Intervention Summary

Brief Strategic Family Therapy: Family Therapy Training Institute of Miami

See Brief Strategic Family Therapy (BSFT) for past.

Brief Strategic Family Therapy® (BSFT®) is designed to (1) prevent, reduce, and/or treat adolescent behavior problems such as drug use, conduct problems, delinquency, sexually risky behavior, aggressive/violent behavior, and association with antisocial peers; (2) improve prosocial behaviors such as school attendance and performance; and (3) improve family functioning, including effective parental leadership and management, positive parenting, and parental involvement with the child and his or her peers and school. BSFT® is typically delivered in 12–16 family sessions, but may be delivered in as few as 8 or as many as 24 sessions, depending on the severity of the communication and management problems within the family. Sessions are conducted at locations that are convenient to the family, including the family's home in some cases. While early studies were conducted mainly with Hispanic families, the effectiveness study included African American and White American families.

BSFT® considers adolescent symptoms to be rooted in maladaptive family interactions that do not permit the family to achieve its own goals, such as inappropriate alliances between family members, overly rigid or permeable family boundaries, and parents' tendency to blame all family problems on a single individual (usually the adolescent). BSFT® operates according to the assumption that transforming how the family functions will help improve the teen's presenting problem. BSFT®'s therapeutic techniques fall into four categories: joining; tracking, eliciting and diagnosing; reframing; and, restructuring. The therapist initially "joins" the family by encouraging family members to behave in their normal fashion. The therapist then diagnoses repetitive patterns of family interactions. Reframing interventions reduce negativity and create a motivational context for change, which act as springboard for change-producing restructuring interventions that promote new, more adaptive patterns of interactions.

Descriptive Information

Areas of Interest	Mental health promotion Mental health treatment Substance use disorder prevention Substance use disorder treatment
Outcomes	1: Drug use 2: Treatment engagement 3: Treatment retention 4: Family functioning
Outcome Categories	Drugs Social functioning Treatment/recovery
Ages	13-17 (Adolescent)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Home Other community settings
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	See Brief Strategic Family Therapy (BSFT) BSFT® has been in use and under continual development for over 35 years. It has been implemented at approximately 150 sites in the United States, as well as in Chile, Germany, Puerto Rico, and Sweden; and has served more than 10,000 families. The intervention has been used by substance-abuse, mental-health, juvenile-justice, and child-welfare agencies.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: No
Adaptations	Originally developed for Hispanic families, BSFT® has been adapted for use with other ethnic populations, including African American, German, and Swedish families.
Adverse Effects	Among 900 individuals, seven adverse events were determined to be related to the delivery of BSFT®. Four events were classified as "runaway." These events were determined to be related to the intervention because the adolescent ran away from home during, or immediately after, a session. For two events classified as "violence (victim/exposure)," a physical altercation between at least two family members occurred during a therapy session when family members became agitated. The single "arrest" event occurred at the conclusion of one of these two events when a family member was arrested and detained by police.
IOM Prevention Categories	Indicated

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Robbins, M. S., Feaster, D. J., Horigian, V. E., Rohrbaugh, M., Shoham, V., Bachrach, K., Miller, M., Burlew, K. A., Hodgkins, C., Carrion, I., Vandermark, N., Schindler, E., Werstlein, R., & Szapocznik, J. Brief Strategic Family Therapy versus treatment as usual: Results of a multisite randomized trial for substance using adolescents. Journal of Consulting and Clinical Psychology, 79(6), 713–727.

Supplementary Materials

Robbins, M. S., Feaster, D. J., Horigian, V. E., Puccinelli, M. J., Henderson, C., & Szapocznik, J. Therapist adherence in Brief Strategic Family Therapy for adolescent drug abusers. Journal of Consulting and Clinical Psychology, 79(6), 43–53.

Outcomes

Outcome 1: Drug use
Description of Measures	Adolescent drug use was assessed using the Timeline Follow-Back (TLFB) method, a semistructured, self-report, calendar-based interview that asks participants to retrospectively estimate their drug consumption over the previous month. The TLFB was administered at baseline and at 12 monthly follow-up assessments to establish a pretreatment rate of use and 365 continuous days of data on daily drug use after randomization.
Key Findings	The median number of self-reported drug-use days at 12 months was significantly lower in the BSFT® condition than in the treatment-as-usual condition (p < .02).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 2: Treatment engagement
Description of Measures	On a monthly basis, using participants' clinical charts and billing data, therapists reported the number of therapy sessions of any type delivered since the last interview. Participants were considered to be engaged if they participated in two or more sessions.
Key Findings	Participants in the BSFT® condition were significantly more engaged in treatment than those who received treatment-as-usual (p < .001). Adolescents receiving treatment-as-usual were 2.5 times more likely to fail to engage into therapy (rate of failure = 26.8%) than adolescents receiving the BSFT treatment (rate of failure = 11.4%).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 3: Treatment retention
Description of Measures	On a monthly basis, using participants' clinical charts and billing data, therapists reported the number of therapy sessions of any type delivered since the last interview. Participants were classified as retained if they attended more than seven sessions.
Key Findings	Participants in the BSFT® condition had lower rates of failure to retain in treatment than those who received treatment-as-usual (p < .02). Adolescents receiving treatment-as-usual were 1.4 times more likely to fail to retain in treatment for at least eight sessions (rate of failure = 56.6%) than adolescents in the BSFT® treatment condition (rate of failure = 40%).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 4: Family functioning
Description of Measures	Family functioning was assessed using a composite scale created from two separate scales. The Parenting Practices Questionnaire was completed by adolescents and their parents to identify positive and negative parenting behaviors in four domains: (a) positive parenting, (b) discipline effectiveness, (c) avoidance of discipline, and (d) monitoring. Discipline effectiveness and avoidance of discipline were assessed only of the parents. The Family Environmental Scale was administered to adolescents and their parents to measure cohesion and conflict. Individual subscales were converted to z scores and summed. The resulting composites (one each for adolescent and parent report) were normalized to have standard deviations of 1 (across condition) at baseline.
Key Findings	There were significant differences in the trajectories of parent-reported family functioning (p < .011), suggesting that BSFT was significantly more effective than the control condition in improving family processes. This pattern held true for the parenting practices (p < .023) and family environment subcomponents (p < .033). Adolescents in both conditions reported significant improvements over time in family functioning; however, no statistically significant differences between treatment conditions were observed.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	13-17 (Adolescent)	78.5% Male 21.5% Female	44.4% Hispanic or Latino 30.8% White 22.9% Black or African American 1% American Indian or Alaska Native 0.4% Asian 0.4% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Drug use	3.5	3.5	3.5	3.0	3.0	4.0	3.4
2: Treatment engagement	3.5	3.5	3.5	3.0	3.0	4.0	3.4
3: Treatment retention	3.5	3.5	3.5	3.0	3.0	4.0	3.4
4: Family functioning	3.5	3.5	3.5	3.0	3.0	4.0	3.4

Study Strengths

The outcome instruments were well-established with acceptable levels of reliability and validity. The study was implemented with considerable attention to assuring adherence to the BSFT® protocol, including manuals, training, supervision, and pilot cases that were worked on prior to beginning the study. Random sessions were assessed for adherence, using an instrument with known psychometric properties by independent raters with high interrater reliability across the four principal domains. No differences were found between the two conditions on any of the key demographic variables or baseline levels of the outcomes. Factorial validity was ensured for the family functioning measure across the three major groups, African American, Hispanics and Whites. Families were randomly assigned within each provider agency to study condition using an urn randomization procedure, which was intended to balance participants across conditions on ethnicity/race and level of drug use at baseline. Within each provider agency, therapist randomization was carried out within therapist pairs that were balanced, insofar as feasible, in regard to academic degrees and years of clinical experience. The participants in the treatment-as-usual condition received standard agency services in reducing adolescent drug use, including individual and/or group therapy, parent-training groups, nonmanualized family therapy, and case management. All agencies were expected to provide at least one intervention session per week, which is at least as many sessions as participants in the intervention condition. The analytic strategy was very thorough and appropriate, and included random effects for both sites and therapists, nested within site, to account for these two levels of nesting. These models are robust to data that are missing at random.

Study Weaknesses

The researchers acknowledged that some therapists had little or no experience in family therapy and occasionally no experience with adolescents. This, and also allowing BSFT® therapists to have multiple roles beyond BSFT® treatment, may have had a negative impact on the effectiveness of the intervention. Although attrition is expected in longitudinal research, and rates of attrition were comparable across study conditions, the level of attrition was notably high, particularly among African American youths. In addition, 25 percent of the clinicians left the study while it was in process and it is unclear how this impacted the study findings. The researchers mentioned that adolescent drug use was likely depressed in the period preceding treatment and during the intervention itself, which created a floor effect that permitted only the examination of prevention of relapse or escalation of drug use.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Organizational Presentation

2 Workshops PowerPoints

BSFT® Curriculum Outline

Training Program Description

Training Evaluation

BSFT® Implementation Information Packet

Therapist Eligibility Form

Supervision Checklist

Therapist Certification Overall Supervision Evaluation

Therapist Certification Rating Manual

Therapist Videotape Certification Checklist

BSFT® Manual

Recommendations for Measuring BSFT® Outcomes

Outline Organizational Site Visit

Supervisor Week 3

Supervisor Training Outline

Supervisor Trainee Program

Supervisor Trainer Presentation

FAD Subscales

McMaster GF Spanish2

Organizational Booster

Organizational Considerations Chart

Parent Practices Questionnaire

PPQ Spanish2

Recommended BSFT Outcome Measures

Scoring and Interpreting the PPQ and FAD

Supervision Agreement

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.5	3.5	2.6	3.2

Dissemination Strengths

A number of documents supporting implementation are provided. The BSFT® Implementation Information Packet provides a clear description of implementation documents and process. Of all the documents provided, two methods offer the potential for assuring quality of implementation. First, the supervision agreement noted above offers the best source for ongoing training for supervisors who will be providing training on the approach. Second, the assessment tools provide guidance along with information on measuring outcomes. The specificity of the agreement offers opportunities for improvement in skills, training, and overall implementation of the BSFT. The extent to which both of these methods are employed with fidelity will ultimately determine the quality of the implementation. The Training Program Description is very thorough and informative, which includes a directory or table of contents that presents the order of implementation by section, with relevant documents in each section. The assessment tools, the McMaster Family Assessment Device (FAD) and the Parenting Practices Questionnaire (PPQ) are available in both English and Spanish, and are relatively easy to comprehend and administer. The outcome-testing section of the organizational-booster presentation materials recommends that adopters report three dimensions of outcome measures that BSFT has shown to be consistently effective, one of which includes IP measures. Two of the three recommend the outcome measurement tools that are included (FAD and PPQ). In addition, it is very helpful that the link is provided for at least one of the referenced IP-related measurements. Frequently asked questions (FAQs) for the BSFT outcome measures are also included and are a very helpful resource. The Recommendations for Measuring BSFT® Outcomes is a helpful tool for ensuring the proper assessments are used.

Dissemination Weaknesses

Materials are poorly organized. With the exception of the assessment tools and the "Organizational Site Visit" onsite training and presentation, which aligned with the PowerPoint document on "BSFT-An Empirically Validated Therapy," it was difficult to identify the functionality of the other materials and how they related to each other in the context of implementing this particular program. There is minimal information to support quality assurance of program implementation.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Implementation, training, and quality assurance materials and resources	Contact developer for cost information	Yes