Program Goals and Target Population
Brief Strategic Family Therapy (BSFT) is a family-based intervention designed to prevent and treat child and adolescent behavior problems. The goal of BSFT is to improve a youth’s behavior by improving family interactions that are presumed to be directly related to the child’s symptoms, thus reducing risk factors and strengthening protective factors for adolescent drug abuse and other conduct problems. BSFT targets children and adolescents who are displaying—or are at risk for developing—behavior problems, including substance abuse.
BSFT is based on the fundamental assumption that adaptive family interactions can play a pivotal role in protecting children from negative influences and that maladaptive family interactions can contribute to the evolution of behavior problems and consequently are a primary target for intervention. The therapy is tailored to target the particular problem interactions and behaviors in each client family. Therapists seek to change maladaptive family interaction patterns by coaching family interactions as they occur in session to create the opportunity for new, more functional interactions to emerge.
Major techniques used are joining (engaging and entering the family system), tracking and diagnosing (identifying maladaptive interactions and family strengths), and restructuring (transforming maladaptive interactions). Through the technique of joining, the therapist develops a therapeutic alliance with the family, one that gives due respect to each individual within the family as well as to the way the family is organized. As this working alliance is established, the therapist tracks and diagnoses family strengths, weaknesses, and patterns, which sets the foundation for the treatment plan. Restructuring or reframing techniques help the family reduce problematic relations and patterns, and instead develop mutually supportive and effective relations and patterns. Depending on the case, these techniques may include helping families develop effective behavior management skills, conflict resolution skills, or communications skills and helping parents learn parenting skills.
BSFT is a short-term, problem-oriented intervention. A typical session lasts 60 to 90 minutes and is held with the adolescent and one or more other family members. The average length of treatment is 12 to 16 sessions over a 3- to 4-month period. For more severe cases, such as substance-abusing adolescents, the average number of sessions and length of treatment may be doubled. Treatment can take place in the office, home, or community settings.
Robbins and colleagues (2011) used a random assignment design at eight community treatment provider sites to assess the impact of Brief Strategic Family Therapy (BSFT) on family functioning and adolescent substance abuse. Therapists were randomly assigned to the treatment condition or to treatment as usual (TAU). Therapists who volunteered to participate in the study did not know in advance to which group they would be assigned. Drug use was assessed at baseline and at 12 monthly follow-up assessments. All other measures were assessed at baseline, then at 4, 8, and 12 months postrandomization. Other measures included family functioning and retention and engagement.
TAU varied across the eight community treatment providers. It included individual therapy, group therapy, parent training groups, nonmanualized family therapy, and case management. Participants received 12 to 16 sessions over a 3- to 4-month period. Participation in ancillary services (e.g., case management, Alcoholic Anonymous) was typical.
BSFT included 12 to 16 sessions over a 4-month period. Other systems could be addressed during these sessions (e.g., parents could be coached on how to communicate with a probation officer or a school official). Most sessions were delivered in either the home (52.2 percent) or the clinic (45.3 percent) but could also be delivered elsewhere, such as at school or work (2.5 percent). Participation in ancillary services was permitted (e.g., case management, Alcoholic Anonymous), but most sessions were classified as family therapy.
Booster sessions were allowed for participants in either condition.
Families were recruited from eight community treatment centers. To be included in the study, adolescents had to self-report illicit drug use (other than alcohol or tobacco) within the past 30 days. They had to live with a family (any parent or guardian). Adolescents with pending criminal offenses were excluded to eliminate the possibility of participant incarceration. The urn randomization process was used to assign families to either the control or treatment condition. A total of 480 adolescents and their family members participated in the study across eight sites. Participants were predominately male (n=377). The racial/ethnic breakdown consisted of 213 Hispanics/Latinos, 148 non-Hispanic whites, 110 non-Hispanic blacks, 5 American Indians/Alaskans, 2 Japanese/Whites, 1 Persian, and 1 Lebanese. Seventy-two percent were referred from the juvenile justice system.
The statistical model used for analysis included random effects for site and therapists. Various methods were used to assess the differences in engagement and retention, drug use, and family functioning, such as logistic regression, contingency table methods, generalized estimating equations, and the Wilcoxon rank–sum test.
Coatsworth and colleagues (2001) used an experimental pretest–posttest design with 104 families of Hispanic (n=79) or African American (n=25) descent. Families were eligible for the study if they had a 12- to 14-year-old child who had significant academic problems, had initiated drug or alcohol use, or about whom the family or school reported a complaint of externalizing problems in the form of misconduct or internalizing problems in the form of anxiety/depression. Adolescents who had attempted suicide were excluded from the study. The sample was 75 percent male, with a mean age of 13.1.
Participants were randomized to the experimental condition or the community comparison condition. The two groups did not significantly differ. The experimental group received BSFT, while the comparison group received whatever therapy the particular community agency used. Researchers assessed the adolescents’ behavior problems as well as engagement and retention in treatment at baseline and at the completion of treatment.
Santisteban and colleagues (2003) used an experimental design to assess the efficacy of BSFT for Hispanic youth with behavior problems and drug use. A total of 126 Hispanic adolescents and their families participated in the study. To be eligible for inclusion, adolescents needed to exhibit externalizing behavior problems according to parents or school.
Adolescents ranged in age from 12 to 18 (M=15.6). The majority of participants (87 percent) were male. The ethnic breakdown was 64 Cuban, 18 Nicaraguan, 12 Columbian, 8 Puerto Rican, 4 Peruvian, 2 Mexican, and 18 from other Hispanic nationalities. Youths were randomly assigned to either BSFT or a group treatment control (GC).
GC participants received a participatory-learning group intervention; facilitators led the group and encouraged participants to discuss and solve problems among themselves. The facilitator encouraged group cohesion, disseminated information regarding drug use, and maintained a problem-solving atmosphere. Groups consisted of four to eight adolescents; family members were not included. Participants received from 6 to 16 sessions of weekly therapy; sessions lasted on average 90 minutes.
Attrition for the BSFT condition was 30 percent and for the GC condition 37 percent. Adolescent behavior problems were assessed using the Revised Behavior Problem Checklist. Drug involvement was measured using the Addition Severity Index and urine toxicology screens. Family functioning was measured using the Family Environment Scale and the Structural Family Systems Rating. The researchers analyzed how the impact of treatment varied according to whether the families were in better family functioning/better family cohesion group at baseline or whether they were in the worse family functioning/worse family cohesion group.
The three evaluations of Brief Strategic Family Therapy (BSFT) produced inconsistent findings. Study 1 largely demonstrated no effects on adolescent drug use or family functioning, although the program had some positive effects on engagement and retention. Study 2 showed positive effects of the program on engagement and retention. Study 3 demonstrated promising reductions in behavior problems and some drug use behavior, as well as increases in family functioning. While the preponderance of evidence suggests promising outcomes, there were inconsistent findings, which should be considered prior to implementation.
Adolescent Drug Use
Robbins and colleagues (2011) found that there were no overall significant differences of treatment on the trajectories of adolescent self-reported drug use. The median number of self-reported drug use days was significantly higher in the treatment as usual (TAU) condition than in the Brief Strategic Family Therapy (BSFT) condition at 12 months, but there were no significant differences at any other assessment time points.
According to parent reports, BSFT was significantly more effective (although with a small effect) than TAU at improving family functioning. According to adolescent reports, however, there were no statistically significant differences between the treatment and control conditions in improvements in family functioning.
Engagement and Retention
Compared with TAU participants, BSFT participants had lower rates of failure to engage and failure to retain in treatment. BSFT treatment was 0.43 times as likely as TAU to fail to engage a participant into therapy and 0.71 as times as likely to fail to retain participants in therapy for at least eight sessions. BSFT had 48.6 percent of cases with unplanned termination, compared with 70.2 percent of TAU cases. BSFT condition also had significantly higher levels of attendance.
Engagement and Retention
Coatsworth and colleagues (2001) found that BSFT was able to engage and retain a significantly larger number of cases than other forms of treatment. Families in the treatment group were more likely to engage in treatment (81percent versus 61 percent) and once engaged were more likely to stay in treatment to completion (71 percent versus 42 percent). Families in BSFT were 2.3 times as likely to engage and complete treatment as families in the comparison group. Researchers also found that BSFT was more successful at retaining cases with high levels of conduct disorder. Despite the higher percentage of difficult-to- treat cases, BSFT achieved comparable, if not slightly better, treatment effects on behavior problems than the comparison condition.
Santisteban and colleagues (2003) found that BSFT participants showed significantly greater reductions in behavior problems at termination than did adolescents in the comparison condition. Participants in the BSFT group showed clinically significant improvement for both conduct disorder and socialized aggression.
Compared with the group treatment control (GC), participants in the BSFT group demonstrated a statistically significant reduction in marijuana use, but not in alcohol use.
According to assessments with the Structural Family Systems Rating, families who demonstrated initial lower family functioning pretreatment showed significant improvement after participating in the BSFT group. Families with initial higher family functioning showed no improvements in functioning after BSFT treatment, but families in the GC showed statistically significant deterioration.
According to assessments using the Family Environment Scale, adolescent-reported cohesion showed a significant increase after BSFT treatment, but not within the GC condition in families in the worse family cohesion group.