydrocannabinol (THC) and other drugs, and reducing substance use problems and internal mental distress. Results also indicated that The Seven Challenges drug counselors effectively established and maintained therapeutic alliance but this seems to not play a role in the effectiveness of The Seven Challenges. Both treatment dose and completion played a role in the effectiveness of The Seven Challenges; they were both positively related to post-treatment days refrained from AOD use, and negatively related to days of THC use, substance use problems, and internal mental distress. However, the strength of the influence of treatment completion was stronger when treatment dose was low than when it was high. Despite a small sample and other limitations, findings add to existing literature that suggests that The Seven Challenges is an effective substance abuse treatment for adolescents. Furthermore, findings suggest that adolescent substance abuse treatment should focus on clients meeting pre-determined program goals as well as on dose.     

Sociodemographic and maternal behaviors in younger and older pregnant adolescents

Sociodemographic and maternal behaviors were examined in a group of 295 (59%) younger adolescents 10–17 years of age, and compared to a group of older adolescents over 18 (n=203, 41%). Younger adolescents were more likely to be single, of minority group status, family dependent, and poor users of contraceptives. Older adolescents had higher rates of substance abuse, treated psychiatric problems, and abortion histories. Both groups reported parental drinking problems, parental divorce, and poverty. Health indicators did not show differences between groups, although older adolescents had higher than national average low birth weight babies. The age of first pregnancy was markedly lower for the younger than older teen. These findings support the need for prevention strategies in treatment programs.     

Structuring a multi-site evaluation for youth mentoring programs to prevent teen alcohol and drug use

Despite mentoring's rapidly increasing popularity as an intervention for the prevention of teen alcohol and drug abuse and associated problems, there is little research consensus on its overall effectiveness or on the core principles and components that define effective mentoring. To advance knowledge concerning this important prevention intervention, the Center for Substance Abuse Prevention has designed and funded a multi-site cooperative agreement involving seven mentoring programs. The programs are designed to provide a rigorous outcome evaluation that allows comparisons of differing approaches to organizing and delivering mentoring services to adolescents at high risk for substance abuse. The cooperative agreement guidelines set service parameters and options that focus on issues that are grounded in past research on mentoring prevention interventions. The cooperative agreement includes a quasi-experimental, longitudinal multi-site evaluation that provides evidence-based recommendations to advance the effective use of mentoring as a prevention strategy.     

Relationships of sexual, physical, and emotional abuse to emotional and behavioral problems among incarcerated adolescents

This study examined the relationships of sexual, physical and emotional abuse to emotional (internalizing) and behavioral (externalizing) problems among incarcerated girls and boys. Participants were youth who were remanded to the correctional facilities within a statewide juvenile correctional system in a southern state in the United States of America. Each participant completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographic characteristics. Multiple regression analyses indicated that girls were more likely than boys to internalize their problems. The only abuse variable that was positively and significantly associated with emotional problems was emotional abuse. Greater behavioral problems were significantly related to youths being younger in age, white ethnicity, history of sexual abuse, and history of physical abuse. There were overall gender differences for internalizing problems, but not for externalizing problems among incarcerated adolescents. Furthermore, physical and sexual abuses were related to externalizing problems but not to internalizing problems. Thus, different types of abuse appear to have different effects on adolescent behavior. Implications for future research and practice are discussed.