Transcript Open poster - CTN Dissemination Library

Does Case Difficulty Compromise the Fidelity of Family Therapy for Substance-Using Adolescents?
Florencia
Treatment fidelity (or integrity), defined as the extent to
which a therapist faithfully implements manualized
intervention procedures, is an increasingly important
area in psychotherapy research (Perepletchickova et
al., 2007). While most interest centers on associations
between fidelity and outcome, recent studies of
therapeutic “responsiveness” suggest that client
characteristics such as problem severity or case
difficulty might help to explain how competently a
therapist applies a given manualized intervention
(Schoenwald at el, 2003; Stiles et al., 1998). We
investigated this possibility in a multisite trial of Brief
Strategic Family Therapy (BSFT) for adolescent
substance abuse.
The parent study compared BSFT to treatment as usual for
substance-using adolescents in 8 community treatment
programs, where volunteer clinicians randomly assigned to
provide BSFT completed a training (certification) program
before seeing cases in the clinical trial. The index adolescents
were 12-17 years old (M = 15.9), 79% male, 44% Hispanic, and
23% African-American.
An expert panel rated treatment fidelity for 104 cases
receiving at least 5 sessions of BSFT from one of 17 community
therapists in NIDA CTN Protocol 014. The fidelity panel used
session videos and progress notes from the first 4 months of
therapy to generate case-level consensus ratings of formulation
quality, intervention quality, off-model behavior, and over-all
fidelity to the BSFT model. The panel also coded whether
specific patterns of fidelity failure were present in each case.
We used baseline data to construct indices of case difficulty
representing both the severity of adolescent problem behavior
and the quality of family functioning. Indicators of problem
severity included (a) a composite measure of substance-use,
which combined Timeline Follow-back self-reports and urine
drug screens; (b) a composite measure of externalizing
behavior, combining scores from the Youth Self Report (YSR),
the DISC Predictive Scales (completed by the adolescent and
one parent), and the Delinquency scale of the National Youth
Survey (Feaster et al., 2010); and (c) a simple index of multiple
prior arrests. Indicators of family functioning included (d) a selfreport composite of the Family Environment Scale and
Parenting Practices Questionnaire, completed by the
adolescent and a parent (Feaster et al., 2010); and (e) observer
ratings of the overall quality of family functioning during a
structured family interaction task, based on the Global
Assessment of Relational Functioning (GARF) scale (Dausch et
al., 1996).
a
Lebensohn-Chialvo ,
b
Hasler ,
a
Rohrbaugh ,
Brant P.
Michael J.
Varda
aUniversity of Arizona, bUniversity of Pittsburgh
NIDA Blending Conference, Albuquerque, NM, April 2010
Treatment fidelity in a multisite trial of Brief Strategic Family Therapy for adolescent drug
abuse was poorest when youth had multiple arrests, high substance use, and high
externalizing scores before treatment began. Research using fidelity ratings as a proxy
independent variable should account for possible responsiveness related to case difficulty.
The modal quality of BSFT was less than
ideal, as only a third of the TFS cases
received what the expert panel considered
“adequate” BSFT (fidelity > 3 on a 1-5
scale).
As reported elsewhere, case-level fidelity
correlated positively and often significantly
with most outcomes at most follow-up
intervals, with minority participants
accounting for most of these associations
(Shoham & Rohrbaugh, 2009).
In the main regression analyses (Table 1),
the three indicators of adolescent problem
severity together accounted functioning did
not (R2 ∆ = .01).
Youth externalizing problems predicted offmodel therapist behavior most clearly, and
the specific forms or a significant proportion
of BSFT fidelity variance (R2 ∆ = .10, p =
.012) while the two measures of family of
fidelity failure most implicated in this were
therapist centrality (r = .39), didactic
intervention style (r = .36), and nonsystemic formulations (r = .33; all ps < .01).
a
Shoham
California-Arizona Node, NIDA Clinical Trials Network
U10 DA 015815
The fidelity with which community therapists
implemented a complex, manualized family therapy for
adolescent substance users was responsive to case
difficulty, with youth problem severity predicting
compromised fidelity more than the quality of family
interaction. In particular, youth with relatively severe
externalizing problems appeared to “pull” specific kinds
off-model therapist behavior, and this may imply
directions for training (or inoculating) family therapists
who work with this difficult population. Another
implication is that research using treatment fidelity
ratings as a proxy “independent” variable should
account for possible responsiveness effects related to
case difficulty.
Dausch, B.M., Miklowitz,D.J., & Richards, J.A. (1996). Global
Assessment of Relational Functioning Scale (GARF): II.
Reliability and validity in a sample of bipolar patients. Family
Process, 35, 175-189.
Feaster, D.J., Robbins, M.S., et al. (2010). Equivalence of
family functioning and externalizing behaviors in adolescent
substance users of different race/ethnicity. Journal of
Substance Abuse Treatment, 38, S113-S124.
Perepletchickova, F., Treat, T.A., & Kazdin, A.E. (2007).
Treatment integrity in psychotherapy research: Analysis of the
studies and examination of the associated factors. Journal of
Consulting and Clinical Psychology, 75, 825-841.
Shoham, V., & Rohrbaugh, M.J. (2009, October). Elusive
effects of Brief Strategic Family Therapy for adolescent drug
abuse: Results from the CTN-014 mediator-moderator platform
study. Steering committee of the Clinical Trials Network,
National Institute on Drug Abuse, Bethesda, MD.
Schoenwald, S.J., Halliday-Boykins, C.A., & Henggeler, S.W.
(2003). Client-level predictors of adherence to MST in
community service settings. Family Process, 42, 345-359.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998).
Responsiveness in psychotherapy. Clinical Psychology:
Science and Practice, 5, 439-458.
The study was supported by NIDA awards
R01-DA17539-01, U10-DA15815, and U10-DA13720.
Correspondence: Florencia Lebensohn-Chialvo,
Department of Psychology, University of Arizona,
P.O. Box 210068, Tucson, AZ 85721 ([email protected]).