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The BEST Plus approach to assisting families recover from youth substance problems

by John Bamberg, Steven Findley & John Toumbourou

The Best plus program is a whole-of-family therapy option for families to address not only youth substance abuse issues, but also challenging and antisocial adolescent behaviours. It uses an evidence-based strategy that can be implemented widely in the community, and is proving to be a popular and relevant framework for professionals to engage and assist families in reducing adolescent problem behaviours. Evaluations indicate that the program is an effective forum for parents and siblings of adolescent drug abusers to redevelop positive family environments that encourage responsible behaviour and recovery from drug abuse.

Adolescent substance abuse has become a significant and all too common public health issue for the community and of direct concern to many Australian families. Recent research completed by the Centre for Adolescent Health in Victoria (e.g. Toumbourou et al. 2005), confirms high levels of youth substance use in Australia, but also demonstrates that there may be ways to reduce this problem by working with families. Considerable advances have been made in recent years to provide treatment and support structures for families. In Victoria, the BEST program was developed as an eight-week, facilitated, group-work model for parents in families where there is an adolescent using substances problematically.

Up until the mid-1990s, most resources were aimed at the treatment of the substance-using person, with little assistance made available to other family members. To respond to the concerns expressed by families and parents regarding their adolescent's substance abuse, the authors designed the eight-session BEST curriculum (Blyth, Bamberg & Toumbourou 2000).

The BEST program's design was originally informed by the authors' clinical experiences but was frequently altered and adjusted in response to information gained from the program's evaluation protocols. The BEST program evaluation used an action research model with pre- and post-program questionnaires. The series of evaluation studies included a waiting-list trial of 66 parents accepted for entry into the program between 1997 and 1998 (six groups). These parents revealed high levels of mental health problems at program entry (87% with elevated General Health Questionnaire symptoms). Reduction to near normal levels (24% elevated) at intervention completion (eight weeks) was observed for parents entered immediately into the program, but was not apparent for parents on the waiting list (Toumbourou et al. 2001). Exposure to the program was also associated with significant increases in assertive parenting behaviours; reduction in family stress; decreases in personal levels of depression, anxiety and alienation; and with adolescent efforts to recover from substance abuse (Toumbourou et al. 2001).

Bamberg et al. (2001) described outcomes for families completing the BEST program after 1998 and observed recovery in adolescent substance abuse in one-third of families, which was sustained at two years post intervention. Bamberg and colleagues observed family motivation to proceed through additional change strategies in a further one-third of families. They concluded that it could be feasible to achieve substance abuse recovery for as many as two-thirds of adolescents through further program investment. To increase support for parents and to extend support further to the siblings of drug users, the BEST Plus program was developed in 2003, with support from the Ross Trust philanthropic foundation, as a whole-of-family therapy program.

The BEST Plus program offers a theoretically sound treatment option for families to address youth substance abuse issues using an evidence-based strategy that can be implemented widely in the community. Evaluations over the past two years support the BEST Plus program as an effective forum for the parents and siblings of adolescent drug abusers to redevelop positive family environments that encourage responsible behaviour and recovery from drug abuse.

The BEST Plus program consists of eight sessions conducted over eight weeks using a family systems approach in treating drug addiction and associated problematic behaviours (Stanton, Todd & Associates 1982). As well as offering support, the program also explores various strategies to assist families to cope with and, hopefully, overcome the emotional and physical difficulties associated with substance abuse.

The first four sessions are exclusively for parents. The siblings of the drug user are invited to attend sessions five to eight. The attendance of siblings is strongly encouraged to help rebuild family cohesion, which has often suffered a decline when families experience one of their members using drugs. The sibling who uses drugs may also be invited to attend the program, but on the condition that they have not used drugs for a minimum of four weeks.

The BEST Plus program encourages families to continue to incorporate and explore the changes they wish to make in their family by providing them with tasks they complete in between sessions at home. Some tasks challenge parents to consider alternative viewpoints of the problems while other tasks require families to work together and therefore redevelop closer and more cohesive bonds.

This paper provides a description of each session within the BEST Plus program structure. To explore the therapeutic process we will follow a family's journey through the program and record their progress through each session. Although the family presented is real, for the purpose of confidentiality, their names have been changed and their situation generalised to protect their privacy.

Family background

The parents presented as a couple in their early forties with both parents in full-time employment. Janet (mother) has two children from a previous relationship, Jay (25) and Meg (23), while John (father) has a son, Tim (16) also from a previous relationship. Jay lives away from the family home. Meg and Tim continue to live at home with their parents.

Meg was identified as displaying the problematic behaviour for which the family sought help. In addition to abusing alcohol and using drugs, such as cannabis, amphetamines and ecstasy, individual family members also described the following behaviour:

Janet

"She [Meg] comes home in the middle of the night, slams the door, eats some food and then leaves again. I don't know where she's going or whom she is staying with. I'm really worried about how she behaves. I feel like a bad mother for having a daughter that behaves this way."

John

"I don't know where she is, who she is hanging out with. I spend most of my time trying to look after Janet because she is so worried about Meg. I'm just sick of it. I walk around the house on eggshells because the place feels so tense. She (Meg) doesn't show me any respect, and she looks disgusting."

Tim

"She is always asking to borrow my iPod. I don't see her much, but I wake up at night when she comes home at all hours. I've had to lock some things away so she doesn't take them."

Best plus program sessions
Session 1: Helping parents to get comfortable within the group

Outline

Two group facilitators establish a rapport and "join" with a group of six to 10 parents to create a therapeutic relationship. Parents are given the opportunity to explore the problem behaviours they have been experiencing and to meet others who have similar experiences. To quickly develop a working relationship and trust in the group process, parents are asked to participate in a small group exercise that helps them become more comfortable discussing their difficulties and also assists them in setting personal goals for the program.

Family presentation

Janet and John appeared quite apprehensive on arrival. Their interactions were brief and they appeared quite agitated. The group facilitators observed an avoidance of contact between Janet and John, which was interpreted as indicating the presence of tension and difficulties in their relationship. This hypothesis was confirmed when Janet spoke about how her daughter's behaviour has adversely affected her relationship with John. When speaking about her daughter, Janet became quite tearful. Her distress prompted John to step in and talk about the difficulties they are facing with Meg's behaviour. He emphasised how Janet's response to Meg's behaviour had placed undue stress on their relationship. John stated that their relationship was "on the skids". Near the end of the session, Janet and John appeared more relaxed and spoke about the relief they had experienced when given the opportunity to talk with someone about how they felt. Prior to attending the program, Janet and John had not discussed Meg's behaviour with others for fear of attracting judgmental responses. They both felt the program could offer them some hope.

Session 2: Normal adolescent development within the family lifecycle

Outline

When parents view their adolescent's behaviour as aberrant or indicating a physical or psychological disorder, they feel that they do not have the knowledge or the ability to intervene. This session aims to reframe the behaviour as belonging to more normative adolescent behaviours such as rebellion, risk-taking and experimentation. To reframe the behaviour, facilitators introduce the family life cycle to parents and emphasise the adolescent phase of the cycle. Parents are asked to remember their own adolescence and focus on how they rebelled and how it affected their parents. Viewing the behaviours on a continuum of rebellious risk-taking allows parents to realise that they do not have to rely on "experts" to overcome the problems. Because parents often neglect their own happiness in their endeavours to cope with family difficulties, they are encouraged to initiate self-care activities between sessions. When parents understand that they too are allowed to be happy in their life, they find implementing change less difficult.

Family presentation

John was very forthcoming about his rebellious acts as a teenager and appeared happy to explore some of the consequences related to his actions. Janet was less certain about her rebellious acts, saying, "I didn't really do anything. I came from a very strict home". Her lack of rebellious behaviour was further explored by the group, which resulted in Janet recalling changing in and out of her uniform between leaving school and arriving home. Being able to reflect and label these behaviours as rebellious seemed to lessen the perceived severity of Meg's behaviour for Janet. It also highlighted the notion that if Janet and John worked together to overcome the problems, Meg might find it difficult to manipulate her parents by playing them off against each other. John acknowledged this notion and Janet submissively said, "I know, I know". This reply from Janet did not appear to reassure John of her sincerity to change their parenting roles. But it did open up further discussions.

Session 3: A process model to encourage adolescent learning

Outline

To reinforce the progress families are making, each session begins with a process of "spotlighting" families that have successfully implement-ed program tasks and change strategies offered in previous sessions. Session three introduces the importance for adolescent learning of the process of making decisions, taking responsibility and setting consequences. Parents will often accept the responsibility and consequences for their adolescent's choices and decisions and thereby deny their children the opportunity to learn from their own experiences. In this session parents are encouraged to modify their family practices by returning the responsibility for un-acceptable behavioural choices to their children and then setting and enforcing agreed consequences for misbehaviour.

Participants are introduced to the concept of setting "logical consequences", with facilitators assisting parents in exploring individual consequences that would work in their family. The concept of "evolution not revolution" is employed to discourage parents from making large changes. Sole parents are asked to involve someone else (a close friend or relative) who they can use as a sounding board for their ideas.

Family presentation

The session topic of responsibility was discussed in-group with John and Janet raising various ideas of who is responsible for different tasks. Facilitators noted that Janet was unwilling to step back and allow Meg to face the consequences of her behaviour. John stated that Janet did far too much for Meg and had not received anything in return. Facilitators explored this juncture in terms of Janet allowing Meg to learn by her mistakes, rather then stepping in and rescuing her. This was further reinforced by breaking down Janet's day into compartments and looking at the amount of time and effort Janet spends on Meg compared to the rest of the family. Janet was able to acknowledge that she would like to spend more time with John and Tim. John indicated that he appreciated what Janet had said. The remainder of the session focused on what type of consequences could be implemented. Facilitators posed questions regarding what Janet and John "do" for Meg, suggesting that she could "earn" what was given, rather than be provided with their services and goodwill freely. Janet said that she would find it difficult not to help her daughter, especially when she looks so terrible, but John maintained that Meg needed to take responsibility for looking after her self. To address this tension in their relationship, facilitators suggested that Janet trial some of her ideas and discuss them with John. Janet agreed to try out the suggestion.

Session 4: Developing practical parent change strategies

Outline

Session four assists parents to practically implement the concepts discussed in the previous session in their family situation. Parents discuss how to work together to overcome the difficulties, how to set effective consequences, the importance of following through with set consequences and how to provide options or alternatives in place of "telling" their children what to do or what they want.

Family presentation

At the beginning of session four, facilitators noted that Janet and John were talking more openly and comfortably in regard to their issues. Janet raised the question of "why people take drugs". This was discussed within a framework of either wanting to escape reality or to avoid emotional pain. In response to the discussion, Janet stated that she now could understand why Meg had decided to use drugs. John stated that although there may have been a reason for Meg's drug use, he felt that her behaviour had affected other people and should not be excused. John's statement signalled a change in their relationship. He became more assertive about wanting a greater role in their relationship and dealing with Meg's behaviour. Janet reiterated her concern about Meg's choices. The facilitators reframed her concerns as being related to her fears about something she could not control. She was advised that by holding Meg accountable for her behaviour, she might be able to influence Meg's decisions. John fully supported this concept with Janet appearing to support his stance by nodding her agreement. As the siblings were invited to attend the next four sessions, John informed the group his son would join them next week and that Janet would also ask her son to come along. It was decided not to invite Meg as she was continuing to use drugs.

Session 5: Hearing the voices of siblings

Outline

Siblings join their parents for the remainder of the program. The facilitators integrate the siblings into the program by encouraging parents to reflect on and emphasise what has had the greatest impact on them during the previous four sessions. This discussion not only orientates the siblings to the program but also informs the facilitators as to what the parents feel is important to them.

The siblings are asked to tell the group how the behaviour of their brother or sister has affected them. Parents are often unaware that others are affected by their child's behaviour. To be informed about the effect of the behaviours on their children can be quite confronting for parents. The ensuing debate will require the facilitators to guide group interactions with sensitivity and direction.

Family presentation

Tim and Jay joined their parents for the remainder of the program. Tim was introduced first and spoke briefly about Meg's behaviour with a focus on how it had impacted on him.
He tended to describe events rather than say how he felt about his relationship with Meg. When Jay spoke, he strongly agreed with giving more responsibility back to Meg. He indicated his diminishing tolerance of her behaviour by describing recent incidents in which she had let him down. Jay provided examples of how he had moved out of home and taken responsibility for his own life, which was in contrast to Meg's current attitude. Janet acknowledged the difference between Jay's and Meg's attitudes in taking responsibility. Jay's and Tim's inclusion in the program prompted Janet to acknowledge that Meg's behaviour had affected everyone in the family. Furthermore, the broader family reinforced the fact that Janet's parenting strategies were not working and that it might be helpful to try a different approach. The session ended with the family agreeing to be more united in a common goal of looking after each other.

Session 6: Freeing families from negative emotions attached to past difficulties

Outline

Families experiencing behaviours such as substance use will frequently employ methods of coping that were effective when the family was at an earlier life stage (i.e. childhood). These methods, when employed at a later life stage (with adolescents), may have lost their impact, but parents in their attempt to cope with problem behaviours will, at times, continue to apply the same obsolete strategies. For example, while ordering children to their room may be appropriate, it may incite rebellion or aggression from adolescents. The negative emotions parents have attached to past family difficulties can block their attempts to create and employ alternative strategies. These past events may no longer have relevance in their present lives but continue to adversely influence their current strategies for dealing with adolescent behaviours (Young 1994).

The aim of session six is to free families from past emotions that continue to impact upon and block their ability to deal with the present situation. Freeing families from the constraints of those emotions may allow them to explore or find alternative coping mechanisms. Families are assisted to identify negative emotions that undermine their family life. A powerful therapeutic task encouraged in this session involves a "mock funeral" where accounts of past difficulties are written and then symbolically "buried".

Family presentation

Janet appeared tired while John seemed rather agitated. When asked how their week had been, Janet informed the group that Meg had not been home for five days, which greatly worried her. Her worrying had led her to experience difficulty sleeping. John added that Meg had been home fleetingly during the day but had not remained at home. The home rules had been given to Meg but Janet said she found it hard not to do things for Meg because she looked so bad. John showed his frustration at this comment by rubbing his face but said nothing. An exercise involving individual input was organised where each family member identified the emotion they felt when the problem was at its worst. John picked frustration, Janet chose worried, Jay and Tim both said angry. After further discussion it was decided that "angry" was the one emotion that they all felt. John appeared more relaxed after having had an opportunity to air his feelings. Janet acknowledged that she did feel anger towards Meg. Janet said "... she makes me feel guilty for being a bad mother, I'm not a bad mum". This provided the motivation for Janet to continue with the house rules/consequences and give more responsibility back to Meg. Each family member undertook to work together to reduce the influence of anger in their family life.

Session 7: rebuilding emotional ties within the family

Outline

In an attempt to overcome the problem, parents often allocate large amounts of emotional and capital resources to the "problem child". Inadvertently, other siblings in the family can suffer a loss of involvement with their parents and may find it difficult to have their emotional "needs" met. The couple may also find themselves reacting to an ever-increasing number of crises. In session seven, each participant is asked to identify at least one emotional "need" they would like their family to fulfil. As people generally do not always communi-cate what having their "needs" met means, the session asks families to define the meaning of their "needs" and how they will know their "needs" have been met. For example, what does "being supported" mean? Does it mean being provided for financially, being physically held up, being agreed with or being listened to? Another aspect often overlooked when encouraging communication is the family's ability to find the time and space to talk to each other. Session seven encourages families to formulate "rituals" and to create routines in which communication and closer family relationships can be redeveloped.

Family presentation

The week in review was more positive for the family. John said that Janet had supported him more and had followed through with the set consequences for Meg's behaviour. They sat closer together and Janet looked more relaxed then the previous week. Tim added that Meg was treating him differently and that he liked receiving more attention from his parents. Jay mentioned that Meg had called him a few times asking for favours and that he had turned her down. The different strategies used by the family indicated to Meg that her family members were no longer tolerating infringements of their rights created by her behaviour. In the session, a list of individual needs was created that gave the family an understanding of how each person was feeling. The exercise of identifying the needs of each family member encouraged the family to consider spending more time with each other by having regular evening meals and being together for a day at least once a month. The family's resolve to devote more energy to being a family enabled them to regain some power over their lives and feel more connected to each other. The family agreed that if Meg wanted to be part of the family's reconnection she could, but on the condition she addressed her substance use behaviour.

In this session, Janet was praised for her resolve to make the tough decisions. Similarly, John received a special mention in regard to his efforts to help Janet and his loyalty to her. Janet's personal rights and self-care were reinforced to encourage her to continue her efforts.

Session 8: planning to continue positive family changes

Outline

In session eight, the families are invited to revisit program information and concepts to address any outstanding issues or misunderstandings related to their participation in the program. Facilitators provide the families with an opportunity to discuss their current situation and help set plans for the future.

Families are asked by the facilitators to give feedback as to how being involved in the program has affected them and what they felt was useful or not useful. The facilitators thank the families for allowing them to be involved with them and wish them success in the future. If necessary, the facilitators may provide the families with further treatment options if desired.

Family presentation

John and Janet initially appeared anxious but seemed to relax more when invited to review their week. As they spoke, they described feeling more in control and confident with the way they were dealing with the problem behaviour. Janet stated that Meg was still not coming home but had contacted Janet without prompting. As Meg had not contacted Janet for some months prior to this, the incident was highlighted as an example of how the situation at home had changed. John and Janet were both congratulated on their efforts to overcome their difficulties thus far. Tim said he felt a lot happier at home now that everyone "talked about something different" from Meg's behaviour. Janet said, "I keep telling myself, what I was doing before wasn't working, so why not try something different?". When she also said, "I want to give Tim more attention, he's such a lovely boy", John kissed Janet's cheek.

When asked about their marriage, John said, "It's better, but we still have things we have to work on". Janet added, "I love John and I want to work at it".

John was interested to know how to maintain the changes and Janet requested further support. A contact name/number in the facilitating organisation was given to the family, which they appreciated. On closing the final session, both Janet and John described the program as having provided a "life raft" for them. The parents left the session agreeing to continue meeting as an informal group.

Conclusion

The BEST Plus program is the product of an action research learning cycle that has combined evaluation and reflection to chart new service improvement directions (e.g. Bamberg et al. 2001). The emotional turmoil, relationship fragmentation and feelings of helplessness experienced by the family described in this paper bear similarities to those of a range of parents and siblings of substance users who have participated in the BEST Plus program. The authors have noted, through both observation and evaluation protocols, that families participating in the BEST Plus program typically show positive progress in self-care and confidence comparable to that of the family described in this paper. However, the intensity and longevity of the adolescent difficulties families have experienced can affect the rate of adolescent progress, as can family factors such as parental mental health and parenting disagreement (see Bamberg et al. 2001). Family members who come forward seeking help for their concerns about adolescent substance abuse frequently place their own lives on hold while they continue to respond to the daily crises substance abuse can present. Due to feelings of shame and embarrassment, families often withdraw and isolate themselves from other family and friends. Families frequently blame themselves and hence feel they have to cope with the problems alone. Through their introduction to a supportive group of parents who have experienced similar problems, and through the program's encouragement to develop self-care strategies, families gradually reverse their feelings of isolation and work together to explore new and creative solutions to their problems. Where parents and siblings adhere to the program advice, families develop respectful communication and attractive rituals, and adolescents engaged in problem behaviour experience greatly increased consequential learning.

Substance abuse is but one of many problematic adolescent behaviours a family can experience. For example, families can also experience problems such as anger, stealing, truancy, and abusive and violent behaviours. The authors consider these behaviours to be symptoms rather than causes of family interrelational difficulties. To provide assistance with adolescent behaviours other than substance abuse, the BEST Plus program has recently been modified to broaden its application to address challenging and antisocial adolescent behaviours more generally. Over 2005, three pilot groups were conducted with families experiencing behaviours other than substance use. Early evaluation results suggest that the BEST Plus program has a similar positive impact on other adolescent behaviours as it does in families coping with adolescent substance abuse. The authors feel that the BEST Plus program is proving to be a popular and relevant framework for professionals to use to engage and assist families in reducing adolescent problem behaviours.

References

Bamberg, J., Toumbourou, J.W., Blyth, A. & Forer, D. 2001, 'Changes for the BEST: Family changes for parents coping with youth substance abuse', Australian and New Zealand Journal of Family Therapy, v.22, pp.189-98.

Blyth, A., Bamberg, J. & Toumbourou, J. 2000, Behaviour exchange systems training: A program for parents stressed by adolescent substance abuse, ACER Press, Melbourne.

Stanton, M.D., Todd, T.C. & Associates 1982, The family therapy of drug abuse and addiction, The Guilford Press, New York.

Toumbourou, J.W., Beyers, J.M., Catalano, R.F., Hawkins, J.D., Arthur, M.W., Evans-Whipp, T., Bond, L. & Patton, G.C. 2005, 'Youth alcohol and other drug use in the United States and Australia: A cross-national comparison of three state-wide samples', Drug and Alcohol Review, v.24, n.6, pp.515-23.

Toumbourou, J.W., Blyth, A., Bamberg, J. & Forer, D. 2001, 'Early impact of the BEST intervention for parents stressed by adolescent substance use', Journal of Community and Applied Psychology, v.11, pp.291-304.

Young, J. 1994, 'The loss of time in chronic systems: An intervention model for working with longer term conditions', Australian and New Zealand Journal of Family Therapy, v.15, pp.73-80.

AUTHORS.

John Bamberg is a family therapist with many years experience working on issues associated with substance abuse. He works as the Family Programs Coordinator at the Centre for Adolescent Health and is the leader of the BEST Plus initiative.

Steven Findley contributed to this paper as part of his student paper.

John Toumbourou is Associate Professor within the Department of Paediatrics at the University of Melbourne, and a Senior Researcher at the Centre for Adolescent Health.