Working Collaboratively for Substance Abusing Young Offenders10 November 2013 by Cynthia L. Rowe, Ph.D.
Introductory Comment
The perplexing syndrome of adolescent substance abuse and delinquency poses serious challenges for the juvenile justice system, social services, policy makers, and clinicians. Studies show that the majority of juvenile justice involved teens have drug problems severe enough to require intervention,1,2 yet most of these youth never receive adequate treatment, leaving them at high risk for recidivism, relapse, and a host of life-long legal, family, social, and occupational problems.
While treating these multiple-problem youth seems to many a daunting task, there are now treatment strategies for drug abusing juveniles that are developmentally informed, empirically validated, and attend to key risk and protective factors within the youth’s family and natural ecology. Treatment for teen offenders who are also drug abusing must intervene in a systemic, comprehensive, collaborative way to alter their negatively cascading developmental trajectories.
Current Juvenile Justice System
Unfortunately, the vast majority of youth in juvenile justice settings do not receive these kinds of intensive, effective interventions. There are a number of reasons for this, including insufficient collaboration between juvenile justice professionals and substance abuse treatment researchers and providers. A host of interrelated barriers, including fragmentation of services, poor coordination of assessment, referral, and treatment, and lack of resources across multiple systems of care leave most substance abusing offenders without the help they need. Policy planners and federal funding agencies call for a more collaborative model in which drug abuse treatment providers, juvenile justice authorities, researchers, policy makers, and other social service agencies work together to provide the most powerful interventions available for these youth.3-5
The MDFT Case Study
This case study describes an empirically supported family-oriented, multiple-systems approach to working with drug abusing teens in the juvenile justice system, Multidimensional Family Therapy (MDFT).6 Forestalling the progression into deeper deviancy and a more chronic drug abusing and criminal justice involved lifestyle is the overarching goal of the treatment approach. Achieving this kind of systemic, multi-domain change in an adolescent’s life requires interventions that target many domains of functioning and reach into different corners of the drug and criminal justice involved individual’s life, including different psychosocial contexts at different critical transition points. Because of its consistently strong results in empirical studies with a range of young drug abusing offender populations, MDFT is recognized in the United States and internationally as among the most effective treatment approaches for adolescent drug abuse and delinquency.7-9 The overall objective of this article is to inform legal professionals about its empirical base and describe basic principles and interventions for using it in practice. Interventions for working collaboratively with juvenile justice personnel are highlighted.
The MDFT model has been the focus of consistent empirical development and refinement since 1985 and continues to be tested in federal research initiatives and international studies. The model has been applied in geographically distinct settings with a range of populations, targeting ethnically diverse adolescents at risk for abuse and/or abusing substances and experiencing other emotional and behavioral problems.
This multidimensional approach assumes that reductions in target symptoms and increases in prosocial target behaviors occur via multiple pathways, in differing contexts, and through different mechanisms. It assesses and intervenes in four main areas:
• the adolescent as an individual;
• the parent/parents as a subsystem;
• the family interactional system; and
• extrafamilial systems (systems outside of the family).
With the adolescent, the therapist seeks to transform the youth’s drug using lifestyle in developmentally normative directions and improve functioning across domains, including promoting positive peer relations, healthy identity formation, and bonding to school. Goals with the parent include:
• increasing parental commitment and preventing parental abdication;
• improving communication with the adolescent; and
• increasing knowledge and skills in the realm of parenting practices (e.g., limit-setting, monitoring).
The key intention with the family is to promote new interactional patterns that promote healthy development. In the extrafamilial realm, we aim to improve the parents’ and adolescent’s functioning relative to important and influential social systems outside of the family, principally with school and juvenile justice.
The format of MDFT has been modified to suit the clinical needs of different populations ranging from prevention and early intervention to intensive treatment that is an alternative to residential placement. An intensive outpatient version of the approach, for example, delivers MDFT in several sessions each week over four to six months. Sessions may be held in a variety of contexts including in the home, clinic, other community settings, or by phone.
Juvenile Justice Focused Interventions
Intervening successfully with multiple problem, drug abusing youth involves intensive, collaborative work with juvenile justice system personnel. Altering the teen’s negative and escalating cycle of defeat with the juvenile justice system takes determination and a positive attitude from the therapist. This mind-set and therapeutic stance engenders hope and a willingness to cooperate from both the teen and parent. In working productively with juvenile justice personnel, relationships with both the adolescent’s probation officer (PO) and judge are critical. Therapists’ contact PO’s at the very outset of a case, asking about their experience with and knowledge of the teenager and any opinions or insights into what has happened with the teen and his family. This work rests on building relationships and establishing multiple alliances based on respect and mutual accountability for the adolescent’s outcome. The therapist clarifies how the PO wants to proceed with the teen in terms of a monitoring protocol (e.g., weekly drug screens, meetings, etc.) and takes steps with the adolescent and family to abide by the PO’s requests.
The core principle of collaboration is emphasized throughout the process. A therapist focuses on what he or she can and will do, and only secondarily upon what the PO may have to offer. MDFT therapists emphasize that they can make the PO’s job easier by facilitating compliance from both the teen and parent. In return, the MDFT therapist asks for cooperation from the PO in advocating for the adolescent in court, being willing to provide leniency when appropriate, and coming to agreement to provide limits when clinically and judicially necessary. As is the case when one joins with a teen and family, we look for common ground and points of connection. The therapist offers an analysis of the teen and family that provides hope for change, helping the PO understand that the focus on family relationship dynamics will pay off in practical terms – in better parental monitoring and compliance to the terms of probation.
In order to help teens successfully transition out of the juvenile justice system, MDFT therapists must also integrate effective interventions for enlisting the court’s involvement. We educate judges about the model, which influences outcomes by helping keep the teen in MDFT when he/she has reoffended or must appear before the judge for a prior charge during the course of treatment. Critical for success is a judge’s prior awareness of:
• how the treatment works;
• what is required of the adolescent;
• the extent of the therapist’s involvement and dedication; and
• treatment effectiveness.
The judge must have adequate information on treatment in order to make informed decisions on the disposition of adolescent cases – not only an understanding of the theory and the science supporting MDFT’s efficacy, but also the basic structure of therapy. Judges tend to be responsive to this type of input, but even more enthusiastic about the actual results of MDFT with adolescents presenting in their courtrooms. In the end, judges act on their experience with teens and families who have had success.
Impact of Collaboration
Effective integration of juvenile justice system work is integral to success. With juvenile justice involved youth, decisions about their legal status profoundly impact the trajectory of the teen’s life. Although it is time consuming, careful coordination with juvenile justice personnel makes therapeutically sound decisions possible. Close collaboration with POs and judges also enhances therapeutic work by offering the adolescent a second or sometimes a third chance to remain in our program (and thus not incarcerated or advanced to adult offender status) when faced with new or in some cases existing charges. Finally, coordinated involvement with the legal system gives us leverage to motivate both the adolescent and parent to work hard in therapy toward attainable goals such as avoiding a more restrictive placement, getting off probation, and eventually escaping the system altogether. It is up to the therapist to make this coordination occur, and to present the work required as part of therapy and the mandates of the court in an integrated way to teens and parents. When adolescents and parents have evidence that their therapist has an impact on outcomes in court and they see their therapist fight for them, hope is resuscitated and family members are willing to work harder in therapy.
Closing Remarks
MDFT has accumulated a strong body of empirical support with young drug abusing offenders. Its promise in previous studies laid a solid foundation for examining MDFT’s potential within juvenile justice settings such as detention and juvenile drug court. In the newest series of studies, MDFT researchers aim to identify the mechanisms and processes by which the model can be adapted for community-based providers in a range of practice settings, including the juvenile justice system. We have found through our clinical experience and research findings that this kind of coordinated work is of the utmost importance to maximize the wellbeing and overall health of our youngest generations and is best approached in an interdisciplinary manner.
Please see www.mdft.org for more details about the approach and our clinical, training and research initiatives.
References
1. Aarons, G. A., Brown, S. A., Hough, R. L., Garland, A. F., & Wood, P. A. (2001). Prevalence of adolescent substance use disorders across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 419-426.
2. OJJDP Annual Report: 2000. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice.
3. Center for Substance Abuse Treatment (CSAT). (1998). Adolescent substance abuse: Assessment and treatment (CSAT Treatment Improvement Protocol Series). Rockville, MD: SAMSHA.
4. Office of Juvenile Justice and Delinquency Prevention(OJJDP) (1997). OJJDP Fact Sheet# 53: Drug offense cases in juvenile court, 1985-1994. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice.
5. National Institute on Drug Abuse. (2007). Principles of drug addiction treatment: A research based guide. Retrieved from http://www.nida.nih.gov/podat/Evidence2.html
6. Liddle, H. (2002). Multidimensional Family Therapy Treatment (MDFT) for adolescent cannabis users. Volume 5 of the Cannabis Youth Treatment (CYT) manual series. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services.
7. Center for Substance Abuse Prevention (CSAP). (2000). Strengthening America’s families: Model family programs for substance abuse and delinquency prevention. Salt Lake City, Utah, University of Utah.
8. Department of Health and Human Services (2002). Best practice initiative: Multidimensional Family therapy for adolescent substance abuse. Retrieved from http://phs.os.dhhs.gov/ophs/bestpractice/mdft_miami.htm
9. National Institute on Drug Abuse (NIDA) (1999). Scientifically based approaches to drug addiction treatment. In Principles of Drug Addiction Treatment: A research-based guide. (Rep. No. NIH publication No. 99-4180, pp.35-47). Rockville, MD: National Institute on Drug Abuse.
Introductory Comment
The perplexing syndrome of adolescent substance abuse and delinquency poses serious challenges for the juvenile justice system, social services, policy makers, and clinicians. Studies show that the majority of juvenile justice involved teens have drug problems severe enough to require intervention,1,2 yet most of these youth never receive adequate treatment, leaving them at high risk for recidivism, relapse, and a host of life-long legal, family, social, and occupational problems.
While treating these multiple-problem youth seems to many a daunting task, there are now treatment strategies for drug abusing juveniles that are developmentally informed, empirically validated, and attend to key risk and protective factors within the youth’s family and natural ecology. Treatment for teen offenders who are also drug abusing must intervene in a systemic, comprehensive, collaborative way to alter their negatively cascading developmental trajectories.
Current Juvenile Justice System
Unfortunately, the vast majority of youth in juvenile justice settings do not receive these kinds of intensive, effective interventions. There are a number of reasons for this, including insufficient collaboration between juvenile justice professionals and substance abuse treatment researchers and providers. A host of interrelated barriers, including fragmentation of services, poor coordination of assessment, referral, and treatment, and lack of resources across multiple systems of care leave most substance abusing offenders without the help they need. Policy planners and federal funding agencies call for a more collaborative model in which drug abuse treatment providers, juvenile justice authorities, researchers, policy makers, and other social service agencies work together to provide the most powerful interventions available for these youth.3-5
The MDFT Case Study
This case study describes an empirically supported family-oriented, multiple-systems approach to working with drug abusing teens in the juvenile justice system, Multidimensional Family Therapy (MDFT).6 Forestalling the progression into deeper deviancy and a more chronic drug abusing and criminal justice involved lifestyle is the overarching goal of the treatment approach. Achieving this kind of systemic, multi-domain change in an adolescent’s life requires interventions that target many domains of functioning and reach into different corners of the drug and criminal justice involved individual’s life, including different psychosocial contexts at different critical transition points. Because of its consistently strong results in empirical studies with a range of young drug abusing offender populations, MDFT is recognized in the United States and internationally as among the most effective treatment approaches for adolescent drug abuse and delinquency.7-9 The overall objective of this article is to inform legal professionals about its empirical base and describe basic principles and interventions for using it in practice. Interventions for working collaboratively with juvenile justice personnel are highlighted.
The MDFT model has been the focus of consistent empirical development and refinement since 1985 and continues to be tested in federal research initiatives and international studies. The model has been applied in geographically distinct settings with a range of populations, targeting ethnically diverse adolescents at risk for abuse and/or abusing substances and experiencing other emotional and behavioral problems.
This multidimensional approach assumes that reductions in target symptoms and increases in prosocial target behaviors occur via multiple pathways, in differing contexts, and through different mechanisms. It assesses and intervenes in four main areas:
• the adolescent as an individual;
• the parent/parents as a subsystem;
• the family interactional system; and
• extrafamilial systems (systems outside of the family).
With the adolescent, the therapist seeks to transform the youth’s drug using lifestyle in developmentally normative directions and improve functioning across domains, including promoting positive peer relations, healthy identity formation, and bonding to school. Goals with the parent include:
• increasing parental commitment and preventing parental abdication;
• improving communication with the adolescent; and
• increasing knowledge and skills in the realm of parenting practices (e.g., limit-setting, monitoring).
The key intention with the family is to promote new interactional patterns that promote healthy development. In the extrafamilial realm, we aim to improve the parents’ and adolescent’s functioning relative to important and influential social systems outside of the family, principally with school and juvenile justice.
The format of MDFT has been modified to suit the clinical needs of different populations ranging from prevention and early intervention to intensive treatment that is an alternative to residential placement. An intensive outpatient version of the approach, for example, delivers MDFT in several sessions each week over four to six months. Sessions may be held in a variety of contexts including in the home, clinic, other community settings, or by phone.
Juvenile Justice Focused Interventions
Intervening successfully with multiple problem, drug abusing youth involves intensive, collaborative work with juvenile justice system personnel. Altering the teen’s negative and escalating cycle of defeat with the juvenile justice system takes determination and a positive attitude from the therapist. This mind-set and therapeutic stance engenders hope and a willingness to cooperate from both the teen and parent. In working productively with juvenile justice personnel, relationships with both the adolescent’s probation officer (PO) and judge are critical. Therapists’ contact PO’s at the very outset of a case, asking about their experience with and knowledge of the teenager and any opinions or insights into what has happened with the teen and his family. This work rests on building relationships and establishing multiple alliances based on respect and mutual accountability for the adolescent’s outcome. The therapist clarifies how the PO wants to proceed with the teen in terms of a monitoring protocol (e.g., weekly drug screens, meetings, etc.) and takes steps with the adolescent and family to abide by the PO’s requests.
The core principle of collaboration is emphasized throughout the process. A therapist focuses on what he or she can and will do, and only secondarily upon what the PO may have to offer. MDFT therapists emphasize that they can make the PO’s job easier by facilitating compliance from both the teen and parent. In return, the MDFT therapist asks for cooperation from the PO in advocating for the adolescent in court, being willing to provide leniency when appropriate, and coming to agreement to provide limits when clinically and judicially necessary. As is the case when one joins with a teen and family, we look for common ground and points of connection. The therapist offers an analysis of the teen and family that provides hope for change, helping the PO understand that the focus on family relationship dynamics will pay off in practical terms – in better parental monitoring and compliance to the terms of probation.
In order to help teens successfully transition out of the juvenile justice system, MDFT therapists must also integrate effective interventions for enlisting the court’s involvement. We educate judges about the model, which influences outcomes by helping keep the teen in MDFT when he/she has reoffended or must appear before the judge for a prior charge during the course of treatment. Critical for success is a judge’s prior awareness of:
• how the treatment works;
• what is required of the adolescent;
• the extent of the therapist’s involvement and dedication; and
• treatment effectiveness.
The judge must have adequate information on treatment in order to make informed decisions on the disposition of adolescent cases – not only an understanding of the theory and the science supporting MDFT’s efficacy, but also the basic structure of therapy. Judges tend to be responsive to this type of input, but even more enthusiastic about the actual results of MDFT with adolescents presenting in their courtrooms. In the end, judges act on their experience with teens and families who have had success.
Impact of Collaboration
Effective integration of juvenile justice system work is integral to success. With juvenile justice involved youth, decisions about their legal status profoundly impact the trajectory of the teen’s life. Although it is time consuming, careful coordination with juvenile justice personnel makes therapeutically sound decisions possible. Close collaboration with POs and judges also enhances therapeutic work by offering the adolescent a second or sometimes a third chance to remain in our program (and thus not incarcerated or advanced to adult offender status) when faced with new or in some cases existing charges. Finally, coordinated involvement with the legal system gives us leverage to motivate both the adolescent and parent to work hard in therapy toward attainable goals such as avoiding a more restrictive placement, getting off probation, and eventually escaping the system altogether. It is up to the therapist to make this coordination occur, and to present the work required as part of therapy and the mandates of the court in an integrated way to teens and parents. When adolescents and parents have evidence that their therapist has an impact on outcomes in court and they see their therapist fight for them, hope is resuscitated and family members are willing to work harder in therapy.
Closing Remarks
MDFT has accumulated a strong body of empirical support with young drug abusing offenders. Its promise in previous studies laid a solid foundation for examining MDFT’s potential within juvenile justice settings such as detention and juvenile drug court. In the newest series of studies, MDFT researchers aim to identify the mechanisms and processes by which the model can be adapted for community-based providers in a range of practice settings, including the juvenile justice system. We have found through our clinical experience and research findings that this kind of coordinated work is of the utmost importance to maximize the wellbeing and overall health of our youngest generations and is best approached in an interdisciplinary manner.
Please see www.mdft.org for more details about the approach and our clinical, training and research initiatives.
References
1. Aarons, G. A., Brown, S. A., Hough, R. L., Garland, A. F., & Wood, P. A. (2001). Prevalence of adolescent substance use disorders across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 419-426.
2. OJJDP Annual Report: 2000. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice.
3. Center for Substance Abuse Treatment (CSAT). (1998). Adolescent substance abuse: Assessment and treatment (CSAT Treatment Improvement Protocol Series). Rockville, MD: SAMSHA.
4. Office of Juvenile Justice and Delinquency Prevention(OJJDP) (1997). OJJDP Fact Sheet# 53: Drug offense cases in juvenile court, 1985-1994. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice.
5. National Institute on Drug Abuse. (2007). Principles of drug addiction treatment: A research based guide. Retrieved from http://www.nida.nih.gov/podat/Evidence2.html
6. Liddle, H. (2002). Multidimensional Family Therapy Treatment (MDFT) for adolescent cannabis users. Volume 5 of the Cannabis Youth Treatment (CYT) manual series. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services.
7. Center for Substance Abuse Prevention (CSAP). (2000). Strengthening America’s families: Model family programs for substance abuse and delinquency prevention. Salt Lake City, Utah, University of Utah.
8. Department of Health and Human Services (2002). Best practice initiative: Multidimensional Family therapy for adolescent substance abuse. Retrieved from http://phs.os.dhhs.gov/ophs/bestpractice/mdft_miami.htm
9. National Institute on Drug Abuse (NIDA) (1999). Scientifically based approaches to drug addiction treatment. In Principles of Drug Addiction Treatment: A research-based guide. (Rep. No. NIH publication No. 99-4180, pp.35-47). Rockville, MD: National Institute on Drug Abuse.