Brief Strategic Family Therapy (BSFT) for Young People in Treatment for Non‐Opioid Drug Use: A Systematic Review

This publication is a Campbell Systematic Review of the effect of the family therapy approach Brief Strategic Family Therapy (BSFT) for treatment for non‐opioid drug use (cannabis, amphetamines, ecstasy or cocaine) among young people aged 11‐21 years. The misuse of prescription drugs and the use of ketamine, nitrous oxide and inhalants such as glue and petrol are not considered in this review. Recent reports describe an alarming trend of drug use by young people and a lack of available treatment for those who require it. BSFT is a manual‐based family therapy approach that seeks to reduce drug use among young people and to correct the problem behavior that often accompanies drug use by addressing the mediating family risk factors. This approach is based on the assumption that the family exerts a profound influence on child and youth development. It is also assumed that interventions needs to be well planned, problem‐focused, and tailored to the unique characteristics of the individual family. BSFT initially targets those patterns of interactions that most directly influence the youth's behavior. After a rigorous search for all relevant studies conducted to date, we identified three studies with 806 participants that met the inclusion criteria. The effectiveness of BSFT on reducing drug usage, family functioning, and treatment retention was explored though meta‐analysis. The findings are as follows: –On drug usage: There is no evidence that BSFT has an effect on reducing the frequency of drug use compared to community treatment programs, group treatment, and minimum contact comparisons –On family functioning: There is no evidence that BSFT has an effect on family functioning compared to community treatment programs, group treatment, and minimum contact comparisons –On treatment retention: BSFT may improve treatment retention in young drug users compared to community treatment programs, group treatment, and minimum contact comparisons. The evidence found was limited. Only three studies were included in the data analysis, which provides very low statistical power to detect an effect of BSFT. The evidence is also limited in terms of outcomes reported on education, risk behavior and other adverse effects, and is therefore insufficient to allow any firm conclusions to be drawn regarding the effectiveness of the treatment. The review found that the methodological rigor and the adequacy of reporting in the included studies were generally insufficient to allow confident assessment of the effects of BSFT for young drug users. Two of the three included studies provided insufficient information on core issues to allow us to assess the risk of bias (e.g. methods of sequence generation, allocation concealment and completeness of outcome data). This methodological weakness makes us question the validity of these two studies. Overall, BSFT for treating young people's drug use has not been evaluated with sufficient rigor to allow its effectiveness to be determined. Well designed, randomized controlled trials within this population are needed. Key messages PLAIN LANGUAGE SUMMARY This publication is a Campbell Systematic Review of the effect of the family therapy approach Brief Strategic Family Therapy (BSFT) for treatment for non‐opioid drug use (cannabis, amphetamines, ecstasy or cocaine) among young people aged 11‐21 years. The misuse of prescription drugs and the use of ketamine, nitrous oxide and inhalants such as glue and petrol are not considered in this review. Recent reports describe an alarming trend of drug use by young people and a lack of available treatment for those who require it. BSFT is a manual‐based family therapy approach that seeks to reduce drug use among young people and to correct the problem behavior that often accompanies drug use by addressing the mediating family risk factors. This approach is based on the assumption that the family exerts a profound influence on child and youth development. It is also assumed that interventions needs to be well planned, problem‐focused, and tailored to the unique characteristics of the individual family. BSFT initially targets those patterns of interactions that most directly influence the youth's behavior. After a rigorous search for all relevant studies conducted to date, we identified three studies with 806 participants that met the inclusion criteria. The effectiveness of BSFT on reducing drug usage, family functioning, and treatment retention was explored though meta‐analysis. The findings are as follows: ‐ On drug usage: There is no evidence that BSFT has an effect on reducing the frequency of drug use compared to community treatment programs, group treatment, and minimum contact comparisons1. ‐ On family functioning: There is no evidence that BSFT has an effect on family functioning compared to community treatment programs, group treatment, and minimum contact comparisons1. ‐ On treatment retention: BSFT may improve treatment retention in young drug users compared to community treatment programs, group treatment, and minimum contact comparisons1. The evidence found was limited. Only three studies were included in the data analysis, which provides very low statistical power to detect an effect of BSFT. The evidence is also limited in terms of outcomes reported on education, risk behavior and other adverse effects, and is therefore insufficient to allow any firm conclusions to be drawn regarding the effectiveness of the treatment. The review found that the methodological rigor and the adequacy of reporting in the included studies were generally insufficient to allow confident assessment of the effects of BSFT for young drug users. Two of the three included studies provided insufficient information on core issues to allow us to assess the risk of bias (e.g. methods of sequence generation, allocation concealment and completeness of outcome data). This methodological weakness makes us question the validity of these two studies. Overall, Brief Strategic Family Therapy for treating young people's drug use has not been evaluated with sufficient rigor to allow its effectiveness to be determined. Well‐designed, randomized controlled trials within this population are needed. Executive summary/Abstract BACKGROUND Youth drug use is a severe problem worldwide. This review focuses on a treatment for non‐opioid drugs2 such as cannabis, amphetamines, ecstasy and cocaine, which are strongly associated with a range of health and social problems. Brief Strategic Family Therapy (BSFT) is a manual‐based family therapy approach concerned with identifying and ameliorating patterns of interaction in the family system that are presumed to be directly related to the youth's drug usage. BSFT relies primarily on structural family theory (i.e. how the structure of the family influences the youth's behavior) and strategic family theory (i.e. treatment methods are problem‐focused and pragmatic). OBJECTIVES The main objectives of this review are to evaluate the current evidence on the effects of BSFT on drug use reduction for young people in treatment for non‐opioid drug use and, if possible, to examine moderators of drug use reduction effects to determine whether BSFT works better for particular types of participants. SEARCH STRATEGY An extensive search strategy was used to identify qualifying studies. A wide range of electronic bibliographic databases were searched in June 2011, along with government and policy databanks, grey literature databases, and citations in other reviews. We additionally searched the reference lists of primary studies, hand‐searched relevant journals, and searched the Internet using Google. We also maintained a correspondence with researchers within in the field of BSFT. Neither language nor date restrictions were applied to the searches. SELECTION CRITERIA Studies were required to meet several criteria to be eligible for inclusion. Studies must: • have involved a manual‐based outpatient BSFT treatment for young people aged 11‐21 years enrolled for non‐opioid drug use. • have used experimental, quasi‐randomized or non‐randomized controlled designs. • have reported on at least one of the following eligible outcome variables: drug use frequency, family functioning, education or vocational involvement, treatment retention, risk behavior or any other adverse effect. • not have focused exclusively on treating mental disorders. • have had BSFT as the primary intervention. DATA COLLECTION AND ANALYSIS The literature search yielded a total of 2100 references, of which 58 studies were deemed potentially relevant and retrieved for eligibility determination. Six papers were data‐extracted, two of which were subsequently excluded for not focusing on treatment effect. Four papers describing three unique studies were included in the final review. Meta‐analysis was used to examine the effects of BSFT on drug use reduction, family functioning and treatment retention compared to Treatment as Usual (TAU) in the included studies, where TAU encompassed a range of conditions and interventions3. RESULTS The results of the review should be interpreted with great caution, given the extremely small amount of data available and thus the low statistical power to detect the effects of BSFT. For drug use reduction, there is no evidence that BSFT has an effect on drug use frequency at the end of treatment compared to community treatment programs, group treatment, and minimum contact comparisons3. The random effects standardized mean difference was ‐0.04 (95% CI ‐0.25, 0.34), based on three studies with 520 participants. For family functioning, there is no evidence that BSFT has an effect on family functioning at the end of treatment compared to control conditions3. The random effects standardized mean difference was 0.06 (95% CI ‐0.13, 0.25) for family functioning as reported by parents, based on three studies with 568 participants. The random effects standardized mean difference for family functioning reported by the youth themselves was 0.16 (95% CI ‐0.19, 0.51), based on two studies with 416 participants. For treatment retention, we found evidence that BSFT may improve treatment retention in young drug users compared to control conditions4. The random effects standardized mean difference was 0.55 (95% CI 0.39, 0.76), based on two studies with 606 participants. Meta‐analysis was not feasible for the outcome of risk behavior due to differences in the measures used in the individual studies. Horigian et al. (2010) did not report significant effects on risk behavior. Santisteban et al. (2003) used the socialized aggression scale of RBPC, and reported that youth in BSFT intervention showed greater reduction in peer‐based delinquency. The random effects standardized mean difference at end of treatment was ‐0.27 (95% CI ‐0.72, 0.18). Only Horigian et al. (2010) reported on adverse effects; here more than 50 percent of the young people in the study experienced risk behavior or other adverse events during the trial. The most common event noted was arrest, followed by suspension from or dropping out of school, and absconding from home. However, the distribution of events in both BSFT and control conditions does not indicate clear differences between BSFT and the control conditions. No studies reported on the outcome of education or vocational involvement. We found that the methodological rigor and the adequacy of reporting in the included studies were generally insufficient to allow confident assessment of the effects of BSFT for young drug users. Two of the three included studies provided insufficient information on core issues to allow us to assess the risk of bias (e.g. methods of sequence generation, allocation concealment, and completeness of outcome data). These flaws in methodology have forced us to question the validity of the two studies. Correspondingly, caution should also be placed on any interpretation of the results. Due to the small number of studies included in the review, it was not possible to assess possible moderators of drug use reduction effects. AUTHORS' CONCLUSIONS There is insufficient firm evidence to allow conclusions to be drawn on the effect of BSFT on non‐opioid drug use in young people. While additional research is needed, there is currently no evidence that BSFT treatment reduces the drug use or improves family functioning for young non‐opioid drug users compared to other treatments4. The review provides us with mixed findings: on one hand, BSFT does not seem to have better or worse effects on drug use frequency and family functioning than community treatment programs, group treatment, or minimum contact comparisons, but has positive effects on treatment retention compared to control conditions4, and longer retention in treatment has been identified as a consistent predictor of a favorable outcome from drug use treatment. Although the possibility remains that the length of follow up in the included studies was insufficient to detect significant changes, it should be noted that the evidence we found was limited, both in terms of the number of studies and in their quality. The aim of this systematic review was to explore what is known about the effectiveness of BSFT for reducing drug use in young people who use non‐opioid drugs. The information currently available does not provide a sufficient basis for drawing conclusions about actual outcomes and impacts. Consequently, no substantive conclusion about the effectiveness of BSFT can be made, and we can neither support nor reject the BSFT treatment approach examined in this review. There is a need for well‐designed randomized controlled trials in this area. New trials should report their results clearly and include long‐term follow‐up to allow the tracking of effects after treatment cessation.