Mental Health Disorders In Adolescents And Treatment Invention Write an Article overview on two PowerPoint Slides on ” Brief Strategic Family Therapy: Enga

Mental Health Disorders In Adolescents And Treatment Invention Write an Article overview on two PowerPoint Slides on ” Brief Strategic Family Therapy: Engaging Drug Using/Problem Behavior Adolescents and their families in Treatment” (Article will be provided) and a one to two page paper on Family therapy engaging Drug using/problem behavior adolescents and their families in treatment ( peer review Scholar article) – (1)Paper should include presenting problems/diagnostic criteria of the mental health: (problem: chemical dependency and withdrawal symptoms between using). (2) Impact this concern has on the child or adolescents’s environment – school, family and interpersonal. (3)Treatment invention (4) any additional information that may be helpful Social Work in Public Health, 28:206–223, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1937-1918 print/1937-190X online
DOI: 10.1080/19371918.2013.774666
Brief Strategic Family Therapy: Engaging Drug
Using/Problem Behavior Adolescents and
Their Families in Treatment
José Szapocznik, Monica Zarate, Johnathan Duff, and Joan Muir
Brief Strategic Family Therapy Institute, Center for Family Studies, University of Miami
Miller School of Medicine, Miami, Florida, USA
Despite the efficacy of family-based interventions for improving outcomes for adolescent behavior
problems such as substance use, engaging and retaining whole families in treatment is one of the
greatest challenges therapists confront. This article illustrates how the Brief Strategic Family Therapy
model, a family-based, empirically validated intervention designed to treat children and adolescents’
problem behaviors, can be used to increase engagement, improve retention, and bring about positive
outcomes for families. Research evidence for efficacy and effectiveness is also presented.
Keywords: Family therapy, engagement, adolescent, substance use, family
INTRODUCTION
The Johnson family includes 15-year-old Andrew, his mother Mrs. Johnson, stepfather Mr. Johnson,
and 13-year-old son Jordan, and mother and stepfather’s 5-year-old son, Malik. Andrew was referred for
treatment by the Probation Officer assigned to his case after his recent release from an inpatient locked
treatment facility for sexual offenders where he was receiving treatment following a sexual incident
involving two neighborhood boys 3 and 4 years younger than he. Andrew had been using alcohol
and drugs at the time of the incident. Mr. and Mrs. Johnson struggled with their son’s incarceration
and consequently only visited him twice during his 16-month stay. Mrs. Johnson reported that upon
returning home, Andrew has been increasingly distant from his family; he now consistently isolates
himself from others. Andrew is also increasingly in conflict with his parents, is performing poorly in
school, and has been using marijuana. Mrs. Johnson worries that Andrew will fall in with the wrong
crowd of peers and continue a dangerous path toward drug use and delinquency. Mr. and Mrs. Johnson
would like to help Andrew but often appear at odds with each other on how to accomplish this goal.
The example of the Johnson family illustrates that Brief Strategic Family Therapy (BSFT) is
designed to treat a range of adolescent behavioral problems that often accompany adolescent
drug use (Jessor & Jessor, 1977; McGee & Newcomb, 1992), such as school underachievement,
This work was supported by NIH Grants U10DA013720 to José Szapocznik, R01DA029081 to Yongtao Guan and
R01DA025694 to Seth Schwartz. José Szapocznik is the developer of Brief Strategic Family Therapy and the University
of Miami holds the registry for the intervention.
Address correspondence to José Szapocznik, University of Miami, 1120 N.W. 10th Ave., Room 1010, Miami, FL
33136, USA. E-mail: jszapocz@med.miami.edu
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oppositional defiance, delinquency, and disengagement from prosocial activities. Although the
focus of the BSFT model is to address drug use and related behavior problems of the adolescent,
therapists accomplish this by working relationally with the entire family. Family relations therefore,
represent the targets for change in concert with the individual problems associated with these
maladaptive family relations. Specifically, the BSFT model aims to strengthen adaptive family
interactions, such as the concerns of Mr. and Mrs. Johnson for Andrew and correct maladaptive
patterns of family interactions, such as Mr. and Mrs. Johnson being at odds with how to approach
Andrew’s problems that could be unwittingly supporting Andrew’s isolation, alienation from the
family, and drug use.
As discussed below, the role of social systems is a central tenet of the BSFT approach and social
work. Clinical social workers will find the BSFT approach to be consistent with their systems training and clinical practice. The BSFT model offers concepts that can be useful to the social worker
in practice such as the emphasis on repetitive patterns of family interactions. When multiproblem
families present for services, the therapist can become overwhelmed by the many urgent issues
confronting (and overwhelming) these families. Attention to repetitive patterns of interactions
among family members allows the therapist to attend to family systemic processes common across
the many problems confronting a family, without getting lost in the multiplicity of urgent contents.
The BSFT model also provides social workers with a set of intervention tools to engage families
in treatment, become an accepted member of the family system so that interventions are more
easily accepted by the family, to create a motivational context for change, and finally to change
the maladaptive patterns of interactions that do not allow families to achieve their own goals.
BRIEF STRATEGIC FAMILY THERAPY
Over the past 30 years, research investigating the effects of psychotherapeutic interventions for
adolescent substance users has demonstrated that involvement of family members in treatment
consistently produces more positive outcomes (Cannon & Levy, 2008; O’Farell & Fals-Stewart,
2003; Williams & Chang, 2000). Although social workers and other human service professionals
as well as public health institutions targeting adolescent drug use such as health care and juvenile
justice systems have acknowledged the necessity of involving families in treatment, engaging
family members remains a serious challenge (Armbruster & Kazdin, 1994; Hornberger & Smith;
2011; Kazdin & Mazurick, 1994; Kazdin, Mazurick, & Bass, 1993; Stanton & Todd, 1981;
Szapocznik et al., 1988). Often families do not show up to the first intake or therapy session, for
instance, or drop before treatment goals are achieved (Flicker et al., 2008; Szapocznik, Kurtines,
Foote, Perez-Vidal, & Hervis, 1986). In one study with adolescent substance users referred to
treatment, it was reported that in usual adolescent services only 22% of the families received
any substance abuse or mental health services (Henggeler, Pickrel, Brondino, & Crouch, 1996).
Research has demonstrated potential, however, for certain family therapy modalities that emphasize
family engagement to enhance retention rates and subsequently improve treatment outcomes
(Stanton & Shadish, 1997).
BSFT is a family-based, empirically validated intervention designed to treat children’s and
adolescents’ problem behaviors such as those presented by Andrew in our case example. Based
on the structural theory of Minuchin (e.g., Minuchin & Fishman, 1981), and the strategic thinking of Haley (1976) and Madanes (1981), the BSFT model targets for change family patterns
of interactions (i.e., repetitive behaviors of family members with each other, such as mother
tells Andrew that he cannot use drugs and father undermines mother by saying, “boys will be
boys”) that may be associated with the adolescent’s drug use and related problem behaviors.
To produce behavior change, BSFT therapists work to increase motivation for behavior change,
reduce concerns about change, identify adaptive interactions and strengthen them, and identify
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troubled family interactions and modify them. BSFT therapists employ four sets of techniques
including joining, tracking and eliciting, reframing/creating a motivational context for change, and
restructuring throughout the treatment process to elicit change.
One of the most important innovations of the BSFT approach has been the belief that challenges
in engaging families into treatment are derived from the same interactional problems maintaining
the adolescent’s problem behaviors. In the Johnson case for example, Mr. and Mrs. Johnson were
often incongruent in their parenting beliefs, preventing them from taking a unified, collaborative
stance in supporting Andrew. Their discrepant parenting opinions similarly represented an obstacle
to entering treatment. The same intervention techniques, namely joining, tracking and diagnostic
enactment, and reframing, therefore were utilized to engage the family into therapy. In this article
we describe how the principles and techniques used in the BSFT approach can be applied by
social workers to engaging family members for treatment and provide a detailed case example of
how this approach looks in practice. We also provide evidence for the efficacy and effectiveness
of BSFT engagement strategies and briefly discuss potential policy implications.
BSFT THEORETICAL UNDERPINNINGS: SYSTEM, STRUCTURE,
AND STRATEGY
The BSFT approach is based on the fundamental assumption that the family is the most proximal
and influential context for child development (Szapocznik & Coatsworth, 1999). As suggested by
Bronfenbrenner (1986), we perceive the family as the principal force shaping the way a child
thinks, feels, and behaves. Research demonstrates that adjusting family interactional patterns can
significantly improve adolescent behavior problems (Liddle & Dakof, 1995; Robbins, Alexander,
& Turner, 2000). The BSFT approach asserts, therefore, that family relations—as the child’s
most proximal social-ecological context—play a central role in the development and maintenance
of behavior problems including drug abuse, and consequently represent a primary target for
intervention.
Fundamental to social work practice is the concept of systems and the impact of the social
ecology on human development and behavior (Hepworth, Rooney, Rooney, Strom-Gottfried, &
Larsen, 2010). The BSFT approach recognizes that although the family is the primary context of
human development, the family itself is also part of a larger social system and, like an adolescent
is influenced by his or her family, the family is influenced by the larger social system in which
it exists (Bronfenbrenner, 1979). For instance, the Johnson family resided in a relatively close,
tight-knit community in which many community members knew about their son Andrew’s recent
difficulties. Their shame, combined with their desire to not draw attention to his incarceration,
influenced Andrew’s presenting symptom of isolation. The BSFT therapist in this case recognized
this sensitivity to contextual factors that created on the one hand risk through peers of substance
abuse, and on the other the family’s shame toward its community that was manifested in Andrew’s
isolation.
Theoretical Underpinnings
The BSFT approach is best articulated around three central constructs: system, structure/patterns
of interactions, and strategy (Szapocznik & Kurtines, 1989).
System. The first construct central to the BSFT approach is a systems approach. Systems
are a basic element of modern family systems theory (Bavelas & Segal, 1982). Systems and
eco-systemic perspectives have long been central to social work theory and practice (Wakefield,
1996). It is not surprising then, that in the authors’ experience, social workers readily learn BSFT.
BRIEF STRATEGIC FAMILY THERAPY
209
A system is an organized whole comprising separate interrelated and interdependent parts. A
family, for example, is a system comprising individuals whose behaviors and interactional patterns
inherently affect each other. The BSFT model is based on the principle that family members
are interdependent: The experiences and behavior of each individual family member affect the
experiences and behavior of all other family members. According to family systems theory, for
example, the troubled adolescent is a family member who displays risk-taking behaviors such
as drug use that reflect, at least in part, what else is going in the interactions among family
members (Szapocznik & Kurtines, 1989). The adolescent’s behavior, therefore, is believed to
reflect larger maladaptive family interactions. The case of the Johnson family, as we explain,
represents an example of how the son Andrew’s problem behaviors, particularly his isolation
and involvement in drugs, co-occurred with maladaptive interactional patterns that prevented the
family from adequately achieving their goal of changing Andrew’s conduct.
Structure. The second construct fundamental to the BSFT approach is structure. The set
of repetitive patterns of interactions within the family system is called the family’s structure. A
maladaptive family structure is characterized by repetitive family interactions in which family
members repeatedly elicit the same unsatisfactory and potentially harmful responses from other
family members. In our case example, Mr. and Mrs. Johnson’s inability to effectively collaborate
on parenting functions interfered with their goals of changing Andrew’s behaviors. In particular,
when the conflict between the parents was around Andrew’s behavior, often the parent in frustration
with each other lashed out at Andrew, causing him to withdraw and pull away from the family.
Strategy. The third essential concept of the BSFT approach is strategy, characterized by
using interventions that are practical, problem focused, and deliberate. Practical interventions
are selected for their likelihood to move the family toward desired objectives. The overarching
goal of BSFT strategy is to target the repetitive maladaptive patterns of family interactions while
strengthening adaptive patterns of interaction that will achieve the caregivers’ goal of reducing
the adolescent’s problematic and risky behavior.
As a problem-focused approach, the BSFT model targets family interaction patterns that are
directly relevant to the youth’s symptoms. As we see in the Johnson family, addressing the conflict
between the two parents was essential to avoid their taking their frustration out on Andrew.
Interventions simultaneously attempted to reduce the attacking and blaming between the parents,
allow for more positive communication that led to collaborative parenting behaviors that could
effectively improve the issues that so much concerned them in Andrew’s behaviors, isolation,
poor school functioning, and drug use. Also, of course, confronting the shame that prevented
them from talking with Andrew about the sexual incident that sent him to jail, was essential to
avoid a similar incident reoccurring.
BSFT intervention strategies are very deliberate, meaning that the therapist identifies the
maladaptive interactions that if changed are most likely to lead to the desired outcomes (i.e.,
adolescent prosocial behavior). For instance, before working on Andrew’s behavior management,
the BSFT therapist has to focus on reestablishing the positive emotional connection between
Andrew and his parents so that their attempt to address his behavior can be viewed as an expression
of concern and love for him and will be less likely to be rejected.
BSFT: THE INTERVENTION
To produce behavior change, BSFT therapists employ four sets of techniques: joining, tracking
and eliciting, reframing/creating a motivational context for change, and restructuring. As Figure 1
indicates, though there is a general sequence to their use, the sequence is used continuously during
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J. SZAPOCZNIK ET AL.
FIGURE 1
Brief Strategic Family Therapy circular theory of change.
the intervention, and early interventions such as joining are often used frequently throughout the
treatment process.
Joining is the process by which the therapist moves from being an outsider to becoming
a member of the therapeutic team that includes the therapist and the family. The fundamental
principle underlying joining is that the therapist must empathize with each family member’s
wants and needs and must offer a tangible way to help each family member to reach her or his
stated goals. Joining includes not only accepting, respecting, and following initially the family’s
unwritten rules and established power structure, but also behaving in ways that blend with the
family. If family members use specific slang words, for example, the therapist may use these
same words when interacting with the family. Social-psychological research has demonstrated
that family members are most likely to trust the therapist when she or he behaves in ways that
are familiar to the family.
A second technique used in the BSFT approach is tracking which diagnostic enactment
interventions are utilized to systematically identify family interactional strengths and weaknesses
that can be used to formulate a treatment plan. A core tactic of tracking and diagnostic enactment
is encouraging the family to behave as they do when the counselor is not present. For instance
encouraging family members to speak directly with one another about the concerns that bring them
to therapy, rather than directing comments to the therapist. One of the primary goals of the Johnson
family for example, was to reduce Andrew’s isolation and distance from other family members.
When Mrs. Johnson revealed this in a session, the therapist encouraged her to state this to Andrew
directly. As family members interact with one another more naturally within session, the therapist
tracks or follows the interactional process and then identifies/diagnoses family strengths as well
as problematic patterns of interactions.
Diagnosis is the process by which the therapist identifies the interactional patterns within the
family that are most closely related to the adolescent’s symptoms. Developing a diagnosis involves
asking the family to interact and observing the specific interactions that involve the adolescent
(either directly or indirectly) and that are most problematic. Families may interact spontaneously,
or the BSFT therapist may need to ask them to interact. One of the most straightforward ways
to prompt an interaction is to redirect to the family communications that were initially directed
toward the therapist. Once the therapist did this with the Johnson family for instance, the therapist
observed how when Mrs. Johnson spoke to Andrew, Mr. Johnson quickly revealed his disagreement
with his wife—thus the family behaved as if the therapist was not present, allowing the therapist
to observe these interactions.
Another set of techniques involves reframing and creating a motivational context for change.
Robbins and colleagues (2006) showed that families are more likely to remain in treatment if their
BRIEF STRATEGIC FAMILY THERAPY
211
interactions are positive and constructive, particularly during the initial therapy session. Negativity
is one of the strongest predictors of early dropout from family therapy, though it also represents
one of the primary reasons why families seek help. One of the most effective ways to reduce
negativity is to reframe (change) the perspective through which an interaction is viewed, thereby
creating a motivational context for change. For example, when Mr. Johnson disagreed with his
wife, the therapist reframed the behavior as “I can see how committed both of you (the parents)
are to doing the right thing for Andrew,” thereby creating a potential motivational context within
which to address the parent’s disagreement with each other. That is, changing the meaning of the
interaction from negative to positive to allow the individuals involved in the interaction to move
to a different level of discussion about their behavior.
Finally, once the therapist has been accepted as a temporary member of the family, maladaptive
family patterns of interactions associated with the adolescent’s problem behaviors have been
identified, a treatment plan can be formulated (i.e., which patterns of interactions need changing).
Once this plan is in place, the therapist is ready to restructure or change the targeted maladaptive
family interactional patterns. Like all BSFT interventions, restructuring interventions work in the
present and can involve a var…
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