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Implementing and Sustaining MDFT in Practice

Cynthia Rowe, PhD., Howard A. Liddle, Ed.D.,

Gayle A. Dakof, Ph.D., Craig Henderson, Ph.D., Alina Gonzalez, & Dana S. Mills, Ph.D.

Center for Treatment Research on Adolescent Drug Abuse

University of Miami School of Medicine

Presented at the 2005 Joint Meeting on Adolescent Treatment Effectiveness;

Washington, DC, March 22, 2005

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OverviewOverview

What did we do?

How did we do it?

How did it work?

What’s next?

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What Did We Do?What Did We Do? NIDA-funded study to “bridge the gap” (“Bridging” Study)

Worked with providers at a representative adolescent day treatment program to adapt and transport MDFT

4 study phases: Baseline, Training, Implementation, and Durability

Tested whether MDFT was implemented and sustained in the treatment program

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Study AimsStudy Aims

Clinical Practices: Determine whether providers implemented MDFT in the program

Program Changes: Determine whether the program could be transformed based on MDFT principles and interventions

Client Changes: Determine whether youths’ drug use and other outcomes improved

Durability: Determine whether these changes could be sustained without MDFT trainers

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Study PhasesStudy Phases

Phase I. Baseline: Assessment of provider practices, program environment, and

client outcomes

Phase II. Training: Work with all staff in day treatment program and larger system

Phase III. Implementation: Continue expert supervision and booster trainings as

needed;Assess impact of training

Phase IV. Durability: MDFT experts withdraw;

Assess sustainability of approach

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Adolescent Day Treatment Adolescent Day Treatment Program FeaturesProgram Features

Multicomponent program/multidisciplinary staff

Behaviorally oriented “levels approach”

School through alternative education program

Group therapy daily and recreational activities

Psychiatric evaluation and intervention

Individual therapy weekly

Family therapy “as needed”

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How Did We do It?How Did We do It?

Guiding principle: Isomorphism between training approach and therapy model

Collaboration/ Consultation approachCollaboration/ Consultation approach

Empowering clinical staff and defining Empowering clinical staff and defining rolesroles

Conceptualizing change at different Conceptualizing change at different levelslevels

Modeling, practice, and feedbackModeling, practice, and feedback

Increasing staff accountabilityIncreasing staff accountability

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Known Barriers to Technology Transfer

Treatment providers not ready for change

Lack of organizational commitment to change

Treatment technology not seen as credible

Treatment too complex or unclear

Insufficient incentives/resources

Decay of new knowledge over time

 

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Addressing Barriers To Technology Transfer

Start with what providers feel needs to change

  Demonstrate outcomes in concrete ways

Simplify the intervention with protocols

Highlight the ways practices are consistent

Be creative in providing incentives for change

  Discuss and address obstacles openly

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How Did It Work?How Did It Work?

Clinical PracticesClinical Practices: : Changes in sessions and contacts Changes in sessions and contacts (parameters)(parameters) Changes in session content (interventions)Changes in session content (interventions)

Program ChangesProgram Changes:: Changes in program environmentChanges in program environment

Client Changes: Drug use and delinquency Externalizing/internalizing symptoms Placements in controlled settings

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Results: Treatment Parameters

Average number of weekly sessions/contacts compared across phases: individual sessions, family sessions, DJJ contacts, and school contacts

Baseline to Implementation: all parameters increased significantly (p<.01)

Baseline to Durability: all parameters increased significantly (p<.01)

Implementation to Durability: Individual sessions and school contacts

significantly increased DJJ contacts significantly decreased (p<.05)

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Increases in Contacts over Study Phases

0

0.2

0.4

0.6

0.8

Ave

rage N

um

ber

of W

eekly

Conta

cts

DJ J Contacts School Contacts

Baseline

Implementation

Durability

More contacts with schools in

Implementation and Durability

More DJJ contacts in Implementation than

Baseline

Slight decrease in DJJ contacts in

Durability

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Results: Session Content

Therapy session notes coded for core MDFT themes

Therapists focused more on drugs in Baseline phase than in Implementation and Durability (p<.05)

Therapists focused on school and the adolescents’ thoughts and feelings about themselves more in the Implementation and Durability phases than in Baseline (p’s<.01)

Therapists in Implementation and Durability addressed more core MDFT content themes per session than in Baseline (p<.05)

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Results: Program Environment

Adolescents’ perceptions of the program were compared across study phases (COPES)

Implementation vs. Baseline: increased Order and Organization (p<.05)

Implementation and Durability vs. Baseline: increased Practical Orientation (p<.05) increased Clarity (p<.05) decreased controlling behavior (p<.01)

Durability vs. Baseline: increased staff involvement (p<.05)

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Results: Client Outcomes

Implementation and Durability vs. Baseline Drug use decreased more significantly (p<.05)

Durability vs. Baseline: Delinquent behavior decreased more significantly

(p<.05) Externalizing and internalizing symptoms decreased

more significantly (p<.05) (adolescent and parent reports)

Youth in Baseline were more likely to be placed in a controlled environment (37%) compared with those in Implementation (8%) or Durability (4%)

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45

50

55

60

65

70

75

Intake 1 Month Discharge 9 Months

Baseline

Implementation

Durability

Change in Parent-Reported Externalizing

ProblemsYouth in Durability improved more rapidly than youth in Baseline

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45

47

49

51

53

55

57

59

61

63

Intake 1 Month Discharge 9 Months

Baseline

Implementation

Durability

Change in Parent-Reported Internalizing

Problems

Youth in Durability improved more rapidly than youth in Baseline

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Percent in Controlled Environment at Follow-Up

37

8

4

0

5

10

15

20

25

30

35

40

Baseline

Implementation

Durability

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Factors that Increased Factors that Increased Acceptability Acceptability

““It’s been a collaborative effort… IIt’s been a collaborative effort… I think everybody was pretty good about understanding these are the parameters we work with and we’re doing a good job in the real world… I I think you abbreviated it and think you abbreviated it and accommodated it within our setting.”accommodated it within our setting.”

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Addressing Potential Addressing Potential Implementation BarriersImplementation Barriers

““I didn’t see it as increased work. I saw it as good. Not only were they getting this one to one supervision from an expert, but the clinical meetings brought them to another level. I don’t think it was a burden at all…I think it made me get involved more which is good.”

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Factors linked to Factors linked to SustainabilitySustainability

Ongoing Structure: “We still have the clinical meeting. At that meeting we’ll rehash the very tough stuff and come up with program action plans and clinical action plans for the kids.”

Accountability: “I am holding them accountable about making sure the kids are coming in and they are urging involvement in family therapy… The accountability’s gotta be there.”

OutcomesOutcomes: “You know you get some sort : “You know you get some sort of gratification from it when you see the of gratification from it when you see the kids, you see their changes, things in the kids, you see their changes, things in the home are changing. So why would we home are changing. So why would we stop?”stop?”

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Summary of Findings Clinical Practices: Therapists implemented MDFT in

line with parameters and prescribed interventions

Program Environment: Program changed in line with MDFT principles (e.g., “be therapeutic all the time’)

Client Outcomes: Youths’ outcomes improved concurrently with staff/program changes

Durability: Staff continued to use MDFT and to have positive outcomes a year after MDFT experts withdrew

Training successfully created lasting change in fundamental and targeted areas (staff behavior, program, and client)

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What’s next? New MDFT training studies focus on

several unanswered questions: How can training tools be developed that

are “user friendly” and cost effective?

Can new technologies enhance learning?

How do trainers address unique provider and program level factors?

What level of ongoing monitoring is needed from expert trainers to sustain learning?

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Acknowledgements

Completion of this research was supported by a grant from the National Institute on Drug Abuse (Grant No. NIDA R01 DA13089, H.

Liddle, PI).

We also thank Paul Greenbaum, Ph.D., as well as our colleagues at Jackson Memorial Hospital for their significant contributions to this study.

Please see our website for more information on the Center’s program of research:

www.miami.edu/ctrada

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