Adolescent Conduct Disorders

Three family therapy models have proven effective in treating adolescent conduct disorders—functional family therapy, multisystemic therapy, and the Treatment Foster Care Program of the Oregon Social Learning Center (Chamberlain & Reid, 1998). Studies in this area have been exemplary in terms of rigorous, “gold standard” criteria laid out by scholars such as Kazdin and Weisz (1998): (a) multiple randomized clinical trials; (b) well-described, replicable treatment procedures; (c) uniform training of therapists and careful monitoring of their fidelity to the treatment model; (d) use of real-world, clinical samples; (e) broad-based assessment of outcomes; and (f) evidence of long-term outcomes.

To single out the model with the most evidence, multisystemic therapy, created by Henggeler and his colleagues, is a home-based approach that works closely with schools and other community systems (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). Treatment is intensive, involving about 60 hours of direct service over 3 to 6 months. Therapists have small caseloads and are on call to families 24 hours a day, 7 days per week. The clinical procedures in multisystem therapy (MST) are derived from strategic family therapy, structural family therapy, behavior parent training, cognitive–behavioral therapies, and ecosystemic therapies. Psychopharmacological interventions are also incorporated as needed. When parents and other family caregivers have problems that interfere with treatment goals for the adolescent, the therapist helps them get treatment for their problems.

The typical outcome study of MST involves youth presenting with serious antisocial behavior and at acute risk of out-of-home placement. Reduction rates for recidivism have ranged between 25% and 70% across studies in comparison with control groups receiving standard care. MST has produced decreased out-of-home placement days by 47% to 64% compared to usual services, and these differences have held up to 5 years of follow-up (Henggeler & Sheidow, 2002). MST has been demonstrated to be a highly effective way to treat adolescent conduct disorder.

Adolescent Substance Abuse

In their review of family therapy outcomes in adolescent drug abuse, Rowe and Liddle (2003) found family therapy superior to any other intervention. The major models of family therapy shown to be effective are multisystemic therapy, multidimensional family therapy, and functional family therapy. All of these models work intensively with the family and with community systems.

Multidimensional family therapy (MDFT) for adolescent drug abuse was created by Howard Liddle and his colleagues (Liddle et al., 2001) out of structural and strategic family therapy models. MDFT has three phases consisting of individual and family sessions. The first phase builds therapeutic alliances with the adolescent, parents/family, and important stakeholders outside the family. Here goals are set and agreed upon. The second phase helps the adolescent to build skills in handling stress and communicating with others, the parents to develop better skills in relating to the adolescent, and the whole family to learn better ways of dealing with challenges in their relationships. The third phase helps the family learn how to relate to the outside world and to plan for their family life after the therapy ends.

Functional family therapy was developed by James Alexander in the 1970s as a way to treat oppositional children and adolescents and became one of the first evidence-based models in the field (Sexton & Alexander, 2002). Originally a behaviorist, Alexander incorporated strategic family therapy and other models into an integrative approach that starts from the assumption that negative child and adolescent behaviors serve functions within the family, such as attempts to become more connected. Functional family therapists aim to help the family achieve its goals through more constructive means rather than symptomatic means. Reframing the child’s negative behavior as a misguided attempt to do something good for the family is one of the distinctive therapeutic tools in this model. The three phases of treatment are: engagement and motivation, behavior change, and generalization.

In comparison with standard treatments, MDFT, functional family therapy, and MST have been found superior in the following areas summarized by Rowe and Liddle (2003):

Engagement and retention in treatment. These models all have strong family engagement protocols that get resistant adolescents into therapy and keep them in therapy.

Effects on drug use. Family therapy decreases the use of a variety of drugs, including alcohol, marijuana, cocaine, and heroin. These effects tend to be long term.

Related emotional and behavior problems. The multiple system focus is effective at reducing non-drug behavioral problems, especially externalizing problems. Adolescents who have had family therapy improve their school outcomes as well.

Family functioning. Families improve on areas such as cohesion and conflict more than in other therapies.

Cost effectiveness. Initial studies indicate that family therapy is more cost effective than standard treatment programs.