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 can be viewed as systems and as such each individual in the family is important for the family system as a whole (Poulsen, 2006). In family systems theory the family is perceived as a unique system consisting of interdependent and interrelated members. The family members are influenced by each other's actions and are strongly related to each other, and as such they can be viewed as a unique and changeable system. The behavior of each family member must be understood in relation to the family context. Young family member's problematic behavior is associated with maladaptive social interaction patterns in the family, and therefore interventions must be implemented at the family level. The family itself is part of a larger social system, and as young people are influenced by their families, the family is influenced by the larger social (and cultural) systems in which they exist (Poulsen, 2006; Doherty & McDaniel, 2010; O'Farrell & Fals-Steward, 2008; Kaminer & Slesnick, 2005; Austin et al., 2005). Family therapies are concerned with the wider social context in which the individual and the family is embedded. The structural family theory is based on the idea that subsystems, structures and hierarchies within families influence or determine individual family members' actions (Goldenberg & Goldenberg, 2008; Minuchin, 1985). In structural family theory social interactions are understood structurally, as repetitive patterns of interaction. The family structure can range from a supportive structure to a maladaptive structure. Either way the structure of interactions affects the family members and could play a pivotal part in maintaining positive as well as problem behavior (Poulsen, 2006; Doherty & McDaniel, 2010; O'Farrell & Fals-Steward, 2008; Kaminer & Slesnick, 2005; Austin et al., 2005). The strategic theory-based dimension of FBT focuses on creating changes in behavior and interactions relevant to the identified problems within families, and in individual family members resisting changes (Goldenberg & Goldenberg, 2008). Behavioral theory focuses on observable behavior (i.e. symptoms, problems). It is characterized by an ongoing assessment of the behavior to be altered and a focus on enhancing or reducing targeted undesired/unwanted behavior(s) by manipulating external contingencies of reinforcement. Therapists teach and coach communication and problem solving skills, and the members of the young drug user's family are trained to monitor and modify their own reinforcement contingencies. FBT is based on a behavioral conceptualization of drug use and drug use problems, where drugs are considered a strong primary reinforcer, which is further reinforced by both physiological stimuli and situational stimuli (Austin et al., 2005; Donohue & Azrin, 2001). FBT emphasizes contingency management, utilization of impulse control strategies specific to drug use scenarios, and explicitly monitors environmental stimuli relevant to drug use (Donohue et al., 2009). FBT incorporates multilevel components to target young people's drug use, as well as the young person's behavior, problem solving skills, family relationships and communication skills (Donohue & Azrin, 2001). The young person attends therapy sessions with at least one family member, typically one of the parents. In addition, the FBT program encourages involvement and participation of siblings and peers in therapy. FBT includes the following core foundation components: The therapist will initially provide an overview of FBT to engage participants in treatment. During the sessions the reasons for referral and support methods that are most helpful to the young drug user and his or her family will be discussed. Furthermore the therapist will clearly "differentiate" him or herself from third parties, e.g. social service authorities and probation agencies (Donohue & Azrin, 2001). It is important for the therapist to take an independent role in order to gain family members' confidence and to navigate on behalf of the family to solve their problem (the young person's drug use). The young person will be asked to identify relevant triggers and stimuli for drug use. These triggers and stimuli are targeted in treatment and guides the identification of behavioral goals. The aim of the behavioral contracting procedures is to establish an environment that facilitates reinforcement of behaviors associated with drug abstinence (Donohue & Azrin, 2001; Donohue et al., 2009; California Evidence-Based Clearinghouse (CEBC), 2011; Achievement Center, 2011). The goals can be adjusted and new goals can be added during treatment, as needs may change and develop during the work with various FBT components during treatment. Focus can shift between different goals based on participants changing needs and behavioral development (Donohue et al., 2009). When goals and contingencies are established, treatment is planned. In this process the young person and his/her parents are asked to determine which skill-based components are the most appropriate to include in treatment (Donohue et al., 2009; CEBC, 2011; Achievement Centre, 2011). Young people using drugs often experience problematic situations and difficulties (i.e. dismissed from school or work, economical problems, violence), which often disrupts treatment. The FBT component Assurance of basic necessities, (Donohue et al., 2009) aims at teaching the young person (and parents) how to monitor conditions that have been found to increase the likelihood of problematic situations and difficulties, and integrate "urgency management" in their treatment plan (Donohue et al., 2009; CEBC, 2011; Achievement Center, 2011). The young person and his or her parents are asked to create two comprehensive lists; 1) a safe list of behavioral stimuli that decrease the young person's likelihood of using drugs and 2) a risk list of behavioral stimuli that increase the likelihood of drug use. The young person and their parents are asked to monitor the time the young person spends on safe and risk behaviors. The therapist assists treatment participants in finding methods of spending more time with safe stimuli and less time with risk stimuli (Donohue & Azrin, 2001; Donohue et al., 2009; CEBC, 2011; Achievement Center, 2011). The therapist reviews the stimulus control items, and in this process the therapist has the opportunity to add goals to the "behavioral goals and contingency management" treatment component. Furthermore, within FBT young people and their parents are asked to select from a range of the following optional therapy components: The young person is instructed to avoid locations, objects and events that stimulate drug cravings. Recognition of the stimuli is regarded as key in self control, in order to stop or discipline drug related thoughts and reward goal-oriented, drug incompatible behavior (Donohue et al., 2009; Donohue & Azrin, 2001; CEBC, 2011; Achievement Center, 2011). The aim of this optional component is to assist young drug users in consistent school attendance or obtaining a job. Training is focused on disclosing positive qualities and skills relevant for schooling or work, such as interviewing techniques, and meeting potential employers or school officers. FBT focuses on teaching the young person to identify stimuli, prioritize spending and methods to manage and gain income in order to appropriately allocate resources and avoid financial crisis that may stimulate drug use (National Registry of Evidence-based Programs and Practices (NREPP), 2011; Donohue et al., 2009; Donohue & Azrin, 2001; CEBC, 2011). All FBT core and optional components aim at skills development and behavior change, and use role play and behavior rehearsals actively in treatment. FBT is designed to accommodate a diverse population of young people with varying cultural backgrounds, behavioral patterns and individual preferences. The range of eligible and optional components provides the opportunity for FBT to be flexible and tailored to the individual needs of the young person and family (CEBC, 2011; Donohue & Azrin, 2001; NREPP, 2011; Austin et al., 2005). Retention being a challenge in drug treatments, FBT incorporates weekly phone calls to participants to enhance session attendance (Donohue et al., 2009). Furthermore participants are screened prior to enrollment in FBT to determine issues that are contraindicative with participation in FBT treatment, i.e. lack of stable local residence, lack of significant other to attend sessions. Therapists are trained to manage drug user's lack of motivation for treatment and non-compliance with therapeutic guidelines (i.e. refusing to do role-playing, forgetting to do assigned home-work, and arguing during therapy). Therapists evaluate participant's behavior efforts and disclose this information to relevant authorities (e.g. juvenile justice, social service). Participants are asked to rank the helpfulness of each intervention component immediately after termination, and therapist can adjust the program based on the rankings and solve discontent early in the therapeutic process. Furthermore therapists rate participant's level of active participation and these rating are sent to the referral agency. In cases of recurring non-compliance the program supervisor will co-lead the next session with the therapist and provide on-site supervision and facilitate the management of difficult cases (Donohue et al., 2009). FBT is a behavior and skill-oriented intervention that can include up to 20 treatment sessions of 1-2 hours. Duration ranges from 6-12 months. Delivery is flexible and the intervention can be delivered in an office-based setting or in the family home (Donohue et al., 2009). FBT has two primary objectives: 1) to reduce young people's drug use, and 2) to change behaviors associated with drug use in young people and their family. The intervention aims at engaging young people and their family in therapy, improving family interactions and skills training to assist in changing behaviors related to young people's drug use. Randomized controlled trials and systematic reviews show that FBT reduces drug use in participants and contributes to reduction in behavioral problems (Austin et al., 2005; Deas & Thomas, 2001; Azrin et al., 1994a; Azrin et al., 1994b; Azrin et al., 1996; Azrin et al., 2001). The program outcomes may be affected by participant characteristics and program mechanisms. Participant characteristics that have been found to predict program drug use reduction or abstinence are history and severity of drug use, and higher levels of school attendance and functioning pretreatment (Williams et al., 2000). Practitioners need knowledge on highly relevant participant characteristics such as age, gender, minority background, family composition (e.g., single parents) and co-occurring conditions. These participant characteristics are potential predictors of treatment outcome and practitioners need to be able to assess the programs relevance for any particular type of client. Treatment variables with positive impact on treatment outcomes have been identified across reviews of a range of treatments for youth drug use (Williams et al., 2000; Austin et al., 2005). Treatment completion is the variable with most consistent relationship to drug use reduction (Williams et al., 2000; Austin et al., 2005). Early alliance building has been found to predict the likelihood that the young people complete treatment and reduce drug use (Waldron & Turner, 2008). Consequently, it remains unclear if this is a direct treatment impact, or an indicator for treatment motivation, which is identified as another key variable to positive treatment outcome. Either way, these findings points to the importance of the FBT components 'program orientation' and 'methods for enhancing motivation for treatment' as key mechanisms, influencing treatment compliance and attendance. In FBT, the motivational enhancement mechanisms has two aspects: program orientation are the steps a therapist takes to prepare the family for change, and methods for enhancing motivation for treatment are techniques by the therapist to participants active participation and in treatment. and strategies as well as strategic treatment based on behavioral assessment are other possible mechanisms to behavior change, related to the strategic focus of and are in treatment of young people with drug use problems. FBT includes strategies as well as active involvement of young people and their parents in treatment Furthermore, the intervention is based on behavioral and tailored to the participants as well as family behavioral problems, which is part of the to impact on young people's drugs use. being key to positive treatment outcome (Williams et al., is also to the support and influence of the family system. The family systems to influence the young person to a is a possible of change related to the family systems focus of that FBT with family youth there is a decrease in youth among of FBT, and contributes to the reduction in young people's drug use et al., 1994a; Austin et al., 2005; Azrin et al., 1994b; Azrin et al., 2001; Deas & Thomas, 2001). Azrin et al., and Azrin et al., in drug use to active parental participation in the young person's drug treatment. Family and peer support to is related to relapse management (Williams et al., 2000). skills training and positive reinforcement to change the behavior of the young person are possible mechanisms of behavior change, related to the behavioral focus of that FBT participants experience 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 skills training in family social support and contracting procedures 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., 2000). These findings suggest that youth behavior is and that skills training and positive reinforcement may support the young people in and with possible relapse to drug use. 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