Family-based treatments for adolescent drug abuse and related behavior problems have been developed and evaluated with success. Empirical support exists for the efficacy of family-based treatments, and process studies have begun to identify mechanisms by which these treatments may achieve their effects. This article discusses theory and related clinical refinements in a contemporary family-based intervention, multidimensional family therapy. Expansions in the theoretical basis of the model are discussed. I highlight 2 aspects of the theory evolution process, resulting in a sharper clinical focus on intrapersonal development and on adolescents' and families `functioning vis-a-vis influential extra familial ecologies of development.
MDFT is an outpatient, family-based treatment developed for multiproblem adolescents, in particular those teenagers presenting with drug and behavior problems (Liddle, 1992). The approach strives for a consistent and clinically practical connection among its organizational levels: theory, principles of intervention, and intervention strategies and methods. The interventions of the model derive from overarching principles of MDFT theory and target population characteristics, and they are guided by research-based knowledge about dysfunctional and normative adolescent and family development (Liddle, 1998). Interventions target the multiple ecologies of adolescent development and within these ecologies, they address the circumstances and processes known to produce or to continue dysfunction (Liddle, Rowe, Dakof, & Lyke, 1998). Although the same developmental challenges may be common to all adolescents and their families, we work to understand the differential and idiosyncratic individual adolescent and family expressions of these generic developmental challenges. Consistent with the recommendations of those who have discussed the need for a strong developmental basis in child and adolescent therapy (Vernberg, Routh, & Koocher, 1992), we strive to understand the unique manifestations of developmental competence and detours with each case.
The approach has been operationalized into different treatment applications. Versions of this manualized model have varied on dimensions such as treatment length, dosage and intensity, intervention locale (i.e., in-clinic or combination in-clinic and home based), and inclusion of particular therapeutic methods, such as the clinical use of within-treatment drug screens and intensive case management for the family (Liddle, 1998). The model has been developed and tested since 1985 in randomized clinical trials and treatment development and process studies (Liddle & Hogue, in press-b). These studies were conducted at different locations in the United States, including Philadelphia, the San Francisco Bay area, and Miami. The study populations were ethnically diverse, and their problem severity varied as well. Study participants have included high-risk early adolescents (Liddle & Hogue, in press-a) and multi-problem, juvenile-justice-involved, dually diagnosed, female and male adolescent substance abusers (Liddle & Dakof, 1995). This approach has been recognized as part of a new generation of comprehensive, multi-component, theoretically derived and empirically supported adolescent drag abuse treatments (Center for Substance Abuse Treatment, 1999; Lebow & Gurman, 1995; Nichols & Schwartz, 1998; Robbins, Szapocznik, Alexander, & Miller, in press; Selekman & Todd, 1990; Stanton & Shadish, 1997; Waldron, 1997; Weinberg, Rahdert, Colliver, & Glantz, 1998; Winters, Latimer, & Stinchfield, 1999).
From Structural-Strategic to MDFT
First-generation family therapy models differentiated themselves from individual and group therapies in a variety of ways. Family therapy, in the classic sense of the term, invoked a unit of analysis and intervention that honed in on the family per se. Individual and intrapersonal processes or extrafamilial processes were not emphasized in early era family therapy (Nichols & Schwartz, 1998). New family therapy models developed over time, however. The theoretical boundaries of new family intervention approaches were more comprehensive and were not based only in family systems theory. Today, in the adolescent treatment specialty, a few new treatments exemplify these changes. These approaches are functional family therapy (Alexander & Parsons, 1982), multisystemic therapy (Henggeler & Borduin, 1990; Henggeler et al., 1997), MDFT (Liddle, 1992, 1998), and structural ecosystems therapy (Szapocznik & Coatsworth, in press). In MDFT, for instance, the intrapersonal psychosocial functioning of several individuals in a family is understood as complementary to and interdependent with theoretical tenets that were the stock in trade of family therapy--a focus on intrafamilial behavioral interactions. A second major development in family therapy theory concerns how circumstances and events outside of the family--the role of ecological factors--are understood as influential in the promotion of development as well as the creation of dysfunction (Bronfenbrenner, 1979). The first version of MDFT was called structural-strategic family therapy (Liddle, 1984, 1985). This early version of the model aimed to be integrative. It blended the in-session change strategies of structural family therapy, with its emphasis on changing the in-session patterns of family interaction through enactment (S. Minuchin, 1974), and problem-solving therapy (Haley, 1976), with its focus on changing out-of-session sequences of behavior via behavioral tasks.
Theory of Dysfunction
Although less obvious than in-session therapy techniques, presumptions about how dysfunction develops, maintains, or worsens are implicit in every intervention and in the overall model in which the interventions reside. Ideally, the techniques of a treatment derive from the premises of a model about the development and persistence of dysfunction. Interventions, actualized via particular techniques, target the phenomena of interest (e.g., session content, person characteristics, and interpersonal processes). Treatment models should also specify processes or mechanisms by which the therapy techniques affect the intervention targets. Specification should include statements about how interventions influence the relevant domains of functioning.
Theory of Change
Therapy techniques are the agency-oriented extensions of the premises and knowledge--the theory--about how dysfunction comes about and how it can change. Techniques also connect to and flow from the ideas of a therapy approach about person characteristics, interpersonal processes and environmental circumstances, within and across developmental niches that facilitate positive development (Kazdin, 1994). Adolescent drug abuse involves factors that are intrapersonal (e.g., adolescent identity, competence development), interpersonal (e.g., family and peer), contextual and environmental (e.g., school supports, neighborhood or community influences on antisocial opportunities and behaviors), and historical (e.g., age of onset of drug taking and other problem behavior). Because we know that teenagers who abuse drugs generally also have impairments in two or more of these functional domains, MDFT targets all domains in which there is poor functioning for coordinated, simultaneous intervention. The therapist reviews the risk areas and scans for problems across contexts. These problem processes often seem to show synergistic and cumulative effects. The currently appearing negative outcomes are aspects of a process that has unfolded over time. These outcomes are a piece of and sequelae to previous negative developmental outcomes. We try to stop the cascading effects and the momentum established by these interacting, development-derailing risk processes. Many adolescents may take a "There's nothing for me at school" position, and parents may assume "It's too late for me to do anything to help my teenager." These statements reflect a progression of concatenating processes that must be slowed or stopped. The provision of concrete, practical alternatives within and outside the family are connection-oriented and relationship-focused, and this work begins with the small moves of therapy in which in-session parent-adolescent conversations are listened to carefully as signals of what has gone wrong and what needs to happen next if development is to be retracked (G. S. Diamond & Liddle, 1999).
Theory-Derived Intervention Targets
Treatment focus and organization derive from the previously described theoretical bases. Four areas, all primary developmental arenas for the adolescent and the family, organize treatment: (a) the adolescent, (b) the parent(s) and other family members, (c) family interactional patterns, and (d) extrafamilial systems of influence. The adolescent focus includes the self of the teenager apart from the family, particularly her or his peer relationships (Liddle et al., 1992; Liddle & Diamond, 1991). The parent focus includes parents and parent figures (e.g., biological parents, stepparents, informal caretakers), other family members, and extended family who may or may not be living nearby (Liddle et al., 1998). Family interactional patterns concern the transactional system of parent(s), the family, and the adolescent (G. S. Diamond & Liddle, 1999). This area was the main emphasis in classic family therapy models, which posited that change in family interaction patterns was sufficient to create change in the symptomatic behavior of the child or adolescent. We include family interactional change as one of several foci. Extrafamilial foci include significant others and other systems external to the family (Liddle, 1995).
Some family therapy models have changed dramatically since their formative developmental periods. Today, the empirical grounding of these models is more solid than ever before. Many of these approaches are developing inside varied and long-term programs of research (Alexander, Robbins, & Sexton, in press; Henggeler et al., 1997; Liddle & Hogue, in press-b; Szapocznik, Rio, & Kurtines, 1991). In accord with available contemporary blueprints for the conduct of child and adolescent treatment research (Kazdin, 1997; Kazdin & Kendall, 1998), these research programs conduct outcome and process studies and include attention to cost effectiveness, efficacy, and the mechanisms of therapeutic action. Contemporary family therapy models differ from first-generation family therapy approaches on many dimensions, including their theory basis. This article described how one of these family-based treatments for adolescent drug abuse has refined its theoretical base. Developmental and ecological theory, including developmental psychopathology theory, has been used to further expand the theoretical boundaries of our family-based treatment. We are interested in assessing the intrapersonal and extrafamilial factors that contribute to the development of dysfunction as well as factors that facilitate development, and we strive to improve our understanding of the interactions and processes within and across these domains. The story of the theoretical changes in our treatment is really a tale of treatment development. That is, making theory refinements in an existing therapy was stimulated by our new understandings of the inner workings of therapy (i.e., process studies), clinical experience, the training of many clinicians to practice this approach, as well as the changing clinical phenomena that we observed in the process of conducting clinical research with adolescents over an extended period. Above all, however, theoretical alterations are driven by a quest to use every aspect of our work--theory development, clinical method articulation, attention to therapist issues, and the incorporation of the best available scientific advances in the conduct of our research--to build the most effective intervention possible. This mission is one that continues to exert compelling force over the life course of a career.
- Liddle, Howard; Theory Development in a Family-based Therapy for Adolescent Drug Abuse; Journal of Clinical Child Psychology, Dec 1999, Vol. 80, Issue 4.
Reflection Exercise #9
The preceding section contained information
about family-based therapy for adolescent drug abuse. Write
three case study examples regarding how you might use the content of this section
in your practice.
What four areas, which are primary developmental arenas for the adolescent and the family, organize MDFT (multidimensional family therapy) treatment? Record the letter of the correct answer