Conduct disorder and delinquency

Overviews evidence-based family treatments for adolescent conduct problems. Three treatments succeed in meeting recommendations for treatment development set forth in recent evaluations by reviewers and federal entities. These treatments (Functional Family Therapy, Multisystemic Therapy, and Oregon Treatment Foster Care) have achieved their success by using the science base of known risk factors, providing an effective alternative to restrictive placements, and using scientific methods to evaluate effectiveness. Major features of these three treatments are presented, including clinical and quality assurance procedures, controlled outcome research support, cost analyses, and process research. Bases of treatment success and parallels among the three approaches are summarized, as is their transport and dissemination to practice settings. Finally, suggestions for future research and clinical implications are discussed.     

The implementation and the cultural adjustment of functional family therapy in a Dutch psychiatric day-treatment center

Because of the increasing severity of adolescent problem behavior, evidence-based practices are becoming of interest as an alternative to traditional treatment with the behavior problems of adolescents in juvenile justice settings. Despite interest in evidence-based practices, questions exist regarding whether or not evidence-based intervention models can be successfully transported to cultures other than those in which they were developed. This article describes the transportation process of an American evidence-based family therapy (Functional Family Therapy [FFT]) into the service delivery system of a psychiatric day treatment center for juvenile delinquents in Amsterdam. The characteristics of FFT that make it cross-culturally sensitive are discussed. Results from the changes in service delivery suggest FFT can be successfully implemented in international settings with adjustments to make the model fit the culture(s) of The Netherlands without changing the model of FFT itself.     

Multisystemic Therapy for Child Abuse and Neglect: Do Parents Show Improvement in Parental Mental Health Problems and Parental Stress?

Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) is an evidence-based program for families with children who experience maltreatment. This clinical trial is the first evaluation of MST-CAN in a German-speaking area. Parental psychological problems and parental stress have been shown to be risk factors for child abuse and neglect. By the end of treatment, parents reported significantly less psychological distress than before the start of MST-CAN. Six months after treatment, this reduction was still evident. However, parents did not report any significant reduction of parental stress at any of the three time points. MST-CAN is an effective intervention for child maltreatment that not only combats child abuse and neglect but also has the potential to alleviate parental psychological distress.     

Evidence-based practice in group care: the effects of policy, research, and organizational practices

This article describes the effect of a province-wide vision of evidence-based and outcome-based services for children and youth and the challenges of implementing evidence-based practice (EBP) and evidence-based treatment (EBT) approaches within group care settings. The paper is based on the results of a survey of group care settings in the province of Ontario, Canada, which was designed to understand the factors affecting the use of EBP and EBT. The critical roles of policy, access to research, and organizational structure as they affect the frontline workforce were explored. The results identified key differences between programs who implemented an evidence-based approach and those who are struggling to do so. Differences in case management practices as well as organizational factors affect the program's ability to use an evidence-based approach.     

Risk factors for attrition from an evidence-based parenting program: Findings from the Netherlands

Parent management training programs for the treatment of childhood conduct problems are increasingly being transported from their country of origin to international settings. Family interactions, however, may be influenced by different cultural expectations and children's mental health problems may be addressed within different systems. Demonstrating reductions in symptoms within the new population is insufficient to support the wide-scale transport of a treatment model. Implementation outcomes such as the rates of treatment retention and factors related to treatment attrition must also be considered. We explored predictors of attrition in families from the Netherlands referred to the evidence-based parenting program Parent–Child Interaction Therapy (PCIT). Participants included 40 children with conduct problems (2–7 years; 68% boys) and their caregivers. Attrition (40%) was somewhat lower than findings with similar community samples in the US. Significant predictors of attrition were child age and maternal levels of internalizing symptoms. Low parental demandingness and high child compliance before start of treatment were related to early attrition within twelve treatment sessions. Meeting the needs of families at risk for attrition is an important goal for parent management training programs within and outside the US if families in need of services are to benefit from them.     

Surviving the swamp: Using cognitive behavioural therapy in a social work setting

This paper explores the attempts of an adolescent support team working for South Gloucestershire Social Services, to integrate Cognitive Behavioural Therapy (CBT) into its practice. We explain how we, as a team, undertook a year-long course of study in CBT and discuss the advantages and difficulties we encountered. Then, beginning with a case study, we draw out the limitations of trying to use CBT in a social work setting. We focus specifically on how the complications of wider family systems will often compromise individual therapeutic work with young people and conclude that a more pragmatic approach to CBT is required in social work, rather than attempts to replicate work carried out in the clinical setting.     

Integrative Families and Systems Treatment: a middle path toward integrating common and specific factors in evidence-based family therapy

A moderate common factors approach is proposed as a synthesis or middle path to integrate common and specific factors in evidence-based approaches to high-risk youth and families. The debate in family therapy between common and specific factors camps is reviewed and followed by suggestions from the literature for synthesis and creative flexibility in manual development. A preliminary integrative model termed Integrative Family and Systems Treatment is offered as one option in developing and testing a moderate common factors approach. Such a model might then be studied in eventual clinical trials with other well-developed evidence-based protocols to further address the common versus specific factor debate. Implications for further research and practice are offered.     

Integrative module-based family therapy: application and training

The field of marriage and family therapy is currently at a crossroads. The challenge for contemporary therapists is how to incorporate the wisdom of previous models with the accountability that comes from evidence-based practice. The Integrative Module-Based Family Therapy treatment model provides a formalized series of steps that clinicians can use in their case planning and implementation. It is based on nine clinically relevant modules for assessment and intervention that are consistent with current best practices and empirically supported treatments. It thus meets the need for a structured family therapy practice and training approach that is respectful of the "art" of family therapy while still adhering to the principles of the "science" of evidence-based treatment.     

Effectiveness of Multisystemic Therapy for gang-involved youth offenders: One year follow-up analysis of recidivism outcomes

The objective of this investigation was to examine the longer-term (12 months post-discharge) outcomes of gang involved and uninvolved youth who were referred for Multisystemic Therapy by their local justice authorities. This is the first systematic investigation of longer-term outcomes for gang-involved youth in treatment. From an initial sample of 421 youth, we applied an intent-to-treat analysis to 409 youth with available recidivism data (97% retention). We analyzed data on re-arrests using nonparametric and event history analytic methods. Overall, we observed a re-arrest rate of 30%. This rate did not differ significantly as the function of gang involvement (gang re-arrest: 35%; nongang re-arrest: 29%). We also observed no significant differences between gang and nongang youth in the numbers of re-arrests, nor in the time to arrest. Although gang youth had higher rates of violent arrests (18%) than did nongang youth (13% overall), this difference also was not statistically significant. This first study examining longer-term impacts of treatment for gang-involved youth suggests that evidence-based intervention can be effective in this population. Future research is needed to examine whether there are particular components of or different approaches to intervention necessary to support positive change among gang-involved youth.     

Building an evidence-base for the training of evidence-based treatments in community settings: Use of an expert-informed approach

In order to make EBTs available to a large number of children and families, developers and expert therapists have used their experience and expertise to train community-based therapists in EBTs. Understanding current training practices of treatment experts may be one method for establishing best practices for training community-based therapists prior to comprehensive empirical examinations of training practices. A qualitative study was conducted using surveys and phone interviews to identify the specific procedures used by treatment experts to train and implement an evidence-based treatment in community settings. Twenty-three doctoral-level, clinical psychologists were identified to participate because of their expertise in conducting and training Parent–Child Interaction Therapy. Semi-structured qualitative interviews were completed by phone, later transcribed verbatim, and analyzed using thematic coding. The de-identified data were coded by two independent qualitative data researchers and then compared for consistency of interpretation. The themes that emerged following the final coding were used to construct a training protocol to be empirically tested. The goal of this paper is not only to understand the current state of training practices for training therapists in a particular EBT, Parent–Child Interaction Therapy, but also to illustrate the use of expert opinion as the best available evidence in preparation for empirical evaluation.     

Trauma Without Borders: The Necessity for School-Based Interventions in Treating Unaccompanied Refugee Minors

This article explores migration trauma among Mexican and Central American unaccompanied refugee minors (URM) with the purpose of developing an understanding of migration as a tripartite process consisting of: pre-migration exposure to traumatic stressors, in-journey stressors, and post-migration stressors. The migration experience of these youth may be subjectively different depending on a wide range of factors. The complexities of migration are explored as a traumatic, tripartite process. These three salient components of migration may act as precursors, often resulting in psychological sequelae such as: post-traumatic stress disorder (PTSD), anxiety, and depression. Of all migrant groups, URM are more likely to develop psychiatric symptoms. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Mental Health for Immigrants Program (MHIP) are among the most effective interventions in the treatment of PTSD, anxiety, and depression in refugee minors. Social workers in schools are in unique positions to provide mental health services to URM. A case example illustrating a cultural adaptation of TF-CBT in an urban public high school is included. Clinical implications of culturally responsive and trauma-informed treatment of URM in schools will be discussed. Additionally, this article will emphasize the importance of bridging the gap between research and culturally responsive, trauma-informed interventions for URM in schools.     

The Dodo Manifesto

In this article I review the psychotherapy outcomes literature as it pertains to the Dodo hypothesis. This is the proposition that the effects of psychotherapy are due to common factors rather than specific techniques. A variety of sources provide substantial empirical support for the Dodo hypothesis. I conclude that CBT and medication do not appear to be any better than other methodologies for the treatment of psychological distress. I look at some of the criticisms of the Dodo hypothesis. I suggest that the major themes that emerge from the literature as it stands are conclusions that would be immediately obvious to most clinicians. Further, the utility of specific techniques has not been ruled out, due to some serious conceptual flaws in efficacy trials. I suggest that there are a number of ways for family therapists to survive in an evidence‐based world. One is to point out to champions of evidence‐based practice just how flimsy their claims are. Another would be to advocate for pluralism and to practise and conduct research under the aegis of a contextual philosophy.     

Cultural adaptation and implementation of evidence-based parent-training: A systematic review and critique of guiding evidence

With advances in knowledge regarding efficacious evidence-based interventions, there have been significant attempts to culturally adapt, implement, and disseminate parent training interventions broadly, especially across ethnic and cultural groups. We sought to examine the extent to which researchers and developers of evidence-based parent training programs have used cultural adaptation models, tested implementation strategies, and evaluated implementation outcomes when integrating the interventions into routine care by conducting a systematic review of the literature for four evidence-based parent training interventions: Parent-Child Interaction Therapy (PCIT), The Incredible Years (IY), Parent Management Training-Oregon Model (PMTO^TM), and the Positive Parenting Program (Triple P). A total of 610 articles across the four programs were identified. Of those, only eight documented a rigorous cultural adaptation process, and only two sought to test the effectiveness of implementation strategies by using rigorous research designs. Our findings suggest that there is much work to be done to move parent-training intervention research towards a more rigorous examination of cultural adaptation and implementation practices.     

When Is Research Good Evidence? Issues in Reading Research

Although using published research is only one part of the evidence-based practice process, clinical social workers more often doubt their abilities in this area than in client assessment or in the individualizing of treatment approaches to fit client preferences, values and resources. This article reviews the nature of research and the reason it is often a preferred source of information; common flaws to watch for in published research; types of research studies and how different kinds of studies are viewed by those interested in treatment outcome research; and the elements of a published research report that must be considered when deciding on its usefulness for decision-making about practice. It will also include discussion of the controversies that surround these topics, which are significant. While readers will have been introduced to these topics in their professional education, when knowledge is not used it is often not well-remembered. Few clinicians find that reading, assessing, or conducting research is part of their daily work, which is one reason why the discussion of evidence-based practice and other approaches to the use of research in clinical practice can be anxiety-provoking. This “refresher” emphasizes that critical thinking skills, which clinicians often have in abundance, are the single most important element in using research to inform practice.     

Interpretation: Event or process?

Interpretation is defined as a process of the creation of meaning rather than the event of a translation between codes as Freud originally saw it. Therapy is then seen as consisting of a process in which two persons negotiate over meaning. Within treatment the two participants create a meaning system or concordance, part of which the client comes to utilize in his/her personal meaning system or identity. The selection of a central metaphor around which to focus the concordance is seen as an important part of the treatment.     

The Healing Power of Laughter: The Applicability of Humor as a Psychotherapy Technique With Depressed and Anxious Older Adults

The nation’s older adult population is steadily increasing in numbers as the Baby Boomer generation ages over time. Mental health providers are encountering older adults who are presenting to therapy with problems related to depression and anxiety. The authors demonstrate how empirically-supported treatments such as Cognitive-Behavioral Therapy, Problem Solving Therapy, and Interpersonal Therapy are effective in treating older adults within the individual and group counseling setting. Humor as a therapeutic tool is introduced as an easily integrated instrument of positive change through several case studies as depicted by the authors.     

Audio-Video Reviews

Barbara Knothe, Consultant Psychiatrist, Bouverie Family Therapy Centre, has reviewed two videotapes, produced by Anita Morawetz. The tapes demonstrate Anita's work with two families, seen at the Bouverie Family Therapy Centre. In one tape, Anita supervised one of the trainees on the Training Programme and it is interesting to see how the work of the training group, family and supervisor evolves. The tapes were produced in 1988–1989 and are available from: Bouverie Family Therapy Centre, 31 Poplar Road, Parkville Vic 3052 Tel: (03) 389 2480. The contact person is Ms Kate Gerber, Clerical Officer. There is no charge for borrowing the tapes, although interstate borrowers must pay for postage (“Cash on Delivery” charges). People may borrow 2 tapes at a time, for a period of 2 weeks. Each borrower is asked to sign a form, which will be sent to them, stating they will accept responsibility for the tape and they will respect the confidentiality of the family. Thanks to Anita for producing the tapes and making her work available to other therapists and trainees, for their professional development. Thanks also to Barbara for her reviews and to Bouverie Family Therapy Centre for their generosity and for maintaining an excellent tape library. I would like to encourage other therapists in Australia and New Zealand to produce audio and/or videotapes of their work, on particular areas of interest. David Epston was one of the first therapists to do this — when he produced a videotape called “The Family who loved to stay at Home” which was reviewed by Jim Birch. Many “local” therapists are making recordings of their work and these provide an invaluable resource for training, supervision, consultation and research. If you are interested in producing some material for reviewing and “public” use, please contact me on: (Work) 03 550 130 (Home) 03 898 6983. You may feel overwhelmed by the task, but please don't abandon the idea. Call me and we can talk about this and your ideas. Making tapes for these purposes may not be as difficult or as daunting as you think.     

Reconsidering the ‘idea’ of evidence in evidence-based policy and practice

Evidence-based policy and practice (EBP) has become an important social work conceptual framework. Yet, the core EBP concept, the concept of evidence, remains ill-defined. I propose a modification of the concept of evidence as applied to EBP effectiveness questions. As a basis for this reformulation ideas about evidence are examined from cross-disciplinary and multidisciplinary perspectives including epistemology, philosophy of science, evidence-science, and law. I propose that for EBP effectiveness questions: (1) to be considered ‘relevant evidence’ an explanatory connection between an intervention and an outcome must be established rather than a mere association; (2) the EBP definition of ‘best available evidence’ should include total available evidence (rather than a subset) about effectiveness, causal roles (i.e., mechanisms), and support factors and be inclusive of high-quality experimental and observational studies as well as high-quality mechanistic reasoning; (3) the familiar five-step EBP process should be expanded to include formulation of warranted, evidence-based arguments and that evidence appraisal be guided by three high level criteria of relevance, credibility, and strength rather than rigid evidence hierarchies; (4) comparative effectiveness research strategies, especially pragmatic controlled studies, hold promise for providing relevant and actionable evidence needed for policy and practice decision-making and successful implementation.