Brief strategic family therapy (BSFT) has proven effective with African-American families and appears to be superior to group therapy for conduct disorders in youth, according to child psychiatrist Barbara Johnson, M.D.
BSFT emphasizes features such as parental hierarchy, discipline, and strong parent-child bonds that have been traditional in African-American families, Johnson told psychiatrists at the annual meeting of the Black Psychiatrists of America in Kansas City, Mo., in March.
"This intervention is clearly acceptable and appropriate for African-American families," Johnson said. "There have been African-American parents who have told me that they are not interested in family therapy because they equate the therapist encouraging the children to speak with giving the children in the family permission to criticize and argue with them. Their first thought is that the therapist is going to encourage the child to ‘talk back.’ But BSFT says parents should play a leadership role. One of the things this intervention focuses on is improving family structure and parental monitoring—knowing where your child is and who he or she is with."
She is an associate medical director at Community Care Behavioral Health Organization in Pittsburgh.
The Web site of the Center for the Study and Prevention of Violence at the University of Colorado at Boulder describes BSFT as "a short-term, problem-focused intervention with an emphasis on modifying maladaptive patterns of interactions."
According to the center, typical sessions last from 60 to 90 minutes, with 12 to 15 sessions over three months. Therapy is based upon the assumption that each family has unique characteristics that emerge when family members interact and that this family system influences all members of the family. The existing repetitive interactions, or ways in which family members interact and behave with regard to one another, can be either successful or unsuccessful. BSFT targets these interaction patterns, which are directly related to the youth’s behavior problems, and establishes a practical plan to help the family develop more effective patterns of interaction.
According to the Center for the Study and Prevention of Violence’s Web site, these are the three primary components of the intervention:
• Joining: understanding resistance and engaging the family in therapy.
• Diagnosis: identifying the interaction patterns that encourage problematic behavior.
• Restructuring: developing a specific plan to help change maladaptive family interaction patterns by working in the present, reframing, and working with boundaries and alliances.
Johnson said that in group counseling, acting out by teenagers actually increased because of the reinforcement teens received for negative behaviors from having an audience of peers "silently cheering them on," she said.
Johnson said BSFT has a number of advantages that make it appropriate for use in African-American families.
The intervention has been "manualized" and disseminated widely to local treatment agencies. "So it’s not a matter of having [to have] a Ph.D. and years of experience to deliver the intervention," Johnson said.
Moreover, it has been found to be useful for a wide range of problems, including conduct disorders, substance abuse, and family problems associated with having an HIV-positive mother, among others.
Johnson said many of the disadvantaged youth for whom she is responsible at Community Care Behavioral Health Organization have two or more diagnoses, sometimes including substance abuse, and have attracted the attention of multiple social service and juvenile justice agencies.
"They suffer with the stigma of mental illness that makes families very ambivalent about mental health treatment, especially medication," Johnson said. "And many families struggle with the concept of how volitional their child’s behavior is. For these families there is a question about whether [the behavior] is really a mental illness and whether they are indulging them and encouraging negative behavior by saying that they can’t help themselves."
Yet for many adolescents taking medication for a serious mental illness, sometimes there are profound family problems that interfere with their medication treatment.
"Sometimes well-meaning psychiatrists tell patients not to take medication and smoke marijuana at the same time," she said. "Yet the level of problems at home is such that the teens feel they cannot go home without being high. So given the choice, they quit taking their medication—in keeping with the doctor’s orders—even if they have a serious illness such as manic depression. Yet we actually expect these children will get better with a pill that they may not necessarily even be taking."
She emphasized the need for psychiatrists and mental health professionals to check the evidence base for their favored therapies, because states and local agencies are increasingly disinclined to spend money on interventions for which there is no evidence of effectiveness.
"In the field of juvenile justice and to a lesser degree in child welfare, programs across the country have come to the conclusion that if they are going to spend money on the neediest kids and the most at-risk kids, they might as well be spending it on practices that have some evidence base," she said.