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

2. Acknowledgments SAMHSA’s Center for Substance Abuse Treatment: (TI11317, TI11320, TI11321, TI11323, TI11324) CYT colleagues National Institute on Drug Abuse: RO1 DA 018183

3. 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

4. . 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 )

5. CYT Cannabis 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, IL University of Miami, Miami, FL University of Connecticut Health Center, Farmington, CT Sites: Univ. Conn. Health Center, Farmington, CT Operation PAR, St. Petersburg, FL Chestnut Health Systems, Madison County, IL Children’s Hospital of Phil., Philadelphia, PA

6. Treatment Series Cannabis Youth Treatment Experiment 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)

7. Treatment Series Cannabis Youth Treatment Experiment 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)

8. Treatment Series Cannabis Youth Treatment Experiment 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)

9. Treatment Series Cannabis Youth Treatment Experiment 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)

10. Treatment Series Cannabis Youth Treatment Experiment 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)

11. Randomly assigned to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) MET/CBT12 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (12 weeks) FSN Family Support Network Plus MET/CBT12 (12 weeks) Trial 1 Two Study Trials N = 300 ACRA Adolescent Community Reinforcement Approach(12 weeks) MDFT Multidimensional Family Therapy Trial 2 Randomly assigned to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) (12 weeks) N = 300

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

13. Demographic Characteristics 62% 15% 55% 50% 30% 83% 17% 0% 20% 40% 60% 80% 100% FemaleMale African American Caucasian Under 15 to 16Single parent family 15

14. Institutional Involvement 25% 87% 47% 62% 0% 20% 40% 60% 80% 100% In schoolEmployedCurrent CJ Involvement Coming from Controlled Environment

15. Patterns of Substance Use 9% 17% 71% 73% 0% 20% 40% 60% 80%   Weekly Tobacco Use Weekly Marijuana Use Weekly Alcohol Use Significant Time in Controlled Environment

16. Multiple Problems are the Norm Self-Reported in Past Year

17. 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 Service MET/ CBT5 MET/ CBT12 FSNACRAMDFT 2 2 2 3 10 6 6 23 426 512221415 Case management/ Other Contacts As needed Total Expected Contacts51222+14+15+ Total Expected Hours Total Expected Weeks 51222+14+15+ 6-712-13

18. 5 10 5 11 14 23 0 5 10 15 20 25 MET/ CBT5 MET/ CBT12 MET/ CBT12 + FSN MET/ CBT5 ACRAMDFT Hours Days Case Management Family Counseling Caregiver only Multi-Family group Multi-Participant Group 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

19. 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 Intake36912 Days Abstinent Per Quarter 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % in Recovery at the End of the Quarter Percent in Recovery Days Abstinent

20. Similarity of Clinical Outcomes by Conditions Source: Dennis et al., 2004 200 220 240 260 280 300 Total days abstinent. over 12 months 0% 10% 20% 30% 40% 50% Percent in Recovery. at Month 12 Total Days Abstinent* 269256260251265257 Percent in Recovery** 0.280.170.220.230.340.19 MET/ CBT5MET/ CBT12 FSNMET/ CBT5ACRAMDFT 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

21. Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., 2004 $0 $4 $8 $12 $16 $20 Cost per day of abstinence over 12 months $0 $4,000 $8,000 $12,000 $16,000 $20,000 Cost per person in recovery at month 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/ CBT5 MET/ CBT12 FSN 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

22. 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?

23. Path Model with Services & Other Process Measures Cohesion Conflict Recovery Environment Social Risk Substance Frequency Substance Problems.26.30.12 -.14.27.14.49.18 Baseline Value Family Index (FES) Source: Godley, Kahn et al., 2005 Risk

24. Path Model with Services & Other Process Measures Multi-Family Cohesion Conflict Recovery Environment Social Risk Substance Frequency Substance Problems.26.30.12 -.14.27.12.14.49.18 Baseline Value Family Hours Index (FES) Family (FES Risk

25. Path Model with Services & Other Process Measures Single Family Multi-Family Cohesion Conflict Social Support Recovery Environment Social Risk Substance Frequency Substance Problems.26.30.12 -.14.27.12.14 Treatment Satisfaction Service Diversity.49.30.11.18 -.08 Baseline Value Family Hours Index (FES).18 Risk

26. Path Model with Services & Other Process Measures Social Support Recovery Environment Social Risk Substance Frequency.45 Substance Problems.26.30.12 -.14.27.12.14 Treatment Satisfaction Service Diversity.49 -.12.30.18.11.18 -.08 Baseline Value Multi-Family Hours Case Management Hours Single Family Hours Index Conflict Family (FES).14 Cohesion (FES) Family Risk

27. Path Model with Services & Other Process Measures.15 Social Support Recovery Environment Social Risk Substance Frequency Substance Problems.26.30.12 -.14.27.12.14 Treatment Satisfaction Service Diversity.49 -.12.14.30.19.18.11.18 -.08 Baseline Value Multi-Family Hours Single Family Hours Cohesion (FES) Family Conflict Family (FES) Individual Hours Case Management Hours Risk Index Index

28. Path Model with Services & Other Process Measures Single Family Group Hours Social Support Recovery Environment Social Risk Substance Frequency Substance Problems.26.30.12 -.14.27.12.14 Individual Hours Treatment Satisfaction Service Diversity.49 -.12.14.30.11.19.18.22.11.18 -.08.10 Baseline Value Multi-Family Hours Case Management Hours Cohesion (FES) Family Conflict Family (FES) Risk Index Index -.08

29. Path Model with Services & Other Process Measures Single Family Group Hours.27.23.15 Social Support.23 Recovery Environment.16 Social Risk.28 Substance Frequency.45 Substance Problems.26.30.12 -.14.27.12.14 Case Management Individual Hours Alliance.23 Treatment Satisfaction.19 Service Diversity.49 -.12.10.14.30 -.13.11.19.18.22.11 -.08.33.18 -.08.10 Baseline Value Multi-Family Hours Cohesion (FES) Family Conflict Family (FES) (WAI) Risk Index Index

30. Path Model with Services & Other Process Measures Single Family Group Hours.27.23.15 Social Support.23 Recovery Environment.16 Social Risk.28 Substance Frequency.45 Substance Problems.26.30.12 -.14.27.12.14 Case Management Individual Hours Alliance.23 Treatment Satisfaction.19 Service Diversity.49 -.12.10.14.30 -.13.11.19.18.22.11 -.08.33.18 -.08.10 Baseline Value Multi-Family Hours Cohesion (FES) Family Conflict Family (FES) (WAI) Index Risk Index CFI=.914 RMSEA =.048

31. 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

32. 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 services Clinicians ‘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’

33. Conclusions/ Recommendations Family-related factors appear to be predictive of outcome; direct links between family therapies and outcomes are less evident Family-related procedures necessary for clinical ‘acceptability’ of an adolescent intervention Findings provide support ‘packages’ of services due to the relation of service diversity to outcome Comparing family to non-family treatment conditions not a relevant question for by the practice community Increase 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

34. Contact Information Susan H. Godley, Rh.D. Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.829.3543 ext.83343 sgodley@chestnut.org