PROTOCOL: Family Behavior Therapy (FBT) for young people in treatment for non‐opioid drug use

Youth drug use1 that persists beyond curious experimentation is a severe problem worldwide (United Nations Office on Drugs and Crime (UNODC), 2010). Use of non-opioids drugs such as cannabis, amphetamine and cocaine is strongly associated with a range of health and social problems, including delinquency, poor scholastic attainment, fatal automobile accidents, suicide and other individual and public calamities (Deas & Thomas, 2001; Essau, 2006; Rowe & Liddle, 2006; Office of National Drug Control Policy (ONDCP), 2000; Shelton, Taylor, Bonner & van den Bree, 2009). More than 20 million of the 12 to 25 year-olds in the US, and more than 11 million of the 12 to 34 year-olds in Europe have used illicit2 drugs during the month prior to survey interviews in 2009 (Substance Abuse and Mental Health Services Administration (SAMSHA), 2010; European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2010). Seven percent of Australian 12-17 year olds have used some kind of drug during the month prior to survey interviews in 2008 (White & Smith, 2009). In Canada 26 percent of 15-24 year olds had used any illicit drugs during the past year (Health Canada, 2010). Not all young drug users progress to severe dependence, however some do and may therefore require treatment (for further reading, see e.g. Liddle et al., 2004; Crowley, Macdonald, Whitmore & Mikulich, 1998). For example, 8.4 percent of 18 to 25 year-olds in the US are classified as needing treatment for illicit drug use, but less than one tenth of these young people actually receive treatment (National Survey on Drug Use and Health (NSDUH), 2007). Likewise among young people aged 12 to 17, 4.5 percent were estimated to be in need of treatment for a drug use problem, but only one tenth in this group actually received any (SAMSHA, 2010). Research calls attention to the significant gap between young people classified in need of treatment and young people actually receiving treatment (SAMSHA, 2010; NSDUH, 2007). There is a growing public concern regarding the effectiveness and high costs of available treatments for young people, and by the high rates of treatment dropout and post-treatment relapse to drug use (Austin, Macgowan & Wagner, 2005; Najavits & Weiss, 1994; Stanton & Shadish, 1997). Accordingly, treatment to help young drug users should be as engaging as possible in order to avoid dropout and relapse (Simmons et al., 2008; National Institute on Drug Abuse, 2009), and services provided should be empirically supported in order to increase the likelihood that 1. Treatment will be successful, and 2. Public spending supports the interventions with the most effect. Researchers point to the fact that many research projects have empirically validated different kinds of treatment approaches for young drug users as effective (e.g. Rowe & Liddle, 2006; Waldron, Turner & Ozechowski, 2006; Williams, Chang & Addiction Centre Adolescent Research Group, 2000; Austin et al., 2005). The current dilemma in the field of youth substance abuse treatment is that it is not clear what works best as the research suggest that most interventions lead to reduced drug use. While there are some promising individually based cognitive and motivational therapies, i. e. Cognitive Behavioral Therapy (CBT) (Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001; Galanter & Kleber, 2008), family-based approaches may also show some promise. Family therapy covers a range of different interventions, based on different manuals and varying theoretical sources such as behavioral and cognitive behavioral theory, structural and strategic family theory, and family systems theory (Williams et al., 2000; Austin et al., 2005). Some reviews suggest that these family-based therapies are superior to individual-based programs in reducing youth drug use (Williams et al., 2000: Lipsey, Tanner-Smith & Wilson, 2010; Waldron, 1997). Young people with persistent drug use have unique needs due to their particular cognitive and psychosocial development. Young people are specifically sensitive to social influence, with family and peer groups being highly influential. Youth drug treatments facilitating positive parental and peer involvement, and integrating other systems in which the young person participates (such as schools, social services, justice authorities) are key to youth drug reduction (NIDA, 2009). A number of studies and reviews show 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 users (Williams et al., 2000; Austin et al., 2005; Waldron & Turner, 2008; Kaminer, 2008; Deas & Thomas, 2001). This review will specifically explore the family-based intervention Family Behavior Therapy (FBT) (Azrin, Donohue, Besalel, Kogan & Acierno, 1994a; Donohue & Azrin, 2001; Donohue et al., 2009) as aggregated evidence for the effects of FBT is needed. The review seeks to clarify the effects of the FBT program for relevant groups of young people age 11-21. The review focus on young people enrolled in treatment for drug use, independent of how their problem is labeled. Enrolment in treatment means that the severity of the young person's drug use has caused a significant adult close to the young person (teacher, parent, social services, school counselor, etc.) to require treatment. The intervention in focus is FBT delivered as outpatient treatment3 to young people age 11-21 living with their family. Furthermore the review will focus primarily on non-opioid drug use4, and will consider poly-drug use if relevant. The review will be one in a series of reviews on manual-based Family Therapy interventions for young people in treatment for non-opioid drug use5. FBT is a manual based family-oriented intervention for young people with drug use problems. FBT is a behavior focused family therapy, where young people's drug use is understood in relation to family behavior problems. FBT is one of many family therapy forms that meet the general characteristics of manual-based family therapies as it targets young people and their families as a system throughout treatment, and thereby recognizes the important role of the family system in the development and treatment of young people's drug use problems (Liddle et al., 2001, Muck et al., 2001). FBT was developed in the late 1980s on request from the US National Institute on Drug Abuse (NIDA) (Donohue et al., 2009). The development of FBT was initially heavily inspired by the alcohol abuse program Community Reinforcement Approach (CRA), which was aimed at restructuring the environment to reinforce non-alcohol associated activities. FBT developed to have more emphasis on contingency contracting, impulse control strategies specific to drug use, and increased emphasis on involvement of family members in treatment. FBT is designed to accommodate diverse populations of youths with a variety of behavioral, cultural and individual preferences. FBT has evolved for use in severe behavioral disturbances known to co-exist with substance use and dependence, and the core interventions have been enhanced to address several mental health related problems commonly occurring as comorbid conditions in drug use treatment participants (Austin et al., 2005; Donohue et al., 2009). FBT is a family systems approach that relies on structural and strategic family theory as well as behavioral family theory (Robbins & Szapocznik, 2000; Szapocznik, Hervis & Schwartz, 2003; Azrin et al., 1994a; Donohue & Azrin, 2001). FBT along with other family-systems based therapies builds on the assumption that families be as systems and as such individual in the family is important for the family system as a In family systems theory the family is as a unique system of and The family members are by and are strongly related to and as such be as a unique and The behavior of family be understood in relation to the family Young family behavior is associated with social in the and therefore interventions be at the family The family is of a social and as young people are by their the family is by the social systems in which 2006; & 2010; & 2008; & 2005; Austin et al., 2005). Family therapies are with the social in which the individual and the family is The structural family theory is based on the that and families determine individual family & 2008; In structural family theory social are understood as of The family range from a to a the of the family members and a in positive as well as problem behavior 2006; & 2010; & 2008; & 2005; Austin et al., 2005). The strategic of FBT on in behavior and relevant to the problems and in individual family members & Behavioral theory on behavior is by of the behavior to be and a focus on reducing by of and and problem and the members of the young drug family are to and their FBT is based on a behavioral of drug use and drug use problems, where drugs are a which is further by and (Austin et al., 2005; Donohue & Azrin, 2001). FBT contingency of impulse control strategies specific to drug use and relevant to drug use (Donohue et al., 2009). FBT to young people's drug use, as well as the young person's problem family and (Donohue & Azrin, 2001). The young person therapy with at one family one of the In the FBT program involvement and of and in FBT the core The will initially of FBT to participants in treatment. the the for and that are most to the young drug and family will be Furthermore the will from e.g. social and (Donohue & Azrin, 2001). is important for the to independent role in order to family and to on of the family to their problem young person's drug The young person will be to relevant and for drug use. and are in treatment and the of behavioral The of the behavioral is to environment that of associated with drug (Donohue & Azrin, 2001; Donohue et al., The be and be during treatment, as needs may and during the work with FBT during treatment. between different based on participants needs and behavioral development (Donohue et al., 2009). and are treatment is In this the young person and are to determine which are the most to in treatment (Donohue et al., Young people drugs and from school problems, which treatment. The FBT of (Donohue et al., 2009) at the young person how to conditions that have been to increase the likelihood of and and in their treatment (Donohue et al., The young person and are to a of behavioral that the young person's likelihood of drugs and a of behavioral that increase the likelihood of drug use. The young person and their are to the the young person on and The treatment participants in of spending more with and less with (Donohue & Azrin, 2001; Donohue et al., The reviews the control and in this the has the to to the and contingency treatment FBT young people and their are to from a range of the therapy The young person is to avoid and that drug of the is as key in in order to drug related and drug behavior (Donohue et al., Donohue & Azrin, 2001; The of this is to young drug users in school a is focused on positive and relevant for such as and school FBT on the young person to spending and to and in order to and avoid that may drug use (National of and Donohue et al., Donohue & Azrin, 2001; FBT core and at development and behavior and use role and behavior in treatment. FBT is designed to accommodate a diverse of young people with varying cultural behavioral and individual preferences. The range of and the for FBT to be and to the individual needs of the young person and family Donohue & Azrin, 2001; Austin et al., 2005). being a in drug FBT calls to participants to (Donohue et al., 2009). Furthermore participants are prior to in FBT to determine that are with in FBT treatment, of of significant other to are to drug of for treatment and with to do to do and during behavior and this to relevant (e.g. social are to the of intervention and the program based on the and in the Furthermore of and these are to the In of the program will the with the and and the of (Donohue et al., 2009). FBT is a behavior and intervention that to 20 treatment of from is and the intervention be delivered in in the family (Donohue et al., 2009). FBT has to young people's drug use, and to associated with drug use in young people and their family. The intervention at engaging young people and their family in therapy, family and to in related to young people's drug use. and reviews show that FBT drug use in participants and to reduction in behavioral problems (Austin et al., 2005; Deas & Thomas, 2001; Azrin et al., 1994a; Azrin et al., Azrin et al., Azrin et al., 2001). The program may be by characteristics and program characteristics that have been to program drug use reduction are and severity of drug use, and of school and (Williams et al., need on highly relevant characteristics such as family and characteristics are of treatment and need to be to the programs for any particular of Treatment with positive on treatment have been reviews of a range of treatments for youth drug use (Williams et al., 2000; Austin et al., 2005). Treatment is the with most to drug use reduction (Williams et al., 2000; Austin et al., 2005). has been to the likelihood that the young people treatment and drug use (Waldron & Turner, it if this is a treatment for treatment which is as key to positive treatment these to the of the FBT and for for as key treatment and In the motivational has program are the a to the family for and for for treatment are by the to participants and in treatment. and strategies as well as strategic treatment based on behavioral are other possible to behavior related to the strategic focus of and are in treatment of young people with drug use problems. FBT strategies as well as involvement of young people and their in treatment the intervention is based on behavioral and to the participants as well as family behavioral problems, which is of the to on young people's drugs use. being key to positive treatment (Williams et al., is also to the and of the family The family systems to the young person to a is a possible of related to the family systems focus of that FBT with family youth there is a in youth among of and to the reduction in young people's drug use et al., 1994a; Austin et al., 2005; Azrin et al., Azrin et al., 2001; Deas & Thomas, 2001). Azrin et al., and Azrin et al., in drug use to parental in the young person's drug treatment. Family and peer to is related to relapse (Williams et al., and positive to the behavior of the young person are possible of behavior related to the behavioral focus of that FBT participants family et al., 1994a; Austin et al., 2005; Azrin et al., 2001; Deas & Thomas, 2001). in family and family behavior may be related to the FBT in family social and et al., suggest that problem behavior is reduced from to treatment also for young people with (Austin et al., 2005; Azrin et al., 1994a; Azrin et al., 2001; Deas & Thomas, 2001, et al., suggest that youth behavior is and that and positive may the young people in and with possible relapse to drug use. Azrin et suggest that the use of of by the family on drug drug use in the and The behavioral family systems and the strategic focus are all possible of intervention family behavior and and in young people's drug use problems. drug use among young people is a significant social problem, and treatment of young people's drug use is and not treatments for young people's drug use problems are by high dropout rates and post-treatment relapse to drug use. Research that of the young drug users drug use treatment (Substance Abuse and Mental Health Services Administration (SAMSHA), There is a need to effective treatments for young people's drug use problems, and to treatment dropout and post-treatment Young drug users are at of to severe Furthermore the growing among in for empirically supported interventions is a to to the evidence with a review on a promising treatment for young drug There are a number of studies that FBT is a promising treatment for young people with non-opioid drug use. individual results on FBT this review will to the treatment of young and their The review will by the effects of FBT for relevant The of this review is to the current evidence on the effects of FBT on drug use reduction for young people in treatment for non-opioid drug use. A further of this review if to of drug use reduction specifically whether FBT works for particular of will study that use a control will be and group will not be The for including is as The in this review will be young people age 11-21 enrolled in manual based FBT drug treatment for non-opioid drug use cannabis, of young people, and the age in which a person is a young person and may be services, such as drug treatment (United group for young people are as the are and specific Furthermore young people with drugs at different in different et al., 2009). of young people's from and independent living In order to have the age range from 11 to et al., 2010; Youth In only interventions are in order to effects of FBT on youth living with their family are in what to use drug and different and of the severity of drug use are in different research studies 2000; Health participants of drug use The for is the fact that the young person is enrolled to in treatment intervention and in drug use treatment a of drug use such that a significant the young it to require treatment. the as young people to in treatment for non-opioid will drug as as the of drug users in a study are non-opioid drug interventions for youth has been in reviews et al., et al., and to avoid of use alcohol will be The review will outpatient manual based FBT interventions of any delivered to young people and their families of the The FBT intervention be outpatient intervention that not in a other treatment The FBT intervention in the at in a at outpatient in such as other for will be FBT is a family intervention the of the young drug and and with the of family In with the young drug the family (e.g. treatment and in any the core of the program will be on mental will also be where FBT is delivered with will be as as FBT is the control and will and interventions, as are in and to and of the problem young people's drug the likelihood of treatment control group is that the most will be interventions et al., 2010). 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