Andreas Gantner

Implementation fidelity of Multidimensional Family Therapy in an international trial

Implementation fidelity, a critical aspect of clinical trials research that establishes adequate delivery of the treatment as prescribed in treatment manuals and protocols, is also essential to the successful implementation of effective programs into new practice settings. Although infrequently studied in the drug abuse field, stronger implementation fidelity has been linked to better outcomes in practice but appears to be more difficult to achieve with greater distance from model developers. In the INternational CAnnabis Need for Treatment (INCANT) multi-national randomized clinical trial, investigators tested the effectiveness of Multidimensional Family Therapy (MDFT) in comparison to individual psychotherapy (IP) in Brussels, Berlin, Paris, The Hague, and Geneva with 450 adolescents with a cannabis use disorder and their parents. This study reports on the implementation fidelity of MDFT across these five Western European sites in terms of treatment adherence, dose and program differentiation, and discusses possible implications for international implementation efforts.

From Research to Practice: The International Implementation of Multidimensional Family Therapy

To address a growing public health problem with youth cannabis use, five Western European countries – Belgium, France, Germany, the Netherlands and Switzerland – collaborated on a cannabis treatment research effort. After deliberation, the research priority chosen was to implement and rigorously evaluate a treatment program for adolescents with cannabis use disorders – virtually unavailable in Western Europe at the time. Adolescent cannabis use disorders were even denied by some policy makers as bona fide public health problems. The most promising candidate for the treatment program to be studied, based on cross-national expert analyses and an exhaustive review of research findings to date, was Multidimensional Family Therapy (MDFT), developed in the USA. When pilot training with candidate clinicians began, some claimed it was “too American.” Some did not understand its innovation at first glance, stating that aspects of MDFT interventions were already part of daily clinical work. Others worried whether the senior role of psychiatrists would be jeopardized, and if the approach engaged in too much outreach, and would be a threat to in-office work. Still others said the model might be too practical, and ignore the need for depth-oriented, psychodynamic treatment – still dominant in parts of Europe. While at the outset MDFT presented as a cultural shock, concerns disappeared when the approach was taught, attempted and integrated into the regular practice settings. The multi-country randomized controlled trial was designed with considerable discussion and collaboration. Referred to as INCANT (International Cannabis Need of Treatment), this study, the first independent replication of MDFT, showed that most adolescents with cannabis use disorders in these five countries have multiple behavioral problems, including criminality, truancy and mental co-morbidity. MDFT proved to be more effective than a high level treatment as usual in reducing cannabis dependence and on other problem behavior measures as well. Positive outcomes were seen in all the five countries. And given the clinical outcomes, the therapist competence and fidelity outcomes, and the capacity of the sites to absorb this new clinical approach, MDFT was found to be feasible and adaptable to representative regular clinical care Western Europe settings, adding expanded treatment alternative to standard care. The challenges 890 H. Rigter et al.