Engaging Hard-To-Reach Families

Although it is possible to conduct family therapy through one person, getting individuals to begin treatment continues to be a problem. For example, in the clinical trial discussed above, only 250 of approximately 650 families who met intake criteria on the basis of a telephone screening began the intake process. Of this number, 145 completed the intake procedure and only 72 completed treatment. Clearly, a very large proportion of families who initially seek treatment never participate in therapy.

Strategic Structural Systems Engagement

Strategic structural systems engagement was developed to more effectively engage drug abusers and their families in treatment (Szapocznik, Perez-Vidal, et al., 1990; Szapocznik and Kurtines, 1989). It is based on the premise that resistance to change within the family results from two systems properties. First, the family is a self-regulatory system—that is, the family will attempt to maintain structural equilibrium (status quo) which, in the case of drug-abusing youth with behavior problems, can be accomplished by avoiding therapy. Second, while the presenting symptom may be drug abuse, the initial obstacle to change is resistance to treatment. The same structural principles that apply to family functioning and treatment also apply to understanding and handling the family's resistance to treatment (Szapocznik, Perez-Vidal, et al., 1990). The solution to overcoming the undesirable "symptom" of resistance is to restructure the family's patterns of interaction that permit the symptom of resistance to continue to exist. It is here that one-person family therapy techniques become useful because the person requesting help becomes the person through whom therapy can work to improve the family's pattern of interaction. Having accomplished the first phase of the therapeutic process in which resistance has been overcome and the family, including the drug-abusing youth, have agreed to participate in therapy, the therapist may shift the focus of the intervention toward the removal of behavior problems and drug abuse.

Clinical work suggests that the patterns of interaction that permitted the symptoms to exist may be the same patterns of interaction that keep the families from entering treatment. Hence, to have the opportunity to intervene in these hard-to-reach families, the therapist using strategic structural systems engagement must begin the intervention with the first phone call rather than the first office session.

To test the effectiveness of strategic structural systems engagement in engaging and retaining Hispanic families with drug-abusing youth in treatment, a major clinical trial⁴ was conducted (Szapocznik, Perez-Vidal, et al., 1988). In this study, strategic structural systems engagement was compared to an engagement-as-usual control condition. Clients in the control condition were approached in a way that resembled as closely as possible the kind of engagement that usually takes place in outpatient centers. There were two basic findings from the study (Szapocznik, Perez-Vidal, et al., 1988). First, as figure 1 shows, the effects of the experimental condition were dramatic. More than 57 percent of the families in the engagement-as-usual condition failed to participate in treatment. In contrast, only 7.15 percent (four families) in the strategic structural systems engagement condition failed to participate in treatment. The differences in the retention rates were also dramatic. In the engagement-as-usual condition, 41 percent of cases did not complete treatment; whereas, in the treatment condition, 17 percent of cases did not complete treatment. Thus, of all cases assigned to therapy, 25 percent in the engagement-as-usual condition and 77 percent in the strategic structural systems engagement condition were successfully completed. For families that completed treatment in both conditions, behavioral improvements by adolescents were highly significant and these improvements were not significantly different across the engagement conditions. The critical distinction between the conditions was in the rates of participation and completion.

A second major finding of the project (Szapocznik et al., 1988) was the identification of a number of resistant family types and the development of intervention strategies for engaging these families (Szapocznik and Kurtines, 1989).

Replication Study

An additional study⁵ was designed to replicate these findings and to further explore the elements of effective interventions (Santisteban et al., 1996). This study, which included a large multicultural sample, demonstrated the overall effectiveness of the specialized engagement interventions discussed above. Significant differences in rates of engagement were found between the treatment group and the control group. In the treatment group, 81 percent of the families were successfully brought into treatment. In contrast, 60 percent of the families assigned to the two control groups were successfully brought into treatment.

In addition to investigating the overall effectiveness of the specialized engagement intervention, the study also investigated the influence of culture/ethnicity on the multicultural Hispanic sample. The data suggested varying rates of engagement across Hispanic groups. Among the non-Cuban Hispanics (primarily Nicaraguan, but also including Colombian, Puerto Rican, Peruvian, and Mexican) assigned to the treatment group, the rate of intervention failure was extremely low (3 percent). Fully 97 percent of the non-Cuban Hispanic families were successfully treated. In contrast, among the Cuban Hispanic sample assigned to the treatment group, the rate of intervention failure was relatively high at 36 percent, with 64 percent of the Cuban Hispanic families successfully treated.

5 This study was funded by NIDA grant #DAO5334.

Brief Strategic Family Therapy	Juvenile Justice Bulletin • April 2000