Brief Strategic Family Therapy (BSFT) is an empirically supported treatment for adolescent drug abuse. Previous research on this and other promising drug abuse treatments has focused largely on outcomes, giving little attention to how a treatment works (mediator questions) or for whom it may be especially beneficial (moderator questions). The main aims of this study involve testing theory-derived hypotheses about mediators and moderators (M&Ms) of BSFT's clinical effects. Based on family systems theory, we hypothesize that family functioning plays a critical mediating and moderating role in effective implementation of BSFT. Specifically, family change assessed during therapy should mediate effects of treatment (or BSFT intervention quality) on subsequent drug use outcomes, whereas family functioning assessed before therapy should moderate those effects, with BSFT proving most useful when prior family functioning is poor. Secondary aims are to compare the relative M&M contributions of observational v. self-report measures of family functioning, and to identify therapist characteristics and training processes that predict effective implementation of BSFT in community treatment programs. We propose to use an approved protocol in NIDA's Clinical Trials Network (CTN-0014) as a platform for testing M&M hypotheses about BSFT. The parent grant is a large randomized clinical trial (RCT) beginning later this year, in which BSFT will be compared to treatment as usual (TAU) for adolescent substance abuse in 14 community treatment programs around the country. The parent grant will fund standardized self-report assessments at baseline and for 12 months following the initiation of treatment, and the current grant will fund additional, more intensive data collection based on direct observation of family and therapeutic interactions vital to testing M&M hypotheses. The latter includes (a) ratings of videotaped family interaction at baseline and 4 months for both treatment groups, coded according to the Structural Family Systems Rating scheme; and (b) ratings of therapist adherence/competence (intervention fidelity) in the first and fourth sessions of BSFT only. This CTN protocol affords a unique opportunity to study M&Ms both between treatments (capitalizing on randomization to BSFT and TAU) and within BSFT itself. Finally, because a substantial pool of therapists will also be randomized to treatments, the design provides a rare opportunity to study training processes related to effective treatment implementation. To this end we will collect supplementary data on skill-acquisition trajectories of the BSFT therapists as they progress through training and the clinical trial.
