PROVEN: Brief Strategic Family Therapy Also Helps Reduce Substance Use in Parents

Due to the paramount importance of the current OPIOID CRISIS, we thought it wise to republish this article:

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).

Can BSFT Help That Family?

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

Trauma Work and BSFT - An Effective Combination

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.

How Do We Best Serve Our Kids And Families Using Evidence-Based Practices?


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

The Changing Landscape of Children’s Mental Health

Recent incidents of violence perpetrated by teenagers and young adults have once again focused attention on the nation’s mental health system. The alarming frequency of events like the fatal Oregon high school shooting is making our nation take pause. And many concerned parents and government leaders are calling for changes in policy and practice to address these concerns.

Mental health is often at the center of these debates. While we know that children or youth with mental health problems are not inherently violent and that mental health problems do not cause someone to become violent, we also know that untreated mental health issues put our children and youth at higher risk for a variety of lifelong problems and can exacerbate social and behavioral problems — especially in youth prone to violence.

Increased incidents of trauma, school failure, and behavioral health concerns are debated when youths who apparently “fall through the cracks” turn to violence or drug use as means to express their anger and frustration with the world, or escape from it. Well-intentioned government agencies and policy makers often try to address such problems by proposing increases in spending to expand existing services. Massachusetts recently confronted the dramatic rise in opiate addiction by investing $20 million in treatment and recovery services. But more money invested in treatment as usual is not always the best solution; nor is casting blame about who failed our children. We need to invest in solutions that have the optimal chance of helping our children in need.

In recent years, the Commonwealth of Massachusetts, faced with an unprecedented federal lawsuit, has invested hundreds of millions of dollars each year to better meet the needs of vulnerable children and families through the creation of the Children’s Behavioral Health Initiative . As a result of this litigation, Massachusetts must provide behavioral health screening, diagnostic evaluation and an array of behavioral health services to children up to age 21 who have MassHealth. The Initiative’s broader goal is to identify and treat all children at risk earlier, and to support a more robust system of community-based services for children and families. This initiative is both noble and ambitious. It is a good example of how state government, as a result of legal action, has made sweeping reforms to try to better meet the mental health needs of children. However, when trying to improve the current mental health system for children, we shouldn’t only look at the lack of needed services and supports. We must also examine the quality of available services and supports.

Interventions for children that have been demonstrated by research to be effective, referred to as “evidence-based treatments,” have been developed for a wide range of common childhood mental health disorders such as PTSD, anxiety, depression, substance abuse and behavioral problems. These interventions use effective strategies to reduce problematic symptoms and help restore the child’s ability to function normally. Interventions that can be provided in community-based outpatient settings, such as Trauma-focused Cognitive Behavior Therapy and the Modular Approach to Therapy for Children, or treatments that can be provided in the family’s home, such as Multisystemic Therapy, have proven track records to address targeted mental health problems and help children and families recover.

Although states like Massachusetts and Connecticut have begun to implement some evidence-based treatments, in most cases they are not widely available. When working to reform our mental health systems, one of our primary tasks should be making sure effective services and supports such as these are available to all children in need. It’s not always easy to translate research to practice in the real world, but we have learned a great deal about how to bridge that gap and raise the standard of mental health care for children and families. Investments in training, dissemination, and sustainability of treatments proven to work would be dollars well spent to ensure a healthy future for our children.

Residents of Massachusetts — and the nation — deserve the best mental health interventions available. We must recognize that quality care means paying attention to what services are delivered, how they are delivered, and how we train professionals who work with families. We need to identify what works, routinely collect data that measure outcomes and include families in our decision-making. By implementing quality, evidence-based treatments we can provide our children with the best chance for recovery and healthy development. Families deserve no less, and the futures of our most vulnerable children depend on it.

Robert P. Franks is president and CEO of Judge Baker Children’s Center in Boston.

This article, originally published in the Boston Globe on June 20, 2014, has been reprinted with expressed permission from Dr. Robert Franks and the Boston Globe.