Therapist Strategies for Managing Midtreatment Problems in Evidence-based Interventions in Community Settings.

The National Institute of Health has made it a priority to identify, develop, and refine strategies to disseminate and implement effective interventions (National Institute of Health, 2015). This study examined qualitative reports of the strategies therapists used to manage common implementation problems they encountered during midtreatment in Multisystemic Therapy® (MST) and Functional Family Therapy (FFT), two widely disseminated evidence- and family-based treatments for substance abusing and delinquent adolescents. Experienced therapists from dissemination sites across the U.S. described cases in which they encountered midtreatment problems they perceived as serious threats to treatment success. They indicated why each case terminated and rated the outcome of the case. Qualitative analyses examined 16 treatment failures and then 16 treatment successes to identify contextual obstacles that accompanied the problems therapists identified, along with strategies they reported using with families that ultimately succeeded or failed. Therapists reported that midtreatment problems were often embedded in additional related difficulties and that they employed multiple relationship techniques and process-focused strategies to try to resolve these problems. For the most part, therapists described obstacles and strategies for successful and unsuccessful families in similar ways. Patterns of themes and subthemes suggested, however, that therapists in successful cases may be more likely to report "on-script" strategies and therapists in unsuccessful cases may describe more "off-script" strategies as well as more generic relationship building and advice-giving strategies.

Los Institutos Nacionales de Salud (NIH, por sus siglas en inglés) han priorizado la detección, el desarrollo y la perfección de estrategias para difundir e implementar intervenciones eficaces (National Institute of Health, 2015). Este estudio analizó los informes cualitativos de las estrategias que usaron los terapeutas para manejar los problemas comunes de implementación que encontraron durante la mitad del tratamiento en la terapia multisistémica (Multisystemic Therapy® , MST) y en la terapia familiar funcional (Functional Family Therapy, FFT), dos tratamientos factuales y basados en la familia ampliamente difundidos para adolescentes con problemas de delincuencia y de abuso de sustancias. Un grupo de terapeutas experimentados de centros de difusión de todo Estados Unidos describió casos en los cuales encontraron problemas en la mitad del tratamiento que ellos percibieron como amenazas graves para el éxito del tratamiento. Estos terapeutas indicaron por qué cada caso terminó y calificaron el resultado del caso. Los análisis cualitativos analizaron 16 fallas del tratamiento y luego 16 aciertos del tratamiento para detectar obstáculos contextuales que acompañaban a los problemas mencionados por los terapeutas, junto con estrategias que informaron haber usado con familias y que finalmente fueron satisfactorias o fallaron. Los terapeutas informaron que los problemas en la mitad del tratamiento generalmente formaban parte de otras dificultades relacionadas y que ellos emplearon varias técnicas relacionales y estrategias centradas en los procesos para intentar resolver estos problemas. En su mayoría, los terapeutas describieron los obstáculos y las estrategias utilizadas con las familias favorables y con las desfavorables de maneras similares. Sin embargo, los patrones de temas y subtemas indicaron que los terapeutas de los casos favorables pueden ser más propensos a informar estrategias "dentro del libreto" y que los terapeutas de los casos desfavorables pueden describir más estrategias "fuera del libreto", así como estrategias más genéricas de construcción de relaciones y de asesoramiento.

Midtreatment Problems Implementing Evidence-based Interventions in Community Settings.

Multisystemic Therapy® (MST) and Functional Family Therapy (FFT) are two widely disseminated evidence-based family-based treatments for substance abusing and delinquent 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 treatment success. Coders extracted descriptions of problems from interview transcripts and coded them into 12 categories that fell into five major themes: engaging families in treatment; difficulties implementing strategies; family relational and communication problems; 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, therapy model, and race/ethnic match of therapist and family. MST and FFT therapists and supervisors identified many similar problems. There were, however, model-specific differences 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.

La terapia multisistémica (Multisystemic Therapy®, MST) y la terapia familiar funcional (Functional Family Therapy, FFT) son dos tratamientos factuales familiares ampliamente difundidos para adolescentes con problemas de abuso de sustancias y delincuencia. Este estudio de métodos combinados analizó los problemas de implementación comunes a mediados del tratamiento en la MST y la FFT. Una muestra de conveniencia de terapeutas experimentados (20 MST, 20 FFT) y supervisores (10 MST, 10 FFT) de centros de difusión de todo EE. UU. participaron en entrevistas telefónicas semiestructuradas. Los participantes reconocieron retrospectivamente graves problemas en el proceso a mediados del tratamiento que percibieron como amenazas para el éxito del tratamiento. Los codificadores extrajeron las descripciones de problemas de las transcripciones de las entrevistas y los codificaron en 12 categorías que comprendían cinco temas principales: interés de las familias por el tratamiento; dificultades para implementar estrategias; problemas de comunicación y relacionales con la familia; complicaciones ajenas a la terapia; y comportamiento problemático de los jóvenes. Los análisis examinaron las variables de cuidador, terapeuta y joven como predictores de estos problemas comunes a mediados del tratamiento y si los resultados del tratamiento variaron según el tipo de problema, el modelo de terapia y la coincidencia étnica/racial entre el terapeuta y la familia. Los terapeutas y los supervisores de la MST y la FFT detectaron varios problemas similares. Sin embargo, hubo diferencias específicas de los modelos que coincidieron con las distintas características de los modelos (p. ej.: los participantes de la FFT reconocieron más problemas de relaciones familiares y menos problemas para terminar el tratamiento que sus homólogos de la MST). Los resultados subrayan las necesidad de tener en cuenta tanto los factores comunes como específicos del proceso de tratamiento.

Therapists' and Clients' Perceptions of Bonding as Predictors of Outcome in Multisystemic Therapy®.

This longitudinal study examined whether strength of and balance in self-reported caregiver, youth, and therapist emotional bonds in mid- and late treatment predicted outcomes in Multisystemic Therapy of adolescent behavior problems in a sample of 164 caregiver-youth dyads. Strength of and balance in bonds related to outcome in different ways, depending on the source of the report and time. Results showed a limited association between family members' emotional connection with the therapist and treatment outcome, whereas therapists' perceptions of bond with the caregiver showed highly significant associations across time. Caregiver-therapist agreement on emotional connection at both time points predicted therapist evaluation of treatment success and successful termination, but this was largely explained by therapists' level of alliance. Balance in bonds with the therapist between caregiver and youth had no significant associations with any outcome. The study major limitations such as examining only one component of alliance and possible implications are discussed.

Multisystemic Therapy(®) : Clinical Overview, Outcomes, and Implementation Research.

Multisystemic therapy (MST) is an evidence-based treatment originally developed for youth with serious antisocial behavior who are at high risk for out-of-home placement and their families; and subsequently adapted to address other challenging clinical problems experience by youths and their families. The social-ecological theoretical framework of MST is presented as well as its home-based model of treatment delivery, defining clinical intervention strategies, and ongoing quality assurance/quality improvement system. With more than 100 peer-reviewed outcome and implementation journal articles published as of January 2016, the majority by independent investigators, MST is one of the most extensively evaluated family based treatments. Outcome research has yielded almost uniformly favorable results for youths and families, and implementation research has demonstrated the importance of treatment and program fidelity in achieving such outcomes.