Guy S. Diamond

MULTIDIMENSIONAL FAMILY THERAPY FOR ADOLESCENT DRUG ABUSE: RESULTS OF A RANDOMIZED CLINICAL TRIAL

Random assignment was made of 182 clinically referred marijuana- and alcohol-abusing adolescents to one of three treatments: multidimensional family therapy (MDFT), adolescent group therapy (AGT), and multifamily educational intervention (MEI). Each treatment represented a different theory base and treatment format. All treatments were based on a manual and were delivered on a once-a-week outpatient basis. The therapists were experienced community clinicians trained to model-specific competence prior to the study and then supervised throughout the clinical trial. A theory-based multimodal assessment strategy measured symptom changes and prosocial functioning at intake, termination, and 6 and 12 months following termination. Results indicate improvement among youths in all three treatments, with MDFT showing superior improvement overall. MDFT participants also demonstrated change at the 1-year follow-up period in the important prosocial factors of school/academic performance and family functioning as measured by behavioral ratings. Results support the efficacy of MDFT, a relatively short-term, multicomponent, multitarget, family-based intervention in significantly reducing adolescent drug abuse and facilitating adaptive and protective developmental processes.

Resolving a Therapeutic Impasse Between Parents and Adolescents in Multidimensional Family Therapy

This study explored the process of resolving an in-session impasse between a parent and an adolescent in family therapy. Focusing on altering the content and affective tone of a discussion, the shift intervention was used to direct a familys conversation away from trying to solve behavior management problems and toward a discussion of fundamental relationship problems. Task analysis was used to specify problematic family interactions, the intervention strategy, and successful and unsuccessful outcomes. Descriptive analyses of 5 successful and 5 unsuccessful interventions yielded a detailed performance model of therapist and family behaviors involved in breaking the impasse. The Beavers Timberlawn Family Evaluation Scale was used to verify the presence of the shift intervention in the data set and to embellish the performance model. The model suggested that adolescents became more cooperative and engaged in treatment when parents shifted from trying to control them to trying to understand them. A detailed performance map for accomplishing this shift is offered.

Early Therapeutic Alliance as a Predictor of Treatment Outcome for Adolescent Cannabis Users in Outpatient Treatment

The association of early alliance to treatment attendance and longitudinal outcomes were examined in 356 adolescents participating in a randomized clinical trial targeting cannabis use. Both patient and therapist views of alliance were examined, and outcomes were evaluated over 12 months after numerous other sources of variance were controlled. Patient-rated alliance predicted a reduction in cannabis use at three and six months and a reduction in substance-related problem behaviors at six months. Therapist-rated alliance did not predict outcomes. Neither patient nor therapist alliance ratings were associated with attendance. The findings support the important and often overlooked role that alliance can play in treating substance abusing, often delinquent, adolescents.

The therapeutic alliance in adolescent substance abuse treatment: A one-with-many analysis

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cooks (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes.

Screening for atypical suicide risk with person fit statistics among people presenting to alcohol and other drug treatment

UNLABELLEDnSymptoms of internalizing disorders (depression, anxiety, somatic, trauma) are the major risk factors for suicide. Atypical suicide risk is characterized by people with few or no symptoms of internalizing disorders.nnnOBJECTIVEnIn persons screened at intake to alcohol or other drug (AOD) treatment, this research examined whether person fit statistics would support an atypical subtype at high risk for suicide that did not present with typical depression and other internalizing disorders.nnnMETHODSnSymptom profiles of the prototypical, typical, and atypical persons, as defined using fit statistics, were tested on 7408 persons entering AOD treatment using the Global Appraisal of Individual Needs (GAIN; Dennis et al., 2003a,b).nnnRESULTSnOf those with suicide symptoms, the findings were as expected with the atypical group being higher on suicide and lower on symptoms of internalizing disorders. In addition, the atypical group was similar or lower on substance problems, symptoms of externalizing disorders, and crime and violence.nnnCONCLUSIONSnPerson fit statistics were useful in identifying persons with atypical suicide profiles and in enlightening aspects of existing theory concerning atypical suicidal ideation.

Impact of victimization on substance abuse treatment outcomes for adolescents in outpatient and residential substance abuse treatment.

This paper considers whether victimization moderates adolescents outcomes in substance abuse treatment. Adolescents (N=975) in outpatient and residential settings were assessed at intake, three, six, nine, and 12 months. Differential outcomes by gender and degree of victimization were analyzed. Dependent variables were marijuana use and substance-related problems. The residential sample reported higher baseline marijuana use and victimization. Both samples significantly reduced marijuana use and associated problems during treatment. Victimization was significantly related to more substance-related problems at intake and follow-up. More severe trauma histories in residential females were associated with significantly greater persistence in substance-related problems post-discharge.

Changes in Tobacco Use Among Adolescent Smokers in Substance Abuse Treatment

Adolescents with substance use disorders (SUDs) smoke cigarettes more than youth in the general population. Little is known about changes in smoking patterns during and after outpatient SUD treatment. We examined whether receiving SUD treatment had a differential impact on cigarette smoking behaviors of mild (<10 cigarettes per day [CPD]), moderate (10-19 CPD), and heavy (>or=20 CPD) smokers (smoked on >or=60 days in the past 90). Our sample included 378 adolescents from the Cannabis Youth Treatment study, who were assessed at intake, and after 3, 6, 9, and 12 months. Results indicate that after controlling for the effect of changes in cannabis use, mild smokers decreased days of smoking during treatment and follow-up, whereas moderate and heavy smokers demonstrated a small decrease over treatment, and no change over follow-up. Heavy smokers demonstrated a slight decrease in CPD during the treatment phase. These results suggest that, whereas cigarette smoking may decrease for mild smokers while in SUD treatment, the addition of specialized smoking interventions may be necessary to effect change in cigarette smoking for moderate and heavy smokers.

Providers' experiences caring for adolescents who smoke cigarettes.

OBJECTIVEnTo describe providers experiences screening for and counseling adolescent patients who smoke cigarettes.nnnDESIGNnEight qualitative focus groups were conducted with 51 health care providers in primary care settings. Focus groups were video- and audiotaped; tapes were transcribed for coding by an interdisciplinary team using the constant comparative method.nnnMAIN OUTCOME MEASURESnProviders reported experiences screening for and managing adolescent patients who reported smoking cigarettes.nnnRESULTSnProviders expressed confidence in their ability to screen adolescent patients for tobacco use, particularly as part of regularly scheduled preventive and medical visits. Providers reported difficulty balancing screening for smoking with their concern for maintaining rapport with their adolescent patients. In addition, providers reported that adolescent smoking patterns differed from those of adults, and consequently, providers were not certain at what level of smoking an adolescent required intervention. Furthermore, providers were unclear regarding what interventions were recommended for and effective with adolescents.nnnCONCLUSIONnProviders are interested in adolescent evidence-based screening methods and cessation interventions that are supportive of a nonjudgmental and empathic approach to caring for adolescent smokers, particularly those with irregular and situational smoking patterns.

Communication about smoking between depressed adolescents and their parents

INTRODUCTIONnBetter understanding of effective parent-adolescent communication regarding tobacco use could inform smoking cessation intervention.nnnMETHODSnSemistructured interviews related to communication about smoking were conducted with 15 depressed adolescent smokers and their parents, primarily from urban areas. This study, conducted in 2006-2008, was funded by the Pennsylvania Department of Health. Interview transcripts (N = 30) were coded in QSR N6.nnnRESULTSnQuality of communication, rather than content, seemed to determine whether parental communication was effective. Parents reactivity to, or avoidance of, adolescent smoking presented a barrier to effective communication. In this sample, parents and adolescents were more concerned about problems, such as depression, than smoking.nnnDISCUSSIONnInvolving parents in adolescent smoking cessation programs may be promising. Parental involvement may include teaching parent-child communication skills, building stronger relational bonds, or helping parents quit simultaneously. Further research is needed to explore whether coupling smoking cessation with depression treatment increases parent and adolescent treatment engagement and effectiveness.