LINKING SESSION FOCUS TO TREATMENT OUTCOME IN EVIDENCE-BASED TREATMENTS FOR ADOLESCENT SUBSTANCE ABU

NIH Public AccessAuthor ManuscriptPsychotherapy (Chic). Author manuscript; available in PMC 2010 May 14.Published in final edited form as:Psychotherapy (Chic). 2004 ; 41(2): 83–96. doi:10.1037/0033-3204.41.2.83.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLINKING SESSION FOCUS TO TREATMENT OUTCOME INEVIDENCE-BASED TREATMENTS FOR ADOLESCENTSUBSTANCE ABUSEAARON HOGUE,National Center on Addiction and Substance Abuse at Columbia UniversitySARAH DAUBER,National Center on Addiction and Substance Abuse at Columbia UniversityHOWARD A. LIDDLE, andCenter for Treatment Research on Adolescent Drug Abuse, University of Miami School ofMedicineJESSICA SAMUOLISMailman School of Public Health, Columbia University College of Physicians and SurgeonsAbstractThe relation between specific therapy techniques and treatment outcome was examined for 2empirically supported treatments for adolescent substance abuse: individual cognitive–behavioraltherapy and multidimensional family therapy. Participants were 51 inner-city, substance-abusingadolescents receiving outpatient psychotherapy within a larger randomized trial. One session percase was evaluated using a 17-item observational measure of model-specific techniques andtherapeutic foci. Exploratory factor analysis identified 2 subscales, Adolescent Focus and FamilyFocus, with strong interrater reliability and internal consistency. Process–outcome analysesrevealed that family focus, but not adolescent focus, predicted posttreatment improvement in druguse, externalizing symptoms, and internalizing symptoms within both study conditions.Implications for the implementation and dissemination of individual-based and family-basedapproaches for adolescent drug use are discussed.Psychotherapy process research plays an integral role in the development of empiricallybased treatments. Treatment development refers to systematic efforts to test, critique, andrevise the theoretical underpinnings and technical ingredients of intervention models inconnection with an accumulating research base (Kazdin, 1994; Rounsaville, Carroll, &Onken, 2001). Treatment development relies on process research that can elucidate themechanisms of change responsible for observed outcome effects: How does a treatmentwork and what features are essential for its success? (Kazdin, 1999).Process research is also poised to make a substantial contribution to treatment disseminationefforts. The imposing gap between efficacy research (testing therapies under highlycontrolled conditions to maximize internal validity) and effectiveness research (testingtherapies under standard practice conditions to maximize external and ecological validity)has prompted demand for research on transporting treatment models from the lab to theclinic (Nathan, Stuart, & Dolan, 2000; Weisz, Donenberg, Han, & Weiss, 1995). One key toCorrespondence regarding this article should be addressed to Aaron Hogue, PhD, National Center on Addiction and Substance Abuseat Columbia University, 633 Third Avenue, 19th Floor, New York, NY 10017. ahogue@casacolumbia.org.HOGUE et al.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptPage 2

successful transportation will be identifying the specific aspects of efficacious models thatare linked with good outcomes—knowing what, exactly, should be transported (Kazdin,2001). This is particularly true for multicomponent, flexibly delivered models whose clinicallook may vary from case to case as therapists attempt to meet the unique needs of each client(Gaston & Gagnon, 1996).

The current study investigated specific therapy processes for two empirically supportedoutpatient treatments for adolescent substance abuse: cognitive–behavioral therapy andfamily therapy. National surveys and household probability studies conducted within thepast decade reveal that adolescent drug use remains a prevalent and serious problem

(Department of Health and Human Services, 2000; Gfroerer, 1995; Johnston, O’Malley, &Bachman, 1995; Kilpatrick et al., 2000). To date, family therapy has generated the largestevidence base in the treatment of adolescent drug use and cooccurring symptoms (Stanton &Shadish, 1997; Williams, Chang, & ACARG, 2000). Rigorous empirical studies have shownthat family-based therapy can produce engagement and retention of drug users and theirfamilies in treatment (Henggeler et al., 1991); reduction or elimination of drug use (Liddle etal., 2001; Waldron, Slesnick, Brody, Turner, & Peterson, 2001); decreased involvement indelinquent activities (Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993);

improvement in multiple domains of psychosocial functioning such as school grades, schoolattendance, and family functioning (Liddle et al., 2000); and increased quality of parentingbehavior (Mann, Borduin, Henggeler, & Blaske, 1990; Schmidt, Liddle, & Dakof, 1996).There is also evidence that therapeutic gains maintain at long-term follow-up (Liddle et al.,2001) and that family-based approaches are cost-effective in comparison to treatment asusual (Schoenwald, Ward, Henggeler, Pickrel, & Patel, 1996).

A second highly regarded treatment approach for adolescent drug abuse is cognitive–behavioral therapy (Bukstein, 1995; Weinberg, Rahdert, Colliver, & Glantz, 1998).Cognitive–behavioral approaches have demonstrated efficacy in reducing adolescent

substance abuse (Waldron et al., 2001; Winters, Latimer, & Stinchfield, 1999) and comorbidpsychiatric problems (Kaminer, Blitz, Burleson, & Sussman, 1998). Cognitive–behavioralapproaches are also widely practiced with adolescent drug users (Bukstein, 1995), makingthem a critical target for further empirical validation.

This study investigated two manualized treatments for adolescent substance use: individualcognitive–behavioral therapy (CBT) and multidimensional family therapy (MDFT). Thesemodels were previously tested in a randomized controlled trial with inner-city, primarilyethnic minority adolescent drug abusers (Liddle & Hogue, 2001). Results of that studyindicated that both treatments were effective in reducing marijuana use, externalizing

symptoms, and internalizing symptoms at posttreatment and up to 1 year later, with MDFTshowing some superiority in producing gains more rapidly and maintaining posttreatmentgains at follow-up.

The main goals of the current study were to identify differences between CBT and MDFT inthe use of specific therapy techniques and to link these process elements to outcomes foundin the parent randomized trial. Specific therapy techniques are the technical aspects of atreatment model that derive directly from its fundamental theory- and practice-basedprinciples (Elkin, Pilkonis, Docherty, & Sotsky, 1988). Advances in the technology ofpsychotherapy process research, including specification of clinically meaningful processvariables and use of dimensional scales to measure therapist behavior (Greenberg, 1986;Schaffer, 1982; Sechrest, 1994), have spurred efforts to identify specific techniques thatpredict treatment outcome. A recent meta-analysis found that the effects of specific therapycomponents exceeded those of non-specific and facilitative factors, particularly for clientswith more severe problems (Stevens, Hynan, & Allen, 2000). Nevertheless, the therapeutic

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potency of specific techniques (Messer & Wampold, 2002; Wampold et al., 1997), and thetheoretical and methodological feasibility of discovering process–outcome correlationsinvolving discrete technique variables (Stiles & Shapiro, 1994), are still in question.This study examined the degree to which individual-focused and family-focused techniqueswithin CBT and MDFT promote change in core behavioral symptoms related to adolescentsubstance abuse. Both approaches provide for some degree of therapist flexibility in

targeting both individual and family functioning in order to achieve treatment goals. CBTfocuses on changing the behaviors and cognitions of individual adolescents and workspredominantly with teens alone in session. However, CBT therapists are trained to discusssalient issues pertaining to the youth’s relationships with parents and family members and,also, to meet periodically with care-givers. In the same vein, whereas MDFT targets familyinteractions directly and works predominantly with caregivers and other family participantsin session, MDFT therapists also routinely hold individual sessions and work on thepersonal attitudes and behaviors of teens.

There are two primary study hypotheses: Greater use of adolescent-focused interventiontechniques will predict improvement in CBT, whereas greater use of family-focusedtechniques will predict improvement in MDFT. Adolescent outcomes in drug use,externalizing symptoms, and internalizing symptoms were measured at pre- andposttreatment. Therapy techniques were measured using observational scales from a

psychotherapy process instrument developed in a previous study on this sample (Hogue etal., 1998). The current study extended the Hogue et al. 1998 study by adding new items tothe observational scales, conducting new exploratory factor analyses of the expanded scale,increasing the number of participants, and conducting process–outcome analyses.

NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMethod

Participants

Clients—The sample was made up of 51 substance-abusing adolescents (67% male youths)and their families. The ethnic composition was 65% African American, 25% EuropeanAmerican, and 10% Hispanic American. Adolescent characteristics included the following:mean age was 15.2 years (SD = 1.3); 84% of the adolescents were enrolled in school atintake, 63% were on juvenile probation, 22% were court ordered into treatment, and 16%attended previous drug counseling; 61% were living in single-parent households, 10% wereliving with both biological parents, and 29% had various other family compositions; and37% had a yearly household income less than $10,000. Family characteristics included thefollowing: 73% of mothers and 80% of fathers completed at least a high school education,57% of mothers and 86% of fathers were employed at full- or part-time jobs, and 53% of thesample had a family member with previous criminal involvement. Adolescent substance usediagnoses were 75% marijuana dependence, 12% marijuana abuse, 16% alcohol

dependence, 12% dependence on other substances; comorbid diagnoses were 69% conductdisorder, 61% oppositional defiant disorder, and 61% at least one mood disorder.

Therapists—The 12 therapists who delivered the treatments, 6 in each condition, ranged inage from 29 to 54 years (M = 40). Each condition had 3 men and 3 women, and each had 3African American and 3 European American therapists. In the MDFT condition, 4 therapistshad master’s degrees and 2 doctorates, with an average of 7.7 years (SD = 4.5) postgraduateexperience in family therapy. In the CBT condition, 3 therapists had master’s and 3

doctorates, with an average of 3.5 years (SD = 1.7) postgraduate experience in cognitive–behavioral therapy.

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Raters—Observational coding was completed by 11 undergraduate students (9 women): 2African Americans, 5 European Americans, and 4 Hispanic Americans. Raters had no priorexperience in process coding or with the treatment models and were na?ve to treatmentcondition during coding.

Treatments

NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptBoth treatments were designed for office-based, weekly sessions conducted over 16–24

weeks. Therapists in both conditions completed 6 months of training prior to receiving studycases, were supervised directly by model developers in weekly individual meetings (bothlive and with videotape) and monthly group meetings, and showed strong treatment

adherence and differentiation in a previous treatment integrity study (reported in Hogue etal., 1998).

Multidimensional family therapy (MDFT)—MDFT (Liddle, 2002) is a

multicomponent, developmental–ecological treatment for adolescent drug abuse and relatedproblems that seeks to reduce symptoms and enhance developmental functioning byfacilitating change in several behavioral domains. Treatment targets within-familyinteractions as well as interactions between the family and relevant social systems, andparticular intervention outcomes (e.g., emotional reconnection of caregivers to their

adolescents) are understood to be the platforms from which other, more complex outcomesare attempted (e.g., changes in parenting practices). MDFT has four interdependent modulesthat target multiple aspects of adolescent and family functioning: (a) the adolescent moduleaddresses developmental issues such as identity formation, peer relations, prosocial

involvement, and drug use consequences; (b) the parent module enhances parenting skills inthe areas of monitoring and limit setting, rebuilding emotional bonds with the adolescentand participating in the teen’s life outside of the family; (c) the interactional module

facilitates change in family relationship patterns by helping families develop the motivationand skills to revitalize attachments and interact in more adaptive ways; and (d) the

extrafamilial module seeks to establish collaborative relationships among all social systemsin which the adolescent participates (i.e., family, school, peer, recreational, and juvenilejustice). MDFT has been tested in a variety of clinical settings and subjected to numerousprocess studies; see Liddle and Hogue (2001) for a summary.

Individual cognitive–behavioral therapy—The CBT model for multiproblemadolescent substance abusers used in this study is based on a broadly defined cognitive–behavioral framework (Turner, 1992, 1993) that emphasizes adolescent coping skills and aharm-reduction approach to substance use. Treatment is divided into three stages. Treatmentplanning focuses on identifying and prioritizing adolescent problems and making atreatment contract in conjunction with both adolescent and caregiver. Parents, or theirsurrogates, participate in the first two sessions to facilitate support for the adolescent’sparticipation in treatment and to get parents’ perspectives on the youth’s strengths andproblematic behaviors. Problems described by the adolescent and parents, in addition toproblems reported by school and juvenile court, are used to develop a treatment plan.Intensive CBT program aims to increase coping competence and reduce problematicbehavior, with intervention selection based on clinical need from multiple therapeuticmodules. Typical therapeutic modules include the following: drug education, contingencycontracting, coping and relaxation skills, communication and problem-solving skills, self-monitoring and cognitive distortions, and increasing prosocial activities. Specifically

regarding substance abuse, harm reduction (Marlatt & Tapert, 1993), not abstinence, is theprimary goal. Clients are taught to recognize behavioral and cognitive cues for cravings anddrug use and to increase behavioral self-control. Termination focuses on treatment

termination issues and relapse prevention. The goal is to enhance clients’ long-term self-

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management skills. Role rehearsal and problem solving are used to strengthen adolescents’ability to resist against peer pressure to use drugs and engage in delinquent behavior.

NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptProcess Measure

Therapist Behavior Rating Scale (TBRS)—The TBRS (Hogue et al., 1998) is an

observational rating system that assesses core theory-based intervention strategies prescribedby CBT and MDFT, including both individual and family techniques. This observer-basedmethodology for evaluating the implementation of model-specific techniques withinmanualized treatments has been widely adopted (Carroll et al., 1998; Hill, O’Grady, &Elkin, 1992; Morgenstern, Morgan, McCrady, Keller, & Carroll, 2001), and thepsychometric properties of the TBRS are sound (Hogue et al., 1998). Two kinds of

interventions were coded for this study sample (see Table 1): 12 therapist technique itemsthat are scored based upon therapist behavior only, and 5 session focus items that are scoredbased on the content of therapist–client discussions. The session focus items were not usedin the Hogue et al. study. For both kinds of items, raters estimate the extent to which itemsare observed during an entire session using a 7-point Likert scale ranging from 1 (not at all)to 7 (extensively). Both thoroughness and frequency are considered in making each rating.Thoroughness refers to the depth, complexity, or persistence with which the intervention ispursued. Frequency refers to the number of times throughout the session that a givenintervention appears (regardless of thoroughness in any particular segment). Raters areinstructed that complex interventions may be characterized by more than one scale item,although each item is theoretically independent of all others.

Outcome Measures

Timeline Follow-Back Interview—The Time-line Follow-Back (TLFB) interview(Sobell & Sobell, 1996) measures quantity and frequency of daily consumption of drugsusing a calendar and other memory aids to gather retrospective estimates. The TLFB isreliable and valid for the measurement of alcohol consumption and cigarette and cannabisuse (Brandon, Copeland, & Saper, 1995; Breslin, Sobell, & Sobell, 1996; Sobell & Sobell,1996). The TLFB has shown high temporal stability for measurement of alcohol

consumption, with most test–retest correlations exceeding .85 (Fals-Stewart, O’Farrell,

Freitas, McFarlin, & Rutigliano, 2000). Criterion validity has been established by comparingself- and collateral reports, as well as self-reports and records of verifiable events such ashospitalizations and jail stays (Fals-Stewart et al., 2000). For this study, the variable

measuring the number of days out of the previous 30 during which the adolescent smokedmarijuana was used.

Child Behavior Checklist (CBCL): Externalizing and Internalizing dimensions—The Revised Child Behavior Checklist (Achenbach & Edelbrock, 1983) is a parent self-report measure that assesses children’s behavioral problems and social competencies. TheCBCL contains groupings of Externalizing (delinquent and aggressive) and Internalizing(withdrawn, anxious/depressed, and somatic complaints) symptoms (Achenbach &

Edelbrock, 1983). One-week test–retest reliability of .93, and interparent reliability of .66for Internalizing and .80 for Externalizing, have been shown (Achenbach, 1991). Contentand criterion validity are supported by the ability of CBCL items to discriminate betweenmatched referred and nonreferred youth (Achenbach, 1991). The CBCL also has excellentinternal consistency, construct validity, and discriminant validity properties (Achenbach,1991), and it has proven useful for assessing changes in behavior following psychotherapy(Webster-Stratton, 1984).

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