Chapter 1 - Brief Strategic Family Therapy: An Overview

Brief Strategic Family Therapy (BSFT) is a brief intervention used to treat adolescent drug use that occurs with other problem behaviors. These co-occurring problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior (Jessor and Jessor 1977; Newcomb and Bentler 1989; Perrino et al. 2000).

BSFT is based on three basic principles. The first is that BSFT is a family systems approach. Family systems means that family members are interdependent: What affects one family member affects other family members. According to family systems theory, the drug-using adolescent is a family member who displays symptoms, including drug use and related co-occurring problem behaviors. These symptoms are indicative, at least in part, of what else is going on in the family system (Szapocznik and Kurtines 1989). Just as important, research shows that families are the strongest and most enduring force in the development of children and adolescents (Szapocznik and Coatsworth 1999). For this reason, family-based interventions have been studied as treatments for drug-abusing adolescents and have been found to be efficacious in treating both the drug abuse and related co-occurring problem behaviors (for reviews, see Liddle and Dakof 1995; Robbins et al. 1998; Ozechowski and Liddle 2000).

The second BSFT principle is that the patterns of interaction in the family influence the behavior of each family member. Patterns of interaction are defined as the sequential behaviors among family members that become habitual and repeat over time (Minuchin et al. 1967). An example of this is an adolescent who attracts attention to herself when her two caregivers (e.g., her mother and grandmother) are fighting as a way to disrupt the fight. In extreme cases, the adolescent may suffer a drug overdose or get arrested to attract attention to herself when her mother and grandmother are having a very serious fight.

The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent's behavior problems. For example, a mother and grandmother who are arguing about establishing rules and consequences for a problem adolescent never reach an agreement because the adolescent disrupts their arguments with self-destructive attempts to get attention.

Therefore, the third principle of BSFT is to plan interventions that carefully target and provide practical ways to change those patterns of interaction (e.g., the way in which mother and grandmother attempt but fail to establish rules and consequences) that are directly linked to the adolescent's drug use and other problem behaviors.

The scientific literature describes various treatment approaches for adolescents with drug addictions, including behavioral therapy, multisystemic therapy, and several family therapy approaches. Each of these approaches has strengths.

BSFT's strengths include the following:

• BSFT is an intervention that targets self-sustaining changes in the family environment of the adolescent. That means that the treatment environment is built into the adolescent's daily family life.
• BSFT can be implemented in approximately 8 to 24 sessions. The number of sessions needed depends on the severity of the problem.
• BSFT has been extensively evaluated for more than 25 years and has been found to be efficacious in treating adolescent drug abuse, conduct problems, associations with antisocial peers, and impaired family functioning.
• BSFT is "manualized," and training programs are available to certify BSFT counselors.
• BSFT is a flexible approach that can be adapted to a broad range of family situations in a variety of service settings (e.g., mental health clinics, drug abuse treatment programs, and other social service settings) and in a variety of treatment modalities (e.g., as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service to residential treatment).
• BSFT appeals to cultural groups that emphasize family and interpersonal relationships.

In BSFT, whenever possible, preserving the family is desirable. While family preservation is important, two goals must be set: to eliminate or reduce the adolescent's use of drugs and associated problem behaviors, known as "symptom focus," and to change the family interactions that are associated with the adolescent's drug abuse, known as "system focus." An example of the latter occurs when families direct their negative feelings toward the drug-abusing youth. The parents' negativity toward the adolescent directly affects his or her drug abuse, and the adolescent's drug abuse increases the parents' negativity. At the family systems level, the counselor intervenes to change the way family members act toward each other (i.e., patterns of interaction). This will prompt family members to speak and act in ways that promote more positive family interaction, which, in turn, will make it possible for the adolescent to reduce his or her drug abuse and other problematic behaviors.

The makeup and dynamics of the family are discussed in terms of the adolescent's symptoms and the family's problems.

The Family Profile of a Drug-Abusing Adolescent

Research shows that many adolescent behavior problems have common causes and that families, in particular, play a large role in those problems in many cases (Szapocznik and Coatsworth 1999). Some of the family problems that have been identified as linked to adolescent problem behaviors include:

• Parental drug use or other antisocial behavior
• Parental under- or over-involvement with the adolescent
• Parental over- or under-control of the adolescent
• Poor quality of parent-adolescent communication
• Lack of clear rules and consequences for adolescent behavior
• Inconsistent application of rules and consequences for adolescent behavior
• Inadequate monitoring and management of the adolescent's activities with peers
• Lack of adult supervision of the adolescent's activities with peers
• Poor adolescent bonding to family
• Poor family cohesiveness

Some adolescents may have families who had these problems before they began using drugs (Szapocznik and Coatsworth 1999). Other families may have developed problems in response to the adolescent's problem behaviors (Santisteban et al. in press).

Because family problems are an integral part of the profile of drugabusing adolescents and have been linked to the initiation and maintenance of adolescent drug use, it is necessary to improve conditions in the youth's most lasting and influential environment: the family. BSFT targets all of the family problems listed on page 3.

The Behavioral Profile of a Drug-Abusing Adolescent

Adolescents who need drug abuse treatment usually exhibit a variety of externalizing behavior problems. These may include:

• School truancy
• Delinquency
• Associating with antisocial peers
• Conduct problems at home and/or school
• Violent or aggressive behavior
• Oppositional behavior
• Risky sexual behavior

Negativity in the Family

Families of drug-abusing adolescents exhibit high degrees of negativity (Robbins et al. 1998). Very often, this negativity takes the form of family members blaming each other for both the adolescent's and the family's problems. Examples might include a parent who refers to her drug-abusing son as "no good" or "a lost cause." Parents or parent figures may blame each other for what they perceive as a failure in raising the child. For example, one parent may accuse the other of having been a "bad example," or for not "being there" when the youngster needed him or her. The adolescent, in turn, may speak about the parent accused of setting a bad example with disrespect and resentment. The communication among family members is contaminated with anger, bitterness, and animosity. To the BSFT counselor, these signs of emotional or affective distress indicate that the work of changing dysfunctional behaviors must start with changing the negative tone of the family members' emotions and the negative content of their interactions. Research shows that when family negativity is reduced early in treatment, families are more likely to remain in therapy (Robbins et al. 1998).

BSFT has not been tested with adult addicts. For this reason, BSFT is not considered a treatment for adult addiction. Instead, when a parent is found to be using drugs, a counselor needs to decide the severity of the parent's drug problem. A parent who is moderately involved with drugs can be helped as part of his or her adolescent's BSFT treatment. However, if a parent is drug dependent, the BSFT counselor should work to engage the parent in drug abuse treatment. If the parent is unwilling to get drug abuse treatment, the BSFT counselor should work to protect and disengage the adolescent from the drug dependent parent. This is done by creating an interpersonal wall or boundary that separates the adolescent and non-drug-using family members from the drug dependent parent(s). This process is discussed in Chapter 4 in the section on "Working With Boundaries and Alliances," beginning on page 36.

This manual introduces counselors to concepts that are needed to understand the family as a vital context within which adolescent drug abuse occurs. It also describes strategies for creating a therapeutic relationship with families, assessing and diagnosing maladaptive patterns of family interaction, and changing patterns of family interaction from maladaptive to adaptive. This manual assumes that therapists who adopt these BSFT techniques will be able to engage and retain families in drug abuse treatment and ultimately cause them to behave more effectively. Chapter 2 will discuss the basic theoretical concepts of BSFT. Chapter 3 will present the BSFT diagnostic approach, and Chapter 4 will explain how change is achieved. Chapter 5 is a detailed discussion of how to engage resistant families of drug-abusing adolescents in treatment. Chapter 6 summarizes some of the research that supports the use of BSFT with adolescents. The manual also has two appendices, one on training counselors to implement BSFT and another presenting case examples from the authors' work. Concepts and techniques discussed by Minuchin and Fishman (1981) have been adapted in this BSFT manual for application to drug-abusing adolescents. Additional discussion of BSFT can be found in Szapocznik and Kurtines (1989).

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