1. 1 Implementing and Sustaining MDFT in Practice Cynthia Rowe, PhD., Howard A. Liddle, Ed.D., Gayle A. Dakof, Ph.D., Craig Henderson, Ph.D., Alina Gonzalez, & Dana S. Mills, Ph.D. Center for Treatment Research on Adolescent Drug Abuse University of Miami School of Medicine Presented at the 2005 Joint Meeting on Adolescent Treatment Effectiveness; Washington, DC, March 22, 2005

2. 2 Overview   What did we do?  How did we do it?  How did it work?  What’s next?

3. 3 What Did We Do?   NIDA-funded study to “bridge the gap” (“Bridging” Study)  Worked with providers at a representative adolescent day treatment program to adapt and transport MDFT  4 study phases: Baseline, Training, Implementation, and Durability  Tested whether MDFT was implemented and sustained in the treatment program

4. 4 Study Aims  Clinical Practices: Determine whether providers implemented MDFT in the program  Program Changes: Determine whether the program could be transformed based on MDFT principles and interventions  Client Changes: Determine whether youths’ drug use and other outcomes improved  Durability: Determine whether these changes could be sustained without MDFT trainers

5. 5 Study Phases   Phase I. Baseline: Assessment of provider practices, program environment, and client outcomes  Phase II. Training: Work with all staff in day treatment program and larger system  Phase III. Implementation: Continue expert supervision and booster trainings as needed; Assess impact of training  Phase IV. Durability: MDFT experts withdraw; Assess sustainability of approach

6. 6 Adolescent Day Treatment Program Features   Multicomponent program/multidisciplinary staff  Behaviorally oriented “levels approach”  School through alternative education program  Group therapy daily and recreational activities  Psychiatric evaluation and intervention  Individual therapy weekly  Family therapy “as needed”

7. 7 How Did We do It?   Guiding principle: Isomorphism between training approach and therapy model  Collaboration/ Consultation approach  Empowering clinical staff and defining roles  Conceptualizing change at different levels  Modeling, practice, and feedback  Increasing staff accountability

8. 8 Known Barriers to Technology Transfer  Treatment providers not ready for change  Lack of organizational commitment to change  Treatment technology not seen as credible  Treatment too complex or unclear  Insufficient incentives/resources  Decay of new knowledge over time

9. 9 Addressing Barriers To Technology Transfer  Start with what providers feel needs to change  Demonstrate outcomes in concrete ways  Simplify the intervention with protocols  Highlight the ways practices are consistent  Be creative in providing incentives for change  Discuss and address obstacles openly

10. 10 How Did It Work? Clinical Practices: Clinical Practices: Changes in sessions and contacts (parameters) Changes in sessions and contacts (parameters) Changes in session content (interventions) Changes in session content (interventions) Program Changes: Program Changes: Changes in program environment Changes in program environment Client Changes: Drug use and delinquency Externalizing/internalizing symptoms Placements in controlled settings

11. 11 Results: Treatment Parameters  Average number of weekly sessions/contacts compared across phases: individual sessions, family sessions, DJJ contacts, and school contacts  Baseline to Implementation: all parameters increased significantly (p<.01)  Baseline to Durability: all parameters increased significantly (p<.01)  Implementation to Durability:  Individual sessions and school contacts significantly increased  DJJ contacts significantly decreased (p<.05)

12. 12 Increases in Contacts over Study Phases More contacts with schools in Implementation and Durability More DJJ contacts in Implementation than Baseline Slight decrease in DJJ contacts in Durability

13. 13 Results: Session Content  Therapy session notes coded for core MDFT themes  Therapists focused more on drugs in Baseline phase than in Implementation and Durability (p<.05)  Therapists focused on school and the adolescents’ thoughts and feelings about themselves more in the Implementation and Durability phases than in Baseline (p’s<.01)  Therapists in Implementation and Durability addressed more core MDFT content themes per session than in Baseline (p<.05)

14. 14 Results: Program Environment  Adolescents’ perceptions of the program were compared across study phases (COPES)  Implementation vs. Baseline:  increased Order and Organization (p<.05)  Implementation and Durability vs. Baseline:  increased Practical Orientation (p<.05)  increased Clarity (p<.05)  decreased controlling behavior (p<.01)  Durability vs. Baseline:  increased staff involvement (p<.05)

15. 15 Results: Client Outcomes  Implementation and Durability vs. Baseline  Drug use decreased more significantly (p<.05)  Durability vs. Baseline:  Delinquent behavior decreased more significantly (p<.05)  Externalizing and internalizing symptoms decreased more significantly (p<.05) (adolescent and parent reports)  Youth in Baseline were more likely to be placed in a controlled environment (37%) compared with those in Implementation (8%) or Durability (4%)

16. 16 Change in Parent-Reported Externalizing Problems Youth in Durability improved more rapidly than youth in Baseline

17. 17 Change in Parent-Reported Internalizing Problems Youth in Durability improved more rapidly than youth in Baseline

18. 18 Percent in Controlled Environment at Follow-Up

19. 19 Factors that Increased Acceptability “It’s been a collaborative effort… I I think you abbreviated it and accommodated it within our setting.” “It’s been a collaborative effort… I think everybody was pretty good about understanding these are the parameters we work with and we’re doing a good job in the real world… I think you abbreviated it and accommodated it within our setting.”

20. 20 Addressing Potential Implementation Barriers “ “ I didn’t see it as increased work. I saw it as good. Not only were they getting this one to one supervision from an expert, but the clinical meetings brought them to another level. I don’t think it was a burden at all…I think it made me get involved more which is good.”

21. 21 Factors linked to Sustainability Ongoing Structure: “We still have the clinical meeting. At that meeting we’ll rehash the very tough stuff and come up with program action plans and clinical action plans for the kids.” Accountability: “I am holding them accountable about making sure the kids are coming in and they are urging involvement in family therapy… The accountability’s gotta be there.” Outcomes: “You know you get some sort of gratification from it when you see the kids, you see their changes, things in the home are changing. So why would we stop?” Outcomes: “You know you get some sort of gratification from it when you see the kids, you see their changes, things in the home are changing. So why would we stop?”

22. 22 Summary of Findings  Clinical Practices: Therapists implemented MDFT in line with parameters and prescribed interventions  Program Environment : Program changed in line with MDFT principles (e.g., “be therapeutic all the time’)  Client Outcomes: Youths’ outcomes improved concurrently with staff/program changes  Durability: Staff continued to use MDFT and to have positive outcomes a year after MDFT experts withdrew  Training successfully created lasting change in fundamental and targeted areas (staff behavior, program, and client)

23. 23 What’s next?  New MDFT training studies focus on several unanswered questions:  How can training tools be developed that are “user friendly” and cost effective?  Can new technologies enhance learning?  How do trainers address unique provider and program level factors?  What level of ongoing monitoring is needed from expert trainers to sustain learning?

24. 24 Acknowledgements Completion of this research was supported by a grant from the National Institute on Drug Abuse (Grant No. NIDA R01 DA13089, H. Liddle, PI). We also thank Paul Greenbaum, Ph.D., as well as our colleagues at Jackson Memorial Hospital for their significant contributions to this study. Please see our website for more information on the Center’s program of research: www.miami.edu/ctrada

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