Ratings of demand-withdraw interaction in a multi-site trial of Brief Strategic Family Therapy for adolescent drug abuse showed complex but intriguing associations with treatment outcome. Attending to parallel demand-withdraw processes in parent-adolescent and therapist-adolescent dyads may be useful in clinical work with families of substance-using adolescents.

Ratings of demand-withdraw interaction in a multi-site trial of Brief Strategic Family Therapy for adolescent drug abuse showed complex but intriguing associations with treatment outcome. Attending to parallel demand-withdraw processes in parent-adolescent and therapist-adolescent dyads may be useful in clinical work with families of substance-using adolescents.

Participants were 91 families who received at least 5 sessions of Brief Strategic Family Therapy (BSFT) for adolescent substance use in NIDA Clinical Trials Network Protocol #014. The adolescents were 12-17 years old (M = 15.9), 80% male, 49% Hispanic, and 15% African American. An average of 3.9 members per family attended at least one therapy session (range = 2 - 9), and 46% of the families had more than one parent figure.

Before treatment began, families participated in videotaped family interaction assessment tasks, during which they planned a menu, described what pleased and displeased them about each other, and discussed a recent family argument. A team of trained observers later coded PD/AW interaction during these tasks with intra-class rs > .75 (Rohrbaugh et al., 2007). Another team of raters coded the therapist’s demands (requests) for adolescent change during two family therapy sessions, as well as the adolescent’s response to those demands (accept vs. reject/withdraw), with ICCs > .80.

The primary dependent variable was a composite (z-score) index of adolescent substance use based on monthly Timeline Follow-back self-reports and urine drug screens during a 12-month follow-up period. We aggregated the substance-use data by 4-month intervals, yielding 3 outcome assessments in addition to baseline.

Demand-withdraw interaction, a problematic pattern in which one person demands change from another who resists or withdraws, occurs in both marital and parent-child dyads (Caughlin & Malis, 2004; Christensen, 1988). In the treatment domain, intriguing evidence of parallel demand-withdraw processes comes from a study of couple therapy for alcoholic men, where a wife-demand/husband-withdraw pattern predicted poor response to high-demand therapeutic intervention (Shoham et al., 1998).

The current study extends this parallel-process idea to family therapy for adolescent drug users. We hypothesized that adolescents entrenched in parent-demand/adolescent-withdraw (PD/AW) interaction before treatment began would show poorer substance-use outcomes if they engaged in parallel therapist-demand/adolescent-withdraw interaction during family therapy.

Demand-Withdraw Interaction in Family Therapy for Adolescent Drug UsersKristina N. Rynes, Florencia Lebensohn-Chialvo, Michael J. Rohrbaugh, & Varda

Shoham

University of Arizona

The results suggest that attending to parallel demand-withdraw processes in parent/adolescent and therapist/adolescent dyads may be useful in clinical work with families of substance-using adolescents. In particular, an inadvertent replication of ineffective parent behavior within the therapeutic system may undermine the prospect of positive youth outcomes. Case conceptualization and treatment planning for families exhibiting high levels of PD/AW interaction may benefit from consideration of how the therapist can best maintain balanced alliances and avoid a high-demand stance toward the target adolescent.

This study was supported by NIDA Awards R01-DA17539-01, U10-DA15815, and U10-DA13720.

Caughlin, J. P., & Malis, R. S. (2004). Demand/withdraw communication between parents and adolescents: Connections with self-esteem and substance use. Journal of Social and Personal Relationships, 21, 125-148.

Christensen, A. (1988). Dysfunctional interaction patterns in couples. In P. Noller, & M. A. Fitzpatrick (Eds.), Perspectives on marital interaction. (pp. 31-52). Clevedon, England: Multilingual Matters.

Rohrbaugh, M.J., Hasler, B.P., Lebensohn-Chialvo, F., & Shoham, V. (2007). Manual for the Global Structural Family Systems Ratings (GSFSR). Tucson, AZ: Family Research Laboratory, University of Arizona.

Shoham, V., Rohrbaugh, M. J., Stickle, T. R., & Jacob, T. (1998). Demand-withdraw couple interaction moderates retention in cognitive-behavioral versus family-systems treatments for alcoholism. Journal of Family Psychology, 12, 557-577.

We analyzed the data in a multi-level model with assessment period and the adolescent (case) intercept as random variables at level 1, while pre-treatment PD/AW, level of therapist demand, and the adolescent’s response (rejection/withdrawal) were fixed variables at level 2. Additional control variables, included as level-2 fixed factors, were the adolescent’s sex, ethnicity, and level of drug use at baseline.

Consistent with the study hypothesis, a 3-way interaction of PD/AW x therapist demand x adolescent withdrawal (illustrated in Figure 1) significantly predicted subsequent adolescent substance use, B = 1.06, SE = .44, t(179) = 2.44, p = 0.02.

An analysis of the difference in simple slopes within this interaction revealed that, as therapist demand increased, high PD/AW adolescents who withdrew from their therapists used drugs to a somewhat greater degree than did high PD/AW adolescents who did not withdraw from their therapists, t(179) = 1.85, p = .067.

California-Arizona Node, NIDA Clinical Trials Network

U10 DA 015815

______________________________________________________________________________________________________________________________Correspondence address: Kristina Rynes, Department of Psychology, University of Arizona, P.O. Box 210068, Tucson, AZ 85721-0068 (knrynes@email.arizona.edu).

Figure 1. Adolescent substance use (z scores) at follow-up predicted by baseline PD/AW, therapist demand, and adolescent rejection/withdrawal during family therapy sessions