Testing an empirically-supported family based therapy (MDFT):

USA vs. The Netherlands

H. Liddle, C. Rowe

Center for Treatment Research on Adolescent Drug Abuse

University of Miami Miller School of Medicine

H. Rigter

Erasmus MC, Rotterdam

V. Hendriks

Parnassia Research Centre, The Hague

NIDA ‘parent grant’NIDA ‘parent grant’

Training clinicians in empirically based family therapy

PI: Dr. Howard Liddle

NIDA grant number IRD1 DA016969

Topics to be covered in our presentation

Our collaboration is not fake Our proposal does not come out of the blue.

It has strong support. Our proposal fits priorities from the Call for

Proposals Major comments by the reviewers The parent grant Supplement study: Some methodological

issues Added value of U.S. – Dutch collaboration

Our collaboration: Some history

In 2000, five European countries (B, F, G, N, S) joined forces to end ideological conflict about cannabis by doing research

On February 2002, joint meeting in Brussels with scientists from all over the world

April 2003, joint Cannabis Research Action Plan of the five countries

Priorities Cannabis Research Action Plan

Assess the importance of age of onset of cannabis use

Cannabis dependence: assessment and course

Relationship with mental health Treatment trial (emphasis on youth)

Chosen from literature review: MDFT

5 Completed RCT’s (generally 1 year follow-up) MDFT more effective than (a) group counselling,

(b) group family sessions, and individual CBT MDFT more effective than residential treatment Effective in white, black and Latino adolescents Effective in adolescents referred by Justice,

schools, or self-referred Effective on multiple outcomes: drug use,

externalizing and internalizing symptoms, delinquency, school performance

Conclusions drawn in the Cannabis Research Action Plan

MDFT is the best established treatment

Pilot study (INCANT) September 2004 – May 2005: European therapists trained in MDFT, one per country (supervisors)

If MDFT is feasible, a main study (RCT) will be considered (2005 – 2008)

And that’s where our collaboration began

In past 1.5 years, many visits to and from Miami

Intensive contacts between CTRADA, Erasmus MC, and treatment centers

E-mails: almost daily. Calls: weekly. Listserve Cannabis Questionnaire; Addiction Treatment

Inventory; Treatment Contact Logs; 8 Video and Audio Taped translated treatment sessions

How about the INCANT main study?

We now know that MDFT is feasible in the Netherlands

The RCT proposed to NIDA and ZonMw

is the INCANT main study in the

Netherlands. No such in-depth study is foreseen in the

other four countries in the immediate future, because of:

1. Treatment conditions being too different from U.S.-based settings

2. Insufficient support from treatment centers

3. Supervisors scoring below standard on measures of MDFT compliance,

adherence, and competence

(Scores of Dutch supervisor were excellent.)

Conclusions so far

Our collaboration has real substance. Much preliminary work has been done.

Dutch conditions for the proposed supplement study are good (excellent supervisor, eager therapists in favor of MDFT, managerial and political support)

Overall judgment of reviewers: Positive – Overall judgment of reviewers: Positive – Very PositiveVery Positive

Major comments

Is there really a need for adolescent treatment in the Netherlands for cannabis use disorder plus associated problems?

What is the focus of MDFT treatment? What is the outcome? Just cannabis use outcomes or more?

Enough power to assess expected outcomes? Long enough follow-up?

Treatments for adolescents: Some notes

Cannabis is not a (lasting) problem for most users

However, for some users it is. Especially when they: Start using the drug at a young age

(true in the Netherlands) Have other problems as well (true in

the Netherlands) Additional complication may be:

increasing potency of cannabis

Comment 1: Adolescents

Our proposal targets 3 key issues in the Call for Proposals: Youth, Cannabis, Treatment

The Netherlands lacks facilities for evidence-based treatment of adolescents with cannabis use disorder (among other behavioral problems; high co-morbidity)

Adolescents are especially sensitive to the development of resilient cannabis use disorder

78

74

39

25

14

16

0 20 40 60 80 100

One-time use

Rare use

Moderate use

Heavy use

Abuse

Dependence

CANNABISHow many stop their use entirely on their own in 5

years time?

Associations of mental disorders with substance use disorders

6.8

4.9

3.1

3.8

3.2

2.6

4.7

2.8

5.2

0 2 4 6 8

Nicotine dependence

Depression

Psychosis

Panic disorder

Agoraphobia

Social phobia

Antisocial personality

PTSD (post-trauma)

Other

Comment 1: Adolescents (Continued)

Age of first use of cannabis has gone down

Treatment demand has increased Unmet treatment need worrying to

Government and treatment centers Concentration of THC has increased

Comment 2What is the focus of MDFT

treatment? What is the outcome?

Primary outcome: cannabis and other substance use

Secondary outcomes: less externalizing and internalizing symptoms, better family and school functioning, less delinquency

Pieces of MDFT approach

MDFT intervenes into multiple systems of development and influence (family, peers, school, etc.). Four domains of attention/intervention:

1.Adolescent

2.Parent(s)

3.Family

4.Extra-familial

Pieces of MDFT approach

Problems are multidimensional Multidimensional problems require multi-

component, multi-focus interventions All those domains/systems may help the

adolescent to overcome his or her problems

Howard, I would include here some slides re. Comment 3 by reviewers:

power, length of follow-up

And also some slides on the parent study, showing proficiency in

implementation research

Wrapping up

Our collaboration is real Much preliminary work has been done Proposal fits priorities of the Call The Netherlands = excellent site for

testing MDFT outside the USA We have addressed the comments by the

reviewers (who were positive – very positive)

Added value (see last slide)

Conditions favoring a collaborative implementation trial

of MDFT in the Netherlands Strong commitment from the two centers

in The Hague: management, trained supervisor, team of dedicated therapists eagerly waiting to be trained

Strong collaboration between the two centers

Treatment philosophy similar to that of CTRADA. Treatment As Usual can be standardized.

Regular flow of adolescents and parents/families demanding treatment (from all over the country; present waiting list will be made undone shortly)

Parents willing to join treatment Training materials ready (no translation

needed) National Government in favor (might

donate additional funds)

Conditions favoring a collaborative implementation trial

of MDFT in the Netherlands

Opportunity to establish the effectiveness of MDFT outside the USA

Broader experience with practical applicability (implementation) of MDFT, across more settings and in more ethnic groups (in the Netherlands including Mediterranean and Caribbean youth: 30% of clients)

In the Netherlands, badly needed addition to treatment repertoire

Emphasis on multidimensionality of problem behaviors in youth

Much appreciated collaboration between research Much appreciated collaboration between research groups from different settingsgroups from different settings

FINALLY: Added value of a NIDA – ZonMw trial