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Family Behavior Therapy

Family Behavior Therapy for drug abuse (FBT) is one of the most scientifically supported treatments available for substance abuse and its associated problems (e.g., depression, unemployment, conduct disorders, family discord, child maltreatment). More than a decade ago, this intervention was the only comprehensive scientifically based intervention listed in National Institute on Drug Abuse's (NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide to demonstrate improved outcomes in both adolescent and adult substance abusers and has received exemplary ratings in Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices. In a review by National Institute on Alcohol Abuse and Alcoholism, FBT was mentioned as one of the few evidence-based, developmentally sensitive approaches emerging for addressing alcohol, nicotine, and other drug use problems among adolescents.

Historical Context

FBT is conceptually similar to the Community Reinforcement Approach (CRA), which was pioneered by Nathan Azrin and his colleagues in the 1970s. In this approach, substance abuse is conceptualized to occur because of its strong inherent reinforcing properties. Therefore, CRA therapists reinforce addicted individuals for their performance of behaviors that are incompatible with substance use and teach skills to assist them in building strong relationships with individuals who do not use substances. Now one of the most widely utilized treatments for the addictions, CRA was unique to existing treatments when it was developed. It was the first approach to involve multiple significant others of the substance abuser into the treatment plan, one of the first interventions to assist significant others in responding to abusive behavior exacerbated by drug use, is aimed at eliminating Stressors that make substance abuse more likely, and teaches communication skills training to enhance the general tone of the relationship.

In the late 1980s, Azrin received funding from NIDA to develop the first behavior therapy for adolescent drug abuse. This study was also the first controlled trial to employ both significant others and self-reports of adolescent substance use in addition to objective urinalysis testing as measures of treatment outcome. Due to initial difficulties in the recruitment of adolescents, adults were also enrolled in the initial clinical trials. This fortuitous event resulted in a robust and developmentally sensitive family-based intervention capable of treating the addictions across the life span. More than 3 decades after the development of CRA, federal funding from NIDA and the National Institute of Mental Health has permitted FBT for substance abuse to evolve into one of the premier evidence-based treatment programs in the world, incorporating standardized treatment plans that are consumer-driven treatment manuals with accompanying step-by-step protocol checklists that may be utilized during sessions to guide treatment implementation and measure program fidelity. Measures of treatment outcome are also now more sophisticated and include standardized methods of conceptualizing assessment results to family members. As the name implies, this cost-effective intervention approach utilizes innovative, easily learned behavioral therapies to treat substance abuse and associated problems within a family context.

Overview

Therapy typically consists of 16 60-minute outpatient sessions scheduled to occur across 6 months. Up to 20 home-based sessions are conducted when target populations are particularly problematic, such as child welfare recipients. After a battery of psychometrically validated assessment measures are completed by the client and adult significant other, standardized methods are utilized to assist therapists in conceptualizing the assessment information for family members and for guiding the family in the selection of their own treatment plan from a menu of alternatives. Selected therapies are implemented successively and cumulatively. That is, after each intervention is implemented for the first time, it is reviewed in all subsequent sessions to a lesser extent as relevant skills are developed. Immediately after treatment, assessment measures are again administered, and comparisons are made to evaluate treatment effects. Almost exclusively in research settings, follow-up assessments occur up to 6 months posttreatment to evaluate treatment outcomes. Recent developments include the incorporation of assessment and prevention programming targeting HIV risk behaviors, child management skills training, and protocols specific to home-based implementation for clients in child protective services. For instance, there are tours of the home to ameliorate safety hazards, teach substance abusing parents to stimulate the cognitive and social development of their children, and monitor adverse events. Controlled trials of FBT are presently testing models that teach children how to reinforce parents for their participation in nondrug associated activities.

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