Multidimensional Family Therapy in Cannabis Abusing Teens
Multidimensional Family Therapy in Cannabis Abusing Teens
In 1999, the (junior) Ministers of Health of five Western European countries – Belgium, France, Germany, the Netherlands, and Switzerland – concluded that their countries were fighting each other over cannabis policies without sufficient evidence to support any view. Among other things, they decided to fund a transnational trial – named INCANT (INternational CAnnabis Need for Treatment) – to test an outpatient treatment of cannabis use disorder among youth who frequently have co-occurring problems.
The treatment selected was Multidimensional Family Therapy (MDFT), which has been developed from 1985 onwards by Liddle and co-workers mainly at the Center for Treatment Research on Adolescent Drug Abuse (CTRADA), University of Miami Miller School of Medicine. MDFT is a family based outpatient treatment programme for adolescent problem behaviour targeting major domains in the life of an adolescent. The life domains include the youth him- or herself, parent(s), family, friends and peers, school and work, and leisure time. MDFT views family functioning as instrumental in creating new, developmentally adaptive lifestyle alternatives for the adolescent. MDFT has been tested with success in different adolescent populations, doses and treatment delivery settings.
The history, design, baseline data, and primary (cannabis use related) outcomes of INCANT have been described before. Across our research sites in the five Western European countries mentioned, cannabis use disorder was responsive to treatment. Relative to comparison treatment, MDFT was superior in decreasing the prevalence of cannabis dependence, and excelled in reducing the frequency of cannabis consumption in youth with most severe cannabis use.
We now report on other outcomes of INCANT, i.e., effects on co-morbid mental and behavioural symptoms and on family functioning. We call these outcomes 'secondary' , not because they are of minor importance, but because the primary focus of INCANT was to establish treatment effects on cannabis use variables. In line with previous MDFT research, we assumed MDFT would be effective in reducing mental and behavioural co-morbidity – internalising and externalising symptoms – in our adolescent cannabis abusing trial participants, while also improving family functioning. Teenagers with internalising symptoms are at increased risk of developing anxiety disorders (symptoms such as feeling nervous, fearful, timid) and mood disorders (symptoms such as feeling lonely, unloved, unhappy, worried, inferior). Externalising symptoms (e.g., arguing, being mean or destructive, getting into fights, stealing, setting fires) are associated for instance with conduct disorder and delinquency.
Interactions between substance use, co-morbidity and family factors have been outlined before. In children and adolescents, externalising symptoms and disorders may foreshadow initiation and progression of later cannabis use, and are associated with an increased risk of later cannabis and other substance dependence. The influence of internalising symptoms on these measures is less clear. Family- and peer-related factors may also predict later cannabis use. When family cohesion is low, a teen is more likely to start using cannabis, and family conflict may decrease the success of cannabis treatment in adolescents. Poor family functioning is a shared risk factor for cannabis use and mental disorders in adolescents. In a prospective study, externalising symptoms and family dysfunctioning jointly correlated with a higher risk of developing substance use disorders during adolescence. In other words, externalising symptoms (perhaps also internalising symptoms), poor family functioning, and cannabis use are interrelated phenomena.
Thus, a treatment programme like MDFT may reduce cannabis use (problems) along at least two pathways, i.e., through a direct effect on cannabis use, and indirectly by decreasing the impact of co-morbidity and/or family factors. As for the indirect influences, MDFT generally was more effective than cognitive behavioural therapy (CBT) and other active comparison treatments in decreasing both internalising symptoms and externalising symptoms and behaviours. If the therapist focuses his or her attention not just on the adolescent but also on the family, this may result in better substance use and externalising/internalising treatment outcomes. We know from recent studies that MDFT reduces cannabis use most strongly in adolescents who have the most severe problems (severity in these studies is defined as heavy drug use or a combination of heavy drug use and more extensive comorbidity including family dysfunction).
We examined if MDFT had positive effects in adolescents on comorbid mental and behavioural symptoms and on family functioning. We assumed that MDFT would be more effective than the comparison treatment (individual psychotherapy; IP) in reducing the rate of externalising (more so than internalising) symptoms.
Background
Why INCANT?
In 1999, the (junior) Ministers of Health of five Western European countries – Belgium, France, Germany, the Netherlands, and Switzerland – concluded that their countries were fighting each other over cannabis policies without sufficient evidence to support any view. Among other things, they decided to fund a transnational trial – named INCANT (INternational CAnnabis Need for Treatment) – to test an outpatient treatment of cannabis use disorder among youth who frequently have co-occurring problems.
The treatment selected was Multidimensional Family Therapy (MDFT), which has been developed from 1985 onwards by Liddle and co-workers mainly at the Center for Treatment Research on Adolescent Drug Abuse (CTRADA), University of Miami Miller School of Medicine. MDFT is a family based outpatient treatment programme for adolescent problem behaviour targeting major domains in the life of an adolescent. The life domains include the youth him- or herself, parent(s), family, friends and peers, school and work, and leisure time. MDFT views family functioning as instrumental in creating new, developmentally adaptive lifestyle alternatives for the adolescent. MDFT has been tested with success in different adolescent populations, doses and treatment delivery settings.
The history, design, baseline data, and primary (cannabis use related) outcomes of INCANT have been described before. Across our research sites in the five Western European countries mentioned, cannabis use disorder was responsive to treatment. Relative to comparison treatment, MDFT was superior in decreasing the prevalence of cannabis dependence, and excelled in reducing the frequency of cannabis consumption in youth with most severe cannabis use.
Secondary Outcomes
We now report on other outcomes of INCANT, i.e., effects on co-morbid mental and behavioural symptoms and on family functioning. We call these outcomes 'secondary' , not because they are of minor importance, but because the primary focus of INCANT was to establish treatment effects on cannabis use variables. In line with previous MDFT research, we assumed MDFT would be effective in reducing mental and behavioural co-morbidity – internalising and externalising symptoms – in our adolescent cannabis abusing trial participants, while also improving family functioning. Teenagers with internalising symptoms are at increased risk of developing anxiety disorders (symptoms such as feeling nervous, fearful, timid) and mood disorders (symptoms such as feeling lonely, unloved, unhappy, worried, inferior). Externalising symptoms (e.g., arguing, being mean or destructive, getting into fights, stealing, setting fires) are associated for instance with conduct disorder and delinquency.
Interactions between substance use, co-morbidity and family factors have been outlined before. In children and adolescents, externalising symptoms and disorders may foreshadow initiation and progression of later cannabis use, and are associated with an increased risk of later cannabis and other substance dependence. The influence of internalising symptoms on these measures is less clear. Family- and peer-related factors may also predict later cannabis use. When family cohesion is low, a teen is more likely to start using cannabis, and family conflict may decrease the success of cannabis treatment in adolescents. Poor family functioning is a shared risk factor for cannabis use and mental disorders in adolescents. In a prospective study, externalising symptoms and family dysfunctioning jointly correlated with a higher risk of developing substance use disorders during adolescence. In other words, externalising symptoms (perhaps also internalising symptoms), poor family functioning, and cannabis use are interrelated phenomena.
Thus, a treatment programme like MDFT may reduce cannabis use (problems) along at least two pathways, i.e., through a direct effect on cannabis use, and indirectly by decreasing the impact of co-morbidity and/or family factors. As for the indirect influences, MDFT generally was more effective than cognitive behavioural therapy (CBT) and other active comparison treatments in decreasing both internalising symptoms and externalising symptoms and behaviours. If the therapist focuses his or her attention not just on the adolescent but also on the family, this may result in better substance use and externalising/internalising treatment outcomes. We know from recent studies that MDFT reduces cannabis use most strongly in adolescents who have the most severe problems (severity in these studies is defined as heavy drug use or a combination of heavy drug use and more extensive comorbidity including family dysfunction).
Objectives
We examined if MDFT had positive effects in adolescents on comorbid mental and behavioural symptoms and on family functioning. We assumed that MDFT would be more effective than the comparison treatment (individual psychotherapy; IP) in reducing the rate of externalising (more so than internalising) symptoms.
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