Co-Occurring Disorders and FFT
with Diverse Populations
Holly Barrett Waldron, Ph.D.
Oregon Research Institute
Funding:
NIDA (R01DA09422; R01DA13350; R01DA13354)
NIAAA (R01AA12183)
Development of Family Therapy
1940s
1950s
WWII
Changing women’s roles
Family reunification
Rise in divorce
Need for mental health
services
1960s
1970s
Early
Model
Development:
Ackerman
Haley
Bowen
Satir
Minuchin
1980s
Efficacy/
Effectiveness
Trials of
Treatment
Models
1990s
2000+
Family Intervention
Science:
Mature Clinical
Models of Practice
Evidence-Based Family Therapy Practices
for Adolescent Problem Behaviors
Functional Family Therapy
– (Alexander, Waldron, Robbins, Turner et al.)
Parent Training (Patterson)
Brief Strategic Family Therapy
– (Szapocznik, Santisteban, Robbins et al.)
Multisystemic Therapy (Henggeler et al.)
Multidimensional Family Therapy (Liddle et al.)
Behavioral Family Therapy (Azrin, Bry, Kazdin)
Multidimensional Treatment Foster Care (Chamberlain)
Integrative Behavioral & Family Therapies
– (Barrett; Brent; Rohde & Waldron)
Family Therapy
FFT (Functional Family Therapy)
Friedman, 1989; Hops et al., 2007; Waldron et al.,
2001; 2005; 2007
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
These Three are “Well Established” for
Adolescent Substance Use Disorders
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
Findings from Three
Controlled Clinical Trials
Evaluating FFT and CBT
for Adolescent Substance
Abuse and Dependence
Study Participants
 Living
 DSM
at home, parent willing to participate
diagnosis Substance Use Disorder
 Appropriate
 No
for outpatient treatment
evidence of psychosis
 Not
receiving other mental health treatment
 English
language
Referral Sources
Juvenile Justice System:
43%
Schools:
31%
Newspaper Ads / Flyers:
11%
Self Referred:
10%
Other Treatment Agency:
5%
Ethnicity
8%
6%
Other/
Mixed
Native
American
Anglo
Hispanic
45%
41%
Drug Use Characteristics
Drug
Marijuana
Alcohol
Tobacco
Hallucinogens
Cocaine
Stimulants
Opiates
Sedatives/Tranquilizers
Inhalants
Other Drugs
% Using
99
95
84
50
33
22
10
4
2
9
% Days Used
57
10
64
2
3
2
<1
<1
<1
<1
Common Design Features of
Three Randomized Clinical Trials
 12-14
sessions of treatment
 Four assessments conducted at:
Intake … 3 mon … 7-9 mon … 15-19 mon
 Substance
Use Measures
– Time-Line Follow-Back Adolescent Interview
– Time-Line Follow-Back Parent Collateral
Report
– Urine Drug Screening
Therapy Sessions Completed
90
% Sessions Completed
80
70
60
50
40
30
20
10
0
GROUP
FFT
CBT
Treatment Group
FFT+CBT
Randomized Trial for Marijuana Abuse
(DAYS Project)
Pretreatment Assessment
Random Assignment:
Skills-Based Group Intervention
n = 30
Cognitive-Behavior Therapy
n = 30
Functional Family Therapy
n = 30
4 Month Follow-up
7 Month Follow-up
19 Month Follow-up
Combined (FFT and CBT)
n = 30
Adolescent Marijuana Use at
Pre- and Post-Treatment Follow-Up
FFT
CBT
FFT+CBT
GROUP
80
Mean Percent Days of Use
70
60
50
40
30
20
10
PreTx
4 Mo F/U 7 Mo F/U
19 Mo
F/U
(Waldron et al., 2001; 2008)
Proportion of Adolescents Abstinent or
Using at Minimal Levels (<10% of days)
FFT
CBT
FFT+CBT
GROUP
Proportion of Adolescents
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
PreTx
4 Mo F/U 7 Mo F/U
(Waldron et al., 2001; 2008)
19 Mo
F/U
Randomized Trial for Alcohol Abuse
(CEDAR Project)
Pretreatment Assessment
Random Assignment:
Skills-Based Group Therapy Cognitive-Behavior Therapy
n = 40
n = 40
Functional Family Therapy
n = 40
5 Month Follow-up
8 Month Follow-up
19 Month Follow-up
Integrative Behavioral &
Family Therapy
n = 40
Adolescent Alcohol Use by Treatment
Condition: Pre-Treatment to Follow-Up
FFT
CBT
IBFT
GROUP
Mean Percent Days of Use
20
15
10
5
0
PreTx
4 Mo F/U 7 Mo F/U
19 Mo
F/U
Summary of Outcomes

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)

Family therapy is a “treatment of choice” for adolescents
with conduct and substance use disorders

No evidence that one family therapy model is superior to
any other for any disorder or co-occurring problems

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
Ethnicity and
Treatment Outcome
Research on Mental Health
Services for Hispanic Clients







At higher risk for mental illness (due to discrimination,
poverty) compared to individuals in dominant culture
Underutilize mental health services
Higher premature drop out rates
Higher likelihood of inappropriate or ineffective services
Benefit less from services than clients of majority culture
Referred to substance abuse treatment at higher rates
than youth in majority culture
Experience higher rates of “unsatisfactory releases from
treatment”
Shillington & Clapp, 2003 Sue, 1977; Sue et al., 1991; Vera et al., 1998)
Two-Site Randomized Trial for DrugAbusing Hispanic and Anglo Youth
(VISTA Project)
New Mexico Site
New Mexico
Newly Immigrated
Hispanic-American Mexican-American
IBFT CBT
(n=30) (n=30)
IBFT CBT
(n=30) (n=30)
Oregon Site
Anglo-American
Newly Immigrated
Mexican-American
Anglo-American
IBFT CBT
(n=30) (n=30)
IBFT CBT
(n=30) (n=30)
IBFT CBT
(n=30) (n=30)
Figure C.1. Effects of CBT and IBFT on Marijuana Use (%
days) in the Hispanic Sample.
Marijuana Use (% days)
65
60
55
50
45
40
35
30
0
3
6
9
12
15
Assessment Point (months)
CBT
IBFT
Note: The individual points represent self-reported days of marijuana use
(percent of days) during the past 90 days on the TLFB interview.
18
Figure C.2. Effects of CBT and IBFT on Marijuana Use (%
days) in the Non Hispanic Sample.
60
Marijuana Use (% days)
55
50
45
40
35
30
25
20
0
5
10
15
Assessm ent Point (m onths)
CBT
IBFT
Note: The individual points represent self-reported days of marijuana use
(percent of days) during the past 90 days on the TLFB interview.
20
Therapist-Client Ethnic
Matching and
Family Therapy Outcome
Source: Flicker, Waldron, Turner, Brody, & Hops
(2008) Journal of Family Psychology
Rationale for Research on Ethnic Matching
of Therapists and Clients







Better communication in primary language and understanding
of client’s cultural background (Flaskerud, 1986).
Better therapeutic alliance due to common experience of
therapist and client (Sue, 1988)
Less frequent miscommunication and misdiagnosis (Sue,
1988; Sue & Sundberg, 1996)
Therapeutic goals similarly conceptualized by the client and
therapist
Similarity positively influences liking, persuasion, and
credibility, processes important to treatment success (Simons
et al., 1970)
Better identification of the impact of cultural issues on problem
Preference of clients for working with culturally-similar
therapist (Atkinson & Lowe, 1995)
Sample
 89
substance-abusing adolescents in FFT
 84% male; 13-19 years
 1/2 Anglo, 1/2 New Mexican Hispanic
 80% in Class 2 & 3 of Hollingshead Scale
 40% 2-parent, 30% 1-parent, 25% blended
 72% in legal system; 1/3 treatment mandate
 Mean sessions completed: 89%
Adolescent Marijuana Use by
Ethnicity and Ethnic Match
70
60
Nonmatched Hispanics
Mean Change in Use
50
Nonmatched Anglos
40
Matched Anglos
30
20
10
Matched Hispanics
0
Pretreatment
Follow -Up 1
Assessment Point
Follow -Up 2
General Ethnicity Findings
 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?
Ethnic Match Findings
 No
significant differences between
ethnically matched Anglos and Hispanics
on engagement or outcome
 Ethnic match not related to attendance or
treatment satisfaction
 Non-matched Anglos had most balanced
alliance
 Ethnically matched Hispanics had greater
decreases in drug use
Therapist Ethnicity Effects
 Hispanic
therapists had more balanced
alliances with families than Anglo
therapists
 Hispanic
therapists achieved better
substance use outcomes with youth
than Anglo therapists
Discussion
 Therapist-family
ethnic matching effect
was found, despite highly acculturated
Hispanic sample
 Relationship
between ethnic match and
treatment outcome was unrelated to
acculturation level
 Therapeutic
alliance was unrelated to
relationship between ethnic match and
change in drug use
Implications
 Evidence
that FFT is as or more
effective with New Mexican Hispanic
families
 Ethnic match more important for
Hispanic families than for Anglo
families
 Findings highlight the need for
– ethnic diversity among therapists
– better cross-cultural competence training
FFT for Co-Occurring
Adolescent SUD and
Depression
Treating Co-morbid Adolescent
SUD and Depression
 Treatments
with the greatest efficacy for
depression and anxiety (i.e., CBT) have
not shown similar effects for SUD
 In
dually diagnosed youth, treating either
depression or substance abuse alone is
insufficient for both disorders
Proportion Heavy Use
1.0
No Family
Low BDI
0.9
0.8
No Family
Hi BDI
0.7
Family
Hi BDI
0.6
0.5
Family
Low BDI
0.4
1
2
3
Time of Measure
Note: BDI > 9 = High BDI; Heavy Marijuana Use = >20% Days Use.
4
Effective Sequencing of Evidence-based Treatments for
Co-Morbid Depression and Substance Use Disorders
Participant Flow through Each Stage of Study
Referral
Screen and Consent
Intake Assessment
Randomize to:
Sequenced Tx. 1
FFT (10 weeks)
Sequenced Tx. 2
ACWD (10 weeks)
Integrated Tx. (20 weeks)
Post-FFT assessment
(Week 10)
Start ACWD (10 weeks)
Post-CWDA assessment
(Week 10)
Start FFT (10 weeks)
Mid-Tx assessment
(Week 9)
Post-ACWD assessment
(Week 20)
Post-FFT assessment
(Week 20)
Post-Tx assessment
(Week 20)
3-month Follow-up
6-month Follow-up
Figure 5
9-month Follow-up
Provision of Treatment in the Three Service Delivery Conditions
Weeks
Sequenced
Tx. 1
1 2 3 4 5
Sequenced
Tx. 2
C C C C C C C C C C
F F
C C
F F
Integrated
Tx.
Figure 6
F F F F F
F F
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
F F F F F C C C C C C C C C C
C C
F F F F F F F
F
F F F F F F
F
F
F
F
F
F
C+
C+
C+ C+ C+ C+ C+ C+ C+ C+ C+ C+
F = FFT Sessions C = ACWD Sessions C+ = Augmented ACWD Sessions
Directions for FFT
Treatment Research
Clear need for improving outcomes for:
– Heavy users, polydrug users
– Co-morbid disorders
Better relapse prevention components
– Booster treatment sessions; aftercare
– Improved consolidation of treatment gains
New ways to approach treatment research
– Evaluate adaptive, progressive interventions or
“stepped” care
– Tailoring treatments to specific subgroups
Research evaluating effectiveness of
dissemination
– Supervision approaches
– Training approaches