PROTOCOL: Functional Family Therapy (FFT) for young people in treatment for non‐opioid drug abuse
Youth drug abuse1 of the kind that persists beyond the experimentation phase is a severe problem worldwide (United Nations Office on Drugs and Crime (UNODC), 2010). Abuse of non-opioid drugs such as cannabis, amphetamine and cocaine is strongly associated with a broad range of negative health implications such as traffic accidents, sexually transmitted diseases, mental problems and suicide as well as social problems including poor academic achievement, delinquency and violent behavior (Deas & Thomas, 2001; Essau, 2006; Rowe & Liddle, 2006; ONDCP, 2000; Shelton, Taylor, Bonner & van den Bree, 2009; Nordstrom & Levin, 2007; Lynskey & Hall, 2000). While cannabis, amphetamine, cocaine and other non-opioid drugs remain illegal in most countries, surveys indicate widespread prevalence. In the US, 25.5 percent of 12th-grade students report having used an illicit drug (any kind) within the last month (Johnston, O'Malley, Miech, Bachman & Schulenberg, 2014). In Canada, 21 percent of 15–24 year olds report having used of some kind of illicit drugs within the last year (Health Canada, 2011). In Australia, seven percent 12–17 year olds report using some kind of drug within the last month (White & Smith, 2009). The European Monitoring Centre for Drugs and Drug Addiction has found that that within Europe prevalence differs significantly from country to country but that overall around a quarter of Europeans report having used some kind of illicit drug in their lifetime (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2013). The prevalence of specific kinds of illicit drug abuse varies significantly, with cannabis generally being the most commonly used drug. In the US, 22.7 percent of 12th-grade students report having used marijuana/hashish (types of cannabis), 4.1 percent amphetamine, and 1.1 percent cocaine during the last 30 days before the National Survey on Drug Use conducted in 2013 (Johnston et al., 2014). The European Drug Report of 2013 indicates that 11.7 percent of the 15 to 34 year-olds in Europe have used cannabis, 1.3 percent amphetamine, and 1.9 percent used cocaine during the last year (EMCDDA, 2013). Although not all young drug users progress to severe dependence, some do and may therefore require treatment (see e.g. Crowley, Macdonald, Whitmore & Mikulich, 1998). Research draws attention to the significant gap between the number of young people classified as in need of treatment and the number of young people who actually receive such treatment (SAMHSA, 2010; National Survey on Drug Use and Health (NSDUH), 2007). In the US, for example, 7.2 million people aged 12 or older are classified as needing treatment for illicit drug abuse, but only 1.4 million of these young people actually receive treatment at a specialty facility for an illicit drug abuse problem (SAMHSA, 2011). The treatment usually provided to young people is delivered in outpatient settings. Accordingly, 90 percent of the 89,521 clients under age 18 registered in substance abuse treatment in 2012 by SAMHSA were in outpatient treatment, which is the same proportion as the total treatment population (SAMHSA, 2013). Equal proportions of the clients under age 18 were enrolled in facilities with a primary focus on substance abuse treatment and in facilities whose primary focus were provision of a mix of mental health and substance abuse treatment services; this differs from the total treatment population as youth tend to be treated in dual focus facilities more often than adults (SAMHSA, 2013). Cognitive-behavioral therapy and motivational interviewing are specific therapeutic approaches that are used at least sometimes by most (respectively 91 and 87 percent) treatment facilities (SAMHSA, 2013). There is growing public concern about the effectiveness and high costs of available treatments for young people, and the high rates of treatment dropout and post-treatment relapse to drug abuse (Austin, Macgowan & Wagner, 2005; Najavits & Weiss, 1994; Stanton & Shadish, 1997). While relapse must be acknowledged as an expected part of any treatment process targeting individual drug use, efforts should be made to make treatment as attractive, accessible and relevant as possible for young people in order to minimize the risk of unwarranted dropout and continuous relapse (Simmons et al., 2008; National Institute on Drug Abuse (NIDA), 2009). Furthermore, the services provided should be empirically supported to increase the likelihood that (a) treatment will be successful, and (b) public spending supports the interventions that are the most effective. Researchers point to the fact that many research projects have empirically validated different types of treatment approaches as effective for young drug users (e.g. Rowe & Liddle, 2006; Waldron, Turner & Ozechowski, 2006; Williams, Chang & Addiction Centre Adolescent Research Group, 2000; Austin et al., 2005). The effectiveness, however, depends upon the interplay between a specific intervention and individual factors such as gender, ethnicity, family composition, co-morbidity and history of drug abuse (Brannigan, Schackman, Falco & Millman, 2004; Hawkins 2009; Horsfall, Cleary, Hunt & Walter 2009). For example, research suggests that treatment outcomes of a specific program such as Functional Family Therapy may vary for different ethnic groups (Hops, Ozechowski, Waldron, Davis, Turner, Brody & Barrera, 2011; Flicker, Waldron, Turner, Brody & Hops, 2011). The current challenge in the field of substance abuse treatment for young people is therefore to establish not only what works best but also what works for different subgroups. In terms of treatment types, there is some documentation of promising individually-based cognitive and motivational therapies (Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001; Galanter & Kleber, 2008). Family-based approaches on the other hand may be equally effective. Family therapy encompasses a range of different interventions with varying theoretical sources, including behavioral and cognitive behavioral theory, structural and strategic family theory, and family systems theory (Williams et al., 2000; Austin et al., 2005). Some reviews have suggested that these family-based therapies are superior to individual-based programs in reducing youth drug abuse (Williams et al., 2000; Lipsey, Tanner-Smith & Wilson, 2010; Waldron, 1997). Young people with persistent drug abuse have unique needs due to their particular cognitive and psychosocial development. Young people are especially sensitive to social influence, with family and peer groups being highly influential. Youth drug treatments which facilitate positive parental and peer involvement, and which integrate other systems in which the young person participates (such as schools, social services, and justice authorities) are thus key to reducing drug abuse by young people (NIDA, 2009). A number of studies and reviews have showed positive results for family therapies in general, but there is a need to synthesize individual study results for specific family therapies to determine whether and to what extent specific family therapy interventions work for young drug abusers (Williams et al., 2000; Austin et al., 2005; Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001). This review is concerned specifically with Functional Family Therapy (hereafter FFT) (Alexander & Parsons, 1973; Alexander & Parsons, 1982; Rowe & Liddle, 2003), as aggregated evidence for the effects of this approach is lacking. The review will seek to clarify the effects of the FFT program for relevant groups of young people aged 11–21, and will focus on young people enrolled in treatment for drug abuse, irrespective of how their problem is defined. Enrolment in treatment is taken to imply that the severity of the young person's drug abuse has compelled a close, significant adult (for example, teacher, parent, social services, or school counselor) to demand that the young person enters treatment. FFT is an intervention offered as an outpatient treatment2 to young people age 11–21 that are living with their families. This review focuses solely on non-opioid drug abuse3, and is one in a series of reviews on manual-based family therapy interventions for young people in treatment for non-opioid drug abuse4. Functional Family Therapy (FFT) is a short-term, manual-based, behaviorally oriented family therapy program for young people with behavior problems such as drug abuse, juvenile delinquency and violence. Delivered in an outpatient setting, it aims to help young people and their families by improving family interactions and relationship function by addressing dysfunctional individual behavior (Sexton & Alexander, 2000; Sexton & Turner, 2011). In an FFT program, the therapist provides intensive family therapy in an attempt to change the patterns of family interaction that are contributing to the problem behavior and to help family members develop specific skills in, for example, communication, conflict resolution, problem solving, and effective parenting. After the desired behavioral change has been achieved within the family, the therapist helps the family generalize changes to other situations and settings, such as school, community, and peers, and identifies support that can help to maintain the progress made (Sexton & Alexander, 2003; Onedera, 2006). As with many other forms of family therapy, FFT targets young people and their families as a system. As such, it recognizes the important role of the family system in the development and treatment of young people's drug abuse problems (Ozechowski & Liddle, 2000). While a specific FFT intervention may focus on improving specific problems such as drug abuse, the FFT approach in itself adds a broader view of the change process and clinical outcomes by switching from an individual problem focus to a relational perspective. The intervention is designed to help families recalibrate their interaction patterns and improve family relations, and through this achieve individual goals such as decreased drug abuse (Alexander, Waldron, Robbins & Neeb, 2013). FFT was developed in the late 1960s and early 1970s (Alexander & Parsons, 1973) with the model described in full by Alexander and Parsons in the early 1980s (Alexander & Parsons, 1982). It was developed to serve diverse populations of under-served and at-risk adolescents and their families because these populations lacked resources, were difficult to treat, and were often perceived by professionals as lacking the motivation for change. The founders of FFT realized that successful treatment of these populations required service providers who were sensitive to the needs of these diverse families, who were competent to work with them, and who understood why the families had traditionally resisted treatment (Sexton & Alexander, 2003). The development of the FFT program has continued, and the therapy has been refined in response to the results of research and the experiences from successful implementation (Alexander & Robbins, 2010). In a systematic review conducted by Austin, Macgowan & Wagner (2005), FFT appeared as one of five interventions identified as consistent with the majority of guidelines for effective treatment for adolescents with substance abuse. Austin et al. (2005) also note, however, that there is some inconsistency in the research on outcomes of FFT and that long-term follow-up assessment is needed. In a meta-analytical study, Waldron & Turner (2008) synthesized findings from 17 studies evaluating outpatient treatments for substance-abusing youth, including several therapy models, among them FFT, other family therapy approaches, group CBT, individual CBT and minimal treatment conditions. Waldron & Turner (2008) found that the effect size associated with reductions in drug abuse was significantly larger for family therapy relative to the minimal treatment condition, but the meta-analysis did not establish one of the treatment approaches as clearly superior to any other in terms of treatment effectiveness for substance-abusing youth. FFT is derived from both family system theory (Alexander & Parsons, 1973) and cognitive behavioral theory and techniques (Alexander & Robbins 2010). The therapy focuses on family functioning, and is thus based on the premise that both positive and negative behavior can have a direct influence, and are influenced by multiple relational systems (Alexander & Sexton, 2002; Sexton & Alexander 2000). It assumes that young people's problem behavior can serve a function within the family. Family members develop ways of interacting that help them meet their relational needs for closeness or distance, but these patterns of interacting may also create or maintain behavioral problems. When changes are made in how the family interacts (by, for example, improving communication, problem-solving, and parenting skills), behavioral problems will be resolved. Interventions must take into account the needs of each family member and be tailored to the family's unique risk and protective factors (Alexander & Sexton, 2002; Sexton & Alexander, 2003; Alexander et al., 2013). While FFT is established as a distinctly unique approach, it has not emerged in a vacuum and is related to other current treatment approaches. Accordingly, Calley (2011) states that one of the most striking elements of the functional family therapy approach is its similarity to other therapeutic models, such as multisystemic family therapy, motivational enhancement therapy and solution-focused brief therapy. She emphasizes that this is not a deficit of the FFT model but rather a reminder of the evolutionary nature of the theories informing psychotherapy in general. Some of the characteristics that make FFT stand out are the emphasis on relational functions (hence the title Functional Family Therapy), the level of implementation of detailed treatment manuals and protocols for training and supervision, as well as the distinctive phase model (Alexander et al., 2013). Furthermore, FFT is a multi-systemic treatment focusing on the multiple domains and systems of which the adolescent is part, such as the community, school and the juvenile justice system (Sexton & Alexander, 2003). Finally, FFT is a multilevel intervention in which the therapist works first to develop the family's inner strengths and sense of being able to improve their situation. This provides a foundation for change and future functioning that extends beyond the direct support of the therapist and other social systems. As FFT is a strength-based model, its philosophy is that the intervention offers self-sufficiency through a platform for change for the family (Sexton & Alexander, 2000; Sexton & Turner 2011). FFT therapists have diverse professional backgrounds. In one FFT intervention targeting youth with behavioral problems that was carried out in a community practice setting, the majority of therapists were Master's degree clinicians; others were Bachelor's level, and the therapists' clinical experience ranged from 1 to 40 years. Regardless of the variations in training and experience, all therapists received ongoing group-based FFT training, and outcome studies suggested that rather than the professional background, the decisive therapist characteristic was the level of treatment model adherence. Thus, the FFT intervention was found to be effective only when the therapists adhered to the treatment model (Sexton & Turner, 2011). In a previous study, undergraduate paraprofessionals trained in FFT produced significant reductions in recidivism rates among youth offenders (Barton, Alexander, Waldron, Turner, and Warburton, 1985), giving some indication of the level of training that might be required to successfully reproduce FFT (cf. Sexton 2011). In general, the FFT model emphasizes the importance of ongoing training and supervision to maintain therapists' model fidelity, and FFT provides training and supervision protocols to facilitate adherence in real-world settings (Alexander et al., 2013). As a clinical model, FFT is both flexible and structured: flexible because it requires individualized treatment strategies to be formulated by sensitive clinicians, and structured because it offers a fixed sequence of treatment strategies (Alexander & Sexton, 2002). The FFT treatment contains five interdependent and sequentially linked phases, in addition to pre-treatment and post-treatment activities. Each of the five phases has specific assessment and intervention components that are tailored to the unique characteristics of each family: (1) Engagement in change; (2) Motivation to change; (3) Relational/interpersonal assessment and change planning; (4) Behavioral Change; (5) Generalization across behavioral domains and multiple systems (Alexander & Robbins, 2010; Alexander et al, 2013). Research on FFT outcomes has emphasized investigations of the intervention's effectiveness in relation to desired outcomes (Alexander et al., 2013 p. 37–62) rather than investigating possible adverse effects (Dishion, McCord & Poulin, 1999) of FFT. Critics have suggested that future evaluations of FFT need to be carried out by a broader group of researchers to ensure rigorous evaluation of the approach in practice settings and to nuance the documentation of outcomes (Calley, 2011). Stressing desired outcomes at the expense of turning attention to the investigation of adverse effects is characteristic of much research into effects of psychotherapy, not just FFT (cf. Barlow 2010). Nonetheless, research suggests that possible adverse effects of therapy include exacerbating clients' problematic symptoms or initiating an experience of passive dependence (Dishion et al., 1999, Barlow 2010). Before the therapist contacts the family, he or she will gather all information available about the youth and his or her family (including from formal assessments and official records). The ultimate goal of the Pre-treatment phase is that the therapist is fully ready both to assist the youth and family, and also to anticipate potential barriers and utilize strengths so that a positive experience for the family may be created (Alexander & Robbins, 2010; Onedera, 2006). The engagement phase involves activities that encourage the family to attend sessions. The therapist strives to create a positive contact with the family by, for example, scheduling appointments via telephone rather than by letter (this has the additional advantage of allowing the therapist to form a first impression of the family and to identify potential problems such as resistance to or confusion about treatment). It is considered important that the therapist be culturally competent and able to assist the family in feeling respected and comfortable (Alexander et al, 2013). The goal of this phase is to create a positive and motivational context within which change can occur. Alexander (interview in Onedera, 2006) stresses that motivation is fundamental for subsequent behavioral change. It is considered important that any negativity is decreased in this early phase before targeting actual behavioral change; this is because negative emotions can prevent family members from making a realistic commitment to change (Onedera, 2006). Using a range of therapeutic techniques, the family members are helped to feel a reduction of blame, anger, and hopelessness and an increase in hopefulness (Alexander & Sexton, 2002; Sexton & Alexander, 2003). The phase consists of two major domains of activity: Changing Focus and Changing Focus attempt to negativity and family interactions by or seek to change the of how family members and each other (Alexander & Robbins, 2010; Alexander et al., 2013). The goals of relational assessment are to and information to relational and to develop for the assessment focuses on two family relationship (a) the degree of between members of the family, and (b) the in In this the therapist identifies how to approach specific changes in the family to meet the least resistance and create the most assessment provides a that not only the specific problem behavior (e.g. youth drug but also the unique and of the family members with to each The focus is to and which include interaction and of resistance (Alexander & Robbins, 2010; Alexander et al., 2013). In this the goals are to develop an implementation for change. It is important that the the unique family, each of its and their relational The therapist provides behavioral interventions to and model specific behavior changes (e.g. training, problem solving, parental skills training, and conflict It is as important that the techniques used are individualized and and that the family relational system (Alexander & Sexton, 2002; Alexander et al., 2013). In the last the goals are to maintain and support change by community The is to encourage family members to their problems using the identified strengths and skills have and to dependence on the Interventions seek to help the family to generalize across different to be more in or and to community There is a focus on the families to family has at the same the family to on their are in the is as of the of the family system (Alexander & Sexton, 2002; Alexander & Robbins, 2010; Alexander et al., 2013). FFT is a intervention on for and to 30 for more The are a of between and The therapist at least one with the youth and his or her family. The program is flexible and can be in a of settings, including at a clinical or community facility or with in the family (Sexton & Alexander, 2003). FFT has two primary to or young people's drug abuse, and to change associated with drug abuse in young people and their families. and systematic reviews have that FFT can drug abuse in can to a reduction in behavioral problems and and is associated with in family patterns and et al., 2005; Waldron, Turner & 2001; Waldron & Turner, 2008; & Liddle, 2009; Stanton & Shadish, 1997). and social have been the key theories that have FFT (Alexander et al., 2013). this theoretical indicates that problem behavior is not as a of individual both positive and negative behavior is in the social that therapists focus their attention more on Furthermore, FFT is influenced by family systems and theories the and that therapists view social and as not of problem behavior (Alexander et al., 2013). on these FFT requires that the therapists focus on the relational functions of all family relevant to the problem behavior (e.g. drug of the youth. In other FFT that individual drug abuse may be achieved through improving family and reducing dysfunctional A premise of FFT is therefore that family members of the substance-abusing youth in the treatment The about who is to in FFT in a particular is based on the of which family members will be important for the change process the youth (Alexander et al., 2013). While parental are expected to are not expected to be at the treatment to the family especially may FFT to have the youth from the and FFT treatment encompasses strategies to them in a positive change process (Alexander et al., 2013). The program outcomes may be by factors such as characteristics and program characteristics that have been found to program drug abuse reduction or history and severity of drug abuse level of peer and parental in relation to and of school and functioning (Williams et al., 2000). information is required by on the of other characteristics such as gender, ethnicity, family and conditions. characteristics are potential of treatment outcome and need to be able to the for any particular of with positive on treatment outcomes have been identified in a number of reviews of a range of treatments for youth drug abuse (Waldron & Turner, 2008; et al., 2000). is the most related to reduction in drug abuse (Williams et al., 2000; Waldron & Turner, 2008). While it is established that a therapeutic early in treatment the likelihood that young people treatment and their drug abuse (Waldron & Turner, it whether this is a direct effect or an of treatment motivation itself has been to have a positive on treatment these findings point to the importance of the FFT components of and as on treatment and The focus on family the behavioral nature of the approach, and the to engagement and motivation are all possible of intervention family behavior and functioning, and facilitate changes in young people's drug abuse. In FFT, the Engagement the first a therapist to the the family for change. This stresses the importance of the to create a positive relation to all family The therapist for the with the family by all available information about the youth and his or her family. The goal of this is to be culturally to meet the family with to and to as much as possible the The Motivation phase is linked to the Engagement phase and contains a number of intervention techniques (e.g. and and positive which can be used by the therapist to change within the family. using the intervention of the therapist cognitive and that help and thus challenge clients to identify for future change help to family members to one so that each one a for the family's as key to positive treatment outcome (Williams et al., is also linked to the support and of the family system. The family to the young person a is a possible of change related to the family systems focus of FFT. have found that FFT family and to the reduction in young people's drug abuse (Ozechowski & Liddle, 2000). are described as in the of change associated with FFT. FFT, therapeutic are associated with interventions delivered in a each family member the therapist and the therapist is to and them of their the therapist is to their emotions and Turner, Alexander & 2003). Research into the importance of therapeutic that therapists who were able to achieve a or level of in which therapists are more with than youth or were more to family in treatment et al., 2003). results the importance of the in a in the engagement and motivation drug abuse among young people is a significant social and the treatment of young people's drug abuse is and not least because the treatments for such problems are by
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