Therapist Adherence in Brief Strategic Family Therapy for Adolescent Drug Abusers

As priorities in drug abuse treatment research have shifted toward transporting evidence-based treatments from research to community practice settings (Miller, Sorensen, Selzer, & Brigham, 2006; National Institute on Drug Abuse [NIDA], 2004), establishing and maintaining fidelity to treatment has achieved a high degree of importance. Treatment fidelity is challenged in real-world settings in many ways, as investigators typically have less control over therapist selection and the formation of procedures to monitor clinical activities. Also, therapists in real-world settings often carry larger caseloads than therapists in clinical trials and have multiple roles within their agency. In contrast to efficacy trials in which supervision and clinical services are covered within the budget and scope of work of the trial, community agencies’ business models require that they recover a certain number of billable hours from each therapist. Despite these concerns, recent studies have suggested cause for optimism by demonstrating that treatments can be transported to the community with high fidelity to core treatment philosophies and techniques (Henggeler, Schoenwald, Liao, Letourneau, & Edwards, 2002; Liddle et al., 2006). The successful dissemination of evidence-based interventions is particularly salient for family-based interventions for adolescents with drug use, delinquency, and associated problem behaviors because hundreds of community agencies (and thousands of therapists)— both nationally and internationally— have been trained to provide empirically based family services such as brief strategic family therapy (Szapocznik, Hervis, & Schwartz, 2003), functional family therapy (Alexander, Pugh, Parsons, & Sexton, 2000), multidimensional family therapy (Liddle et al., 2002), multidimensional treatment foster care (Chamberlain & Mihalic, 1998), and multisystemic therapy (Henggeler & Borduin, 1990). Family therapy research has examined the critical relationship between treatment fidelity (adherence and competence) and clinical outcomes. The term adherence is used to denote the extent to which therapists are implementing key aspects of a clinical model, whereas competence refers to the quality with which the therapist implements these aspects. In general, findings indicate that higher rates of adherence have predicted better clinical outcomes (Hogue et al., 2008; Huey, Henggeler, Brondino, & Pickrel, 2000). Additionally, the relationship between fidelity and outcome has also been established when transporting family-based treatments to community settings (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997). Prior research on treatment fidelity has included different methods for identifying treatment adherence or competence. Henggeler and colleagues have used therapist and family member self-reports to identify adherence to nine key principles of multisystemic therapy (Henggeler et al., 1997), whereas Hogue et al. (2008) used observational methods to capture extensiveness of model-consistent therapist interventions in the four core domains of multidimensional family therapy. The strength of adherence–outcome and competence– outcome relationships may be influenced, in part, by the theoretical specificity of these measures and rigorous methods that were used to collect data in prior studies. Fidelity to empirically based family interventions requires a range of therapeutic skills, including both relational (interpersonal) and structuring (directive) behaviors. Successfully implementing evidence-based family therapy models involves tailoring interventions during moment-to-moment transactions to meet phase-specific goals of treatment. In fact, across all of the empirically supported family therapy approaches, the phase-based nature of change is highlighted, with each phase consisting of specific therapist skills and goals. A major challenge in prior research on therapist fidelity has been to measure and analyze in-session behaviors adequately enough to capture this complexity. For example, although the Hogue et al. (2008) adherence construct is composed of therapist interventions consistent with the theoretical underpinnings and techniques of multidimensional family therapy (Liddle et al., 2002), previous adherence studies with this model have operationalized adherence as a global composite measure (with possible adolescent-focused and family-focused facets; Hogue, Dauber, Samuolis, & Liddle, 2006) rather than focusing on the more specific behaviors therapists apply on a moment-to-moment basis. Similarly, the measurement of adherence in multi-systemic therapy provides a general impression of the extent to which key principles were implemented but does not provide an independent perspective on the specific interventions that occur during sessions. Taken together, the results of adherence studies in family therapy have been useful for establishing adherence– outcome links. However, the measures have not adequately captured the complexity of family-based interventions, nor have they adequately attended to the phase-based nature of adherence to family therapy (e.g., the specific behaviors to which therapist adherence should look different in early sessions compared with later sessions). Thus, the focus of this study was to examine adherence ratings from a multisite, prospective, randomized clinical trial to identify the presence of theoretically based clinical interventions in Brief Strategic Family Therapy (BSFT). The BSFT treatment (Szapocznik et al., 2003) is an evidence-based approach that systematically targets adolescent drug use and behavior by improving family functioning. Interventions are delivered in phases, starting with joining with individual family members and the family system and building to structured and directive interventions intended to facilitate new behaviors and family interactions. The present study pursues five aims: (a) examine the factor structure of the theoretically derived BSFT Adherence Scale (i.e., with four types of behaviors: joining with individual family members and the family system, tracking and eliciting family interactions, creating a motivational context for change, and restructuring family interactions); (b) validate the dimensions of the BSFT Adherence Scale by examining convergence with clinical supervisors’ competence ratings; (c) use the distinct domains identified by this measure to differentiate therapeutic interventions delivered early, middle, and late in treatment; (d) examine differences in the rates of these domains in cases that failed to engage (attend fewer than two sessions), failed to retain (attend between two and seven sessions), and completed treatment (attend eight or more sessions); and (e) examine the relationship between levels and timing of therapist behaviors and reductions in adolescent drug use and improvements in family functioning.