Program Profile: Multidimensional Family Therapy (MDFT)

This program seeks to reduce substance use and problem behaviors of youths with substance use disorders. The program is rated Promising. Relative to treatment-as-usual youths, intervention youths showed a statistically significant reduction in the number of crimes committed (i.e., property and violent crimes), substance use problems, and delinquent behaviors. But there were no statistically significant differences in diagnoses of cannabis use disorder or externalizing and internalizing behaviors

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals/Target Population

Multidimensional Family Therapy (MDFT) is a manualized, family-centered treatment and substance misuse prevention program for youths with substance use disorders and problem behaviors (such as aggression, truancy, and other mental comorbidities). The program is designed to address and reduce a range of youth behavior challenges, such as cannabis use and juvenile offending (Liddle et al., 2001).

Using a multidimensional approach, the MDFT intervention focuses on improving four major domains for youth, which are seen as contributing factors to the rise and decline of behavioral problems in a youth’s life (Liddle et al., 2018; Rigter et al., 2013; van der Pol, 2018). These life domains are 1) the youth, 2) parents, 3) family, and 4) the community (peers, school, etc.). MDFT views family functioning as instrumental in creating adaptive lifestyle alternatives for the youth in each of these domains (Rigter et al., 2013). Overall, the goal of the program is to improve individual and family functioning to reduce substance misuse and related problem behaviors (such as committing crimes).

Program Components

The MDFT curriculum consists of three stages, with trained therapists conducting weekly therapy sessions (at least two sessions per week), over a 6- to 9-month period. In Stage 1, the emphasis is on intensively enhancing treatment motivation, building multiple therapeutic alliances, and drafting the youth’s treatment plan. In Stage 2, treatment plan interventions targeting the youth and their family are executed, which includes education about adolescence, behavioral development, risk factors for problem behavior, and relapse prevention; improving family communication and relationships; and strengthening parental educational skills. In Stage 3, the emphasis is on reinforcing change (i.e., agreeing on a relapse prevention plan) and the youth completing the treatment program. If needed, booster sessions can be provided.

MDFT is typically delivered in an outpatient setting, although it can be delivered in an inpatient setting (such as a detention center). Therapists hold weekly sessions alone with the youth, alone with the parent (or parents), and with the youth and parent combined (a family session), at various times throughout the treatment but in equal proportion to one another.

During sessions, treatment is centralized on the four core-domain areas of life (the youth, parents, family, and the community). The objective of each domain is as follows:

• The youth domain focuses on improving emotion regulation and coping skills, helping them communicate more effectively with their parents and other adults, and enhancing social competence and alternatives to substance use and delinquency.
• The parent domain focuses on increasing the parents’ behavioral and emotional involvement and attachment with their adolescent, reducing parental conflict and enhancing teamwork, and helping parents find practical and effective ways to influence their teen.
• The family domain aims to decrease conflict, deepen emotional attachments, and improve communication and problem-solving skills.
• The community domain fosters the youth’s and family’s competency with social systems (e.g., school, juvenile justice, recreation) and helps young people and families advocate for themselves in these systems.

Therapists work within a multidimensional team, assisted by a case manager and a therapist assistant, who delivers many of the community interventions.

Key Personnel

MDFT therapists are an essential component of the intervention. The MDFT therapist serves as a strong ally to the youth and helps them feel safe to reveal the truth about themselves, which is accomplished by therapist 1) being nonjudgmental, 2) helping the parents control their anger and disappointment and move to a more compassionate and problem-solving stance, 3) encouraging the youth to have positive goals (to dream and hope), and 4) highlighting for the youth the discrepancies between goals and continued substance use and delinquency.

MDFT therapists receive training from MDFT developers.

Program Theory

MDFT is influenced by family therapy, developmental psychology and psychopathology, the risk and protective factors framework, and ecological and family systems theories (Liddle et al., 2001). Additionally, the program is based on the multidimensional perspective, which suggests that symptom reduction and enhancement of prosocial and appropriate developmental functions occur by facilitating adaptive developmental events and processes in several domains of functioning (Liddle et al., 2001; Rigter et al., 2013); thus, changes in one domain are used to facilitate change in others. This is why the program focuses on the four core-domain areas of life.

Study

Rigter and colleagues (2013) conducted a randomized controlled trial to evaluate the efficacy of Multidimensional Family Therapy (MDFT) on substance use and dependence. The study sample included Western European youths from five outpatient treatment sites located in Berlin, Germany; Brussels, Belgium; Geneva, Switzerland; The Hague, Netherlands; and Paris, France. Eligible youths were 13–18 years old; diagnosed with a cannabis use disorder (misuse or dependence, determined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (or the DSM | 4) guidelines (with misuse being diagnosed if at least one of four abuse criteria had been met, and dependence being if at least three of seven dependence criteria had been met); and had at least one parent willing to participate in the treatment. Youths suffering from a current mental disorder or condition (e.g., psychosis, advanced eating disorder, suicide ideation) that required inpatient treatment or had a substance disorder that required maintenance treatment with methadone or buprenorphine were ineligible for the study.

The total sample consisted of 450 youths who were assigned (using a 1:1 ratio; except in Paris, where it was a 2:1 ratio) to the MDFT intervention group (n = 212) or the treatment-as-usual (TAU; n = 238) comparison group. The youths were stratified into the treatment groups based on gender, age (13- to 14-year-olds versus 15- to 18-year-olds), and level of cannabis use in the past 90 days (74 or fewer days of cannabis consumption versus 75 or more). Specific to the study sites, 120 youths (MDFT = 59; TAU = 61) were from Berlin, 60 (MDFT = 30; TAU = 30) were from Brussels, 60 (MDFT = 30; TAU = 30) were from Geneva, 109 (MDFT = 55; TAU = 54) were from The Hague, and 101 (MDFT = 38; TAU = 63) were from Paris. Youths in the MDFT intervention group received weekly therapy sessions (at least two sessions per week), conducted by trained MDFT therapists. Youths in the TAU group received the standard treatment that was provided by individual treatment sites (i.e., individual psychotherapy).

Of the total sample, 85 percent of the youths were boys. Forty percent of the youths were of first- or second-generation foreign descent, 40 percent had an alcohol use disorder, 33 percent had been arrested in the past 3 months (mostly for drug offenses, property crimes, and violent crimes), less than 5 percent had a substance-use disorder for drugs other than cannabis, and 56 percent had parents who were divorced or separated. The average youth age was 16.3 years. There were no statistically significant differences in baseline characteristics between youths in the MDFT and TAU groups; however, in Brussels, there was a higher rate of foreign-descent youths in the MDFT group, compared with those in the TAU group.

Data were collected at baseline and at the 3-month, 6-month, 9-month, and 12-month follow-up periods. The CrimeSolutions review of the study focused on the 12-month follow-up period. The study examined the following outcomes: diagnosis of cannabis use disorder, symptoms of cannabis use dependence, and frequency of cannabis use. The outcome of interest for the CrimeSolutions review was the diagnosis of a cannabis use disorder. The Adolescent Diagnostic Interview Light (ADI | Light for cannabis) was used to measure a diagnosis of cannabis disorder (abuse and dependence). A latent growth curve model was used to estimate the intent-to-treat effects between youths in the MDFT group and youths in the TAU group, at the 12-month follow-up. The study authors did not conduct subgroup analyses.

Study

Van der Pol and colleagues (2018) conducted a randomized controlled trial, using the same study sample as in Study 1 (Rigter et al., 2013), to evaluate the effects of the MDFT intervention on reducing criminal offending. Of the five study sites, only two of the original sites (Geneva and The Hague) were included in the study analysis because of the other sites’ inability to report data on the number and types of criminal offenses committed by adolescents over the previous 90 days (using the Self-Report Delinquency [SRD] scale). Thus, the total sample for this study consisted of 169 youths (MDFT = 85; TAU = 84).

Of the 85 youths in the MDFT group, 83 percent were boys. Fifty-eight percent of youths were of foreign descent, 61 percent had parents who were divorced or separated. Thirty-one percent had a parent with mental health or substance use problems. The average youth age was 16.2 years. Of the 84 youths in the TAU group, 85 percent were boys. Fifty-five percent of youths were of foreign decent, 61 percent had parents who were divorced or separated. Twenty-nine percent had a parent with mental health or substance use problems. The average youth age was 16.2 years. There were no statistically significant differences in baseline characteristics between youths in MDFT and TAU groups. Across treatment sites, there were several differences at baseline. For example, Geneva had a higher percent of youths of foreign descent, The Hague had a higher proportion of youths living with their families, and cannabis dependence was more common among youths in Geneva than in The Hague; however, these differences were not statistically significant between the two treatment conditions.

Data were collected at baseline and at the 6-month and 12-month follow-up periods. The CrimeSolutions review of the study focused on the 12-month follow-up period. Outcomes of interest related to criminal offenses included offenses of any type, property crimes, and violent crimes. The SRD scale measured criminal offenses, asking youths how many and which type of criminal offenses they had committed in the past 90 days. A latent growth curve model with Mplus was used to determine differences between youths in the MDFT and TAU group, at the 12-month follow-up. The study authors did not conduct subgroup analyses.

Study

Liddle and colleagues (2018) conducted a randomized controlled trial to evaluate the efficacy of MDFT, using youths with co-occurring mental health disorders who were referred for residential substance use treatment in the state of Florida. In this study, youths were at high risk for being placed in a long-term juvenile justice or a residential substance-use treatment facility owing to the severity of their substance-use symptoms and delinquency, the number of their psychiatric diagnoses, and the number of their previous substance-use treatment placements. There were 113 youths who consented and met the following eligibility criteria: 1) between the ages of 13 and 18; 2) diagnosed with a substance use disorder and at least one comorbid psychiatric disorder; 3) referred and approved by the Florida Department of Children and Families (DCF) for state-subsidized residential, dual diagnosis substance use treatment; 4) known to have failed a previous treatment for a substance use disorder, or presenting with severe symptoms warranting a higher level of care either because of safety reasons or because this treatment was ordered by a judge; 5) living in the custody of a parent/caregiver (i.e., not in DCF custody); and 6) not currently suicidal, demonstrating psychotic symptoms, or diagnosed with autism spectrum or intellectual disability disorders.

Of the total sample of 113 youths, 57 were assigned to the MDFT group, and 56 were assigned to the TAU comparison group, using an urn randomization procedure. The TAU group consisted of youths who were in residential treatment, provided by a large community-based substance use treatment provider in Miami, Fla. Of the 57 youths in the MDFT group, 75 percent were boys. The majority (70 percent) of youths were Hispanic, 20 percent were African American, and 12 percent were white. The average age of the youths was 15.3 years, with 53 percent of first-time drug use at the ages of 12–14, 39 percent younger than age 12, and 8 percent at ages 15–18. More than one third of the youths (37 percent) had a parent who was involved in the criminal justice system, and 49 percent had a parent with substance use problems. Of the 56 TAU youths, 74 percent were boys. The majority (70 percent) of youths were Hispanic, 17 percent were African American, and 14 percent were white. The average age of the youths was 15.3 years, with 50 percent of first-time drug use at the ages of 12–14, 39 percent younger than age 12, and 11 percent at ages 15–18. One third of the youths (33 percent) had a parent who was involved in the criminal justice system, and 43 percent had a parent with substance use problems. There were no statistically significant differences in baseline characteristics between youths in the MDFT and TAU groups.

Data were collected at baseline (i.e., intake) and at the 2-month, 4-month, 12-month, and 18-month follow-ups. The CrimeSolutions review of the study focused on the 18-month follow-up period. Outcomes of interest included substance use problems, frequency of delinquent behaviors, symptoms of externalizing behaviors, and symptoms of internalizing behaviors. Substance use was measured using 1) the Personal Experience Inventory, a 29-item scale that focuses on psychological and behavioral aspects of substance use and related consequences in the previous 30 days. Delinquent behaviors were measured through self-report, using the National Youth Survey Self-Report Delinquency scale, which assessed criminal behavior and delinquent acts based on the Uniform Crime Report.

A latent growth curve model was used to estimate the intent-to-treat effects between MDFT and TAU youths, at the 18-month follow-up. A subgroup analysis determined whether child welfare outcomes differed for families with different baseline characteristics. The study authors conducted subgroup analyses, using a latent class pattern mixture model, to evaluate differences in posttreatment placement patterns between MDFT and TAU youths. For additional information on this analysis, see the Other Information section.

The Multidimensional Family Therapy (MDFT) curriculum is implemented by trained MDFT therapists, who received training from MDFT developers (Liddle et al., 2018; Rigter et al., 2013; van der Pol et al., 2018). Training is delivered according to the original training model and the MDFT manual.

In Europe (i.e., Belgium, France, Germany, the Netherlands, and Switzerland), training commenced 2 years before the program was implemented, with 4 separate weeks of joint intensive didactic training, followed by several site-specific visits conducted by MDFT trainers (who were based in Miami, Fla.) annually (Rigter et al., 2013; van der Pol et al., 2018). During the program, Miami trainers also provided case review, examination of exemplary MDFT sessions, role playing, review of recorded therapy sessions; the trainers also held consultation calls twice a month with each European team to discuss progress of cases and results from session recordings and treatment contact logs submitted by team members (Rowe et al., 2016). All therapists, regardless of site, also were supervised internally by an MDFT supervisor.

Therapists in the United States were also required to complete weekly contact logs to record the type (i.e., youth, parent, family, community) and length of each therapy session, during the program (Liddle et al., 2018).

For additional information, visit the Multidimensional Family Therapy (MDFT) program website.

Subgroup Analysis

Liddle and colleagues (2018), using a latent class pattern mixture model, identified three posttreatment placement classes: 1) early placement (youths had a high probability of being placed in a controlled environment), 2) late placement (youths had a high probability of an out-of-home-placement), and 3) minimal placement (youths had a low probability of being in placement during the follow-up assessment periods [3–18 months]). Findings for this analysis were reported only for the minimal placement class, for two reasons: 1) the results were less influenced by selection and suppression effects, and 2) the majority of youths (72 percent) were in this class. For youths in the minimal placement class, those in the MDFT group showed statistically significant less growth in the frequency of substance and delinquent behaviors, compared with those in the treatment-as-usual comparison group. For additional information on this subgroup analysis, see the reviewed study.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Dakof, Gayle A., Craig E. Henderson, Cynthia L. Rowe, Maya Boustani, Paul E. Greenbaum, Wei Wang, Samuel Hawes, Clarisa Linares, and Howard A. Liddle. 2015. “A Randomized Clinical Trial of Family Therapy in Juvenile Drug Court.” Journal of Family Psychology 29(2):232–41.

Goorden, M, E. van Der Schee, V. M. Hendriks, and L. Hakkaart-van Roijen. 2016. “Cost-Effectiveness of Multidimensional Family Therapy Compared to Cognitive Behavioral Therapy for Adolescents with a Cannabis Use Disorder: Data from a Randomized Controlled Trial.” Drug and Alcohol Dependence 162:154-61.

Henderson, Craig E., Gayle A. Dakof, Paul E. Greenbaum, and Howard A. Liddle. 2010. “Effectiveness of Multidimensional Family Therapy with Higher-Severity Substance Abusing Adolescents: Report from Two Randomized Controlled Trials.” Journal of Consulting and Clinical Psychology 78:885–897.

Henderson, Craig E., Cynthia L. Rowe, Gayle A. Dakof, S. W. Hawes, and Howard A. Liddle. 2009. “Parenting Practices as Mediators of Treatment Effects in an Early-Intervention Trial of Multidimensional Family Therapy.” American Journal of Drug and Alcohol Abuse 35:220–226.

Hogue, Aaron T., Howard A. Liddle, Dana Becker, and Jodi Johnson–Leckrone. 2002. “Family-Based Prevention Counseling for High-Risk Young Adolescents: Immediate Outcomes.” Journal of Community Psychology 30(1):1–22.

Liddle, Howard A., Gail A. Dakof, Craig E. Henderson, and Cynthia L. Rowe. 2011. “Implementation Outcomes of Multidimensional Family Therapy-Detention to Community: A Reintegration Program for Drug-Using Juvenile Detainees.” International Journal of Offender Therapy and Comparative Criminology 55:587–604.

Liddle, Howard A. 2010. “Treating Adolescent Substance Abuse Using Multidimensional Family Therapy.” In John R. Weisz and Alan E. Kazdin (eds.). Evidence-Based Psychotherapies for Children and Adolescents (Second Edition). New York, N.Y.: Guildford Press, pp. 416–32.

Liddle, Howard A., Cynthia L. Rowe, Gayle A. Dakof, Craig E. Henderson, and Paul E. Greenbaum. 2009. “Early Intervention for Adolescent Substance Abuse: 12-Month Treatment Outcomes of Family-Based Versus Group Treatment.” Journal of Consulting and Clinical Psychology 77:12–25.

Liddle, Howard A., Rosemarie A. Rodriguez, Gayle A. Dakof, Elda Kanzki, and Francoise A. Marvel. 2005. “Multidimensional Family Therapy: A Science-Based Treatment for Adolescent Drug Abuse.” In Jay L. Lebow (ed.). Handbook of Clinical Family Therapy. New York, N.Y.: John Wiley and Sons, pp. 128–63.

Liddle, Howard A., Cynthia L. Rowe, Tanya J. Quille, Gayle A. Dakof, Dana Scott Mills, Eve Sakran, and Hector Biaggi. 2002. “Transporting a Research-Based Adolescent Drug Treatment Into Practice.” Journal of Substance Abuse Treatment 22(4):231–43.

Liddle, Howard A. 2001. Advances in Family-Based Therapy for Adolescent Substance Abuse. College on Problems of Drug Dependence: Proceedings of the 63rd Annual Scientific Meeting, NIDA Research Monograph 182, Bethesda, Md.: National Institute on Drug Abuse.

Liddle, Howard A., and Aaron T. Hogue. 2000. “A Family-Based, Developmental–Ecological Preventive Intervention for High-Risk Adolescents.” Journal of Marital and Family Therapy 26(3):265–79.

Liddle, Howard A., Cynthia L. Rowe, Gayle A. Dakof, and Jennifer Lyke. 1998. “Translating Parenting Research Into Clinical Interventions for Families of Adolescents.” Clinical Child Psychology and Psychiatry 3(3):419–43.

Liddle, Howard A., Gayle A. Dakof, Kenneth Parker, Guy S. Diamond, Kimberley Barrett, and Manuel Tejeda. 2001. “Multidimensional Family Therapy for Adolescent Drug Abuse: Results of a Randomized Clinical Trial.” American Journal of Drug and Alcohol Abuse 27(4):611–88.

Liddle, Howard A., Gayle A. Dakof, Ralph M. Turner, Craig E. Henderson, and Paul E. Greenbaum. 2008. “Treating Adolescent Drug Abuse: A Randomized Trial Comparing Multidimensional Family Therapy and Cognitive Behavior Therapy.” Addiction 103:1660–70.

Rowe, Cynthia L., Linda Alberga, Gayle A. Dakof, Craig E. Henderson, Rocio Ungaro, and Howard A. Liddle. 2016. “Family-Based HIV and Sexually Transmitted Infection Risk Reduction for Drug-Involved Young Offenders: 42-Month Outcomes.” Family Process 55(2):305–20.

Schaub, Michael, Craig Henderson, Isidore Pelc, Peter Tossmann, Olivier Phan, Vincent Hendriks, Cindy Rowe, Henk Rigter, and M.C. Erasmus. 2014. “Multidimensional Family Therapy Decreases the Rate of Externalizing Behavioural Disorder Symptoms in Cannabis Abusing Adolescents: Outcomes of the INCANT Trial.” BMC Psychiatry 14:26.

Schmidt, S. E., Howard A. Liddle, and Gayle A. Dakof. 1996. “Changes in Parenting Practices and Adolescent Drug Abuse During Multidimensional Family Therapy.” Journal of Family Psychology 10:12–27.

van Der Pol, Thimo M., Machteld Hoeve, Marc J. Noom, Geert Jan J.M. Stams, Theo A.H. Doreleijers, Lieke van Domburgh, and Robert R.J.M. Vermeiren. 2017. “Research Review: The Effectiveness of Multidimensional Family Therapy in Treating Adolescents With Multiple Behavior Problems–A Meta-Analysis.” Journal of Child Psychology and Psychiatry 58(5):532–45.

Van Der Pol, Thimo M., Machteld Hoeve, Marc J. Noom, Geert Jan J. M Stams, Theo A. H. Doreleijers, Theo A. H., Lieke Domburgh, and Robert R. J. M. Vermeiren. 2017. “Research Review: The Effectiveness of Multidimensional Family Therapy in Treating Adolescents with Multiple Behavior Problems–A Meta-Analysis.” Journal of Child Psychology and Psychiatry 58(5):532–45.

Following are CrimeSolutions-rated programs that are related to this practice:

Family-based Treatment for Adolescent Delinquency and Problem Behaviors

In general family-based treatment practices consist of a wide range of interventions that are designed to change dysfunctional family patterns that contribute to the onset and maintenance of adolescent delinquency and other problem behaviors. This practice is rated Effective for reducing recidivism, and Promising for reducing antisocial behavior and substance use, and improving psychological functioning and school performance.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Mental Health & Behavioral Health - Externalizing behavior
	Drugs & Substance Abuse - Multiple substances
	Mental Health & Behavioral Health - Psychological functioning
	Education - Academic achievement/school performance

Psychosocial Interventions for Antisocial Behavior of Juveniles

This practice involves the use of psychosocial interventions to reduce antisocial behavior in juveniles. Psychosocial interventions consist of both preventive and therapeutic interventions but share the common goal of improving psychosocial functioning. The practice is rated Effective for the reduction of antisocial behavior.

Evidence Ratings for Outcomes

Juvenile Problem & At-Risk Behaviors - Antisocial behaviors

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?