While BSFT® is well recognized for significantly reducing substance abuse in adolescents,a new randomized study of 480 families completed in 2014 found BSFT significantly more effective than TAU (treatment as usual) at “reducing alcohol use in parents”. Finally there is data to support what Olga Hervis, co-developer of BSFT, has anecdotally found in her 30+ years of BSFT training, and in the hundreds of implementation sites.
Since BSFT's primary focus is on enhancing and realigning the family's structure to be more functional in order to eliminate or reduce externalizing and internalizing behaviors in youth, parental functioning is a primary area of the BSFT treatment plan. Thus, the BSFT treatment plan involves quick and early detection of parental substance use/abuse or a mental health diagnosis.
Some parental substance use---and/or mental health conditions ---can be addressed and improved within the BSFT family therapy sessions. But oftentimes, the parent is "joined" and they are then referred to their own treatment. That treatment can take place tandem to the family therapy. There is also an alternative course of action whereby the rest of the family system receives treatment until the parent has made enough progress in their own treatment to rejoin the group family therapy sessions.
In cases where the dysfunctional parent is a single parent, BSFT assists in the recruitment of other biological or non-biological family members to function in a parenting role in cooperation with the absent parent so as not to usurp their eventual parental role.
BSFT's restructuring approach in families with a substance-involved parent is in line with prevailing addiction treatment centers’ treatment philosophy of helping a family re-organize while the affected individual is recovering; if not, there is a high incidence of relapse. In the case of both a substance-involved parent as well as a symptomatic youth, the risk is greatly multiplied.
The Brief Strategic Family Therapy Training curriculum, authored by our Director Olga Hervis, and the supervised practicum provided by the Family Therapy Training Institute of Miami include teaching clinicians how to intervene with parental dysfunction in order to maintain the integrity of the family therapy (e.g. engagement, retention, results) while achieving therapeutic results with all affected family members.
In summary, the study proved that "BSFT is effective in reducing alcohol use in parents, and in reducing adolescents' substance use in families where parents were using drugs at baseline. BSFT may also decrease alcohol use among parents by improving family functioning".
Viviana E. Horigian, Daniel J. Feaster, et al (2014). "The effects of Brief Strategic Family Therapy (BSFT) on parent substance use and the association between parent and adolescent substance use". Addictive Behaviors, Vol. 42 (pages 44-50).
I am often asked the question regarding what constitutes an appropriate family for BSFT® and always find myself replying in the negative, as most any family with a child or adolescent identified patient (IP) with either internalizing or externalizing symptoms is indeed very appropriate and will respond favorably to the BSFT® intervention.
So, it is easier to discuss who is NOT appropriate: actively psychotic, homicidal or suicidal IP’s (or other family members), as these families need Crisis Intervention before ANY outpatient modality can be instituted; youth who have no families and are living in a residential setting, or are alone and emancipated; youth who are in a foster situation and will not be reuniting with their families of origin (NOTE-maybe they should be seen with their fosters if this is a relatively permanent arrangement). There are also youth who need “other” interventions alongside BSFT, (e.g., autistic children, developmentally disabled).
On a cautios note I must emphasize that children whose parents do not speak English should not be seen by a therapist who does not speak their language. The use of translators who are not professionally trained does not work at all. Additionally, the children must never be used to do the translating.
Therefore, basically BSFT has been proven effective in the treatment of all families who have a child between the ages of 6 and 18 with presenting symptomatology, as long as the family members can be safely treated as outpatients. If family members are reluctant to come to therapy, BSFT has developed ---and tested 4 times---a specialized engagement model which works very effectively, but clinicians and agencies must know that this model is time and effort consuming beyond the typical treatment/billing hours.
An 8-site study conducted in late 2014 proved that "BSFT is effective in reducing alcohol use in parents, and in reducing adolescents' substance use in families where parents were using drugs at baseline. BSFT may also decrease alcohol use among parents by improving family functioning.". [See our recent article].
Finally one last add, real world service delivery of BSFT has shown us that families whose children are on probation do very well with BSFT.
--Interview with Olga Hervis, Executive Director and Model Developer
Brief Strategic Family Therapy (BSFT®) is a highly effective, systemic approach to working with youth with an identified presenting problem in the context of their family system. Often, the presenting problem or problems for a youth include, or are supported by, traumatic experiences in either the youth or their family members.
The framework of BSFT allows for a clinician to diagnose a family system in terms of 5 domain areas that are a factor in the presenting problem for clinical treatment, regardless of what the presenting problem is.
Trauma specific treatment relies first on assessment that demonstrates the direct impact of trauma on an individual’s life, and second on those involved with the individual who may have a positive impact on the survivor’s empowerment and safety. So how might these frameworks come together?
Understanding a youth in the context of their family system and engaging that family system (or parts thereof) in treatment is critical to positive long term outcomes for a youth.
This understanding allows for a clinician to plan for and execute reversals of the negative familial patterns that support a presenting problem or diagnosis. Similarly, trauma models such as Trauma Focused Cognitive Behavioral Therapy show excellent outcomes, particularly when a supportive caregiver is involved in the treatment process. This idea that engaging family members in treatment for a youth is not a new concept, but often not fully conceptualized when delivering trauma focused treatment.
Using a model like BSFT to systemically diagnose the family system allows for integration of trauma specific interventions in a strategic manner
This is achieved by best understanding how the interventions will be received or supported by the family system, and what threats there may be for the intervention not to be successful due to unhealthy family patterns. For example, a well-timed trauma assessment and emphasis on psycho-educational components of trauma can be helpful in reducing family system diagnoses of denial (of the traumatic event, perhaps) or negative views of the youth with a presenting problem that is based in trauma. Similarly, the teaching of cognitive coping skills, done in a family context, can provide a trauma focused skill base for not only the youth, but caregivers, siblings, etc. who likely have experienced some form of the same trauma.
Reversing dysfunctional patterns in a family system, such as lack of direct communication or mind-reading, prior to implementing a trauma specific treatment, allows for a survivor to be empowered with regard to their own experience of their trauma.
EVIDENCE BASED PROGRAMS ARE GREAT, BUT HOW DO WE BEST SERVE OUR KIDS AND FAMILIES USING EBPS?
Service providers across the nation ---with EBPs in hand---still tackle the issue of how to best serve our kids and families in need. And while attesting to the value of EBPs, they further question “how do we maintain EBP fidelity and achieve results?”
At FTTIM we share this concern with other model developers and disseminators. It is not enough that service providers choose an evidence-based program; they must set about this in a manner that will ensure model replications that are viable, sustainable and most critically, able to produce the predictable outcomes that were established in their experimental trials.
To this end, as I moved into the dissemination field, I committed myself to go beyond the simple training of clinicians on how to do the evidence-based model Brief Strategic Family Therapy (and others), but also to helping their organizations make the necessary transitions that create the context where the EBP will “behave as it should.”
There are several issues involved in guaranteeing that agencies will put in place a true replication of the EBP model---BSFT®, for instance--- with its expected success. To do so, we need to address viability, sustainability and effectiveness. Issues such as
1-Agency commitment to the EBP,
2-Finding the right “fit” between the agency and the EBP,
3-Developing organizational structural congruence with the chosen model,
4-Adequate staff deployment and sufficient staffing provision,
5-Maintaining adherence, data-driven monitoring and decision-making, and
6-Development of an effective working relationship not just internally, but also with other systems in the service context.
Successful implementation of an EBP requires that implementers are taught beyond the mere acquisition of new clinical concepts and techniques. Developers and trainers must also ensure that clinicians and their agencies, in tandem, create an environment that maintains programmatic fidelity in all aspects.
In helping organizations successfully implement BSFT® we have to see that the system is congruent theoretically and clinically with the model. If not, symptoms appear ---poor outcomes, engagement and preservation failures, loss of fidelity, staff turnover. The EBP then becomes, as we say in Family Therapy lingo, the "Identified Patient" of the agency system. As effectiveness decreases, funding is lost…. the EBP dies.
Interview with BSFT® model co developer and Institute Executive Director, Olga E. Hervis
Beyond Gender: Ethics, Supervision, and Privilege Information
Recently Silvia Kaminsky, our Deputy Director and Master Trainer and Supervisor, was part of a panel that presented at the American Association for Marriage and Family Therapy (AAMFT) Annual Conference in Austin, Texas August 29 through Sept 1, 2019.
The title of the presentation was “Beyond Gender: Ethics, Supervision, and Privilege Information.” Ms. Kaminsky’s presentation focused on the adaptability of the evidence-based model Brief Strategic Family Therapy (BSFT®) to address issues of therapist gender and racial intersectionality in the application of this model in the real world.
This presentation refers to how the issues of Gender and Intersectionality are addressed in the Supervision sessions that BSFT® therapists undergo with our Institute Master Trainers during training in BSFT® or during the subsequent fidelity monitoring phases.
Intersectionality is “the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.” —from Oxford
Therapist ethnicity and gender are not common variables that have been studied in most evidence-based research studies of systemic therapies, yet it plays an important role in the service delivery arena and in the successful implementation of the model.
BSFT® is a therapeutic modality that focuses on context, not content, so culture is not a “content” that is introduced in the course of the therapeutic intervention. Rather, the therapist uses his/her mimicking skills to blend with the family so that the family’s natural process---which includes their cultural norms--- are displayed through their enactments. The enactments then become the focus of the therapeutic interventions.
For therapists’ supervision sessions, this modality includes videotaping family therapy sessions. In that process, the therapeutic system is readily available for observation of therapist + family system interactions. When there is a lack of progress or a therapeutic failure, we may notice issues of gender/intersectionality. This allows for an efficient and accurate analysis of therapist subjectivity that may be interfering in implementing BSFT skills
The therapist’s personal experience and feelings about working with a family of a different ethnicity or gender mix are not addressed in the BSFT® curriculum UNLESS it is a source of the therapist’s lack or failure to intervene according to the model to achieve the desired healthy outcomes. This is consistent with the model’s principle of Pragmatism.
The topic of acknowledging and integrating the issue of therapist gender intersectionality in BSFT or any evidenced-based practice is critical because in the real world, therapists who practice EBPs, such as BSFT®, experience micro-aggression and burnout. Also, the majority of therapists practicing BSFT are female and increasingly more are people of color. We at FTTIM also believe that supervisors in the real world have an ethical responsibility to attend to the therapists’ well-being as well as the well-being of the client families they serve.
Here are 2 examples of how to maintain fidelity while attending to the unspoken issues of gender and ethnicity. These are real BSFT® supervision cases:
Case Example #1
- The case of “June”, the Therapist
- June the Therapist—African American, from South Carolina, female therapist in early 30's
- Client Family—White, biological father (a Pastor), mother an identified patient
- Father sermonized, and wife and child did not speak up—impeding open and effective communication.
- BSFT Model intervention requires the therapist to block interaction in order to restructure it to a healthier dialogue between family members.
- Therapist was unable to follow through session after session, supervision after supervision.
- Therapist’s obstacle was identified: in her culture a younger person did not interrupt an elder, especially a clergy-person, and from a different and dominant race.
- Our Institute’s supervisor (in charge of June’s BSFT® training) is neither African American nor from the South. She encouraged June to seek advice from her family and friends as to how one would “politely” interrupt such a person.
- June, after following the supervisor’s advice, was both validated, then empowered to block--- “interrupt” ---in a manner consistent with her cultural context that would work effectively in the treatment of this family
Case Example #2
- The case of “Shayna” the Therapist
- Shayna the Therapist—African-American female—from Detroit
- Client Family—White, two males, Lower-Middle socioeconomic status, the uncle and his dependent 16 y/o nephew (IP).
- Negativity, poor communication/conflict, ineffective behavior control (symptom acting out behavior with delinquency).
- Shayna intervened according to the BSFT® model in the session successfully, to help nephew and uncle resolve a conflict, reduce the negativity between them and establish more effective methods of communicating and stronger affective bonds.
- During her BSFT supervision practicum, Shayna presented the session to our Institute’s supervisor as of “poor quality.”
Our Institute supervisor took note of the following while watching Shayna’s video:
- Content of conflict between the nephew and the uncle revolved around the nephew’s African American girlfriend and nephew’s problem with his uncle’s racist remarks and disapproval.
- Shayna, the Therapist, stayed away from content (and so did our supervisor in analyzing the session) and just focused on the process issues between them in order to re-direct uncle and nephew in ways to better communicate and understand each other.
- To her credit, Shayna the Therapist was in a “dissociated state” during the session, automatically perfectly executing the model as she has been practicing it very well for many years. Didn’t think about whether she was left feeling bad and confused (which she was!)
- Therapist was able to acknowledge that the reframes she used to reduce the nephew’s negativity towards uncle---uncle’s “fear,” his own limited upbringing, concerns for nephew being aggressed by White Supremacist groups---were reframes that she herself found helpful in staying joined with the uncle, so that she could direct more open and accepting communication between them. Bravo!
- She also felt that having her feelings being solicited and validated by our Institute supervisor was important in acknowledging the real struggle and effort she went through in working with the “dominant” white culture.
In her soon to be published book, Brief Strategic Family Therapy, co-authored by co-developer Jose Szapocznik and published by the American Psychological Association (release date 1/28/20), FTTIMs Executive Director and Model co-developer, Olga Hervis, uncovers the recent work in epigenetics confirming what they had presumed for many years, basically that contextual experiences can alter genetics: “When we started our clinical work in 1974, we recognized the powerful influences of environment and particularly the family on child and adolescent behavior", said Olga.
Much research has documented the role that families play as risk and protective factors for child and adolescent outcomes 1. Since then, a body of research in the field of epigenetics has revealed how environment “gets under the skin” of adolescents through the continuous interplay between biology and environment 2.
Although many laypersons believe that the impact of heredity is unchangeable, research into gene environment interactions and epigenetics shows that the way heredity is expressed in behavior depends dramatically on environmental influences. Of these, the family is the most impactful. It follows that positive experiences in the family will produce flourishing child and adolescent development, whereas adverse experiences in the family lead to at-risk or poor development. According to the National Academies of Sciences, Engineering, Medicine's recent (2019) consensus report on adolescence, intervention in the present can remedy past adverse experiences. We thus propose that changing families’ patterns of interaction from conflictive to collaborative and from angry to loving in the present will have a positive impact on the development of its children in the future.
Brief Strategic Family Therapy is well-recognized in its ability to transform family patterns of interaction into a positive win-win for family members.
1 (Bögels & Brechman-Toussaint, 2006; Donovan, 2004; Hawkins, Catalano, & Miller, 1992; McComb & Sabiston, 2010; Morris, Silk, Steinberg, Myers, & Robinson, 2007; Pinquart, 2017; Repetti, Taylor, & Seeman, 2002; O. S. Schwartz, Sheeber, Dudgeon, & Allen, 2012; Wight, Williamson, & Henderson, 2006)
2 (National Academies of Sciences, Engineering, and Medicine, 2019).