Treating Adolescent Substance Abuse Using Family Behavior Therapy: A Step-by-Step Approach

257 Pages·2011·1.699 MB·English

by  Brad Donohue, Nathan H. Azrin

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TREATING ADOLESCENT
SUBSTANCE ABUSE
USING FAMILY
BEHAVIOR THERAPY
A STEP-BY-STEP APPROACH
BRAD DONOHUE
NATHAN AZRIN
John Wiley & Sons. Inc.
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Donohue, Brad.
Treating adolescent substance abuse using family behavior therapy : A step-by-step approach / Brad Donohue, Nathan Azrin.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-62192-9 (alk. paper : paper/cd-rom); 978-1-118-16395-5 (eMobi); 978-1-118-16394-8 (ePub); 978-1-118-16393-1 (ePDF)
1. Teenagers—Substance use—Treatment. 2. Substance abuse—Treatment. 3. Family psychotherapy. 4. Behavior therapy. I. Azrin,
Nathan H., 1930- II. Title.
[DNLM: 1. Adolescent. 2. Substance-Related Disorders—therapy. 3. Behavior Therapy. 4. Family Therapy. WM 270]
RJ506.D78D66 2012
362.29'18—dc23 2011025465
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
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Contents
Foreword by Scott Henggeler v
Preface viii
Acknowledgments xi
Chapter 1 Introduction to Family Behavior Therapy 1
Chapter 2 Infrastructure 29
Chapter 3 Therapeutic Style, Techniques, and Implementation
Strategies 59
Chapter 4 Establishing Effective Agendas for Treatment Sessions 77
Chapter 5 Probing Negative and Positive Consequences to Determine
Core Motivation 85
Chapter 6 Establishing and Rewarding Goal Attainment With
Family Support 103
Chapter 7 Developing a Successful Treatment Plan 133
Chapter 8 Reviewing Past Appreciations to Improve
Current Relationships 141
Chapter 9 Improving Communication With Positive Requests 155
Chapter 10 Restructuring the Environment to Facilitate a
Drug-Free Lifestyle 171
Chapter 11 Using Self-Control to Manage Negative Behaviors, Thoughts,
and Feelings 203
iii
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iv Contents
Chapter 12 Gaining Employment 231
Chapter 13 Concluding Treatment and Planning for Success 249
References 255
About the Authors 261
Author Index 263
Subject Index 265
About the CD-ROM 273
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Foreword
This comprehensive clinical specifi cation of Family Behavior Therapy (FBT)
for substance-abusing adolescents has the potential to make a substantive
contribution to the public health and has been long awaited. Adolescent sub-
stance abuse leads to many serious short- and long-term deleterious outcomes
for the youths, their families, and society. Although federal entities such as the
National Institute on Drug Abuse have devoted considerable resources to
the development and validation of effective treatments for adolescent sub-
stance abuse, the gap between science and practice remains very wide.
The most promising treatments for adolescent substance abuse have not
been widely transported among substance abuse treatment providers, and
the vast majority of substance abuse treatment services provided in commu-
nity settings have not demonstrated effectiveness. Thus, a clear need exists
for greater availability of effective substance abuse treatments to community
providers.
FBT is as an effi cient option for treating adolescent substance abuse. In
part, this prospective is based on the promising results from FBT clinical tri-
als and the demonstrated effectiveness of the adult counterpart on which
FBT is derived (i.e., the Community Reinforcement Approach). The poten-
tial, however, is also based on the intensive emphasis that FBT devotes to
engaging caregivers in the treatment of their adolescents. Decades of cor-
relational, longitudinal, and experimental (i.e., clinical trials) research have
shown the central roles that caregivers play in the development, mainte-
nance, and attenuation of serious antisocial behavior in adolescents; and FBT
leverages this knowledge throughout its intervention protocols.
v
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vi Foreword
Perhaps the clearest way to substantiate my very favorable view of FBT
is to enumerate the many strengths of the model as presented in this book:
➣
The authors intentionally specifi ed FBT in ways that should make it rela-
tively easy to learn and implement. For example, session guidelines, ther-
apist checklists, and useful forms are provided to guide implementation.
➣
Multiple options are available for training in FBT, including self-instruction,
workshops provided by FBT experts, and ongoing clinical consultation.
➣
The intervention protocols draw on the long and successful traditions of
the behavioral therapies (e.g., contingency management) and cognitive
behavioral therapies (e.g., problem-solving skill training, communication
training).
➣
Research has shown that high treatment fi delity is often essential to achiev-
ing favorable clinical outcomes in the implementation of evidence-based
treatments. This book provides session checklists that enable therapists to
assess their fi delity to FBT implementation standards after every session.
➣
The authors encourage and provide methods for assessing consumer sat-
isfaction, a rarity in even the evidence-based practice community.
➣
The authors also encourage the assessment of key clinical outcomes,
using validated self-report and biological (i.e., urine drug screens) meas-
ures. Such outcome monitoring can verify the direction of treatment or
suggest that other strategies used in FBT be considered.
➣
The clinical style of FBT is extremely positive and strength focused, with
a clear emphasis on engaging youths and caregivers in treatment. For
example, strategies are provided for changing in-session confl ict into
constructive problem solving, and each session is structured to positive
aspects of family relations and treatment progress.
➣
Therapists are given pragmatic, easy-to-understand tools to address
treatment noncompliance, in-session confl ict, and lack of productivity.
Such problems emerge in almost every clinical case and can derail treat-
ment gains if not addressed satisfactorily.
➣
The proscribed interventions are direct and effi cient, yet very posi-
tive. Moreover, motivational interviewing-like strategies are specifi ed to
address issues that might not respond to more directive efforts. In short,
the book provides an engaging balance of approaches that provide the
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Foreword vii
fl exibility needed to address a range of presenting problems, challenges,
and family contexts.
➣
The contingency management intervention described in the book is espe-
cially well conceived—evidence of the extensive experience that the
authors have in implementing this approach with families and teaching
the model to clinicians.
➣
Importantly, to promote sustainability and ecological validity, the fam-
ily generates and provides the contingencies for the adolescent in the FBT
contingency management intervention. This approach contrasts favorably
with many other contingency management interventions in the fi eld where
contingencies (e.g., vouchers) are provided by the treatment program.
➣
The structure of the FBT program is logical and fl exible. Certain uni-
versal interventions are provided to all youths and families (e.g., moti-
vational interventions), but the sequence of subsequent interventions is
determined by family members. Such fl exibility is consistent with family
empowerment.
➣
It bears repeating: FBT promotes positive interactions among family mem-
bers and between the clinician and family members from beginning (e.g.,
every session starts by reviewing positive outcomes) to end (e.g., the fi nal
session celebrates clinical progress).
In conclusion, Drs. Donohue and Azrin have done an outstanding job
of putting onto paper the intricacies of their exemplary FBT approach. As
noted earlier, this is an extremely positive and strength-focused text that pro-
vides therapists with a structure and the tools to implement interventions
that have a long history of promoting the types of clinical changes desired
by family members and community stakeholders.
Scott W. Henggeler, PhD
Professor, Department of Psychiatry and Behavioral Sciences
Director, Family Services Research Center
Medical University of South Carolina
April 29, 2011
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Preface
In 2006, the Program Review Manager for the Substance Abuse and Mental
Health Services Administration’s (SAMHSA’s) National Registry of Evidence-
Based Programs and Practices (NREPP), Stephen Gardner, invited Nate and
me to complete an application to have FBT listed as an evidence-based treat-
ment (EBT) in their newly formulated National Registry of Evidence-Based
Programs and Practices (NREPP). Stephen explained that community agencies
were experiencing diffi culties adopting EBTs, and NREPP was being devel-
oped to assist in identifying best programs and practices. After our applica-
tion was successfully reviewed, we were immediately inundated with calls
and emails from mental health administrators who were interested in FBT
training. Many queried if we had developed self-study methods to assist them
in affordably learning the nuts and bolts of FBT. At that time we didn’t have
much in the way of dissemination materials such as books, videos depicting
FBT implementation, interactive web sites, and so on. We did, however, have
carefully developed prompting checklists depicting the step-by-step proce-
dures involved in conducting FBT (i.e., “cheat sheets”). Our treatment provid-
ers (TPs) had used these checklists during therapy sessions in our clinical trials
to prompt specifi c intervention procedures. We were initially hesitant to intro-
duce them to TPs in the community because our research team hadn’t tested
our checklists in these settings. However, we were ultimately encouraged to
do so after Scott Henggeler and his colleagues scientifi cally demonstrated the
utility of this approach in TPs who had learned to implement contingency
management within multisytemic therapy (MST). In disseminating FBT, we
experienced overwhelming positive feedback from TPs about the prompting
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