When it comes to drug abuse treatment in the community, sticking to the script helps. It’s not always easy to take the practices developed in a clinical trial and reproduce them in real-world settings, but research has shown again and again that maintaining fidelity to the treatment improves clinical outcomes. Encouragingly, research has also shown that it is possible to transport treatments into the community with high fidelity.

Given the importance of fidelity – both the extent to which therapists implement key aspects of the clinical model (adherence) and how well they do this (competence) – the next question is: can fidelity and adherence be measured? Moreover, are there measurement techniques that can capture the complexity of adherence in multi-phase, family-based interventions where different skills are required from the therapist at different stages?

A recent study argues that a new measure of adherence can indeed “capture and discriminate between distinct dimensions of family therapy.” Even more important, the new measure sheds light on the way effective treatments unfold during the course of complex family-based interactions.

Positive drug outcomes, the researchers found, were predicted not by the techniques of the therapist overall, but by the therapist’s use of different techniques at different phases. In other words, it was the process that was crucial.

The case of Brief Strategic Family Therapy
Researchers from the University of Miami and Sam Houston State University used the case of Brief Strategic Family Therapy (BSFT) to test an adherence measure that tracked four strategies used at different phases of the therapy, and to see whether adherence contributed to outcomes.

The team, which included Michael Robbins, now Director of Research for Functional Family Therapy, Inc., and BSFT’s developer José Szapocznik, examined the four types of interventions that therapists are expected to use at different times. BSFT, which the Blueprints database ranks as a “Promising” program, seeks to address family interactions that are associated with adolescent substance misuse and related behavior problems.

Early sessions are characterized by the therapist’s “joining” interventions, such as mimicking the family style, designed to establish a therapeutic alliance with individuals and the family. Early sessions also include “tracking and diagnostic enactment” interventions intended to identify family strengths and weaknesses and develop a treatment plan. For this to happen families are encouraged to behave as they would if the therapist were not present.

“Reframing” interventions are used to reduce family conflict and create a sense of hope or possibility for positive change. The therapist offers the family new and more positive ways to see themselves, each other, and the situation.

While these three strategies should continue throughout treatment, the focus shifts in later stages to implementing the fourth, “restructuring” activities, to transform family relations from problematic to effective and mutually supportive. These include helping families develop skills in conflict resolution, effective behavior management, and parenting.

Measuring adherence
The study sought to test an adherence measure that tracked these four strategies. The research involved 480 mostly male and Hispanic adolescents and their family members. They were randomized to BSFT or to treatment as usual. Eight outpatient community treatment providers were involved, with four or more therapists at each site.

Therapists received 96 hours of training and attended weekly group supervision. At the same time, BSFT “adherence raters” were given 80 hours of training before rating a random selection of video-taped sessions using a 20-item adherence form that covered the four clinical strategies used in BSFT. Each item was scored between 1 (poor) and 5 (excellent).

Adolescent drug use was measured via interview, using a calendar and other memory prompts to obtain retrospective reports of daily drug use. Family functioning was measured using standardized measures applied to youth and parents.

The results supported the structure of the adherence measure, showing that it is possible to capture and discriminate between distinct dimensions of family therapy. Therapist interventions followed a pattern consistent with BSFT theory. “Joining” interventions were higher in the early stage than later. “Restructuring” interventions, which were low early on, increased dramatically after family members had been successfully engaged.

“Little ‘o’ and big ‘O’ outcomes”
This finding, the authors say, shows that therapists based in community agencies can be trained to deliver an evidence-based program – even a complex, multi-phase program – in an adherent manner.

Most important, the study findings also demonstrated that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning and reductions in adolescent drug use. Indeed, the phasing of the four interventions was crucial. Positive drug use outcomes were predicted by less sharp declines in “joining” and by a sharper increase in “restructuring” over the course of the treatment.

In other words, it was not the overall level of the interventions that was critical, but rather their trajectory. This would not have been picked up by a “global” measure of adherence. “Tracking” and “reframing” were not directly related to clinical outcomes, but they were associated with engagement and retention, which are themselves important to outcomes.

BSFT sees outcome as “a process that unfolds throughout treatment”. Early on there are small changes tied to specific interventions. Then these build and evolve throughout therapy, eventually leading to ultimate outcomes observed following completion of treatment.

Put another way, there are ‘little o’ outcomes and ‘big O’ outcomes, with specific interventions tied to each.

Unlike previous measures, the new adherence measure developed here has the complexity and specificity to capture these process-outcome links, although it is tied specifically to BSFT. But understanding the techniques most responsible for treatment success will help sharpen the focus and efficiency of therapist training and supervision.

Reference
Robbins, M. S., Feaster, D. J., Horigian, V. E., Puccinelli, M. J., Henderson, C. and Szapocznik, J. (2011). Therapist adherence in Brief Strategic Family Therapy for adolescent drug abusers. Journal of Consulting and Clinical Psychology 79(1), 43-53.