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

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

National Institute on Drug Abuse: RO1 DA 018183

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

.

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)

CYTCannabis Youth Treatment Experiment: A Collaborative Study of the Effectiveness of Treatment for Cannabis Use Disorders

Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

Coordinating Center:Chestnut Health Systems, Bloomington, IL, and Chicago, ILUniversity of Miami, Miami, FLUniversity of Connecticut Health Center, Farmington, CT

Sites:Univ. Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hospital of Phil., Philadelphia, PA

Treatment SeriesC

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CYT

1. Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5)

2. MET/CBT12 (uses Cognitive Behavior Therapy 7 [CBT7] manual)

3. Family Support Network (FSN) –uses MET/CBT5 and 7 manuals PLUS FSN manual

4. Adolescent Community Reinforcement Approach (ACRA)

5. Multidimensional Family Therapy (MDFT)

Treatment SeriesC

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CYT






Treatment SeriesC

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CYT






Treatment SeriesC

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CYT






Treatment SeriesC

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Randomly assigned to:

MET/CBT5Motivational Enhancement Therapy/

Cognitive Behavioral Therapy (5 weeks)



FSN

Family Support Network

Plus MET/CBT12 (12 weeks)

Trial 1

Two Study Trials

N = 300

ACRAAdolescent Community

Reinforcement Approach(12 weeks)

MDFTMultidimensional Family Therapy

Trial 2

Randomly assigned to:



(12 weeks)

N = 300

Design

Inclusion Criteria: 12 to 18 year olds with symptoms of cannabis abuse or dependence, past 90 day use, and meeting criteria for outpatient treatmentData 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 AnalysesFollow-up rates were 94% or better at 3, 6, 9, & 12 months post intake

Demographic Characteristics

62%

15%

55%50%

30%

83%

17%

0%

20%

40%

60%

80%

100%

Female Male AfricanAmerican

Caucasian Under

15 to 16 Singleparentfamily

15

Institutional Involvement

25%

87%

47%

62%

0%

20%

40%

60%

80%

100%

In school Employed Current CJInvolvement

Coming fromControlled

Environment

Patterns of Substance Use

9%

17%

71%73%

0%

20%

40%

60%

80%

Weekly Tobacco Use

WeeklyMarijuana Use

Weekly AlcoholUse

Significant Time

in ControlledEnvironment

Multiple Problems are the Norm

86%

37%

12%

25%

61%

60%

66%

83%

83%

0% 20% 40% 60% 80% 100%

Any Marijuana Use Disorder

Any Alcohol Use Disorder

Other Substance Use Disorders

Any Internal Disorder

Any External Disorder

Lifetime History of Victimization

Acts of Physical Violence

Any (other) Illegal Activity

Three to Twelve Problems

Self-Reported in Past Year

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

Type of ServiceMET/CBT5

MET/CBT12 FSN ACRA MDFT

2

2

2

3 10 10

6

10

6

2 3

4 2 6

5 12 22 14 15

Case management/Other Contacts

As needed

As needed

As needed

Total Expected Contacts 5 12 22+ 14+ 15+

Total Expected Hours

Total Expected Weeks

5 12 22+ 14+ 15+

6-7 12-13 12-13 12-13 12-13

5

10

5

11

14

23

0

5

10

15

20

25

MET/CBT5

MET/CBT12

MET/CBT12 +

FSN

MET/CBT5

ACRA MDFT

Hou

rs

Day

s

CaseManagement

FamilyCounseling

Caregiver only

Multi-Familygroup

Multi-ParticipantGroup

Participant only

Trial 1 Trial 2

Actual Treatment Received by Condition

Source: Dennis et al, 2004

92% engaged

FSN, ACRA and MDFT all include types of family

sessions

CYT Increased Days Abstinent and Percent in Recovery

(no use or problems while in community)

Source: Dennis et al., 2004

0

10

20

30

40

50

60

70

80

90

Intake 3 6 9 12

Day

s A

bsti

nent

Per

Qua

rter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% in

Rec

over

y at

the

End

of

the

Qua

rter

Percent in Recovery

Days Abstinent

Similarity of Clinical Outcomes by Conditions


200

220

240

260

280

300

Tot

al d

ays

abst

inen

t.

over

12

mon

ths

0%

10%

20%

30%

40%

50%

Per

cent

in R

ecov

ery

.

at M

onth

12

Total Days Abstinent* 269 256 260 251 265 257

Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19

MET/ CBT5 MET/ CBT12

FSN MET/ CBT5 ACRA MDFT

Trial 1 Trial 2

* n.s.d. effect size f=0.06

** n.s.d., effect size f=0.12

* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16

Moderate to large differences in Cost-Effectiveness by

Condition


$0

$4

$8

$12

$16

$20

Cos

t per

day

of

abst

inen

ce o

ver

12 m

onth

s

$0

$4,000

$8,000

$12,000

$16,000

$20,000

Cos

t per

per

son

in r

ecov

ery

at m

onth

12

CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38

CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775

MET/ CBT5MET/

CBT12FSN MET/ CBT5 ACRA MDFT

* p<.05 effect size f=0.48** p<.05, effect size f=0.72

Trial 1 Trial 2

* p<.05 effect size f=0.22

** p<.05, effect size f=0.78

MET/CBT5 and 12 did better

than FSN

ACRA did better than MET/CBT5, and both did better than MDFT

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?

Path Model with Services & Other Process Measures

Cohesion

Conflict

RecoveryEnvironment

SocialRisk

SubstanceFrequency

SubstanceProblems

.26

.30 .12

-.14

.27

.14

.49

.18

Baseline ValueFamily

Family

Index

Index

(FES)

(FES)

Source: Godley, Kahn et al., 2005

Risk


Multi-FamilyCohesion

Conflict

RecoveryEnvironment

SocialRisk

SubstanceFrequency

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14

.49

.18


Hours

Index

Index

(FES)

Family

(FES

Risk


SingleFamily

Multi-FamilyCohesion

Conflict

SocialSupport

RecoveryEnvironment

SocialRisk

SubstanceFrequency

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14

TreatmentSatisfaction

ServiceDiversity

.49

.30

.11

.18

-.08


Family

Hours

Hours

Index

Index

(FES)

(FES)

.18

Risk


SocialSupport

RecoveryEnvironment

SocialRisk

SubstanceFrequency

.45

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14


ServiceDiversity

.49

-.12

.30.18

.11

.18

-.08

Baseline ValueMulti-Family

Hours

CaseManagement

Hours

SingleFamilyHours

Index

Index

ConflictFamily

(FES).14

Cohesion(FES)

Family

Risk


.15Social

Support

Recovery Environment

SocialRisk

SubstanceFrequency

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14


ServiceDiversity

.49

-.12

.14

.30

.19

.18

.11

.18

-.08


Hours

SingleFamilyHours

Cohesion(FES)

Family

ConflictFamily

(FES)

IndividualHours

CaseManagement

Hours

Risk Index

Index


Single Family

GroupHours

SocialSupport

RecoveryEnvironment

SocialRisk

SubstanceFrequency

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14

IndividualHours


ServiceDiversity

.49

-.12

.14

.30

.11

.19

.18

.22 .11

.18

-.08

.10


Hours

CaseManagement

Hours

Hours

Cohesion(FES)

Family

ConflictFamily

(FES)

Risk Index

Index

-.08


Single Family

GroupHours

.27

.23

.15Social

Support

.23Recovery

Environment

.16SocialRisk

.28

SubstanceFrequency

.45

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14

CaseManagement

IndividualHours

Alliance

.23TreatmentSatisfaction

.19ServiceDiversity

.49

-.12

.10

.14

.30

-.13

.11

.19

.18

.22.11

-.08

.33

.18

-.08

.10


Hours

Hours

Hours

Cohesion(FES)

Family

ConflictFamily

(FES)

(WAI)

Risk Index

Index


Single Family

GroupHours

.27

.23

.15Social

Support

.23Recovery

Environment

.16SocialRisk

.28

SubstanceFrequency

.45

SubstanceProblems

.26

.30 .12

-.14

.27

.12

.14

CaseManagement

IndividualHours

Alliance

.23TreatmentSatisfaction

.19ServiceDiversity

.49

-.12

.10

.14

.30

-.13

.11

.19

.18

.22.11

-.08

.33

.18

-.08

.10


Hours

Hours

Hours

Cohesion(FES)

Family

ConflictFamily

(FES)

(WAI)

Index

Risk Index

CFI=.914

RMSEA =.048

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

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 servicesClinicians ‘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’

Conclusions/Recommendations

Family-related factors appear to be predictive of outcome; direct links between family therapies and outcomes are less evidentFamily-related procedures necessary for clinical ‘acceptability’ of an adolescent interventionFindings provide support ‘packages’ of services due to the relation of service diversity to outcomeComparing family to non-family treatment conditions not a relevant question for by the practice communityIncrease 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

Contact Information

Susan H. Godley, Rh.D.

Chestnut Health Systems

720 W. Chestnut St.

Bloomington, IL 61704

309.829.3543 ext.83343

[email protected]

Documents

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