Brief Strategic Family Therapy
What Is Brief Strategic Family Therapy® (BSFT®)?
Brief Strategic Family Therapy (BSFT®), an award-winning evidence-based practice, is a culturally competent, strength-based model designed to eliminate or reduce behavior problem syndrome in youth aged 6-18 years while restructuring problematic family interactions.
BSFT® uses a structured, problem-focused, directive, and practical approach to the treatment of child/adolescent conduct problems such as drug use, associations with antisocial peers, truancy, bullying, and other recognized youth risk factors. It uniquely addresses cognitive, behavioral, and affective aspects of family life. It incorporates effective processes of change from other models including: strategic and structural approaches, existential/emotive therapy, eco-systemic approaches, and cognitive behavioral approaches.
Through focused interventions and skill building strategies, BSFT® provides families with the tools to overcome individual and family risk factors. The approach is based on the assumption that family-based interactions strongly influence how children behave, and that targeting and improving maladaptive family interactions reduces the likelihood of symptomatic behavior.
The therapist works with the family to identify interactional patterns that give rise to and/or maintain problematic youth behavior. After these patterns are identified, the therapist helps the family change these patterns to encourage positive family interactions.
To restructure interactions and change systems, BSFT addresses family behavior, affect, and cognition. The strategies and treatment plans are designed specifically for each family and are based on a structured diagnostic plan. The therapeutic process uses techniques of:
- Joining - forming a therapeutic alliance with all family members
- Diagnosis - identifying interactional patterns that give rise to/encourage/enable problematic youth behavior
- Restructuring - the process of changing the family interactions that are directly related to problem behaviors
The program fosters parental leadership, appropriate parental involvement, mutual support among parenting figures, family communication, problem solving, clear rules and consequences, nurturing, and shared responsibility for family problems. In addition, because the efficacy of BSFT does depend on family’s abilities to come into the session, BSFT provides specialized engagement strategies for bringing families into therapy.
BSFT was selected as a “Model” program by the Substance Abuse and Mental Health Services Administration (SAMHSA), by the Center for Substance Abuse Prevention (CSAP), and by the OJJDP, and as an "Exemplary" program by Strengthening America’s Families, among others.
How BSFT® Works
Brief Strategic Family Therapy® is typically conducted in an average of 12-17 weekly sessions, depending on the severity of the problems. In various studies, the full range has been 8-24 weekly sessions. A typical therapy session lasts 60 to 90 minutes.
The 4 steps of the intervention consist of:
- Organizing a counselor-family work team. Developing a therapeutic alliance with each family member, and with the family as a whole, is essential for success.
- Diagnosing the nature of family strengths and problematic relationships. Emphasis is made on those family relationships that are supportive or problematic and on the impact, they have upon the children’s behavior and the parental figures’ ability to correct inappropriate responses.
- Developing a treatment strategy aimed at capitalizing on strengths and correcting problematic family relations to increase family competence.
- Implementing change strategies and reinforcing family behaviors that sustain new levels of family competence. Important change strategies include the use of reframes to change the meaning of interactions; shifts alliances and interpersonal boundaries; building conflict resolution skills; and providing parents with guidance and coaching.
One full-time counselor can provide the BSFT intervention to 15-20 families, if conducted in the office, or 10-12 families if conducted at the home, clinic, or other location outside the office. On the average, a BSFT therapist can typically treat 25 - 35 families to completion within one year.
A program structure that includes at least three counselors assigned to conduct the intervention - even if on a part time basis—is strongly encouraged. This will allow counselors to support and consult with each one about BSFT.
BSFT® can be implemented in a variety of settings, including community social services agencies, mental health clinics, substance abuse prevention and treatment clinics, health agencies, and family clinics. Because BSFT works with the whole family, the program usually operates during afternoons, evenings and Saturdays.
Proven Results of BSFT®
While BSFT is notable as a model developed particularly for its cultural competence with language and cultural minority families, the model has been tested with other populations including African-Americans, women, and those with HIV/Aids. An extensive list of adaptations has been made by the co-developer to a variety of settings including foster-care, Native American reservations, home-based and community clinic settings, transitional programs and others. (Note: adaptations to any evidence based practice should only be made by its developer(s) to assure that core elements of the model are preserved.)
Relative to comparisons, participating children/adolescents and their families showed:
- 75% reduction in marijuana use
- 75% of families remained in the program for the full dosage
- 58% reduction in association with antisocial peers
- 42% improvement in conduct disorder
In addition, Families showed significant:
- Increased family participation in therapy (92% of referred/non-mandated families)
- Improvements in maladaptive patterns of family interactions (family functioning)
- Improved family communication, conflict-resolution, and problem-solving skills
- Improvement in family cohesiveness, collaboration, and child/family bonding
- Reduction of alcohol use among parents while reducing the adolescents’ substance use (8-site study concluded in 2014)
ESSENTIAL COMPONENTS FOR IMPLEMENTATION SUCCESS
Therapists must be fully trained to competency in Brief Strategic Family Therapy in order to practice this trademarked model. In fact, immediately upon commencing training, the clinicians begin working with families using the model.
These BSFT practitioners must be able to intervene in families to improve maladaptive patterns of interactions, while at the same time encouraging family members to support and rely on each other, rather than on the facilitator her/himself. It also requires therapists that can be comfortable making close connections to people at all 3 levels of human experience: cognitive, behavioral and emotional. In addition, there are certain key issues that must be addressed to ensure successful replication and sustainability of an evidence-based model program, such as BSFT®.
Preferably, this ideal candidate has a Master's degree in mental health, social work, or marriage and family therapy. However, individuals with a Master's degree in a related field, or a Bachelor's degree plus 3 years of clinical experience may be qualified. At minimum, individuals must have basic knowledge of how family systems operate.
Organizational considerations include:
a) a thorough understanding of the model by the agency's staff;
b) alignment of structure with intended clinical outcomes;
c) proper staffing;
d) training, adherence monitoring and fidelity management;
e) congruence between programming services and the model;
f) adequate funding, and
g) development of internal stability.
Successful organizations aiming to duplicate evidence-based models like BSFT® must have an administrative as well as theoretical commitment to family therapy, provide the necessary administrative support, and address issues prior to implementation. Following program start-up, they must maintain this commitment via a close relationship to the developers that will secure the maintenance of fidelity over time.
Cost Effectiveness of BSFT
The most recent cost-effectiveness study of BSFT, which was conducted in Maryland, showed that the cost for treating one family through the full range of 24 sessions was only $3,200.
That equates to $133 per session, or in a typical family of 4, $800 per person for the full cost of treatment. In summary, in the study, it cost $33 per person, per session. This is a fraction of the cost of maintaining a youth in residential facilities.
For example, in Kansas, the cost of Youth Residential Centers placements was reported at $45,990 annually per bed, with a majority of youth discharging unsuccessfully, and reporting that long term positive results for youth were not achieved. (2015 Cost Study of Youth Residential Centers for Juvenile Offenders, Kansas Dept. of Corrections.)
Similarly, in 2007 The Department of Juvenile Services (DJS), State of Maryland, reported the annual cost for the placement of one youth in a state-run home to be $52,256.
By employing BSFT® as an alternative to sending a youth to such residential facilities results in a cost avoidance that can then be redirected to further funding the model’s implementation so that more families and at-risk populations can be served.
In general, various studies exist in the United States that show how the successful implementation of evidence based practices reduces crime and saves billions of taxpayers' money. "Interventions that follow all evidence-based practices can achieve recidivism reductions of 30 percent. In one widely cited 2006 review of more than 550 program evaluations, the Washington State Institute for Public Policy found that a moderate to-aggressive investment in evidence-based programs would save state taxpayers $2 billion, avert prison construction and reduce the crime rate." Citation: Pew Center on the States, One in 31: The Long Reach of American Corrections (Washington, DC: The Pew Charitable Trusts, March 2009).
Adaptations should only be made in consultation with the model's developers in order to retain the core components of the model while still preserving its effectiveness. BSFT and its adaptations have been implemented in more than 20 states in the USA and in a variety of clinical formats, including home and center-based programs.
BSFT® was originally developed with Hispanic/Latino families but was subsequently tested with African American families as well. More recently it was selected by NIDA to be the adolescent treatment model to be tested as part of the National Clinical Trials Network. It was tested in 8 sites throughout the country with populations of all ethnic groups. The model is currently utilized in a wide variety of geographical settings and has proven to be successful with foster, as well as intact, families of varied ethnic backgrounds, and with deaf and/or hearing impaired families.
It has also been implemented in the service delivery field with several language and cultural minority groups, including Native Americans. BSFT was also successfully tested in the treatment of children ages 6 thru 12 who presented with externalizing and internalizing symptomatology. That study was awarded the Outstanding Research Award by the American Association for Marriage and Family Therapy in 1989.