1. Co-Occurring Disorders and FFT with Diverse Populations Funding: NIDA (R01DA09422; R01DA13350; R01DA13354) NIAAA (R01AA12183) Holly Barrett Waldron, Ph.D. Oregon Research Institute

2. Development of Family Therapy 1940s1950s1960s2000+ Family Intervention Science: Mature Clinical Models of Practice Cybernetics Weiner, 1942 Double-bind theory of schizophrenia Bateson et al., 1956 1980s WWII Changing women’s roles Family reunification Rise in divorce Need for mental health services General Systems Theory von Bertalanffy, 1968 Early Model Development: Ackerman Haley Bowen Satir Minuchin Efficacy/ Effectiveness Trials of Treatment Models 1990s1970s Coercion Theory Patterson, 1982

3. Evidence-Based Family Therapy Practices for Adolescent Problem Behaviors uFunctional Family Therapy –(Alexander, Waldron, Robbins, Turner et al.) uParent Training (Patterson) uBrief Strategic Family Therapy –(Szapocznik, Santisteban, Robbins et al.) uMultisystemic Therapy (Henggeler et al.) uMultidimensional Family Therapy (Liddle et al.) uBehavioral Family Therapy (Azrin, Bry, Kazdin) uMultidimensional Treatment Foster Care (Chamberlain) uIntegrative Behavioral & Family Therapies –(Barrett; Brent; Rohde & Waldron)

4. Family Therapy BFT (Behavioral Family Therapy) Azrin et al., 1994; 2001; Krinsley & Bry, 1995 MDFT (Multidimensional Family Therapy) Dennis et al., 2004; Liddle et al., 2001; 2003; 2004 FFT (Functional Family Therapy) Friedman, 1989; Hops et al., 2007; Waldron et al., 2001; 2005; 2007 These Three are “Well Established” for Adolescent Substance Use Disorders

5. Controlled Clinical Trials for Adolescent Substance Use Disorders: Functional Family Therapy Integrative Behavioral and Family Therapy Group Cognitive Behavioral Therapy Individual Cognitive Behavioral Therapy Team of Investigators Holly Barrett Waldron Hyman Hops Charles W. Turner Manuel Barrera Timothy J. Ozechowski Janet L. Brody

6. Findings from Three Controlled Clinical Trials Evaluating FFT and CBT for Adolescent Substance Abuse and Dependence

7. Study Participants u Living at home, parent willing to participate u DSM diagnosis Substance Use Disorder u Appropriate for outpatient treatment u No evidence of psychosis u Not receiving other mental health treatment u English language

8. Referral Sources Juvenile Justice System:43% Schools:31% Newspaper Ads / Flyers:11% Self Referred:10% Other Treatment Agency: 5%

9. Ethnicity Anglo Hispanic Native American Other/ Mixed

10. Drug Use Characteristics Drug% Using% Days Used Marijuana9957 Alcohol9510 Tobacco8464 Hallucinogens50 2 Cocaine33 3 Stimulants22 2 Opiates10<1 Sedatives/Tranquilizers 4<1 Inhalants 2<1 Other Drugs 9<1

11. Common Design Features of Three Randomized Clinical Trials u 12-14 sessions of treatment u Four assessments conducted at: Intake … 3 mon … 7-9 mon … 15-19 mon u Substance Use Measures –Time-Line Follow-Back Adolescent Interview –Time-Line Follow-Back Parent Collateral Report –Urine Drug Screening

12. Therapy Sessions Completed % Sessions Completed Treatment Group

13. Randomized Trial for Marijuana Abuse (DAYS Project)

14. Adolescent Marijuana Use at Pre- and Post-Treatment Follow-Up Mean Percent Days of Use (Waldron et al., 2001; 2008)

15. Proportion of Adolescents Abstinent or Using at Minimal Levels (<10% of days) Proportion of Adolescents (Waldron et al., 2001; 2008)

16. Randomized Trial for Alcohol Abuse (CEDAR Project)

17. Adolescent Alcohol Use by Treatment Condition: Pre-Treatment to Follow-Up Mean Percent Days of Use

18. Summary of Outcomes u Family therapy produces significant pre- to post-treatment improvement for conduct disorder, substance use disorders, anxiety (also, adult schizophrenia, adult alcohol and drug use disorders) u Family therapy is a “treatment of choice” for adolescents with conduct and substance use disorders u No evidence that one family therapy model is superior to any other for any disorder or co-occurring problems u Re-occurrence of symptoms (e.g., relapse, recidivism) presents major challenges to treatment and booster care or continuing care for a portion of treated youth may be required

19. Ethnicity and Treatment Outcome

20. Research on Mental Health Services for Hispanic Clients u At higher risk for mental illness (due to discrimination, poverty) compared to individuals in dominant culture u Underutilize mental health services u Higher premature drop out rates u Higher likelihood of inappropriate or ineffective services u Benefit less from services than clients of majority culture u Referred to substance abuse treatment at higher rates than youth in majority culture u Experience higher rates of “unsatisfactory releases from treatment” Shillington & Clapp, 2003 Sue, 1977; Sue et al., 1991; Vera et al., 1998)

21. Two-Site Randomized Trial for Drug- Abusing Hispanic and Anglo Youth (VISTA Project)

24. Therapist-Client Ethnic Matching and Family Therapy Outcome Source: Flicker, Waldron, Turner, Brody, & Hops (2008) Journal of Family Psychology

25. Rationale for Research on Ethnic Matching of Therapists and Clients u Better communication in primary language and understanding of client’s cultural background (Flaskerud, 1986). u Better therapeutic alliance due to common experience of therapist and client (Sue, 1988) u Less frequent miscommunication and misdiagnosis (Sue, 1988; Sue & Sundberg, 1996) u Therapeutic goals similarly conceptualized by the client and therapist u Similarity positively influences liking, persuasion, and credibility, processes important to treatment success (Simons et al., 1970) u Better identification of the impact of cultural issues on problem u Preference of clients for working with culturally-similar therapist (Atkinson & Lowe, 1995)

26. Sample u 89 substance-abusing adolescents in FFT u 84% male; 13-19 years u 1/2 Anglo, 1/2 New Mexican Hispanic u 80% in Class 2 & 3 of Hollingshead Scale u 40% 2-parent, 30% 1-parent, 25% blended u 72% in legal system; 1/3 treatment mandate u Mean sessions completed: 89%

27. Adolescent Marijuana Use by Ethnicity and Ethnic Match

28. General Ethnicity Findings u No significant differences between Anglos and Hispanics on treatment engagement or outcome  Hispanic adolescents had significantly lower treatment alliances in 1st session - perhaps Hispanic adolescents have different time course of alliance?

29. Ethnic Match Findings u No significant differences between ethnically matched Anglos and Hispanics on engagement or outcome u Ethnic match not related to attendance or treatment satisfaction u Non-matched Anglos had most balanced alliance u Ethnically matched Hispanics had greater decreases in drug use

30. Therapist Ethnicity Effects u Hispanic therapists had more balanced alliances with families than Anglo therapists u Hispanic therapists achieved better substance use outcomes with youth than Anglo therapists

31. Discussion u Therapist-family ethnic matching effect was found, despite highly acculturated Hispanic sample u Relationship between ethnic match and treatment outcome was unrelated to acculturation level u Therapeutic alliance was unrelated to relationship between ethnic match and change in drug use

32. Implications u Evidence that FFT is as or more effective with New Mexican Hispanic families u Ethnic match more important for Hispanic families than for Anglo families u Findings highlight the need for – ethnic diversity among therapists – better cross-cultural competence training

33. FFT for Co-Occurring Adolescent SUD and Depression

34. Treating Co-morbid Adolescent SUD and Depression u Treatments with the greatest efficacy for depression and anxiety (i.e., CBT) have not shown similar effects for SUD u In dually diagnosed youth, treating either depression or substance abuse alone is insufficient for both disorders

35. Family Low BDI No Family Low BDI Family Hi BDI No Family Hi BDI Note: BDI > 9 = High BDI; Heavy Marijuana Use = >20% Days Use.

36. Effective Sequencing of Evidence-based Treatments for Co-Morbid Depression and Substance Use Disorders

38. Directions for FFT Treatment Research uClear need for improving outcomes for: –Heavy users, polydrug users –Co-morbid disorders uBetter relapse prevention components –Booster treatment sessions; aftercare –Improved consolidation of treatment gains uNew ways to approach treatment research –Evaluate adaptive, progressive interventions or “stepped” care –Tailoring treatments to specific subgroups uResearch evaluating effectiveness of dissemination –Supervision approaches –Training approaches