Multidimensional Family Therapy
Dr. Howard A. Liddle
Multidimensional Family Therapy (MDFT) is a family-based treatment developed for adolescents with drug and behavior problems and for substance abuse prevention with early adolescents. The MDFT intervention has evolved over the last 17 years within a federally funded research program designed to develop and evaluate family-based drug abuse treatment for adolescents. This approach has been recognized as one of a new generation of comprehensive, multicomponent, theoretically-derived and empirically-supported adolescent drug abuse treatments. A multidimensional perspective suggests that symptom reduction and enhancement of prosocial and appropriate developmental functions occur by facilitating adaptive developmental events and processes in several domains of functioning.
The treatment seeks to significantly reduce or eliminate the adolescent's substance abuse and other problem behavior, and to improve overall family functioning. Objectives for the adolescent include transformation of a drug using lifestyle into a developmentally normative lifestyle and improved functioning in several developmental domains, including positive peer relations, healthy identity formation, bonding to school and other prosocial institutions, and a developmentally on target balance between increased autonomy and emotional connection within the parent-adolescent relationship. For the parent(s), objectives include blocking parental abdication by facilitating parental commitment and investment; improving the overall relationship and day to day communication between parent and adolescent; and increased knowledge about and changes in parenting practices (e.g., limit-setting, monitoring, appropriate autonomy granting). The treatment approach has multiple components, assessment and intervention occurs in several core areas of the teen's life simultaneously.
The MDFT model has been applied in a variety of community based clinical settings targeting a range of populations. These clinical groups have comprised ethnically (White, African-American, and Hispanic) and linguistically (Spanish/English) diverse adolescents at risk for abuse and/or abusing substances and their families. The parents of adolescents targeted in MDFT controlled studies have had a range of economic and educational levels, yet the majority of families treated have been from disadvantaged inner-city communities. Adolescents treated in MDFT trials have ranged from high-risk early adolescents, to multi-problem, juvenile justice-involved, dually diagnosed female and male adolescent substance abusers.
By design, the MDFT approach has been developed and tested in different forms or versions, making it a uniquely flexibly approach. The format and components of MDFT has been modified to suit the clinical needs of different clinical populations. For example one intensive outpatient version of MDFT ranges between 16 and 25 sessions over four to six months, and a less intensive version has tested MDFT with success with 12 sessions over three months. The different forms of MDFT are applied according to the clinical needs of the target population. Sessions may occur multiple times during the week, in a variety of contexts including the home, the MDFT clinic, community settings such as schools or courts, or by phone. Five assessment and intervention modules structure the MDFT approach. Session content and foci vary by the stage of treatment but core content/focus, derived from the developmental literature on the most important functional areas to target, is worked with each case (e.g., adolescent's developmental tasks and concerns, peer relations, involvement in legal and juvenile justice systems, drug use as a way of coping with circumstances or psychological status). The three treatment stages are: Stage one, Build the Foundation; Stage two, Work the Themes; and Stage 3, Seal the Changes and Exit. The five assessment and intervention modules are: 1) Interventions with the Adolescent, 2) Interventions with the Parent, 3) Interventions to Change the Parent-Adolescent Interaction, 4) Interventions with Other Family Members, and 5) Interventions with Systems External to the Family. A multiple systems-oriented and developmentally-focused therapy, MDFT targets the known areas of risk associated with adolescent drug abuse and delinquency and enhances those protective factors and processes known to promote successful teen and family development.
Four randomized efficacy studies have been conducted on MDFT and two others are nearly completed. A study conducted in the San Francisco-Oakland area compared the efficacy of MDFT with two well-established drug abuse treatments, multifamily educational intervention (MFEI) and adolescent group therapy (AGT). Participants in the study were 95 drug-using adolescents and their families who completed treatment and were assigned to one of the three conditions. Assessments were administered at treatment intake and at one-year follow-up and consisted of 1) drug use, 2) problem behaviors, 3) school performance, and 4) family functioning. At the end of treatment the general pattern of results indicated improvement among youth in all three conditions, MDFT participants showing the largest and most diverse gains. Importantly, and speaking to the durability of the MDFT intervention, these significant decreases in drug abuse and behavior problem not only remained stable but these changes continued to occur at the one year follow up assessment. MDFT also produced significant changes in important prosocial and protective domains. MDFT families showed significant improvements in family functioning, and teens receiving MDFT demonstrated superior gains in their school performance at one year follow up, relative to the comparison treatments.
Another study was conducted in North Philadelphia comparing MDFT to individual cognitive-behavioral therapy (CBT) for adolescent drug abuse. Participants in the study were 224 drug-using adolescents and their families. Adolescent drug use and adolescent- and parent-reported externalizing and internalizing symptomatology were assessed at intake, termination, and again at 6 and 12 months following treatment termination. Both treatments produced a significant decrease in drug use, externalizing problems, and internalizing problems from intake to termination. However, replicating the finding from an earlier study, adolescents receiving MDFT continued to improve after termination while youth in the comparison treatment (CBT) did not. At 12 months following discharge, 70% of youth who received Multidimensional Family Therapy and 55% of youth who received Cognitive Behavioral Therapy were abstinent. At discharge, 44% in both treatments were abstinent.
A third controlled trial involved MDFT in the Cannibis Youth Treatment (CSAT) Multisite Study.
All five manualized, state of the art treatments studied in this multi-site trial were found to be more effective
than current practice. MDFT was found to be clinically and cost effective. At 6 months post treatment, 42% of
youth who received Multidimensional Family Therapy were abstinent, and 65%, almost two thirds of MDFT youth
reported no substance use disorder symptoms. MDFT was shown to be cost effective with its average cost less
than standard outpatient adolescent treatments. The average weekly cost of MDFT was $164.00 compared to
average weekly costs for standard care ranging from
A prevention version of MDFT has been tested in a randomized clinical trial with adolescents at high risk for alcohol and marijuana use and antisocial behavior. MDFT teens showed greater gains in increased self-concept, family cohesion, increased bonding to school, and decreased association with antisocial behaviors by peers compared to community controls. Further, while controls showed increases in risk factors over the study, MDFT families reported strengthened family and school bonds and reduced peer delinquency.
Two current studies near completion include a comparison of an intensive outpatient version of MDFT vs. a residential drug treatment for dually diagnosed teens, and a technology transfer study that has successfully adapted and transported the MDFT approach into an intensive day treatment setting for substance abusing and juvenile justice involved teenagers. Preliminary findings are available in randomized trial comparing the clinical effectiveness and relative monetary benefits of MDFT vs. residential treatment. Teens in both MDFT and residential treatment significantly reduced their drug use and externalizing symptoms between intake and discharge from treatment (approximately 6 to 8 months in both treatments). However, upon discharge from treatment, MDFT teens continued to decrease their drug use and problem behaviors up to the 12 month follow up, while youth in the residential condition showed an increase in both types of problems. Further, cost analyses reveal an almost 3:1 differential in the costs of the two treatment favoring MDFT ($384 per week vs. $1,138), suggesting that these favorable results can be obtained in MDFT at a fraction of the cost of residential treatment.
To further the development of MDFT, we have engaged in a systematic program of process research aimed at uncovering the primary mechanisms of change within the model. These studies have helped to illuminate the interior of treatment, and hence we now have empirical clues about why MDFT is effective. An example includes the MDFT process studies on the therapeutic alliance. We have established a link between the quality of the two interdependent but individual therapeutic alliances between the therapist and the teenagers, and the therapist and the parent, and engagement and retention in treatment. Other studies have determined the best methods to establish effective therapeutic alliances with the adolescent and the parent, how to transform in-session therapeutic stalemates between parents and teens into productive discussions, how to change parenting behaviors and improve the overall psychosocial functioning of the teen's parent, and how to enhance the treatment engagement of teens using culturally specific interventions.
Program staffing depends on the number of adolescents being served. Case loads are generally low (6 to 10) so that the therapist can work intensively with each adolescent and family. The MDFT clinical team is comprised of one clinical supervisor for two or four therapists and budget permitting, one to two case manager therapist assistants. Most therapists using this approach have had a Master's degree and an average of 2-3 years of experience. MDFT has been implemented in over 16 sites throughout the U.S. Details of certification are available from the program developer.
MDFT implementation training uses the same procedures (training materials and supervision methods) that have been used in the successful randomized trials of MDFT with substance abusing and juvenile justice involved teens. The training begins with an intensive several day workshop. This workshop can be on site at the MDFT site at the University of Miami. Materials from the published MDFT manual, including materials designed to teach MDFT case conceptualization, assessment and interventions methods, and extensive videotapes of actual MDFT treatment comprise the initial training course. The initial course is followed with booster sessions on site and extensive telephone/video conferencing that emphasizes the implementation of MDFT in the particular sites with therapists own current cases. Since we individualize the training package to fit a particular site's needs, it is best to contact the developer for more information.
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