Core Elements of Family Therapy for Adolescent Behavior Problems: Empirical Distillation of Three Manualized Treatments

Abstract

Family therapy has the strongest evidence base for treating adolescent conduct and substance use problems, yet there remain substantial barriers to widespread delivery of this approach in community settings. This study aimed to promote the feasibility of implementing family-based interventions in usual care by empirically distilling the core practice elements of three manualized treatments. The study sampled 302 high-fidelity treatment sessions from 196 cases enrolled in 1 of 3 manualized family therapy models: multidimensional family therapy (102 sessions/56 cases), brief strategic family therapy (100 sessions/94 cases), or functional family therapy (100 sessions/46 cases). Adolescents were 57% male; 41% were African American, 31% White non-Hispanic, 9% Hispanic American, 6% another race/ethnicity, and 13% unknown. The observational fidelity measures of all three models were used to code all 302 sessions. Fidelity ratings were analyzed to derive model-shared treatment techniques via exploratory factor analyses on half the sample; the derived factors were then validated via confirmatory factor analyses supplemented by Bayesian structural equation modeling on the remaining half. Factor analyses distilled 4 clinically coherent practice elements with strong internal consistency: Interactional Change (6 treatment techniques; Cronbach’s α = .93), Relational Reframe (7 techniques; α = .79), Adolescent Engagement (4 techniques; α = .68), and Relational Emphasis (4 techniques; α = .67). The 4 empirically derived factors represent the core elements of 3 manualized family therapy models for adolescent behavior problems, setting the foundation of a more sustainable option for delivering evidence-based family interventions in routine practice settings.

Public Health Significance: Increasing implementation of high-fidelity family-based interventions would improve the quality of treatment services for adolescent conduct and substance use problems.

Acknowledgments

We acknowledge the dedicated work of the observational coders for this project (in addition to author MB): Kate Feiner, Alma Hidalgo, Tiffany John, Naomi Krohner, Tessa Long, Alexis Nager, Nkem Osian, Nicole Piazza, Alana Ribowsky, Lauren Ryan, Maddison Schiafo, Monique Sledd, and Elise Yenne. We also acknowledge the contributions of the Expert Review Panel to conceptualizing and interpreting study data: Guy Diamond, Genoveva Garcia, Olga Hervis, Silvia Kaminsky, Annie Niermann, and Michael Robbins. We are extremely grateful to Ms. Hervis and Ms. Kaminsky (Family Therapy Training Institute of Miami) for providing session recordings of Brief Strategic Family Therapy and for training coders; and to Holly Waldron (Oregon Research Institute) for providing recordings of Functional Family Therapy.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Preparation of this article was supported by the National Institute on Drug Abuse (R01DA037496; PI: Hogue).