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CYT Family Sessions Impact on CYT Process and Outcome

CYT Family Sessions Impact on CYT Process and Outcome. Susan H. Godley, Rodney Funk, Michael L. Dennis, & Mark D. Godley, Chestnut Health Systems. Acknowledgments. SAMHSA’s Center for Substance Abuse Treatment: (TI11317, TI11320, TI11321, TI11323, TI11324) CYT colleagues

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CYT Family Sessions Impact on CYT Process and Outcome

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  1. CYT Family Sessions Impact on CYT Process and Outcome Susan H. Godley, Rodney Funk, Michael L. Dennis, & Mark D. Godley, Chestnut Health Systems

  2. Acknowledgments • SAMHSA’s Center for Substance Abuse Treatment: (TI11317, TI11320, TI11321, TI11323, TI11324) • CYT colleagues • National Institute on Drug Abuse: RO1 DA 018183

  3. Goals for Presentation • Review CYT study design, process, and outcome findings • Review new analyses that examine predictive relationships among family services and adolescent treatment outcomes • Discuss lessons learned about family-sessions from first wide scale CYT implementation

  4. . Funded by: The Center for Substance Abuse Treatment (CSAT) Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Department of Health & Human Services (DHHS)

  5. CYT Cannabis Youth Treatment Experiment: A Collaborative Study of the Effectiveness of Treatment for Cannabis Use Disorders Sites: Univ. Conn. Health Center, Farmington, CT Operation PAR, St. Petersburg, FL Chestnut Health Systems, Madison County, IL Children’s Hospital of Phil., Philadelphia, PA Coordinating Center: Chestnut Health Systems, Bloomington, IL, and Chicago, IL University of Miami, Miami, FL University of Connecticut Health Center, Farmington, CT Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

  6. CYT Treatment Series • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) • MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual) • Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual • Adolescent Community Reinforcement Approach (ACRA) • Multidimensional Family Therapy (MDFT) Cannabis Youth Treatment Experiment

  7. CYT Treatment Series • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) • MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual) • Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual • Adolescent Community Reinforcement Approach (ACRA) • Multidimensional Family Therapy (MDFT) Cannabis Youth Treatment Experiment

  8. CYT Treatment Series • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) • MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual) • Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual • Adolescent Community Reinforcement Approach (ACRA) • Multidimensional Family Therapy (MDFT) Cannabis Youth Treatment Experiment

  9. CYT Treatment Series • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) • MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual) • Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual • Adolescent Community Reinforcement Approach (ACRA) • Multidimensional Family Therapy (MDFT) Cannabis Youth Treatment Experiment

  10. CYT Treatment Series • Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) • MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual) • Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual • Adolescent Community Reinforcement Approach (ACRA) • Multidimensional Family Therapy (MDFT) Cannabis Youth Treatment Experiment

  11. Trial 2 N = 300 Randomly assigned to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) ACRA Adolescent Community Reinforcement Approach(12 weeks) MDFT Multidimensional Family Therapy (12 weeks) Two Study Trials Trial 1 N = 300 Randomly assigned to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) MET/CBT12 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (12 weeks) FSN Family Support Network Plus MET/CBT12 (12 weeks)

  12. Design • Inclusion Criteria: 12 to 18 year olds with symptoms of cannabis abuse or dependence, past 90 day use, and meeting criteria for outpatient treatment • Data Sources: self report, collateral reports, on-site and laboratory urine testing, therapist alliance and discharge reports, staff service logs, and cost analysis. • Intent to Treat Analyses • Follow-up rates were 94% or better at 3, 6, 9, & 12 months post intake

  13. 83% 62% 55% 50% 30% 17% 15% Demographic Characteristics 100% 80% 60% 40% 20% 0% African Female Male Caucasian 15 to 16 Single Under 15 American parent family

  14. 87% 62% 47% 25% Institutional Involvement 100% 80% 60% 40% 20% 0% In school Employed Current CJ Coming from Involvement Controlled Environment

  15. 73% 71% 17% 9% Patterns of Substance Use 100% 80% 60% 40% 20% 0% Significant Time Weekly Weekly Weekly Alcohol Tobacco Use Marijuana Use Use in Controlled Environment

  16. Multiple Problems are the Norm Self-Reported in Past Year

  17. 2 2 2 10 6 3 10 10 Type of Service MET/ CBT5 MET/ CBT12 FSN ACRA MDFT 2 3 4 2 6 6 5 12 22 14 15 As needed As needed As needed 5 5 6-7 12 12-13 12 22+ 12-13 22+ 14+ 12-13 14+ 15+ 15+ 12-13 Planned Contrast of the Treatment Structures Individual Adolescent Sessions CBT Group Sessions Individual Parent Sessions Family Sessions/Home Visits Parent Education Sessions Total Formal Sessions Case management/ Other Contacts Total Expected Contacts Total Expected Hours Total Expected Weeks

  18. FSN, ACRA and MDFT all include types of family sessions Actual Treatment Received by Condition 25 23 Case Management 20 Family Counseling 14 Caregiver only 15 Hours Days 11 10 Multi-Family 10 group 5 5 Multi-Participant 5 Group Participant only 0 MET/ MET/ MET/ MET/ ACRA MDFT CBT5 CBT12 CBT12 + CBT5 FSN 92% engaged Trial 1 Trial 2 Source: Dennis et al, 2004

  19. Days Abstinent Percent in Recovery CYT Increased Days Abstinent and Percent in Recovery (no use or problems while in community) 90 90% 80 80% 70 70% 60 60% 50 50% Days Abstinent Per Quarter % in Recovery at the End of the Quarter 40 40% 30 30% 20 20% 10 10% 0 0% Intake 3 6 9 12 Source: Dennis et al., 2004

  20. Similarity of Clinical Outcomes by Conditions Trial 2 Trial 1 300 50% . 280 40% . Percent in Recovery over 12 months at Month 12 260 30% Total days abstinent 240 20% 220 10% 200 0% MET/ CBT5 MET/ FSN MET/ CBT5 ACRA MDFT CBT12 269 256 260 251 265 257 Total Days Abstinent* 0.28 0.17 0.22 0.23 0.34 0.19 Percent in Recovery** * n.s.d. effect size f=0.06 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16 ** n.s.d., effect size f=0.12 Source: Dennis et al., 2004

  21. ACRA did better than MET/CBT5, and both did better than MDFT MET/CBT5 and 12 did better than FSN Moderate to large differences in Cost-Effectiveness by Condition Trial 2 Trial 1 $20 $20,000 $16 $16,000 $12 $12,000 Cost per person in recovery at month 12 Cost per day of abstinence over 12 months $8 $8,000 $4 $4,000 $0 $0 MET/ MET/ CBT5 FSN MET/ CBT5 ACRA MDFT CBT12 $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPDA* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 CPPR** * p<.05 effect size f=0.48 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.72 ** p<.05, effect size f=0.78 Source: Dennis et al., 2004

  22. But…3 of the 5 CYT Interventions had some type of family sessions (ACRA, FSN, MDFT)—what if we look at different types of family sessions and how they mediate family and substance abuse outcomes?

  23. Path Model with Services & Other Process Measures Baseline Value Family Cohesion -.14 (FES) Recovery Environment Risk Index .18 Family .14 .26 Conflict .27 (FES) Substance .49 Substance Frequency Problems .30 .12 Social Risk Index Source: Godley, Kahn et al., 2005

  24. Path Model with Services & Other Process Measures Baseline Value .12 Family Multi-Family Cohesion -.14 Hours (FES) Recovery Environment Risk Index .18 Family .14 .26 Conflict .27 (FES .49 Substance Substance Frequency Problems .30 .12 Social Risk Index

  25. Path Model with Services & Other Process Measures Baseline Value .12 Family Multi-Family Cohesion -.14 Hours (FES) Recovery Environment Risk Index .18 .14 Family .26 Conflict .27 (FES) .49 Substance Substance Frequency Problems Single Family .18 .30 .30 Service Treatment .12 Social Diversity Hours Satisfaction Risk Index .11 -.08 Social Support

  26. Family Multi-Family Cohesion Hours (FES) Case Management Hours Family Conflict (FES) Single Family Hours Path Model with Services & Other Process Measures Baseline Value .12 -.14 -.12 Recovery Environment Risk Index .18 .14 .26 .27 .14 .45 .49 Substance Substance Frequency Problems .18 .30 .30 Service Treatment .12 Social Diversity Satisfaction Risk Index .11 -.08 Social Support

  27. Family Multi-Family Cohesion Hours (FES) Case Management Hours Family Conflict (FES) Single Family Hours Path Model with Services & Other Process Measures Baseline Value .12 -.14 Recovery Environment -.12 Risk Index .18 .14 .14 .26 .27 .49 Substance Substance Frequency Problems .18 .30 .30 Service .12 Treatment Diversity Satisfaction Social .19 Risk .11 Index Individual Hours .15 -.08 Social Support

  28. Family Multi-Family Cohesion Hours (FES) Case Management Hours Family Conflict (FES) Individual Hours Path Model with Services & Other Process Measures Baseline Value .12 -.14 Recovery -.12 Environment Risk Index .18 .14 .14 .26 .27 .49 Substance Substance .11 Frequency Problems Single Family .18 .30 .30 Service Treatment .12 Diversity Hours Social Satisfaction .19 Risk Index .11 .22 -.08 -.08 Social Support .10 Group Hours

  29. Family Multi-Family Cohesion Hours (FES) Family Conflict (FES) Individual Hours Path Model with Services & Other Process Measures .27 Baseline Value .12 .23 -.14 Recovery Environment -.12 Case Risk Index Management .18 .10 Hours .23 .14 .14 .26 -.13 .27 .45 .28 Alliance -.08 .49 (WAI) Substance Substance .33 .11 Frequency Problems .19 .23 Single Family .18 .16 .30 .30 Service Treatment .12 Diversity Hours Social Satisfaction .19 Risk .11 Index .22 .15 -.08 Social Support .10 Group Hours

  30. Family Multi-Family Cohesion Hours (FES) Family Conflict (FES) Individual Hours Path Model with Services & Other Process Measures .27 Baseline Value .12 .23 -.14 Recovery Environment -.12 Risk Index Case Management .18 .10 Hours .23 .14 .14 .26 -.13 .27 Alliance .45 .28 -.08 (WAI) .49 Substance Substance .33 .11 Frequency Problems .19 .23 Single Family .18 .16 .30 .30 Service Treatment .12 Diversity Hours Social Satisfaction .19 Risk .11 Index .22 .15 -.08 Social CFI=.914 RMSEA =.048 Support .10 Group Hours

  31. And what about implementation of a ‘non-family’ intervention? • In 2003 CSAT initially funded 22 sites to replicate MET/CBT5 • A survey of sites early in the field found that 9/15 had added some type of family component (highly variable) • See family in home • Parent Education • Family psychotherapy • Family Support

  32. Why? • Best practice guidelines say family involvement is critical (Drug Strategies, CSAT Adolescent TIPs) • JCAHO expects to see documentation of family participation in assessments, treatment planning, and treatment, when appropriate.  • Some managed care companies require family participation for reimbursement for services • Clinicians ‘believe in’ the importance of family involvement (Godley et al., 2001) • Belief that one can ‘add to’ a manual-guided intervention easier than ‘taking something away’

  33. Conclusions/Recommendations • Family-related factors appear to be predictive of outcome; direct links between family therapies and outcomes are less evident • Family-related procedures necessary for clinical ‘acceptability’ of an adolescent intervention • Findings provide support ‘packages’ of services due to the relation of service diversity to outcome • Comparing family to non-family treatment conditions not a relevant question for by the practice community • Increase research focus on understanding & enhancing effectiveness of the family components of interventions by more directly targeting environmental risk and social support, and evaluate cost-effectiveness

  34. Susan H. Godley, Rh.D. Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.829.3543 ext.83343 sgodley@chestnut.org Contact Information

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