Title : VOL5.PDF Description : Keywords : Author : tonya ----------------------------------------------- Multidimensional Family Therapy For Adolescent Cannabis Users CYT Cannabis Youth Treatment Series Volume 5 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Howard A. Liddle, Ed.D. CYT Cannabis Youth Treatment Series Volume 5 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 ----------------------------------------------- Acknowledgments Numerous people contributed to this document, which is part of the Cannabis Youth Treatment (CYT) Project Cooperative Agreement. The document was written by Howard A. Liddle, Ed.D. (University of Miami School of Medicine). The Children’s Hospital of Philadelphia (CHOP) staff, University of Miami Center for Treatment Research in Adolescent Drug Abuse staff, and the Steering Committee (Thomas Babor, Michael Dennis, Guy Diamond, Jean Donaldson, Jim Herrell, Susan H. Godley, Frank Tims, Charles Webb, and William White) provided valuable guidance and support on this document. Significant contributions to the MDFT approach have been made by Dana Becker, Gayle Dakof, Gary Diamond, Guy Diamond, Aaron Hogue, Tanya Quille, and Cindy Rowe. Disclaimer This report was developed with support from the Center for Substance Abuse Treatment (CSAT) to CHOP through Grant No. TI11323. The report was produced by Johnson, Bassin & Shaw, Inc., under Contract No. 270–99–7072 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl D. White, Ed.D., served as the CSAT Knowledge Application Program (KAP) Project Officer; Jean Donaldson, M.A., as CSAT CYT Project Officer. The content of this publication does not necessarily reflect the views or policies of CSAT, SAMHSA, or DHHS. Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA or CSAT. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS. Electronic Access and Copies of Publication This publication can be accessed electronically through the following Internet World Wide Web connection: www.samhsa.gov/. For additional copies of this document, please call SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 800–729–6686 or 800–487–4889 (TDD). Recommended Citation Liddle, H.A. Multidimensional Family Therapy for Adolescent Cannabis Users, Cannabis Youth Treatment Series, Volume 5. DHHS Pub. No. 02–3660 Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2002. Originating Office Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857. DHHS Publication No. (SMA) 02–3660 Printed 2002 Cover images ©2000 Digital Stock. ----------------------------------------------- Table of Contents I. Background on the CYT Cooperative Agreement . . . . . . . . . . . . .1 Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Overview of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Expected Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 II. MDFT Approach to Cannabis Treatment . . . . . . . . . . . . . . . . . . . .3 Evolution of the MDFT Protocol . . . . . . . . . . . . . . . . . . . . . . . . . .3 Overview of the Treatment Model Intervention . . . . . . . . . . . . . . .4 Dimensions of Multidimensional Family Therapy . . . . . . . . . . . . . .5 Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Problem Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Ecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Treatment Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Defining the Clinical Model in the CSAT–CYT Multisite Project . . .7 General Theoretical Assumptions and Approach . . . . . . . . . . . . . .7 Theory of Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Protective factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Adolescent development . . . . . . . . . . . . . . . . . . . . . . . . . .9 Theory of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Principles of Multidimensional Family Therapy . . . . . . . . . . . . . .14 Basic Requirements for Clinics Offering MDFT . . . . . . . . . . . . . .16 Treatment Locale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Treatment Duration and Intensity . . . . . . . . . . . . . . . . . . . . .17 Nature of Clinical Contact . . . . . . . . . . . . . . . . . . . . . . . . . .17 Staffing Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Clinical Supervision Requirements . . . . . . . . . . . . . . . . . . . .18 Overview: The Three Stages of the MDFT Treatment Program . . .18 Stage One: Build the Foundation . . . . . . . . . . . . . . . . . . . . . .18 Stage Two: Prompt Action and Change by Working the Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Stage Three: Seal the Changes and Exit . . . . . . . . . . . . . . . .27 Modules Are Intervention Targets . . . . . . . . . . . . . . . . . . . . . . . .28 Whole and Part Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Multiple Domains of Simultaneous Intervention . . . . . . . . . . . . .29 Interventions With an Adolescent . . . . . . . . . . . . . . . . . . . . .30 Interventions With Parents and Other Family Members . . . . .31 Interventions with parents . . . . . . . . . . . . . . . . . . . . . . . .31 Interventions with other family members . . . . . . . . . . . . .31 Interventions To Change the Parent–Adolescent Interaction .32 Interventions With Systems External to the Family . . . . . . . .33 Therapeutic Case Management . . . . . . . . . . . . . . . . . . . . . . . . . .33 iii ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users III. MDFT Sessions: Operational Features of the Approach . . . . . . . .39 The Three Stages of Treatment: An Indepth View . . . . . . . . . . . .39 Stage One: Build the Foundation . . . . . . . . . . . . . . . . . . . . . .39 Engaging the adolescent . . . . . . . . . . . . . . . . . . . . . . . . .39 Engaging parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Stage Two: Work the Themes . . . . . . . . . . . . . . . . . . . . . . . .45 Key themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Therapist guidelines in working the themes . . . . . . . . . . .45 Dealing with the past in a present-centered therapy . . . . .46 Stage Three: Seal the Changes and Exit . . . . . . . . . . . . . . . .47 IV. Goals, Rationale, and Procedures of MDFT Interventions . . . . . .49 Key Concepts of MDFT Interventions . . . . . . . . . . . . . . . . . . . . .49 Multidimensionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Redefining Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Multiple Therapeutic Alliances . . . . . . . . . . . . . . . . . . . . . . .50 Linking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Whole–Part (Holon) Thinking . . . . . . . . . . . . . . . . . . . . . . . .51 Doing What It Takes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 “Parental Hell” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Working All Four Corners . . . . . . . . . . . . . . . . . . . . . . . . . . .52 What You Don’t Know CAN Hurt You . . . . . . . . . . . . . . . . . . .52 Organizing According to Modules and Stages . . . . . . . . . . . .53 Goals and Themes Emerge From the Interaction of the Generic and the Idiosyncratic . . . . . . . . . . . . . . . . . . . . . . .53 Culturally Sensitive Treatment . . . . . . . . . . . . . . . . . . . . . . .54 The Adolescent Subsystem Module . . . . . . . . . . . . . . . . . . . . . . .54 Adolescent Engagement Interventions . . . . . . . . . . . . . . . . . .62 Case Example: There Is Something in This for You . . . . . . . . .65 Clinical Guidelines: Dealing With Drugs in MDFT . . . . . . . . . . . .70 MDFT, Drug Abuse, and Standard Family Therapy Practice . . .70 MDFT, Drug Abuse, and a Chemical Dependency Model . . . . .71 How To Deal With Drug Use and Abuse . . . . . . . . . . . . . . . . .72 In-Session Interventions Pertaining to Drug Use . . . . . . . . . .73 Practical Guidelines for the Use of Urinalysis in MDFT . . . . .77 Use of 12-Step Fellowships in MDFT . . . . . . . . . . . . . . . . . . .84 Case Example: Dealing With Drug Use Directly in Session . . .86 MDFT With Adolescent Girls . . . . . . . . . . . . . . . . . . . . . . . . .92 Cultural Theme Interventions . . . . . . . . . . . . . . . . . . . . . . . .93 Risky Sexual Behavior Interventions . . . . . . . . . . . . . . . . . . .97 Multimedia Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . .99 Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Psychiatric Consultation and Psychotropic Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . .101 The Parents and Other Family Members Subsystem Module . . . .105 Parenting Relationship Interventions . . . . . . . . . . . . . . . . . .107 Parenting Styles and Practices Interventions . . . . . . . . . . . .110 Interventions With Other Family Members . . . . . . . . . . . . . .111 The Family Interaction Module . . . . . . . . . . . . . . . . . . . . . . . . .112 Case Example: I Want My Daughter Back . . . . . . . . . . . . . . .114 iv ----------------------------------------------- Table of Contents Therapist Improvisation: Shifting Domains of Operation . . .114 Intentional and Unintentional Shifts in a Session . . . . . . . .116 Case Example: Building a Relationship Bridge . . . . . . . . . . .119 Extrafamilial Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 Interventions in Relation to the Peer Network: The Ecomap Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Interventions To Improve School Behavior and Academic and Vocational Functioning . . . . . . . . . . . . . . . . . . . . . . . .136 Intervention Guidelines To Improve School Behavior and Academic and Vocational Functioning of Drug-Involved Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 Collaborating With the Juvenile Justice System: Probation Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146 The interaction and interdependence of MDFT and the juvenile justice system . . . . . . . . . . . . . . . . . . . . . .148 A collaborative, purposeful, youth-oriented alliance . . . .148 Additional Collaborations With the Juvenile Justice System: The Important Subsystem of the Juvenile Court Judges . . .149 Repercussions of Lack of Involvement in Extrafamilial Subsystems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152 V. Working the Model: The Interdependence of Emotions and Cognitions in MDFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 Negative Emotions and Problem Behaviors . . . . . . . . . . . . . . . .155 Emotions and Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . .156 Emotions and Dysfunctional Family Patterns . . . . . . . . . . . . . . .156 Case Example: Escalating Negative Emotion . . . . . . . . . . . . . . .157 Segment Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 Segment One (Baseline): Negative Emotion in Action . . . . .158 Segment Two: Focus and Framing . . . . . . . . . . . . . . . . . . . .159 Segment Three: Emotions Inform Theme Development . . . .161 Segment Four: Working an Emotion-Related Theme and the Interrelationship of Empathy and Constructivism . . . . . . .163 Segment Five: Using an Out-of-Session Crisis To Work a Core Interpersonal Theme . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164 Segment Six: In-Session Outcome . . . . . . . . . . . . . . . . . . . .169 VI. Procedural Steps: Implementing MDFT—Facilitating Key Therapeutic Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 Establishing Priorities and Making Decisions . . . . . . . . . . . . . .173 Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 Linking as a Mechanism of Change . . . . . . . . . . . . . . . . . . . . . .174 Use of Self by the Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . .174 Incremental Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174 Therapist Improvisation: Shifting Domains of Operation . . . . . .174 Finding the Middle Ground . . . . . . . . . . . . . . . . . . . . . . . . . . .175 VII. Guidelines for Subsystem Sessions . . . . . . . . . . . . . . . . . . . . . .177 Guidelines for Seeing Parents or an Adolescent Alone . . . . . . . .177 Guidelines for Seeing Parents and an Adolescent Together . . . .179 v ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users VIII. Appendixes Appendix A. Key Terms and Abbreviations . . . . . . . . . . . . . . . . . . .181 Organizing Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Theory-Related Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182 Clinically Related Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 Appendix B. Administrative Issues in Implementing MDFT in CYT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Therapist Training, Supervision, and Protocol Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Roles of clinical coordinator and supervisor . . . . . . . . . . . .187 Supervision goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Supervision schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Cross-site standardization . . . . . . . . . . . . . . . . . . . . . . . . .187 Therapist training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Quality Assurance of Treatment . . . . . . . . . . . . . . . . . . . . . . .188 Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Treatment adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Written documentation . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Chart review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Project Clinical Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 Common Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .190 Missed sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 Lateness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 Participants showing up high . . . . . . . . . . . . . . . . . . . . . . .190 Threat of harm to oneself or others . . . . . . . . . . . . . . . . . .190 Participants receiving collateral services . . . . . . . . . . . . . .191 Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191 Dropped cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191 Data Storage and Staff Access . . . . . . . . . . . . . . . . . . . . . . . . .191 Audiotape and Videotape Storage and Access . . . . . . . . . . . . .192 Participant ID Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192 Crisis Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192 Assessing Suicidality and Threat of Harm to Others . . . . . . . . .192 If the participant commits to safety . . . . . . . . . . . . . . . . . .193 If the participant does not commit to safety . . . . . . . . . . .193 If a patient refuses inpatient admission . . . . . . . . . . . . . . .193 Phone Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193 If the participant commits to safety . . . . . . . . . . . . . . . . . .193 If the participant does not commit to safety . . . . . . . . . . .193 If there is a threat of violence . . . . . . . . . . . . . . . . . . . . . .194 If the participant has contraband (e.g., weapons and drugs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Deciding on a Higher Level of Care . . . . . . . . . . . . . . . . . . . . . .194 Appendix C. Videotape Analysis Outline/Format . . . . . . . . . . . . . .195 Activity Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195 Goals of the Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195 vi ----------------------------------------------- Table of Contents Appendix D. Summary of the MDFT Research Program . . . . . . . . .197 Randomized, Controlled Trials and Studies of MDFT . . . . . . . . . .199 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 Appendix E. Clinical Management of a Multisite Field Trial of Five Outpatient Treatments for Adolescent Substance Abuse . . . . . . .207 IX.References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227 vii ----------------------------------------------- I. Background on the CYT Cooperative Agreement Goals and Objectives The purpose of the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment’s (CSAT’s) Cannabis Youth Treatment (CYT) Project Cooperative Agreement was to test the relative effectiveness and cost-effectiveness of a variety of interven- tions designed to eliminate marijuana use and associated problems in adoles cents and to provide validated models of these interventions to the treatment field. The target population was adolescents with cannabis use disorders of abuse or dependence, as defined by the American Psychiatric Association (1994), who were assessed as appropriate for treatment in outpatient settings. Overview of the Study The study was conducted in collaboration with staff from Chestnut Health Systems (CHS–MC) in Bloomington and Madison County, Illinois; University of Connecticut Health Center (UCHC) in Farmington, Connecticut; Operation Parental Awareness and Responsibility (PAR) in St. Petersburg, Florida; and Children’s Hospital of Philadelphia (CHOP). It involved five manual-based, expert-supported treatment conditions: • Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT5)—This is a five-session treatment composed of two individual sessions of motivational enhancement therapy and three group sessions of cognitive behavioral therapy. The MET sessions focus on factors that motivate clients to change. In the CBT sessions, clients learn skills to cope with problems and meet needs in ways that do not involve marijuana or alcohol. • MET/CBT5 + CBT7—This treatment is composed of the complete MET/CBT5 treatment combined with seven additional group sessions of CBT. The primary difference between this and MET/CBT treatment is the provision of more CBT sessions over a longer (12-week) period. • Family Support Network (FSN)—The family support network treatment includes the MET/CBT5 + CBT7 treatment, with the provision of additional support for families (home visits, parent education meetings, parent support group), aftercare, and case management. • Adolescent Community Reinforcement Approach (ACRA)—The adolescent community reinforcement approach is composed of 12 individual sessions with an adolescent and/or the adolescent’s “concerned other.” It focuses on teaching alternative skills to cope with problems and meet needs, with an emphasis on the adolescent’s environment. Concerted effort is made to change the 1 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users environmental contingencies—both positive and negative— related to continued substance use. • Multidimensional Family Therapy (MDFT)—Multidimensional family therapy is the multisystemic family-focused treatment described in this manual for experienced family therapists that includes 12 weeks of in-clinic and telephone sessions working with individual adolescents and their families. MDFT targets the psychosocial functioning of individual family members, the family members’ relationships, and influential social systems outside the family. These treatments vary by mode. The first three are combinations of individual and group approaches, and the last two combine individual and family or significant-other treatment approaches. Further, the MET/CBT and ACRA interventions are based on behavioral treatment approaches, whereas the FSN and MDFT interventions are based on family treatment approaches. Third, they vary in terms of resource intensity and cost when the final analyses are completed. At each site, approximately 150 adolescents were randomly assigned to one of three conditions. At UCHC and PAR, they were assigned to the brief MET/CBT5 or one of the two other individual/group combinations of MET/CBT5 + CBT7 or FSN. At CHS–MC and CHOP, adolescents were randomly assigned to the MET/CBT5 treatment or one of the two individual/ family approaches of ACRA or MDFT. All conditions were replicated at two or more sites and were manual driven with expert work groups supporting them. All clients were assessed at intake and at 3, 6, and 9 months. To validate clients’ responses, urine tests and collateral assessments were done at intake and at 3 and 6 months. Expected Products The 3-year study began in October 1997. Starting in spring 1998, adolescents with marijuana abuse or dependence problems who were appropriate for outpatient treatment were assigned to one of the treatment conditions. The recruitment and treatment phase of the study lasted 12 to 15 months. Clients were followed up on a flow basis from 9 months after their intake through spring 2000, and analyses were conducted during the project on baseline needs, costs, outcomes, and cost-effectiveness. The study has produced a series of research and treatment manuals that can be used by other providers and evaluators, as well as scientific findings on the characteristics of adolescents entering outpatient treatment, the effectiveness of the five treatment approaches, and estimates of their costs and cost-effectiveness. These materials and findings will be distributed through a variety of channels, including professional conferences, journal articles, annuals, and the project’s Web site (www.chestnut.org/). 2 ----------------------------------------------- II. MDFT Approach to Cannabis Treatment Evolution of the MDFT Protocol MDFT is a family-based outpatient treatment developed for clinically referred adolescents with drug and behavioral problems (Liddle, 1992). The approach strives for consistency and a coherent and logical connection among its theory, principles of intervention, and intervention strategies and methods. The intervention methods derive from target population characteristics, and they are guided by research-based knowledge about dysfunctional and normal adolescent and family development. Interventions work within the multiple ecologies of adolescent development, and they target the processes known to produce and/or maintain drug taking and related problem behaviors. Similar developmental challenges may be common to all adolescents and their families, and these are central assessment and treatment focuses (Liddle & Rowe, 2000). At the same time, considerable variation may be demonstrated in the expression of these generic develop mental challenges. In MDFT, therapists are sensitive to these individual adolescent and family variations. With each case, therapists seek to understand the unique manifestations of developmental problems. MDFT is not a narrowly focused treatment protocol. The approach has been operational in different treatment applications. Different versions of this approach have been developed and tested according to several factors, including study population characteristics, the intent of the study at the time, and findings from an ongoing clinical research program on the MDFT model. The MDFT research program to date is summarized elsewhere (Liddle & Hogue, 2001). The approach has varied in elements such as treatment length (e.g., in one study, 16 sessions over 5 months; in another, a flexible number of sessions from 4 to 25), dosage or intensity (the amount of therapist contact per week), intervention locale (in-clinic or a combination of in-clinic/home-based locales), inclusion of particular therapeutic methods (e.g., clinical use of within-treatment drug screens and case management), and formats (e.g., using a single therapist or a therapist and therapist’s assistant [case management assistant]). This manual details the version tested in the CYT study funded by CSAT from 1997 to 2000. MDFT has been used effectively by both experienced family therapists and line clinicians with no family therapy experience. Ideally, the person who trains and/or supervises the implementation of MDFT should have a background in family therapy and/or child development. The MDFT approach has been developed and tested since 1985 in four major, completed randomized clinical trials; a randomized prevention trial; and several treatment development and process studies, which have illuminated core change-related aspects of the therapeutic process (Liddle & Hogue, 2001). Since 1991, this work has been performed through the Center for Treatment Research on Adolescent Drug Abuse. This was the first National Institutes of Health/National Institute on Drug Abuse- (NIDA-) funded research center on adolescent substance abuse. MDFT studies have been conducted at various urban locations in the United States, including 3 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Philadelphia, the San Francisco Bay area, central Illinois, and Miami. The study populations were ethnically diverse (and their problem severity varied as well), from high-risk subjects in early adolescence to multiproblem, juvenile justice-involved female and male adolescent substance abusers with co-occurring disorders. This approach has been recognized as one of a new generation of comprehensive, multicomponent, theoretically derived, and empirically supported adolescent drug abuse treatments (Center for Substance Abuse Treatment, 1999; Lebow & Gurman, 1995; National Institute on Drug Abuse, 1999; Nichols & Schwartz, 1998; Selekman & Todd, 1990; Stanton & Shadish, 1997; Waldron, 1997; Weinberg et al., 1998; Winters, Latimer & Stinchfield, 1999). MDFT is included in NIDA’s list of empirically supported drug treatments (www.nida.nih.gov/) and in the American Psychological Association’s Division 50 issue on empirically supported drug therapies in The Addictions Newsletter (Liddle & Rowe, 2000). MDFT is also included in the Office of Juvenile Justice and Delinquency Prevention’s Strengthening America’s Families—Exemplary Programs Initiative (www.strengtheningfamilies.org/) with the Center for Substance Abuse Prevention (CSAP). MDFT is being tested within CSAT’s Initiative on Adolescent Treatment Models, formerly known as the funding initiative on Exemplary Adolescent Treatment Programs. Awards recognizing the approach have been presented by the American Psychological Association (1991), the American Family Therapy Academy (1995), the American Association for Marriage and Family Therapy (1996), and the Florida Association for Marriage and Family Therapy (2000). Overview of the Treatment Model Intervention It is important to have a sufficiently complex, multivariate framework to comprehend and act on what could be called the core clinical phenomena— the situations and processes that determine poor developmental outcomes and that, therefore, should be targeted for change. A multidimensional perspective on adolescent substance abuse and behavior problems, and thus a multidimensional framework, orients therapy and the therapist. This framework, made up of empirically based knowledge about how adolescents develop and how development is derailed, drives the therapy. In research, design and statistical methods are tools to answer research queries. Similarly, in treatment, therapy techniques serve the overall approach. Techniques are tools; they are a means to access and facilitate adaptive change. MDFT therapists are taught an overarching conceptual framework that helps them appraise and respond to diverse clinical situations. The MDFT framework focuses on several areas that are critical to a clinician’s understanding of how adolescent drug problems form, develop, and continue and how they can be replaced with adaptive and prosocial development and competence. Therapists are developmentalists in the sense of having a primary job of understanding how development has gone astray and devising means to facilitate its retracking. 4 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment Outcome Dimensions of Multidimensional Family Therapy MDFT is an integrative therapeutic philosophy and clinical approach. It relies on the contemporary empirical knowledge base of risk and protective factors and known determinants of adolescent substance abuse to assess and intervene in the lives of teenagers and their parents. Figure 1 answers the obvious and immediate question that comes from a first encounter with MDFT: What are the dimensions of multidimensional family therapy? The following section gives a thumbnail sketch of each of these dimensions that reflect different aspects of the model’s characteristics as well as the sources of influence on the MDFT approach over the years. Figure 1. Dimensions of Multidimensional Family Therapy Outcome The outcome dimension refers to the model’s and the therapist’s overriding orientation. In every contact with the case or with persons with whom the family interacts, the therapist asks the question, “What are the optimal and 'good enough’ outcomes in this interaction?” Thus, outcome refers here to overall case outcomes (e.g., abstinence or great reductions in the use of illegal substances and the connection of a teen to prosocial influences and activities) as well as to smaller, more proximal outcomes (e.g., the outcome of a phone conversation with a parent or the outcomes of a session). This outcome orientation permeates every session and every contact with a client. This outcome orientation encourages, indeed organizes, a therapist to think in terms of long-term, intermediate, and short-term goals and the mechanisms to achieve them. Process Whereas a goal orientation is a necessary and critical starting place in clinical work, an outcome orientation is incomplete without a vision of the way particular outcomes might be achieved. Process refers to the way the hoped-for change is facilitated. Treatment Parameters Family Therapy Psychotherapy Process Development Problem Behaviors Multiple Dimensions of MDFT Ecology 5 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Development Development is the knowledge base of clinical work. Therapists use their knowledge of development to set an overall treatment course, as well as to pinpoint particular interventions or adjust those already in motion. Knowing about the expected and normal changes in the parent–adolescent relationship or normal changes in the individual aspects of a teen’s development (e.g., focus on self-identity, sexual experimentation, cognitive changes allowing perspective taking) informs the therapist’s assessment and intervention ability. An appreciation and the use of developmental knowledge also include a focus on the teen’s family members. Problem Behaviors Problem behaviors are deviations from normal development. In research literature, the developmental psychopathology perspective allows clinicians and researchers to understand the development of problem behaviors over time, their interrelationship and sequencing, and the risk and protective factors of high-risk adolescent behaviors. As a systemic approach, MDFT includes the behaviors of the caretakers most involved with the teenager. Ecology Adolescent development and treatment necessarily includes the multiple psychosocial ecologies of teens and their families. The ecology dimension reminds the clinician not to narrow his or her understanding to the individual or family level. The therapist has available multiple assessment tools and levels of intervention—and some of these pertain to adolescents’ everyday functioning in social ecologies outside their families. Psychotherapy This sphere of influence pertains to particular forms of therapy that have influenced the MDFT approach. Particularly in MDFT’s early development, behavioral therapies and client-centered therapies influenced the approach. In recent years, thinking and methods from both the drug counseling and chemical dependency perspectives have informed the MDFT approach. Family Therapy Structural Therapy (Minuchin, 1974) and Strategic Family Therapy (SFT) (Haley, 1976) were among the earliest influences on the MDFT approach, which was first called Structural-Strategic Family Therapy (Liddle, 1985). The influences of SFT can be observed in MDFT’s adoption of the enactment principles of change and intervention. Problem Solving Therapy, which emphasizes crafting a strategy for treatment, thinking in stages of therapy and of change, and focusing on out-of-session tasks as a complement to in-session change enactments, has been a major influence on the MDFT approach as well. Stanton and Todd’s (1982) integrative structural and strategic therapy with heroin-addicted adults also was a significant influence in MDFT’s early days. 6 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment Treatment Parameters This dimension refers to the structural or organizational aspects of the treatment approach. In the CYT study, treatment duration was 12 weeks, but the level of therapist contact and case contact time varied according to the needs of the case as determined by the clinician and supervisor. Sessions were held in clinical offices, the home, school, juvenile court, or wherever the appropriate parties could be convened. Using the phone—to call the parent, adolescent, or other family members (e.g., to follow up after face-to-face contact, make more suggestions to follow the action plan set in the previous contact)—is common. It is important not to let limits imposed by traditional ways of service delivery (e.g., in-clinic sessions, 1 hour of treatment per week) define what is perceived to be needed with multiproblem adolescents and their families. Defining the Clinical Model in the CSAT–CYT Multisite Project In the CSAT-funded CYT project, MDFT is defined in terms of the following formula: 4 x 3 = 12 MDFT is 4 (modules) x 3 (stages) = 12 (weeks) “With every case, I’ll work four modules in three stages over 12 weeks.” MDFT includes four modules: adolescent, parent, family interaction, and extrafamilial systems. We use “module” in several ways. It can refer to (1) the various knowledge bases that constitute our understanding of drug and behavior problems, (2) the intervention targets or locales where the interventions aim to facilitate prosocial or healing processes and block dysfunctional processes or actions, or (3) the pathways to and mechanisms of change. Treatment has three stages: (1) build the foundation, (2) prompt action and change by working the themes, and (3) seal the changes and exit. General Theoretical Assumptions and Approach Theory of Dysfunction Presumptions about how problems develop and are maintained or how they are exacerbated are fundamental to any intervention and to an overall model. Ideally, there is a connection between how dysfunction develops and continues and a model’s techniques. Interventions, which are actualized using particular techniques, target certain content, personal characteristics, or interpersonal processes. A model can also specify processes or means by which the therapy techniques affect the intervention targets—such as specific domains of functioning—to facilitate improved overall functioning. Key components of MDFT’s theoretical underpinnings derive from family and developmental 7 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users psychology (Bronfenbrenner, 1979; Kaye, 1985; Minuchin, 1985) and developmental psychopathology (Sroufe & Rutter, 1984). Epidemiological, clinical, and basic research studies indicate that adolescent drug abuse is a multidimensional disorder (Brook et al., 1988; Bukstein, 1995; Newcomb, 1995). Correspondingly, the MDFT treatment model’s philosophy and methods reflect the field’s assessment of this disorder (Segal, 1986). A commitment to translate and use clinical and basic research has been a guiding principle in this model’s development. Risk factors Drug use and drug abuse correlates have been organized into several domains—individual, family, peer, school, neighborhood/community, and societal (Hawkins, Catalano & Miller, 1992). These domains reflect both the intervention philosophy and focuses of MDFT. The correlates—the pieces of the puzzle (Petraitis, Flay & Miller, 1995)—of adolescent substance use and abuse include systemic-level factors, such as extreme economic deprivation, and proximate ones, such as family conflict and disruptions in family management. Individual factors, such as parental psychopathology or drug and alcohol use, and an adolescent’s failure to bond to school, problems in emotion regulation, or poor interpersonal skills and peer relations are implicated in drug problem development as well (Brook et al., 1988). MDFT’s multisystemic family-based approach, rooted in social science versions of systems thinking (Bronfenbrenner, 1979; Minuchin, 1985), is consistent with contemporary understandings of risk and protective processes. Risk factors do not exist or operate in isolation—multiple risk factors interact over time and can have a cumulative impact (Bry, McKeon & Pandina, 1982). Their interaction within a given timeframe can create synergistic effects yielding higher levels of risk, deteriorating functioning, and few development-enhancing circumstances. Risk factors are also mutually influential and reinforcing (Brook, Whiteman & Finch, 1993; Thornberry, 1996). This conceptualization coincides with contemporary ideas about reciprocal effects in human relationships (Lerner & Spanier, 1978; Sameroff, 1975). An adolescent’s academic problems and low commitment to school might make normal developmental tension at home worse. Avoidance of conflictual topics and negative interactions are common coping behaviors in clinical families (and others) in this situation. Together, these circumstances create the motivation and opportunity for affiliating with like-problem peers. Poor family-management skills may be related to a parent’s functioning in other domains, such as parental psychopathology or family disruption created by unemployment. Family management difficulties set the stage for inconsistent parental monitoring, increased frustration, and an inability to address the normal challenges of parenting teenagers. Temperamentally difficult children and teenagers can influence family management strategy, ability, and consistency. Subtle rejection of these children and teenagers by parents is not uncommon (Baumrind & Moselle, 1985). Parents in this situation often experience loosening of their influence and control over the 8 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment adolescent as the teenager’s peer affiliations become stronger (Dishion et al., 1995; Rueger & Liberman, 1984). Although decreased direct parental influence during the adolescent years is normal, in clinical families parents are known to have, or view themselves as having, very little parental influence (Patterson & Chamberlain, 1994; Schmidt, Liddle & Dakof, 1996). Some researchers have argued that part of the deviation-amplifying process (and part of what needs to change) involves increases in parents’ tolerance for deviant behavior (Bell & Chapman, 1986). Protective factors A risk factor focus must be complemented by a therapist’s ability to know about, focus on, and expand protective factors—particularly those having to do with establishing connection to prosocial pursuits and new kinds of relationships within and outside the family. Eliciting hidden strengths is critical (Minuchin & Fishman, 1981). A basic goal is establishing a receptive mindset in both the parent and teenager regarding the fundamental role played by personal relationships in promoting development in the adolescent’s life. A good relationship with one’s parents buffers against development of problem behavior (Wills, 1990). Many recent studies underscore the importance of parents to their teenager’s ongoing development (Resnick et al., 1997), as well as the parents’ capacity to stop the progression of problems once they have begun. Steinberg, Fletcher & Darling (1994) found that particular parenting practices, such as providing emotional support, can reverse the course of negative peer influence even after problem behavior has started. MDFT’s primary goals are to change the adolescent–parent relationship in developmentally normative ways and to change the family environment gen erally, but family relationships are not the only target of change in MDFT. A therapist does not simply memorize the list of risk and protective factors and seize opportunities to discuss them. Rather, clinicians assess and intervene in transactional and interinstitutional processes while using and translating the knowledge base of risk and protective factors, which constitutes a higher objective and skill. Assessing and intervening in the dynamic “moving targets” of reciprocal interactions (i.e., an adolescent’s behavior elicits a parent’s reactions and parenting practices influence the teenager’s behavior and elicit reactions [Lytton, 1990; Stice & Barrera, 1995; Vuchinich, Bank & Patterson, 1992]) is a major challenge. Adolescent development The MDFT approach targets a youth’s relationships across developmental niches. For example, considerable time is spent with the adolescent in individual sessions in this family-based treatment to gain indirect access to his or her intrapersonal world and peer network. These therapeutic contacts vary. Sometimes, they are sessions in the usual sense, but on other occasions they may also take the form of an outing to a movie or a restaurant or an adolescent-led guided tour of the teenager’s neighborhood. The role of influential antisocial peers in the development and amplification of child 9 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users and adolescent problem behaviors is well established (Dishion et al., 1995). Because adolescents are generally not willing to discuss the details of their antisocial activities with peers in the presence of their parents, access to the adolescent’s conception of and activities within his or her peer world, as well as to the intrapersonal aspects of the adolescent’s development (Oyserman & Markus, 1990), is gained by spending time with the teenager alone (Liddle, 1995). Varying the treatment setting to forge relationships with individuals who have “been there and done that” as far as the treatment programs are concerned has been a key factor in gaining the needed access to the teen’s psychological and emotional world. Access is earned. A teen’s referral to treatment by juvenile court or his or her coercion into therapy by a parent or school official has nothing to do with gaining the needed access to the adolescent’s psychosocial world. Only a personal relationship between the therapist and adolescent can create the kind of access that predicts change. For practical clinical reasons and on the basis of research evidence, adolescent problem behavior and drug abuse are defined as problems of development (i.e., deviations in the normal developmental course or failures to successfully meet developmental challenges). These problem behaviors are determined by the interplay between the youth and the social systems—family, peer, school, and community or neighborhood in which he or she lives. Adolescent drug abuse is “embedded within the proximal peer environment, which in turn, emerges and is amplified within a context of low adult involvement and monitoring” (Dishion et al., 1995, p. 803). Because of the many factors involved in the creation and continuation of adolescent drug use and abuse and the number of functional impairments that exist with drug-abusing adolescents, a broad-based, comprehensive treatment strategy is necessary (Kazdin, 1994; Newcomb, 1992). The therapist devises an individualized treatment plan targeting aspects of functioning in individual, familial, and extrafamilial systems known to be related to the creation and continuation of drug abuse and related problem behaviors. The treatment plan is a collaborative effort; each family member and influential extrafamilial other is involved in its creation. Adolescent substance abuse is a systemic problem—a set of behaviors and circumstances that combine to derail attainment of current and future developmental milestones. Key Concepts: • The family is a primary context of healthy identity formation and ego development. • Peer influence is contextual; it interacts with the buffering effects of a family against the deviant peer subculture. • Adolescents need to develop an interdependent rather than an emotionally separated relationship with their parents. Symptom reduction and enhancement of prosocial and normative developmental functions in problem adolescents occur by targeting the family as the foundation for intervention and simultaneously facilitating 10 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment growth and healing processes in several domains of functioning and across several systemic levels. Theory of Change Adolescent developmental psychology and psychopathology research has determined that (1) the family is the primary context of healthy identity formation and ego development, (2) peer influence operates in relation to the family’s buffering effect against the deviant peer subculture, and (3) adolescents need to develop an interdependent rather than an emotionally separated relationship with their parents. Therefore, a multidimensional change perspective holds that symptom reduction and enhancement of prosocial and normative developmental functions in problem adolescents occur by (1) targeting the family as the foundation for intervention and (2) simultaneously facilitating curative processes in several domains of functioning and across several systemic levels. Particular behaviors, emotions, and thinking patterns known to be related to problem formation and continuation are replaced by new behaviors, emotions, and thinking patterns associated with appropriate intrapersonal and familial development. Key Concepts: • MDFT systematically assesses and targets adolescent functioning in six health-related domains: drug use, identity development and autonomy, peers and peer influence, bonding to prosocial institutions, racial and cultural issues, and health and sexuality. • Interventions have both intrapersonal and interpersonal aspects. MDFT systematically assesses and targets adolescent domains of functioning: drug use, adolescent identity development and autonomy, peers and peer influence, bonding to prosocial institutions, racial and cultural issues, and health and sexuality. In addition, MDFT intervention techniques have both intrapersonal (i.e., feeling and thinking processes) and interpersonal (i.e., transactional patterns among family members or between a family member and extrafamilial persons) aspects. For example, changing the parenting practices of parents of adolescent drug abusers involves addressing personal aspects of the parents’ lives apart from their roles as parents. Thus, the approach also conceives of intervention targets chronologically. Change in particular areas first is used as a departure point for subsequent, and usually more difficult, areas of work. Recent process studies have provided beginning empirical support for this epigenetic, multiperson, and multidomain framework for change (Diamond et al., 1999; G.M. Diamond & Liddle, 1996; G.S. Diamond & Liddle, 1996). Because teenagers who abuse drugs also generally have functional impairments in two or more domains, MDFT simultaneously targets all domains in which there is poor functioning. The therapist reviews the risk factors for problems of interaction involving relevant persons in the adolescent’s life as well as interactive problems or effects across domains. 11 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Clinical problems or symptoms are seen as processes that involve synergistic and cumulative effects—the unfolding and worsening of active risk factor dynamics. Therapists try to slow or stop the momentum of these interacting risk and development-derailing processes by replacing them with hopeful, relationship-oriented, and concrete alternatives. The nature and strength of these cascading negative processes create the rationale for multicomponent and comprehensive interventions. As drug use severity increases, when such levels exist alongside several risk (but few protective) factors, and when such development-detouring processes have been present over extended periods, the processes needing change have become quite stable. Although easy to identify, these processes are a challenge to change (Loeber, 1991). When advanced, the problem behaviors have become interdependent elements of the adolescent’s lifestyle (Newcomb & Bentler, 1989). This is most common with teenagers who were early drug users and who exhibited behavior problems in childhood (Kandel, Kessler & Margulies, 1978; Kellam et al., 1983; Shedler & Block, 1990). In these situations, change in more functional domains will be required to decrease the drug taking, correlated behavior problems, and lifestyle patterns and to increase competence and developmental adaptation. Research on successful maintenance of drug-free lifestyles of adolescents following residential treatment reveals that most favorable outcomes occur after changes in several functional domains (Brown et al., 1994). Key Concept: The amount and the nature of the time a therapist spends with each case, his or her attention to the implementation details of the MDFT model, and the nature and quality of the clinical supervision influence case outcome. In the context of understanding the formidable forces involved in problem development and effective intervention, it is important to maintain a deep appreciation of the human elements of working with drug-using teens and families. The therapist’s caseload and high-quality, consistent, and clinically focused supervision (versus administrative supervision) influence case outcome and model development (Schoenwald et al., 2000). These sensibili ties—respect for the work’s difficulty and cognizance of the circumstances required to do this work effectively—are critically important in therapy and therapist development (Bank et al., 1991; Liddle, Becker & Diamond, 1997; Linehan, 1996). Key Concept: Multiple risk factors and a network of biopsychosocial influences have created an adolescent’s drug abuse; hence, multiple dysfunction-producing and dysfunction-maintaining characteristics and processes must be targeted for change. Problem behavior can desist when meaningful concrete alternatives are created, accepted, attempted, and adopted by the adolescents and families. 12 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment Motivating both the parents and teenager is a therapist’s responsibility, and specific techniques to accomplish these short-term objectives have been developed and tested. (See Adolescent Engagement Interventions on page 62 and Parenting Relationship Interventions on page 107 for descriptions of these techniques [Diamond et al., 1999; Liddle & Diamond, 1991; Liddle et al., 1998; Schmidt, Liddle & Dakof, 1996].) If multiple risk factors (Newcomb, 1992) and a network of influences (Brook, Nomura & Cohen, 1989) have created and maintained adolescent drug abuse, then the same complex of interrelated influences must be systematically assessed and targeted for change. Key Concept: Assessing the multiple domains of adolescent and family functioning is not accomplished in a session or two. It occurs over the first several sessions with each family member alone, in conversation with the entire family and extended family, and with parents and the adolescent together. The therapist’s systematically organized and planned conversations with parents, teenagers, and other family members focus on past, current, and hoped-for circumstances in the multiple ecologies (Liddle, 1994a). Focusing on and assessing multiple domains occurs over the first several sessions with each family member alone, in family conversations that may include extended family, and with the parents and adolescent together (Liddle, 1995). Key persons in the adolescent’s environment (e.g., those in school or the juvenile justice system; peers) are included in the treatment. For example, a therapist may expend considerable time in helping organize a meeting between school officials and parents. Many parents are unaccustomed to or unskilled in orchestrating such events. Reestablishing a teenager’s affiliation with some aspect of school (e.g., prosocial activities, academic mastery) or a job training or work-related alternative is a vital part of adolescent drug treatment. Adolescent treatment must be practical. The therapist may work as a coach with the teenager and parents—preparing them for a school conference and defining possible and desirable outcomes. In another case, the focus might be on the teenager’s noncompliance with juvenile justice system sanctions and the influential role a parent might play in an upcoming court hearing. Although MDFT has a practical, results-oriented focus, new behavioral alternatives or potential solutions are not offered prematurely. Problem behaviors, such as affiliating with drug-using peers and disengaging from school and family relationships, are both interrelated and stable. MDFT interventions take into account the relationships, interactions, and factors that contribute to such connections. Early treatment efforts include conversations focusing on the specific life circumstances of the teenager and parents, and small steps toward larger changes are introduced gradually. These small steps might involve discussions with the teen in which he or she is helped to evaluate different areas of his or her life. 13 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Key Concept: Attempts to implement problem solving in relationships will not work without the developmentally appropriate levels of attachment and communication having been reached. The principle of relational epigenesis (Wynne, 1984) is an overall guide for problem assessment and intervention sequencing. This theory proposes a preferred sequence of developmental processes (i.e., attachment or caregiving is an early-stage relationship process, whereas mutuality in relationships is a more evolved, later-stage process characteristic). Although these processes overlap, like all developmental stages, optimally they follow one another in a predictable way (i.e., attachment or caregiving, communicating, joint problem solving, mutuality). When the preferred sequence of development or skill acquisition does not occur, functioning is impaired. In family therapy this means that attempts to implement problem solving in relational systems will not work without the requisite functioning or developmental levels of attachment and communication having been reached (Doane, Hill & Diamond, 1991). For example, it is difficult for parents to feel motivated to try new parenting behaviors if their basic emotional commitment to parenting has weakened (Dix, 1991; Liddle et al., 1998; Patterson & Chamberlain, 1994). In this “first things first” philosophy, the therapist is guided by questions such as, “What is getting in the way of the behavior of interest?” The therapist then attends to those barriers. So far, this discussion has focused on the theoretical and empirical bases of the MDFT treatment model. The clinical principles of MDFT are presented next. Then, for the remainder of the manual, theory–research–practice connections within each module of the core approach are discussed. Principles of Multidimensional Family Therapy Therapy principles are defined as fixed or predetermined rules guiding clinical orientation and behavior (a therapist’s prescribed behaviors and proscribed behaviors; Waltz et al., 1993). Principles of Multidimensional Family Therapy 1. Adolescent drug abuse is a multidimensional phenomenon. 2. Problem situations provide information and opportunity. 3. Change is multidetermined and multifaceted. 4. Motivation is malleable. 5. Working relationships are critical. 6. Interventions are individualized. 7. Planning and flexibility are two sides of the same therapeutic coin. 8. Treatment is phasic, and continuity is stressed. 9. The therapist’s responsibility is emphasized. 10. The therapist’s attitude is fundamental to success. 14 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment The following are the 10 principles of MDFT: 1. Adolescent drug abuse is a multidimensional phenomenon. Its conceptualization and treatment are guided by an ecological and developmental perspective. Developmental knowledge informs interven tions—presenting problems are defined intrapersonally, interpersonally, and in terms of the interaction of multiple systems and levels of influence. 2. Problem situations provide information and opportunity. The current symptoms of adolescents or other family members, as well as crises and complaints pertaining to the adolescent, provide not only critical assessment information but also important intervention opportunities. 3. Change is multidetermined and multifaceted. Change emerges from interaction among systems and levels of systems, people, domains of functioning, and intrapersonal and interpersonal processes. Assessment and intervention give indications about the timing, routes, or kinds of change that are accessible and possibly efficacious with a particular case. A multivariate conception of change commits the clinician to a coordinated and sequential working of multiple change pathways and methods. 4. Motivation is malleable. Motivation to enter treatment or to change will not always be present with adolescents or their parents. Treatment receptivity and motivation vary in individual family members and extrafamilial others. Resistance is normal. “Resistant” behaviors are barriers to successful treatment implementation, and they point to important processes for therapeutic focus. It is difficult for adolescents and families to create lasting lifestyle changes. 5. Working relationships are critical. The therapist makes treatment possible through practically oriented, outcome-focused working relationships with family members and extrafamilial sources of influence and through articulation of personally meaningful relationship and life themes. These therapeutic themes emerge as a result of inquiry about generic individual and family developmental tasks and the idiosyncratic aspects of the adolescent and family’s development. 6. Interventions are individualized. Although they have generic aspects (e.g., promoting competence of adolescents or parents inside and outside the family), interventions are customized according to each family, each family member, and the family’s environmental circumstances. Interventions target known etiologic risk factors related to drug abuse and problem behaviors, and they promote protective intrapersonal and interpersonal processes associated with positive developmental outcomes. 15 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users 7. Planning and flexibility are two sides of the same therapeutic coin. Case formulations are socially constructed blueprints that guide ongoing treatment because formulations are revised on the basis of new information and in-treatment experiences. In collaboration with family members and relevant extrafamilial others, therapists continually evaluate the results of all interventions. Using this feedback, they alter the intervention plan and modify particular interventions accordingly. 8. Treatment is phasic, and continuity is stressed. Particular standard operations (e.g., adolescent engagement and theme formation), parts of a session, whole sessions, phases of therapy, and therapy overall are conceived and organized in phases. Continuity—linking pieces of the therapeutic work together—is important. Sessions have parts, and they are woven together into seamless wholes. Similarly, there is a weaving together of the parts of treatment and an active attempt by the therapist to maintain continuity and linkages between sessions and “chunks” of therapy. 9. The therapist’s responsibility is emphasized. Therapists are responsible for (1) promoting participation and enhancing motivation of all relevant persons, (2) creating a workable agenda and clinical focus, (3) devising multidimensional and multisystemic alternatives, (4) providing thematic focus and consistency throughout treatment, (5) prompting behavior change, (6) evaluating, with the family and extrafamilial others, the ongoing success of interventions, and (7) revising interventions as necessary. 10. The therapist’s attitude is fundamental to success. Therapists are advocates for adolescents and parents. They are neither child savers nor unidimensional “tough love” proponents. Therapists are optimistic but not naive or Pollyannaish about change. Their sensitivity to environmental or societal influences stimulates ideas about interventions rather than reasons for why problems began or excuses for why change is not occurring. As instruments of change, therapists know that their personal functioning can facilitate or handicap their work. Basic Requirements for Clinics Offering MDFT Treatment Locale Most sessions (individual sessions with adolescents and parents, sessions with parents and adolescents together, and sessions with other family members or relevant extrafamilial persons) are conducted in the clinic. On occasion, particularly at the beginning of treatment or during a crisis, sessions might be held in the family’s home or at another accessible, appropriate locale (school, family court). The clinical contact location also may vary according to the phase of treatment, the living circumstances and preferences of youth and families, and the session’s objectives. While the MDFT approach has been used only in clinical research contexts, these efforts have taken place in various settings such as community mental 16 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment health, drug counseling, or youth service agencies. In some studies, clinics were located in the community in which the study clients resided. In other studies, the project was conducted in existing clinics where the randomized study, the selection of the therapists (from existing staff), the pretreatment assessments, the experimental treatments, and the posttreatment assessments were conducted within the agency context. Treatment Duration and Intensity Studies have tested variations in duration and intensity of treatment (Liddle & Hogue, 2001). The CYT study called for delivery of the intervention in a 3-month period. For the initial 2 months, an average of two or three sessions with various combinations of family members could be held weekly (sessions averaged 1 to 2 hours). Phone contact was frequent and used for reviewing and planning for next steps. Phone contacts also presented opportunities for “minisessions” or focused conversations that served to motivate, to hold in place, or to make new suggestions about how to cope or new courses of action. The most frequent contact with family members occurred during the first 2 months of therapy. In the third month of treatment, the amount of contact decreased. Nature of Clinical Contact In MDFT, phone contact with the parent and the adolescent is frequent and moves beyond reminder calls. MDFT therapists use time on the phone to follow up, extend the work done in sessions, and conduct troubleshooting on what is being tried at home and how it is going. In MDFT, the therapist has face-to-face or phone contact with extrafamilial systems such as school, juvenile justice, or case management-related personnel (e.g., academic tutoring, job training). Contact with extrafamilial subsystems is often more frequent at the beginning of therapy, tapering off as the case reaches the final treatment phase. In all situations, the amount of clinical contact occurring will vary according to the stage and module in which the family and therapist are working. Staffing Requirements Most therapists using the MDFT approach have at least a master’s-level degree in counseling and an average of 2 to 3 years of experience (master’s degree therapists at 70 percent; doctoral-level therapists at 30 percent). Certain characteristics are sought in clinicians who will be trained to use the MDFT model. First, a family therapy background and systems orienta tion are helpful. The multisystemic model, which clearly includes a basis in family or systems therapy concepts and methods, is taught in the context of this orientation. Clinicians must be willing to conduct case manager-style interventions along with traditional therapeutic interventions. Previous experience with drug-using and delinquent adolescents is desirable as well. Preferred personal characteristics include intellectual curiosity, a capacity to work in different domains (cognitive, affective, and behavioral), an ability to form good personal relationships, and an openness to receiving feedback 17 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users about one’s personal clinical style. Finally, a clinician’s demonstrated motivation to become an exceptional therapist (and the realization that this achievement takes years of focused work and experience) is one of the most powerful predictors of success with the MDFT system. Therapist characteristics and skills helpful to the MDFT approach are discussed in publications on clinical supervision and training (Liddle, 1988; Liddle, Becker & Diamond, 1997). Clinical Supervision Requirements Clinical supervision is vitally important in the implementation of the MDFT approach. The multidimensionality of the therapeutic orientation is matched in the supervision philosophy and methodology. Multiple supervision methods are used in a coordinated way to produce the desired level of adherence and clinical competence. Therapists prepare written case conceptualizations and segments of videotape or audiotape for presentation and analysis by the supervisor and feedback from other clinicians. Therapists review their own taped work, and they are assigned to continually study the MDFT manual and related clinical materials. As the competencies and learning needs and issues of therapists become manifest, supervisors adjust their supervision and teaching. Therapists are expected to take considerable responsibility for their continued learning and development, although individual and group supervision is provided. Individual supervision allows focus on sensitive topics (e.g., personal or stylistic matters of clinician development), as well as an individualized focus on the standard review of weekly outcomes, adjustment of strategy or method, and planning of next steps (Liddle, Becker & Diamond, 1997). Overview: The Three Stages of the MDFT Treatment Program This section summarizes the key activities in each therapy stage. Detailed implementation guidelines, examples, and troubleshooting tips on making these procedures work appear throughout the manual. Stage One: Build the Foundation (3 weeks) 1. Create a new system. Treatment creates a new social system. When the process works, it joins together the therapeutic system and the family system to create a new entity with a common purpose. Thinking organizationally, therapists strive to understand the many systems and subsystems involved in the treatment process and the nature of their past and current interactions. 2. Welcome the adolescent and the family to a new life space. Starting treatment is a big event. Many outpatient treatment programs do not place sufficient emphasis on the beginning stage of treatment or on the process of welcoming teens and their parents and engaging them in a treatment program. Clinicians know that treatment of adolescents is challenging, and research confirms that more teens and their parents 18 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment drop out of outpatient drug therapy than remain. The beginning phase of treatment, when a therapist does all that he or she can to help all family members feel welcome and understood, is of enormous importance. 3. Explain the program. Do not assume that parents or adolescents will have a positive or accurate perception of treatment. An orientation to the program or treatment that covers “how to benefit from therapy” and “what the treatment entails” is vital. The mindset of family and extrafamilial sources of influence about the new treatment can be addressed by asking about previous treatment experiences or, in the case of the extrafamilial persons, asking about their history with the youth and experiences with other treatment programs. Expectations are important, and they can be shaped. 4. Address the circumstances that bring the client into treatment. Many teens will be referred to treatment by school or juvenile justice personnel. Some of these adolescents will have serious legal problems and will be ordered to treatment as a condition of their probation or involvement with the juvenile justice system or because of their problems in school. It is important to address the specific circumstances that bring them into the program. Therapists should look for points of cooperation and resistance and develop a positive realistic conception about what treatment is and what it might be able to do. 5. Develop a temporal orientation. In this 3-month version of MDFT, not all the interesting or important issues that will be presented can be addressed. Therapists must choose which focal areas might have the most clinical yield (e.g., which seem most malleable and which areas are accessible immediately). MDFT intervention has a fixed number of weeks in which the program will be delivered. Thus, prioritizing treatment focuses is critical. A 3-month calendar in the case notes will remind therapists of the strict timelines within which they must work. 6. Remember, intensive involvement is the norm. Because the available time to work with a case is predetermined, remembering the therapeutic principle of intensive involvement with a case is critically important. With some cases, particularly at the beginning of treatment, there may be in-person or phone contact with one or more persons in the treat ment system (e.g., the adolescent, parent, or other family members; school, legal, court, or probation staff) every day. A core premise of the approach is that positive outcomes will be related to working effectively in several areas (modules) of a case at the same time. 7. Use current crises to mobilize positive forces and create focus. Pioneers in MDFT’s earliest development of structural family therapy (Minuchin, 1974) and problem solving therapy (Haley, 1976; see Liddle, 1984, 1985) understood how important it is to seize opportunities presented by current crises pertaining to the adolescent. School failure, conflict in the home, out-of-home placements, and consequences of current drug use, including arrests and legal problems, are examples of crises with potentially enormous therapeutic value. Inherent in these 19 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users events are the information and opportunity to create a workable (i.e., acceptable to the client, potentially effective according to the approach) therapeutic focus and the kind of step-by-step change that can last. 8. Use distress to facilitate motivation. The distress that accompanies a crisis is a therapeutic ally. It is part of the dynamic that will create motivation for change. Even if no crisis is present, distress, which is perhaps different for each family member and relevant extrafamilial others, is present. The subjective distress of each family member should be accessed; framed, if necessary; amplified; and used to create a foundation and motivation for treatment. 9. Translate therapy goals into an organized and orchestrated treatment that yields various kinds of sessions (individual, familial, extrafamilial). Although the term family therapy is still used, today’s family therapies are better defined as family-based treatments. The term “family therapy” creates an image of working with the whole family, week after week. MDFT is a therapy of systems and subsystems. A hallmark of this approach is its theory-grounded and systematic use of individual, familial, and extrafamilial sessions. Different therapy stage and subsystem- specific therapeutic goals dictate a therapist’s decision about session composition. (See Guidelines for Subsystem Sessions on page 177 for more details about setting up individual and family sessions.) Therapy goals are formulated according to a number of factors. Case-specific treatment is theory based (i.e., development) and principle driven. (See Principles of Multidimensional Family Therapy on page 14.) 10. Create expectations. Negativity, hopelessness, helplessness, and despair frequently accompany adolescents and their parents to treatment. At the outset and as needed throughout therapy, treatment addresses these powerful emotions. It is important to create expectations that the teen’s life course can be redirected, new alternatives can be introduced, the drug-taking lifestyle can stop, family life can change, and parents’ stress and burden can be lessened. 11. Elicit and shape the stories. A therapist’s skill is revealed when he or she uses generic knowledge about family life, positive psychosocial development, and problem solving as a way to make sense of the idiosyncratic details of a teenager’s and his or her parents’ lives. The therapist facilitates this process by eliciting details about the teen’s life, the parents’ lives, and the family’s life together. The developmental issues of adolescence (e.g., a teen’s desire to be heard) are the immediate context in which the teenager’s and parents’ expression of their life story occurs. At the same time, the family’s history together is also relevant and must be explored as well. 12. Work multisystemically. Classical family therapy assumed that changing a family’s interactional style and patterns would yield changes in the symptomatic functioning of the child or adolescent. Contemporary family models do not reject the importance of interactional change in 20 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment the family, but today’s models do place this focus as one among many. MDFT therapists pay attention to the individual, intrapersonal functioning of family members and to how important sources of influence that come from outside the family complement and work synergistically to change family interactional patterns (Liddle, 1995). Working with multiple systems in a coordinated way, inside and outside the family, is fundamental to MDFT. 13. Talk with everybody (family and extrafamilial persons). There are advantages and disadvantages to doing a treatment program within a fixed period. A major advantage is that time can be used to focus on and organize the therapist’s and family’s mindset (“We have only so much time available”) about getting something done. At the same time, working in a time-limited model can influence therapists to narrow their focal areas and targets of change. It is important to be aware of the interplay of the pressure to create a workable focus (which may enhance motivation) with the inclination to expend energy and time trying to include family members or extrafamilial persons in treatment. Phone calls to important therapeutic system members serve various functions. They are strategic, in that they might prepare individuals for a new focus, and functional, in the sense of providing a convenient context for interventions themselves. 14. Build multiple alliances. In the beginning of treatment, key concerns are whom to develop alliances with and how to accomplish this time- consuming, challenging task. Each person within and outside the family is treated as an individual who has his or her own idea about topics important to treatment—the need for therapy, who is the problem, how the problem came about, and how it might be solved. This may be an obvious point, but the mandate of success in multiple therapeutic alliances, including those with relevant persons outside the family, is more difficult to implement than to understand. 15. Use treatment to retrack development. The developmental lens guides every aspect of assessment and intervention. MDFT therapists are developmentalists. Minuchin (1982) warned that therapists who work with the most challenging clinical situations have an occupational hazard—they can, unwittingly, become sleuths for psychopathology or family dysfunction. Searching for individual, family, and community strengths is a critical aspect of MDFT. Accentuation of these resources is the antidote to the pessimism that frequently pervades the teen’s and his or her family’s lives. Knowing about the developmental tasks for adolescents, parents, and family balances the assessment of “what’s gone wrong” with the instigation of processes that retrack the development of all family members. 16. Work the phone. The concept of a session does not have the same meaning as it once did. Therapists think more in terms of therapeutic contact, and variations of contact, with clients (and their multiple constituents inside and outside the family). Telephone work is a critical part of this therapy approach. More than serving as reminders (“I was 21 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users just calling to remind you about our session tomorrow”), phone calls to family members are opportunities to give important new information that may not have been available or offered in a face-to-face session. They are also valuable opportunities to follow up on previous events or interventions. Phone calls serve an intervention function with extrafamilial persons as well. Interventions are thought of in a more broad-based way than they were previously. They do not require face-to-face contact, nor do they have to occur within the confines of an office or a traditionally defined session. 17. Craft themes. Good therapy focuses on events and circumstances that have personal meaning to each participant. Although themes materialize or become apparent through content, they exist at a level different from the content that is revealed in the retelling of life events or discussion of everyday events. A theme in a therapeutic context represents a recurring part of reality; it is a different kind of “truth.” Themes point to a consistency in or repetition of events, feelings, or outcomes of relationships; a summary statement; or a characterization of a relationship’s core nature. These characterizations of past relationships or events can also be used as a reference point for future, hoped-for relationships or life themes. 18. Visit the school and neighborhood. Particularly if he or she is not accustomed to doing such things, a therapist will sometimes avoid school visits and neighborhood assessments early in therapy. However, the establishment of therapeutic alliances (not exclusively with family members) is a critical early-stage accomplishment in this treatment. The MDFT protocol includes school contact and neighborhood visits throughout treatment. This reflects commitment to an ecosystemic assessment and intervention philosophy. The information obtained by a visit to a school, neighborhood, or juvenile justice system setting (e.g., family court, probation officer meeting) is critical to initial case formu- lation and to the implementation of a comprehensive multicomponent intervention. Changes in drug use will be related to changes in the real world circumstances of the teen. It is not possible to intervene directly in all aspects of the adolescent’s environment. At the same time, it is vital to know as much as possible about all those corners of teen and family life. 19. Test different pathways and kinds of change. MDFT assumes that multiple pathways and kinds of change are possible; such combinations may be necessary to change firmly entrenched drug-using lifestyles. Many teens have lived in less than optimally functioning families and developmental circumstances for years. Because important assessment information comes from the feedback received after intervention, early-stage therapy probes for receptivity, for the pathways and kinds of change that may be available, and for which ones may be more sealed off, at least temporarily. 22 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment Stage Two: Prompt Action and Change by Working the Themes (5 weeks) 1. Develop from the foundation. Setting a treatment foundation involves the articulation of themes. There may be several, and they may relate to individuals, subsystems in the family, the family as a whole, or its extrafamilial influences and forces. Themes create reference points for the treatment. These reference points induce consistency and continuity. Focusing themes and working change strategies (enactment, individual emotion processing or regulation, or problem-solving work) facilitate the processes and circumstances that can reverse and provide concrete alternatives to a teenager’s drug-using and problem-behavior lifestyle. 2. Mobilize the troops: Therapeutic leadership. Whereas treatment’s first phase offers beginning experiments in change, in the second stage of therapy the therapist mobilizes various systems, including self-systems (i.e., individuals), and articulates the stakes involved (i.e., often a life-or-death situation for a teenager). The therapist counters the forces (e.g., pessimism in the family; dysfunctional beliefs and attitudes about drugs; influential, deviant peer culture) that perpetuate the interacting and often escalating negative outcomes. Barriers to change can combine to produce a legacy of failure and development gone wrong, a legacy made up of powerful, things-cannot-change feelings, thoughts, and behaviors. 3. Increase action and change orientation. Whereas mobilization works in the realm of emotion, increases in action and change orientation use the focused emotions to prompt new and consistent planning and action. Therapists must show a fierce commitment to the possibilities of change and communicate this commitment to the family and involved extrafamilial others, in every contact with the teenager, parents, and extrafamilial others to avoid a slide toward greater deviance and build connections to prosocial pursuits and developmental adaptation. Establishing concrete alternatives to drug use and the drug-using lifestyle (e.g., school and academic skills, general equivalency diploma [GED] alternatives, confronting legal problems, and options to disaffiliate with deviant peers) helps clients fight despair. 4. Think successive approximations. Shaping is a behavioral psychology principle, a step-by-step approach to change. The change process is conceptualized sequentially (affective, cognitive, and/or behavioral elements may be present and applicable). In assessing the multiple developmental ecologies of teens, therapists ask, “What are the missing aspects of the teenager’s and family’s lives? What set of circumstances and what specific day-to-day activities and intrapersonal and interpersonal processes could reverse the current development-destroying circum stances?” These questions, asked in individual, family, and extrafamilial sessions, begin a change process. They are small steps that facilitate materialization of the missing and developmentally needed processes or behaviors. 23 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Once these new behavioral forms, emotions, or adaptive thoughts emerge, they are helped to grow. Gradually, they are coaxed out and made large in conversations that make the experiments in change real. Change in one area is often used as a prelude to or a foundation for changes in more difficult or challenging areas. For example, change in a parent’s emotional reactions to a son or daughter prepares the parent for changes in actual parenting practices (G.S. Diamond & Liddle, 1996; Liddle, 1995; Schmidt, Liddle & Dakof, 1996). A changed emotional set or response to one’s teen makes a focus on behavioral parenting strategies possible. 5. Work with the most accessible areas first. The first stage of therapy involves determining areas of the parents’ and teenager’s lives that will be most accessible. These will not be the only available areas or necessarily remain available. In the second stage of treatment, the therapist is more consistently in an action-prompting mode to confront avoidance and inaction through alternative-oriented plans that attempt to create new intrapersonal, interpersonal, and contextual circumstances. 6. Link available focus areas to less accessible ones. MDFT therapists think in terms of direct and indirect pathways to achieve a goal. The available focal areas may often be the very pathways that link to work in areas that were previously unavailable. The adolescent’s drug use is a primary case in point. Many teenagers deny their drug use and do not accept an agenda to work on it during the first phase of treatment. With these adolescents, a therapist tries to establish other focal areas of treatment (e.g., problems with school or parents, legal difficulties, unhappiness with life) and uses these accessible areas as routes toward what the teen has closed off from the therapist and others. Many teenagers, for example, become willing to talk about drug use and other problems in a straightforward way if the therapist is willing to do (or actually does) something concrete for them (e.g., intervenes at school, with probation, in family court). Process research confirms that, even in situations in which there is an initially poor therapeutic alliance, certain therapist methods change a negative alliance to a positive one (Diamond et al., 1999). Getting a teen to focus on drug use in outpatient treatment can be a challenge. Drug tests during therapy quickly move the therapy to a place where drug taking and/or the consequences of drug use and abuse, such as legal problems, can be addressed. (See Clinical Guidelines: Dealing With Drugs in MDFT on page 70.) Additionally, using the available leverage and pressure issued by legal or school authorities may be a therapist’s best course of action at the outset of a case. 7. Make theme development more rich. When topics and areas of work are woven together, they become rich in definition and meaning. Asking for deeper levels of details about the themes and linking previously separate events enable a therapist to develop themes that are more meaningful to the adolescent or parent. Focusing on life themes 24 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment (such as a conclusion about one’s life at a particular time) and the emotions that accompany them can be a motivating force. The direction for new and future actions can be inherent in that. Using themes as a reference point in therapy provides a focus, including a focus on the day-to-day changes that are the local pathway out of current circumstances. 8. Think and work in all modules. A multidimensional model implies working in a number of realms simultaneously. It is possible to focus on core themes, keep these areas primary during the middle phase of therapy, and check in and work minimally in other areas. Certainly time limitations, caseloads, and accessibility may hinder this principle’s implementation with any given client. But a multidimensional model of change requires a multidimensional intervention methodology. This necessitates the therapist’s not allowing his or her therapeutic focus, particularly in the middle stage of treatment, to become so concentrated on one area of work that other important areas are ignored. This principle works with number 7. The therapist must focus on important areas of work and, at the same time, be in a position to incorporate other focuses if needed. The therapist’s sound judgment allows this dialectic to stay fluid and productive. 9. Storyboard it: Think in stages. The idea of stages also applies to smaller units of work. Thinking in terms of stages in a session can facilitate goals for any given meeting or treatment session. Preparing for a session by breaking it up into parts requires clear thinking and careful planning. Using storyboards (visual scripts) in therapy is a way to visualize the steps that might be involved in facilitating a particular in-session (short-term) outcome (Liddle, 1982). A session in the middle phase of treatment is often conceived of as a three-act play (plot and story development, conflict, resolution). The first act sets the stage. Individual sessions with a parent or teenager may determine the agenda and develop the details that will be worked out in a joint session. The second act, the middle of the session, may involve an attempt to address issues that have been unresolved in a face-to-face joint session (parents and teenager). Therapists try to create an appropriate environment to help family members improve the way in which these issues have been addressed thus far. The goal is concrete progress in addressing these issues in a reasonable, step-by- step manner (a positive step in and of itself if they are addressed in adaptive ways) (G.S. Diamond & Liddle, 1996, 1999). Again, thinking in phases, the third part of the session may involve an intentional closing up of the work for that day, an attempt to create a certain cognitive frame around these events, and setting the stage for the next attempt at moving the relationships and issues along. This may occur between sessions or at the next formal session (in the home or in the clinic). The storyboard is a session plan that flows directly from the case conceptualization; it has continuity with the therapist and family’s previous work together. A typical middle-stage session is articulated before the session starts in the imagination of the therapist and supervisor. 25 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users 10. Think of crises, slips, and detours as opportunities. Experienced therapists know that crises, slips, and detours are usable. Crises are used to refocus and request even more effort from the involved adults. A teenager’s relapse or slip demands attention; perhaps the intervention needs to be recalibrated. A detour may indicate that the direction and strategy are faulty and need immediate rerouting or adjustment (Liddle, 1985). Perhaps, roadblocks are being created by extrafamilial people unwilling to give the teenager another chance. All these situations require creativity and a nonreactive mindset about unpredictable events. Important information is being conveyed in the unanticipated or negative therapeutic event; it is important to craft a response that maximizes the chance that the event can be used therapeutically and as an opportunity to take further steps toward needed change. 11. Use family enactment. Enactment is the art of helping a family have a new kind of conversation about what are usually difficult topics (prompting and shaping new kinds of interactions). Enactments happen spontaneously in family interviews and can be seen when a family demonstrates, through conversation, an aspect of its interactional problems right in the session (interactions of family members are consistent, and, in the context of therapy, as elsewhere, these patterns show themselves). The therapist tries to instigate interaction because interaction is a manifestation of the relationships that are, in part, related to the creation and perpetuation of problems. Thus, family interaction is one target of change, and developmental knowledge guides and informs enactment. Enactment refers to theoretical principles about the change process (including prompting or shaping of new behaviors) and active therapeutic methods to prompt change (actions to foster new kinds of dialog about important topics). The middle phase of therapy is the one in which enactment is given significant play. Enactment is difficult for most therapists—it raises the emotional temperature in sessions and sometimes prompts the displeasure of a family member toward the therapist. Therapists must overcome their fear of setting up and creating enactments. Knowing enactment allows the therapist to conduct a fully multifaceted and orchestrated set of interventions. 12. Work the sequence: Receptivity, skills, opportunity and context, practice, introduction of variation, generalizing. A therapist should conceive of a sequence of interaction between two or more persons as a unit of a broader context of interaction and interactors. These interac tional sequences break old relational molds and create what Minuchin (1974) called new relationship realities. Attention to the small details of individual reactions in a sequence often provides clues for how to shape the interactional sequence (Diamond & Liddle, 1999; Liddle, 1995). 26 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment 13. Work the core sessions (think domains, people, and topics). Although there are core aspects to MDFT treatment, MDFT is not run on a programmed, session-by-session basis. Treatment is organized according to modules. For example, the therapist aims to help each parent in that individual’s parenting role and personal life. The rationale is that changes in parenting practices lead to improved functioning and well-being in nonparental realms. With teenagers, it is necessary to specify areas of developmental need and make these areas important treatment focuses (examples are identity development, psychosocial competence, and balancing autonomy with connectedness to family). The developmental knowledge bases mentioned previously can help determine what the core treatment emphases ought to be. The therapist asks, “What actions need to be taken or can be taken to create alternative experiences and new organization in this adolescent’s and family’s lives that counter the previous deviance- and drug-related lifestyle patterns?” A sense of “What’s missing in this picture?” thus applies to interaction in a session as well as to sequences or courses of action (generating alternatives) that prompt action outside sessions (e.g., school intervention, increased monitoring, change in family routines). Stage Three: Seal the Changes and Exit (4 weeks) 1. Remember that time is an important treatment dimension. Because the treatment program is delivered in 3 months, the therapist’s every action must be guided by time. 2. Make an honest appraisal of current status. The treatment’s final phase, especially in this relatively short-term, time-limited version, depends on a brutally frank estimation of what has and has not been accomplished in treatment. The therapist should seek a “good-enough” focus and determine which core change targets will be sufficient to create immediate and (it is hoped) lasting change. Change includes avoiding a slide toward greater dysfunction, gravitating toward deviant peers, and deepening disaffiliation with school and other important social institutions, including the youth’s family. Altering the trajectory of and pull toward greater deviance by making sure that problem behaviors do not become more severe can be a major accomplishment in itself. 3. Accept “rough-around-the-edges” outcomes. Rough-around-the-edges is a phrased used to describe potential perfectionism or standards about changes that may be too high (on the therapist’s part). Its connotation is that it is helpful for the therapists to be mindful of the difficulties of any kind of change attempt and of the dangers in holding a teen or family to too high a standard. It is not yet known which kinds of changes (e.g., changes in peer status, family changes, changes in individual skills or competence) are the most influential mediators of bottom-line outcomes such as drug use and abuse, but even a partial change may be sufficient. Abstinence and the development of an 27 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users alternative to the drug-using and drug-abusing lifestyle of the teen are an unequivocal goal of MDFT. 4. Emphasize and make overt the changes in any and all domains. The therapist’s exit is the client’s new beginning: The family and extrafamilial others remain. One important aspect of the final phase of therapy includes establishing meaning for the changes that have occurred and putting into words some of the changes that may yet have to be made (i.e., constructing bridges to still-needed changes). It is important to emphasize that family members have each other and, it is hoped, other sources of support and guidance as well. The specific successes and accomplishments of therapy are discussed and used as evidence of and prompts about how new crises or problems will be handled. The family’s new skills are used to help them exit from the treatment program. An emphasis is placed on the adolescent’s continued orientation toward self-care, development, and health, including his or her involvement in prosocial activities, and the family’s capacity to support continued progress—facing normal developmental tasks. 5. Assess next steps and future needs. Needing future services is not thought of as a sign of failure. Recall that a teenager and his or her family have completed a 3-month treatment. Although treatment occurs in 12 weeks in MDFT, it is important to keep the following points in mind: 1. Method is a variable, and so is time. A critical dimension in the CYT study was the amount of time that was available to see a teenager and his or her family. The amount of time is a given and presents an interesting scientific and intellectual dimension on which to evaluate treatment. 2. Look beyond once-a-week therapy. Although there is a fixed period of time within which the therapy must be delivered, there is flexibility about how much time can be spent with the case during the 12 weeks. Certainly caseloads and a family’s receptivity to an intensive model (an undeveloped area of clinical research) will affect how much time a therapist can spend on each case per week. 3. Look beyond “in-the-room” treatment. Another critical barrier that must be overcome to consider this treatment a true ecological therapy is where the services will be provided. Just as “sessions” have an expanded meaning (e.g., some occur on the phone), expansions of how much therapy occurs (beyond once a week) and where it occurs are critical for the therapist to understand. Modules Are Intervention Targets Four focal areas (or modules), each of which is a primary developmental arena, organize treatment: (1) adolescents, (2) parents and other family members, (3) family interactional patterns, and (4) extrafamilial systems of 28 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment influence. The adolescent focus includes the adolescent and his or her peer world. The parent focus includes parents (biological, step) and parent figures (informal or unofficial caretakers) and other family members and extended family who may or may not live nearby. Family interaction concerns the transactional system made up of the parents, family, and adolescent. Extrafamilial focuses include significant others and other systems external to the family. Whole and Part Thinking The multiple ecologies in which teenagers reside are both wholes and parts (see whole and part thinking in Appendix A. Key Terms and Abbreviations). While functioning as “whole” biopsychosocial units, families are also part of and influenced by other systems of input and organization. A therapist’s job is to understand each system or ecology (family, school, peer, community) as both a whole and a part and to devise interventions that fit this conceptual framework. Interventions target processes within subsystems as well as processes that are happening or need to happen between subsystems as well. Multiple Domains of Simultaneous Intervention What are the interventional implications of this perspective? Each of the four modules has aspects that could be understood as distinct from the others. Together, they represent the adolescent’s psychosocial world. Each area is one of the multiple “locales” in which assessment and intervention occur. These domains reflect organizational units in which risk and dysfunction- producing processes occur. They could also be considered the multiple pathways to follow to activate different versions of change or to instigate changes in one area with stage-specific processes in mind. The primary treatment goal is to alter development of the adolescent and his or her social context in a way that establishes healthy socialization and development. If adolescent drug abuse is a manifestation of a particular lifestyle (Newcomb & Bentler, 1989), then it is the lifestyle that needs to change. Interventions are a series of small steps that occur sequentially, partly by design and partly according to feedback recalibrated or revised in microse quential human interactions (Liddle, 1985) moving toward positive outcomes in various functional domains. Each MDFT module—adolescent, parent, parent–adolescent interactions and extended family, and extrafamilial systems (Liddle, 1999)—is critical to the change process. Each contributes to the creation and continuation of the drug taking and related problem behaviors, as well as to the possibilities of changing the life course to turn it away from the developmental detours of drugs and delinquency. The modules relate to empirically established areas of risk and protection for youth and families, as well as to knowledge about how adolescent drug abuse and related problem behaviors begin, continue, expand, or end. 29 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Interventions With an Adolescent Establishing a therapeutic alliance with a teenager is distinct from a similar effort with a parent. It is critical to establishing the foundation of treatment and creating circumstances under which treatment can progress (G.M. Diamond & Liddle, 1996; Schmidt, Liddle & Dakof, 1996). Just as there are developmental tasks in life, so there are developmental stages in therapy. This first-stage work is called adolescent engagement interventions (AEIs), which include: • Presenting therapy as a collaborative process • Defining therapeutic goals that are meaningful to the adolescent • Generating hope by focusing on the adolescent’s internal locus of control and by presenting oneself as an ally • Attending to the adolescent’s experience (Diamond et al., 1999). Diamond and colleagues (1999) demonstrated how initially poor therapist– adolescent alliances can be improved. Alliance-building interventions occur in both individual and family sessions (Liddle, 1995). It is important for therapists to understand the need for (and inevitability of) different therapeutic alliances with each family member. Therapeutic alliances also exist with outside systems. Adolescents must be made to feel that the treatment program can meet some of their needs and that they can gain something by coming to treatment (Liddle, Dakof & Diamond, 1991). Research has revealed that a focused and systematic use of certain cultural themes (e.g., the journey from boyhood to manhood) enhances early-phase engagement as well as the middle-phase work with adolescents. (See The Adolescent Subsystem Module on page 54 [Jackson- Gilfort et al., 2001].) Although the field is still learning about similarities and differences between male and female adolescent drug abusers (Jainchill, Bhattacharya & Yagelka, 1995), MDFT has begun to articulate gender-sensitive strategies for formulating and addressing the unique needs of female drug users within the context of family-based treatment (Dakof, 2000). The therapist helps teenagers learn how to (1) learn more about their feelings and their thinking patterns, (2) communicate effectively with parents and others, (3) effectively solve social problems, (4) control their anger and impulses, and (5) gain social competence. Much of the work consists of preparing parents and adolescents in individual sessions so that they can come together in joint sessions to talk about issues that have meaning for them. Individual time with adolescents is used to develop alternatives to impulsive and destructive coping behaviors such as drug and alcohol use. Achieving therapeutic objectives with the adolescent requires the therapist to contextualize interventions designed to enhance social and life skills in the peer culture and address the influence of life on the streets. The therapist is systematic and detail oriented in pursuit of the facts of street life as well 30 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment as of the adolescent’s perception of that life and its consequences for his or her future. In this way, the therapist facilitates the process of engaging the adolescent with prosocial peer influences and positive familial influences. Interventions With Parents and Other Family Members Interventions with parents The primary objective of MDFT is to reconfigure the drug-using and deviance-prone lifestyle of the teenager with a replacement lifestyle, literally a new way of being in the world. This new way of living is characterized by more prosocial pursuits, including a more adaptive and active connection with institutions of socialization that keep the teen from continued deviance and easy access to drug-using and delinquent peers. This involves retracking the teen’s development. An adolescent’s symptoms may be related to outside factors and forces. MDFT intervenes multisystemically with many different forces in the teen’s life, and the adolescent’s parents are a source of influence. MDFT has a stepwise way of reaching parents. This procedure parallels the sequenced way teens are reached in the first phase of therapy. Parenting relationship interventions (PRIs) (e.g., enhancing feelings of love and commitment, validating parents’ past efforts, acknowledging difficult past and present circumstances, generating hope by increasing parents’ internal locus of control, generating hope by presenting the therapist as an ally to the parents) were designed to close the emotional distance between the parents and adolescent (Liddle et al., 1998). These can enhance parents’ individual functioning and, in turn, enhance their motivation and willingness to try a new kind of relationship with and parenting strategies for their adolescent. Damaged or disrupted attachment relations are linked not only to adolescent dysfunction (Allen, Hauser & Borman-Spurrell, 1996) but also to impaired parental functioning (Hauser, Powers & Noam, 1991). The ultimate aim of PRIs is to increase parents’ commitment and involvement with their adolescent, even with an adolescent who has abused drugs and is seriously involved in criminal activities (Schmidt, Liddle & Dakof, 1996). Therapists then foster parenting competency by supporting consistent and age- appropriate limit setting and regular monitoring of school attendance, school performance, and other activities. Interventions with other family members Although work with the adolescent drug abuser and his parents is central to MDFT, the approach recognizes that other family members often play key roles in drug taking and maladaptive patterns of teenagers. Siblings, adult friends of parents, and extended family members are taken into account during assessment and interventions. Individuals who play key roles in the teen’s life are invited to participate in family sessions, or sessions are held with these individuals alone. Cooperation is achieved by stressing the serious circumstances the youth is facing at the time of therapy (e.g., school expulsion, arrest, juvenile court problems) and the need for all significant 31 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users others (particularly adults) who can influence the adolescent to join forces in an organized, alternative-seeking manner. Interventions To Change the Parent–Adolescent Interaction Once the therapeutic foundation is successfully established with adolescents and parents through therapeutic alliances, explaining the treatment program, beginning the process of formulating goals with the parents and teen separately, and increasing parental involvement with the adolescent, the therapist requests direct change in the parent–adolescent relationship. Enactment is the foundation for facilitating change in the relationship domain (G.S. Diamond & Liddle, 1996, 1999). Although the parent– adolescent relationship is a focal topic with both the parents and the teen individually, it is in joint interviews that the relationship can be observed and assessed directly and the interaction between parents and teen shaped. Historically, a fundamental aspect of all family-based interventions has been targeting theory-specific dysfunctional family interactions, which were associated with the development and continuation of problem behaviors. Although contemporary family-based models may include many other targets, assessing and trying to change family interactions remains important. These problem interactions may be (1) current manifestations of problems that began as developmental struggles (e.g., increasing independence for the teen), (2) problems that have grown or evolved over time (e.g., noncompliance, school problems, affiliation with deviant peers, drug use and delinquency, legal problems, and family disengagement and despair), or (3) events such as family crises (chronic or acute) or traumas (e.g., parental substance abuse, physical or sexual abuse, physical abandonment). Studies have illustrated how changes in family interactional patterns are related to changes in the symptomatic behavior of children and adolescents (e.g., Alexander et al., 1983; Mann et al., 1990; Robbins et al., 1996; Szapocznik et al., 1989), including changes in the in-session behavior of drug-abusing teens (G.S. Diamond & Liddle, 1996; Schmidt, Liddle & Dakof, 1996). An early marker of progress in the parent and adolescent relationship is how discussions are handled. Initially, the basic focus is on a “first things first” philosophy. Therapists work on basic communication skills and patterns (see Bolton, 1979). For instance, can the parents and adolescents state their points of view? Can they listen and indicate that they heard the other’s point of view? Excessive blame, defensiveness, and recrimination are characteristics of early-stage conversations and indications of the troubles that the relationship has seen. Therapists understand that a session or any discussion creates a context. Over time, new experiences of the other individuals and of the self, as well as the new outcomes from the new kinds of conversations, contribute to new relational outcomes. When parents and their adolescents come together and relate in new ways, the adolescents become more confident and competent in expressing their needs and addressing their responsibilities and parents become less likely to abdicate their roles as parents and more 32 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment likely to provide support, which serve as a buffer against the adolescent’s involvement in substances and deviant peer groups. Family relationships can change; changed family relationships, manifested in new emotions being expressed and new interactional patterns, contribute to reductions in adolescent symptoms and gains in prosocial behavior. Interventions With Systems External to the Family MDFT targets multiple realms and aspects of the adolescent’s functioning for change. The family has not been found sufficient to create or maintain change in all cases, particularly when the teen’s and/or parents’ level of functional impairment is high. When external forces conspire against change or adoption of prosocial competencies, the need for well-organized and integrated multisystem work becomes acute. Multisystem interventions, including those that resemble case management, are therapeutic, particularly when coordinated with individual and family interventions. Common examples of multisystem interventions include the following: • If a parent is overwhelmed, help in negotiating complex bureau cracies or in obtaining needed adjunct services may be critical. • Parents may need help in obtaining services related to housing and medical care coverage. • The teen may need help with transportation to job training or self-help programs. A high level of collaborative involvement is promoted among all the systems to which an adolescent is connected (e.g., school, work, tutoring, job-training programs, juvenile justice appointments). When the adolescent is involved with the juvenile justice system, intensive working relationships are swiftly established with the probation officer or other court staff connected to the adolescent. Therapists also routinely meet with school personnel for case consultation and to help the school understand the treatment and its focus on school attendance and performance. Work with the family and the adolescent alone focuses on devising plans for improving the teen’s school-related behavior (i.e., removing obstructions to school attendance and improved performance). Other interventions may include promoting consistent monitoring by institutions and advocating for the adolescent’s special educational needs. Therapeutic Case Management Practical tips for integrating therapeutic case management activities into an overall intervention plan are listed in Table 1. Therapists should maintain a current file of all available resources in the region and the names and numbers of the appropriate contact persons. Therapeutic case management provides wraparound services that allow the adolescent and family to receive solid, practical support while they learn to function differently. These 33 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users interventions also can stabilize a family in crisis and keep the teen and family in the treatment program. Table 1. Procurement and Organization of Resource Information Outside Tasks 1. Research all resources in the geographic area that would be useful to the MDFT treatment model: A. Schools—Multidisciplinary teams, alternative schools, GED programs, tutoring programs, vocational and technical schools, etc. B. Jobs—Job training, vocational education, etc. C. Prosocial Support—Mentoring, park and athletic programs, Alcoholics Anonymous (AA), Narcotics Anonymous (NA), parent groups, afterschool activities, psychoeducational workshops, etc. D. Economics—County and/or city social services, State and Federal economic services (Aid to Families with Dependent Children, Supplemental Security Income, Temporary Assistance for Needy Families, etc.), emergency food, shelters, charities, housing programs, U.S. Department of Housing and Urban Development programs, etc. E. Medical—Medicaid, Medicare, medical and dental programs, drug prescription services, optometrist and eyeglass services, family planning, etc. F. Other—Court programs, police department programs, juvenile justice and probation procedures, the Immigration and Naturalization Service (INS), etc. 2. Meet with resources to determine their appropriateness, gather direct information on their use, and make contacts. Visit sites, tour facilities (including detention centers), and meet staff. 3. Regularly update the resource file and contacts. Case Management Tasks Related Therapeutic Tasks Schools 1. Monitor attendance of those clients who attend school daily. 2. Compile attendance and in-school behavior (suspensions, detentions, etc.) records monthly. 3. Pick up school records. 4. Monitor parental receipt of and signatures on all school reports and forms (e.g., report cards, interim progress reports, weekly/ daily progress reports). 1. Assess client needs. 2. Assist in curriculum planning. 3. Advocate for the client with the school system. 4. Assist parents in processing interactions with the school system. 5. Educate parents about the school system; enable them to affect the process. 6. Discuss interventions and outcomes with the client. 34 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment 1. Assess client needs. 2. Discuss interventions and outcomes with the client. 1. Assess client needs and interests. 2. Determine which activities are most appropriate for the client. 3. Determine whether an increase or decrease in attendance at activities is necessary. 4. Discuss interventions and outcomes with the client. Table 1 (continued). Procurement and Organization of Resource Information Case Management Tasks Related Therapeutic Tasks 5. Attend school meetings and conferences and multi- disciplinary team meetings. 6. Maintain active contacts with schools, alternative education programs, etc. 7. Monitor contact and progress with tutors. Jobs 1. Make referrals to appropriate agencies. 2. Take the client (parent or adolescent) to appoint ments at job agencies, to vocational education, or to interviews. Pro- 1. Monitor attendance at all social prosocial activities. Support 2. Take clients to 12-Step meetings and record all meetings. 3. Facilitate parental access to support groups and/or 12-Step meetings as necessary. 4. Evaluate the appropriateness of recreational activities in terms of content, staff competence, and rapport. 5. Determine costs, hours, and attendance requirements. 6. Take the client to meet staff and enroll him or her in activities. 7. Accompany client to activities as necessary. 8. Facilitate and monitor mentor contact. 9. Conduct nightly and weekend check-ins by phone. 35 ----------------------------------------------- Multidimensional Family Therapy for Adolescent Cannabis Users Table 1 (continued). Procurement and Organization of Resource Information Case Management Tasks Related Therapeutic Tasks Eco- 1. Facilitate access to all nomics available monetary services. 2. Take clients to apply for and obtain services as necessary. 3. Maintain updated contacts with providers. Medical 1. Facilitate healthcare service access. 2. Make referrals to or appointments with appropriate services. 3. Take family members to appointments with health- care providers as necessary. 4. Obtain reports or results from providers as necessary. 5. Visit family members at inpatient facilities when appropriate. Other 1. Make referrals to appropriate programs. 2. Maintain contact with juvenile probation officer. 3. Conduct daily check-ins with the client about conditions of probation. 4. Attend court hearings as needed. 5. Visit the client in detention as necessary. 6. Take family members to INS appointments as necessary. 7. Take the client to appointments. Sample narrative. It is important to orient the adolescent and family to the MDFT treatment program. Explain to the parents and adolescent the practical focus on extrafamilial systems and activities. The following excerpt comes from a first session and illustrates how therapists typically explain the program’s extrafamilial focus. 1. Assess client needs. 2. Set up a plan with the client to determine how to best meet his or her needs. 3. Attend meetings with service providers when the client’s behavior has affected receipt of services. 4. Discuss interventions and outcomes with the client. 1. Assess client needs. 2. Confer with medical profes- sionals about the client’s health needs, particularly with psychiatrists about medication. 3. Implement human immunodefi ciency virus (HIV) intervention. 4. Discuss interventions and outcomes with the client. 1. Assess client needs. 2. Advocate for the client when appropriate. 3. Make court appearances when necessary AND when the attorney’s agenda fits in with therapeutic plan. 4. Discuss interventions and outcomes with the client. 36 ----------------------------------------------- Part II. MDFT Approach to Cannabis Treatment Therapist: [to Mrs. Jones and Willis] Part of what we’re trying to do is to find out the different sides to every story. [to mother] Are there things that you’re not happy with? Are there things that you want to see him doing? You had hopes for him, dreams for him. [to adolescent] Willis, part of what I will do is to get to know you a little bit, to get to know where you stand on some things, what you’d like to see change, and I’ll try to help you find a way to deal with things in a way that works better for you and for your mom, too. [to both] Our program gets involved with the social workers at probation. I know Miss S. [social worker]. I’ll be calling her to say that Willis is in our program. I will keep connected with her and keep tabs on what is happening there. If there are problems in the school, I will get involved there as well. I always like to let them know we’re on the scene, we’re working on the same team really, trying to get things right for Willis. Sometimes kids have had trouble in school, and it’s helpful if we’re able to go to bat for them a little bit. We might say, “Could you slow things down? Don’t kick this kid out; we’re trying to stop the slide—we’re trying to do something good here.” What I’m saying is that there are some things outside this room that I get involved with. So I’d like to encourage you to call me between our meetings and say, “this or that happened” or “the school called.” If something comes up at home, if there’s an argument—a problem—either of you can call me. It’s not just when you’re here, but I’m thinking about these things all the time. Don’t forget that I’ll be in touch with other people who are involved with your situation, too. So I wanted you to be aware of that part of our program. Today is our first meeting and it’s real important for me to find out from you, Mrs. Jones, and from you, Willis, what’s going on with each of you. Can I meet separately with each of you now? Then we’ll all come back together at the end of our time today. 37 ----------------------------------------------- III. MDFT Sessions: Operational Features of the Approach The Three Stages of Treatment: An Indepth View MDFT treatment unfolds in phases, but like all stage models, it has variation and overlap between the stages. Stage One: Build the Foundation The early work of therapy involves establishing an alliance with both teens and parents. These are distinct relationships, with their own courses, expectations, and contracts for what therapy can and will be. Success with one in no way guarantees success with the other. The alliance between therapist and parent, for instance, does