Program Goals/Target Population
Multidimensional Family Therapy (MDFT) is a manualized family-based treatment and substance abuse prevention program developed for adolescents with drug and behavior problems and delinquency. It is typically delivered in an outpatient setting, though it can also be used in inpatient settings.
There are two intermediate intervention goals for every family: helping the adolescent achieve an interdependent, developmentally appropriate attachment bond to parents and family, and helping the adolescent build strong connections and achieve success in critical systems outside of the family, including school/vocational training, prosocial peer groups, recreational pursuits, and other positive outlets such as spiritual supports.
The treatment seeks to significantly reduce or eliminate an adolescent’s substance abuse and other problem behaviors and improve overall family functioning through multiple components, assessments, and interventions in four core domains areas of life (adolescent, parent, family, and community). Objectives for the adolescent include transforming a drug-using lifestyle into a developmentally normative lifestyle, and improving functioning in several developmental domains. Objectives for the parent include facilitating parental commitment and investment, improving the overall relationship and day-to-day communication with the adolescent, and increasing knowledge about and changes in parenting practices (e.g., limit setting, monitoring, appropriate autonomy granting). Objectives for the family include reduced conflict; improved relationships and greater cohesion; and more effective problem solving, family management practices, communication, and negotiation. Objectives for the community domain include building protective factors in external systems of influence, such as neighborhood, school, health, mental health, social services, and peer supports, and reducing risk factors that may include deepening involvement with juvenile justice and negative peers, as well as school failure.
Trained therapists conduct work with an individual adolescent, his/her parents, and other family members. Therapy sessions are conducted with the adolescent and family at the appropriate intensity and duration for their level of need. Sessions can be delivered one to three times per week, and are usually delivered over a course of 4 to 6 months. Therapists work on a team, with a therapist assistant delivering many of the community interventions. Sessions are held in the family’s home, in the clinic, or at community locations in collaboration with the youth. Different versions of MDFT offer the program in juvenile justice settings, including jails, detention centers, day treatment programs, and residential treatment facilities.
The four domains listed above organize the treatment, with the therapist working simultaneously and systematically linking interventions that occur in each domain. In the adolescent domain, therapists help adolescents engage in treatment; communicate effectively with parents; develop coping, emotion regulation, and problem-solving skills; improve social competence and school/work functioning; and establish alternatives to substance use and delinquency. In the parent domain, therapists work with parents to engage them in therapy, increase their behavioral and emotional involvement with the adolescent, improve parenting skills (e.g., monitoring), and address their role and responsibility as a parent. The family domain focuses on improving family relationships and overall functioning, and the community domain builds family competence within social systems.
In general, work in these domains is completed over three phases. The first phase focuses on building motivation for change with the adolescent, family members, and external supports, as well as the establishment of multiple therapeutic alliances and assessment of the adolescent’s and family members’ life and relationship building. The second phase is most intense, and focuses on requesting changes in relationships, problem solving, and important areas of functioning identified in the first phase. Tasks in this middle phase emphasize decision making, communication skills, and problem-solving skills. Parents focus on improving parenting styles and family interactional patterns. In the final phase, the therapist works with the youth and family to be able to generalize and extend the use of these new skills in new situations and to anticipate potential challenges and develop plans to address them following treatment. This phase focuses on change maintenance.
Treatment is framed by 10 principles (Liddle et al., 2005):
- Adolescent drug abuse is a multidimensional phenomenon.
- Problem situations provide information and opportunities.
- Change is multidetermined and multifaceted.
- Motivation is malleable.
- Working relationships are critical.
- Interventions are individualized.
- Planning and flexibility are two sides of the same therapeutic coin.
- Treatment and its multiple components are phasic.
- Therapist responsibility is emphasized.
- Therapist attitude and behavior are fundamental for success.
MDFT is influenced by family therapy, developmental psychology and psychopathology, the risk and protective factors framework, and ecological and family systems theories. A multidimensional approach is based on the recognition that many factors contribute to drug use initiation and drug abuse, including social–cognitive factors, psychological functioning, values and beliefs, family and peer factors, and environmental and social–cultural influences (e.g., school, media). The multidimensional perspective suggests that symptom reduction and enhancement of prosocial and appropriate developmental functions occur by facilitating adaptive developmental events and processes in several domains of functioning. MDFT thus focuses on intervening in the risk and protective individual adolescent and parent, family, and community level circumstances and processes to achieve a healthier developmental trajectory.
MDFT is a flexible treatment system, rather than a “one-size-fits-all” approach; thus it can be tailored for use with a variety of populations and in office-based or community/home settings (Liddle et al., 2010; Liddle et al., 2002, 2006). Interventions are directed simultaneously at the individual, relationship, and family–community levels. Changes in one domain are used to facilitate change in others. The program can be used for prevention, early intervention, standard outpatient, intensive outpatient treatment, day treatment, or even integrated within residential treatment.
Liddle and colleagues (2001) used an experimental design to assess the impact of three programs on adolescent drug use, antisocial and delinquent behaviors, and family functioning.
One hundred and eighty-two clinically referred marijuana- and alcohol-abusing adolescents were randomized to one of three treatments: Multidimensional Family Therapy (MDFT, n=47), Adolescent Group Therapy (AGT, n=53), or Multifamily Educational Intervention (MFEI, n=52). Thirty adolescents refused treatment. The amount of treatment in all three treatment conditions was controlled so each treatment consisted of 14 to 16 weekly, office-based therapy sessions. A theory-based multimodal assessment strategy measured symptom changes and prosocial functioning at intake, termination, and 6 and 12 months following termination.
Participants were drug-using adolescents who had, on average, a 2 ½-year history of drug use at the time of intake. The age range of participants was 13 to 18 years, with a mean age of 15.9 years. Eighty percent were male. Fifty-one percent were white non-Hispanic, 18 percent were African American, 15 percent were Hispanic, and 16 percent were of other ethnicities. Forty-eight percent came from single parent households, 31 percent came from two-parent households, and 21 percent lived with a stepparent. Median yearly family income was $25,000. Youth were primarily polydrug users, coupling near-daily use of marijuana and alcohol with weekly use of cocaine, hallucinogens, or amphetamines. Sixty-one percent were on juvenile probation.
Treatments were delivered by experienced community clinicians trained in model-specific competence. Attrition was 30 percent from MDFT (n=14), 35 percent from MFEI (n=18), and 47 percent from AGT (n=25).
Liddle and colleagues (2008) used an experimental design to examine effects of MDFT in comparison with cognitive-behavioral therapy (CBT) on drug use.
Two hundred and eighty-seven youth from a community-based drug abuse clinic were referred to the study; 224 completed an intake interview and agreed to participate. These adolescents were randomly assigned to one of two treatments (MDFT or individual CBT). Youth were between the ages of 12 and 17.5 years. The final sample was primarily male (81 percent), African American (72 percent), from single-parent households (58 percent), and had low income (38 percent reported total yearly family income of less than $10,000; 23 percent reported income between $10,000 and $20,000)—with 41 percent of families receiving public assistance. Forty-eight percent were referred by the juvenile justice system, 36 percent were from child welfare services agencies, 11 percent were from schools, and 5 percent were from other sources. All youth were drug users.
Five measures of drug use or abstinence (substance use problem severity, 30-day frequency of cannabis use, 30-day frequency of alcohol use, 30-day frequency of other drug use, 30-day abstinence) were assessed at intake, at the end of treatment, and again at 6 and 12 months following treatment termination. The analyses employed latent growth curve modeling (LGM) to assess individual client change.
Liddle and colleagues (2009) used an experimental design to assess the impact of MDFT and a peer group intervention with young teen substance users.
One hundred and thirty adolescents were referred to the study—45 percent by the juvenile justice system, 41 percent by schools, 2 percent by substance abuse/mental health facilities, and 12 percent by other sources (e.g., parents). Eighty-three were eligible and consented to participate. Seventy-four percent of participants were male; 42 percent were Hispanic, 38 percent were African American, 11 percent were Haitian or Jamaican, 3 percent were white non-Hispanic, and 4 percent were of other ethnicities. Forty-seven percent were involved in the juvenile justice system. Fifty-three percent lived in single parent homes, and median family income was $19,000. Youth ranged from 11 to 15 years of age; the average age was 13.73 years.
Youth and parents were assessed at intake, at 6 weeks post-intake, at discharge, and at 6 and 12 months following intake. Measures included the primary outcomes of substance use, delinquency, and internalized distress, and the secondary outcomes of family functioning, peer delinquency, and school functioning. Treatment lasted 4 months and was delivered by community agency therapists. Analyses used LGM. Ninety-seven percent of MDFT youth completed treatment; 72 percent of group therapy participants completed treatment.
Liddle and colleagues (2001) found that Multidimensional Family Therapy (MDFT) resulted in the greatest and most consistent improvements in adolescent substance abuse and associated behavior problems.
The MDFT group had the greatest number of youth with a clinically significant reduction in drug use—45 percent versus 32 percent in Adolescent Group Therapy (AGT), and 26 percent in Multifamily Educational Intervention (MFEI).
There were no differences between groups in problem behaviors.
Only adolescents in the MDFT group reported significant improvements in grade point average. One year after treatment, 76 percent of MDFT youth had a C average or better (only 25 percent of youth had a C average or better when they were assigned to the MDFT group). For MFEI youth, 36 percent had a C average or better at program entry, which increased to 40 percent 1 year after treatment. For AGT youth, 43 percent had a C average or better at treatment entry, which increased to 60 percent 1 year posttreatment.
Only adolescents in the MDFT group reported significant improvements in family competence, moving from the behaviorally incompetent to the competent range. AGT families showed no change, while MFEI families demonstrated deterioration of the family functioning scales.
While Liddle and colleagues (2008) found that both group cognitive-behavioral therapy (CBT) and MDFT were effective in reducing cannabis and alcohol use, these reductions did not differ significantly between groups during treatment. However, MDFT participants reported significantly less substance use problem severity at the 6- and 12-month follow-up assessments than CBT participants, with larger effect sizes at 12 months than at 6 months. This result indicates that MDFT youth were better able to retain their treatment gains than CBT youth.
Both treatment groups experienced statistically significant reductions for other drug use, with results favoring MDFT.
Sixty-four percent of MDFT youth reported minimal or no substance use at the 12-month follow-up, while 44 percent of CBT youth reported minimal or no substance use—a statistically significant difference. This result indicates that MDFT youth were better able to retain their treatment gains than CBT youth.
Substance Use Problems and Frequency
Liddle and colleagues (2009) found that both the MDTF and peer group intervention groups showed reductions in the number of youth reporting substance use problems during the 1-year follow-up. MDFT participants experienced a more rapid decrease in substance use problems over the 12-month period (effect size d = .74). In a test of clinical significance, MDFT participants reported an average number of substance problems at 12 months comparable to a low-risk sample.
The proportion of youth abstaining from alcohol and drug use increased overall in the 12-month follow-up period. MDFT youth reported fewer days of substance use (effect size d = .77).
Although the overall sample did not significantly improve in either the proportion abstaining from delinquent behavior or frequency of delinquency behavior, youth receiving MDFT decreased their (log) delinquent behavior more rapidly than youth receiving peer group treatment (effect size d = .31). MDFT participants were less likely to be arrested or placed on probation during the 12-month follow-up.
MDFT youth demonstrated reduced scores on internalized distress more rapidly than group treatment participants (effect size d = .54).
Family Functioning, Peer Delinquency, and School Functioning
Overall, MDFT youth and group therapy youth did not report statistically significant increases in positive family interactions. However, MDFT youth reported greater improvement in youth-reported positive family interactions during treatment that were maintained in the follow-up period (effect size d = .27). They also reported greater decreases in negative family interactions during treatment that were maintained during the follow-up period (effect size d = .53).
Youth in both conditions showed decreases in affiliation with delinquent peers, but MDFT youth more rapidly decreased their affiliation during treatment, and maintained those gains during the follow-up period (effect size d = .67).
Academic performance of group treatment youth declined over time, while MDFT participants improved significantly. Conduct grades improved for MDFT youth and declined for group treatment youth (effect size d = .35).