Midtreatment Problems Implementing Evidence‐based Interventions in Community Settings

• Author: Caela Day,Kaila Smith,Sisi Yu,Phillippe B. Cunningham,Ginger Burleson,Sharon L. Foster,Michael S. Robbins,Sophie Bryan,Debra M. Kawahara
• Date: 01 June 2019
• DOI: http://doi.org/10.1111/famp.12380
• Published date: 01 June 2019

Midtreatment Problems Implementing Evidence-

based Interventions in Community Settings

PHILLIPPE B. CUNNINGHAM*

SHARON L. FOSTER

†

DEBRA M. KAWAHARA

†

MICHAEL S. ROBBINS

‡

SOPHIE BRYAN

†

GINGER BURLESON

†

CAELA DAY

†

SISI YU

†

KAILA SMITH

†

Multisystemic Therapy

â

(MST) and Functional Family Therapy (FFT) are two widely

disseminated evidence-based family-based treatments for substance abusing and delin-

quent adolescents. This mixed-method study examined common implementation problems

in midtreatment in MST and FFT. A convenience sample of experienced therapists (20

MST, 20 FFT) and supervisors (10 MST, 10 FFT) from dissemination sites across the

United States participated in semistructured telephone interviews. Participants identified

retrospectively serious midtreatment process problems they perceived as threats to treat-

ment success. Coders extracted descriptions of problems from interview transcripts and

coded them into 12 categories that fell into five major themes: engaging families in treat-

ment; difficulties implementing strategies; family relational and communication prob-

lems; complications external to therapy; and youth problem behavior. Analyses examined

caregiver, therapist, and youth variables as predictors of these common midtreatment

problems and whether treatment outcomes varied depending on the type of problem, ther-

apy model, and race/ethnic match of therapist and family. MST and FFT therapists and

supervisors identified many similar problems. There were, however, model-specific differ-

ences consistent with differing features of the models (e.g., FFT participants identified

more family relational problems and fewer follow-through problems than their MST

counterparts). Results underscore the need to consider both common and specific factors

in treatment process.

Keywords: Multisystemic Therapy; Functional Family Therapy; Midtreatment Problems;

Evidence-Based Treatment

Fam Proc 58:287–304, 2019

*Medical University of South Carolina, Charleston, SC.

†

Alliant International University, San Diego, CA.

‡

Oregon Research Institute, FFT LLC, Seattle, WA.

Correspondence concerning this article should be addressed to Phillippe B. Cunningham, Medical

University of South Carolina, 176 Croghan Spur Rd., Ste. 104, Charleston, SC 29407. E-mail:

cunninpb@musc.edu.

This project was funded by the Fahs-Beck Fund for Research and Experimentation. We are grateful

to the therapists and supervisors who provided interview material, to the participants in our focus groups,

and to the many graduate student research assistants who contributed to the project.

Multisystemic Therapy is a registered trademark of MST Group, LLC.

287

Family Process, Vol. 58, No. 2, 2019 ©2018 Family Process Institute

doi: 10.1111/famp.12380

Adolescent delinquency and drug use remain major public health concerns (Center

on Addiction and Substance Abuse, 2011; U.S. Department of Health and Human

Services [HHS], Office of the Surgeon General, 2016; Welsh et al., 2012; Young,

Greer, & Church, 2017). Nonetheless, over the past three decades, research has

demonstrated the efficacy and effectiveness of family-based interventions with delin-

quent and substance abusing adolescents (e.g., Baldwin, Christian, Berkeljon, Shad-

ish, & Bean, 2012; Waldron & Turner, 2008). Two well-validated family interventions

are Multisystemic Therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cun-

ningham, 2009) and Functional Family Therapy (FFT; Alexander, Waldron, Robbins,

& Neeb, 2013).

Research suggests that evidence-based treatments (EBTs) such as MST and FFT can be

transported to community settings with fidelity (e.g., Henggeler, Clingempeel, Brondino,

& Pickrel, 2002; Liddle et al., 2006; Robbins et al., 2011); however, the effect sizes

observed in clinical trials often diminish in these settings (Baldwin et al., 2012). Identify-

ing factors that contribute to reduced effect sizes is crucial to help real-world therapists

implement EBTs and to reduce the science-service gap.

Family-based EBTs have a rich history in examining in-session treatment processes

that are associated with positive and negative outcomes. Treatment process research

primarily examines what happens between therapists and clients within and across

sessions to identify how and why client change occurs (Hardy & Llewelyn, 2015). For

example, nonspecific treatment factors (such as therapist empathy or ability to man-

age client “resistance”) have been repeatedly shown to be positively related to treat-

ment effectiveness (Sayegh et al., 2016). In FFT, several studies have described the

clinical interior of treatment, providing guidance to therapists about how to manage

family conflict (Robbins, Alexander, & Turner, 2000) and build balanced alliances

with family members (Robbins, Turner, Alexander, & Perez, 2003). Similarly, Foster

et al. (2009) found that therapist strength focus, practical support, reinforcing state-

ments, and problem solving were associated with in-session caregiver engagement.

Nonetheless, Cunningham, Foster, and Warner (2010) indicated that MST therapists

often struggle with identifying what to actually do when faced with challenging

within-session verbalizations from caregivers of substance abusing and delinquent

adolescents.

One limitation of MST and FFT process studies is that most have examined treatment

in controlled efficacy trials which by nature restrict the range of therapist activities. And,

despite the fact that EBTs include rigorous supervision and monitoring protocols to sup-

port therapists in practice settings, it is possible that implementation in community set-

tings is characterized by more variation in therapist activities. Treatment process studies

in real-world settings are needed to fully understand how such variations are related to

outcomes. Furthermore, although some FFT and MST studies have examined processes

across different racial and ethnic groups (e.g., Foster et al., 2009; Robbins et al., 2006,

2008), more research is needed to fully appreciate whether and how clinical processes dif-

fer as a function of race and ethnicity. Findings from MST and FFT treatment process

studies suggest that treatment process variables sometimes operate differently depend ing

on the ethnicity of the family (Foster et al., 2009; Ryan et al., 2013; Sayegh et al., 2016)

and the match between family and therapist race/ethnicity (Flicker, Turner, Waldron,

Brody, & Ozechowski, 2008; Foster et al., 2009) . For example, MST therapist empathy in

midtreatment was associated with positive caregiver responses among therapists and

caregivers whose race/ethnicity was the same, but not when they endorsed different

racial/ethnic backgrounds (Fost er et al., 2009). In general, examining process problems

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