Functional Family Therapy Overview & Implementation Planning

1. Functional Family TherapyOverview & Implementation Planning Todd Sosna. Ph.D., CIMH Senior Associate Pam Hawkins, CIMH Associate *Slides on FFT model and outcomes courtesy of FFT National Training Center

2. Topics • Functional Family Therapy Model • Effectiveness Research • Training Protocol • Model Adherence • Implementation Plan FFT Introduction & Planning

3. Functional Family Therapy-FFT • Research-based prevention and intervention program for at-risk adolescents and their families • Developed by James Alexander, University of Utah • FFT Inc. www.fftinc.com FFT Introduction & Planning

4. FFT Target Population • Youth (11-18) • Appropriate for the full recidivism risk continuum • Presenting serious delinquency, violence and/or substance use • Diversion • Probation or child welfare involved • Family conflict FFT Introduction & Planning

5. FFT Model • Provided by a team of practitioners • 3-8 practitioners per team • Masters level clinician is preferred; however, bachelors level practitioner is acceptable • Home, clinic or community settings • Typically 3 sessions in the first 10 days, and then 1 session per week, but may vary • Typical duration of therapy is 8-30 sessions, depending on severity • Sessions lengths vary (60-120 minutes) • Each therapist works with 10-12 families at one time FFT Introduction & Planning

6. FFT Model • Builds protective factors, reduces risk factors • Therapist assumes responsibility for • Engagement • Develops interventions that give family members hope even before behavior change occurs • Work with families to develop a “roadmap” for change • Provide them tools to be successful in the context of their own values and culture FFT Introduction & Planning

7. FFT Phases • Engagement and motivation • Needs to occur prior to initiating behavior change • Increase hope and expectation for change and decrease negativity (Blaming, hopelessness) • Therapist uses respect and reattribution • Change behavior • Skills development • e.g. communication, parenting, problem solving • Generalization • Increase family’s capacity to utilize community resources, and relapse prevention FFT Introduction & Planning

8. Engagement Generalization Behavior Change Motivation Behavior Change Generalization Early Early Middle Middle Late Late Clinical Model Build within family protective factors -behavior competencies -interaction change -that increase probability of - behavior Reduce within family risk factors -negativity/blame -hopelessness -build engagement/ reduce dropout Build family to context protective /reduce risk factors -peers/school/ community FFT Introduction & Planning

9. Early Middle Late Clinical Model • Changing the problem behavior… • by reducing the delinquency • and family relationships that support it • by…developing individualized change plans • that “fit the family” and increase competence in.. • Parenting • Communication • Problem solving • Conflict management • Generalizing the change…. • by… • Helping family generalize change across situations… • to become self reliant • Maintain change by relapse prevention • Support changes by increasing the use of available • community resources Engagement Behavior Change Generalization Assessment Goal-Skills Goal-Skills Goal-Skills Intervention • Engaging and motivating families to • becoming part of and stay in therapy.. • by… • Building alliance with everyone • Reducing negativity and blame while retaining responsibility • Creating a family focus for problems to open • new solution avenues • Assess individual, family, context, and • how “problem” fits in that system Motivation Behavior Change Generalization FFT Introduction & Planning

10. Engagement and Motivation • Decreasing negativity (Blaming, hopelessness) • Uses respect, sensitivity and reattribution techniques • Therapist need to use relational skills including • Sensitivity to personal and cultural issues and values • Ability to link behavior to affect and to cognition • Willingness to “hear the pain” of all family members without taking sides (balanced alliance) • Reframes and supportive interventions are associated with positive effects, as opposed to reflective, structuring, and acknowledging techniques FFT Introduction & Planning

11. Change Behavior • Reduce and eliminate problem behaviors and accompanying family relational patterns through individualized behavior change interventions • Therapists need to use structuring skills • Ability and willingness to plan interventions that are individualized and respectful to all family members • Match behavior change techniques to the interpersonal functions of all family members • Cognitive-attributional component integrated into skill-training • Communication training, family-specific tasks, technical aides, basic parenting skills, contracting and response-cost techniques, problem solving, conflict management FFT Introduction & Planning

12. Generalization • Increase family’s capacity to utilize community resources • Increase family’s capacity to engage in relapse prevention • Therapists will intervene directly into service systems, if needed, until family develops the ability to do so • Therapists need to • Know the community • Develop contacts with individuals in each agency • Refer to follow-up services consistent with family members’ relational needs, culture and abilities FFT Introduction & Planning

13. Concurrent & Sequential Services • Are services compatible and complimentary? • Compatible services have common theories for change • Complimentary services have additional benefit without being overwhelming • Medication services • Individual or skill building interventions • Be thoughtful • Intended as a guideline to be applied to each situation as appropriate • Exceptions are made when appropriate FFT Introduction & Planning

14. Concurrent & Sequential Services • Are services contradictory or redundant or excessive? • Contradictory services have competing theories for change • Redundant or excessive services address the same issues and/or tax youth and family resources • Individual therapy • Process groups • Again, be thoughtful, apply as appropriate to each individual situation • Contradictory or redundant services may detrimentally impact outcomes FFT Introduction & Planning

15. FFT Outcomes • Low treatment drop out rate • Reduction in criminal activity • Reduction in violent behavior • Reduces younger siblings’ high risk behaviors • Improved family interactions • Decreases family negativity and hostility • Decreases child behavior problems • Decreases the need for out of home placement • Increases parenting competencies FFT Introduction & Planning

16. FFT Research FoundationsEngagement and Retention FFT Introduction & Planning

17. Summary of Findings Demonstrated Effectiveness With a range of client problems Over time Across situations With range of clients And cost effective FFT Introduction & Planning

18. Specific Outcomes • Clinical Trials (5 studies) • 50% reduction in recidivism as compared to alternative family treatment/group treatment for up to 2 years • 50% reduction in recidivism of siblings of referred youth • 50% reduction in violent felony crimes • Significant reduction in drug use as compared to CBT, psycho-eduction and group treatment • Improved family functioning • Significant cost effectiveness (up to $14.87 return for each dollar spent) FFT Introduction & Planning

19. Specific Outcomes • Comparison Studies (6 studies) • 22%-60% reduction in recidivism for up to 5 years for violent drug abusing youth • 50% reduction in out of home placements • Significant reduction in crime severity for those who do re-offend • Significant reductions in youth, mother, father interpersonal distress/somantic complaints FFT Introduction & Planning

20. Relative Effectiveness Absolute Effectiveness FFT Randomized Trials(Recidivism 6 – 12 months, 30 – 42 months, 24 months respectively) FFT Introduction & Planning

21. WA: Randomized Community-Based Replication(Washington Institute for Public Policy, 2003) Client profile Out of school 46.39% Gang involved 16.1% Out of home placement (more than one) 10.51% Runaway (more than once) 14.1% Experienced abuse 46.04% Risk factors (Washington State Risk Assessment): Drug Use/abuse 85.4% Alcohol use/abuse 80.47% Diagnosed conduct disorder/ODD 82.00% Mental Health Problems 27.03% FFT Introduction & Planning

22. Washington State Outcome StudyCrime History • Age at first offense • Before age 12 13.1% • Age 12 - 14 63.8% • Age 14 - 17 23.4% • Types of Crimes • Misdemeanors 41.5% • Felony 56.2% • Weapons charge 10.4% FFT Introduction & Planning

23. Washington Statewide Functional Family Therapy • 38%* reduction in felony crime • 50%* reduction in violent crime • $10.67 return for each $1 invested • $2100 per • family cost to implement * Statistically significant outcome as compared to the random control condition FFT Introduction & Planning

24. FFT Training/Consult • Establishing proficiency--year 1 (phase I) • Prepare implementation plan • Client Service System (CSS) training (1-day or webcast) • Initial clinical training (3-days) • Site visit #1 (2-days) • Site visit #2 (2-days) • Site visit #3 (2-days) • Second clinical training (2-days) • Weekly phone clinical consultation (50 hours) • Routine use of Clinical Service System (CSS) • Full caseload FFT Introduction & Planning

25. FFT Training/Consult • Maintaining proficiency--year 2 (phase II) • One FFT therapist attends externship training out-of-state (three, 3-day visits) • Extern trained therapist attends supervisor training in Indiana (two, 2-day visits) • Bi-weekly phone consultation for supervisor • Site visit (1-day) • Maintain, at least, minimum caseload (6-8 families) • Routine use of CSS • Replace team supervisor when turnover • Replacement training series when therapist turnover or is added (one, 3-day training, and three, 2-day trainings) FFT Introduction & Planning

26. FFT Training/Consult • Maintaining proficiency--year 3+ (phase III) • Site supervisor attends annual training • Monthly phone consultation for site supervisor • Maintain, at least, minimum caseload (6-8 families) • Routine use of CSS • Replacement training when therapist turnover or is added (one, 3-day training, and three, 2-day trainings) FFT Introduction & Planning

27. Clinical Services System (CSS) • Integrated Web-based Information System • Informs practice, accountability, supervision • Client assessment • Model adherence • Client tracking & monitoring • Outcome assessment FFT Introduction & Planning

28. FFT Assessment Model • Referral • Client demographic and referral information • Preassessment-1st session • OQ45 –youth, parent /s • YOQ –parent assessment of youth • YOQ SR -- youth • Process/Adherence • Assessment • Progress Notes • CPQ • Family Risk/Protective Factors • Relational • Assessment • Progress Notes • Postassessment—last session • OQ45 – youth, parent • YOQ and YOQ-SR • TOM (Family R&P factors) • COM FFT Introduction & Planning

29. CSS Measures • Youth Outcome Questionnaire (YOQ) • Administered pre- and post-therapy • No cost with CIMH state license • Youth Outcome Questionnaire-Self Report (YOQ-SR) • Administered pre- and post-therapy • No cost with CIMH state license • Outcome Questionnaire (OQ 45) • Administered pre- and post-therapy • No cost with CIMH state license FFT Introduction & Planning

30. CSS Measures • Progress note (built into CSS) • Counseling Process Questionnaire (CPQ) • Administered every other session • No cost from FFT • Client Outcome Measure (COM) • Administered post-therapy • No cost from FFT • Therapist Outcome Measure (TOM) • Administered post-therapy • No cost from FFT FFT Introduction & Planning

31. Model Adherence and Clinical Outcomes • 38%* reduction in felony crime • 50%* reduction in violent crime • $10.67 return for each $1 invested • $2100 per • family cost to implement * Statistically significant outcome as compared to the random control condition FFT Introduction & Planning

32. Development Team Goals • High quality, model adherent (high fidelity) and sustainable implementation of FFT • Prepare practitioners to be proficient in the use of FFT • Prepare agencies to support and sustain FFT teams FFT Introduction & Planning

33. Development Team Features • Development Teams are a training and technical assistance process to promote adoption of a practice • Consisting of a team of agencies committed to adopting a practice in common • Combines four features • Clinical training • Administrative supports • Site specific planning • Peer-to-peer assistance FFT Introduction & Planning

34. Development Team Features • Clinical training and consultation provided by the FFT national training center • Implementation planning and administrative supports provided by CIMH Planning meetings • Monthly Administrator conference calls • Outcome evaluation support (analysis and reporting) • Channels of communication to support peer-to-peer assistance • Web bulletin board FFT Introduction & Planning

35. Expectations • Agencies are committed to participating fully in all training and consultation activities • Agencies are committed to implementing FFT with fidelity • Agencies will diligently use the CSS and evaluate outcomes • Agencies will establish HIPPA agreements to support sharing of information for clinical consultations and outcome evaluation FFT Introduction & Planning

36. Expectations • Agencies are responsible for the cost of training and consultation • Agencies will be responsible for their own travel expenses • One manager, per team, who will not be providing FFT is welcome to “audit” the clinical trainings • Agencies will have ongoing training and consultation costs associated with replacing/adding therapists, replacing team supervisors, and maintaining model adherence FFT Introduction & Planning

37. Implementation Plans • Clients • Integration into agency services • Staffing • Funding • Administrative oversight FFT Introduction & Planning

38. Integrating Into Agency Services • Where will the practice fit into the service system? • Who will be referred? Inclusion or exclusion criteria? • Who will be responsible for making referrals, and under what circumstances? • Will the service be provided independently of, in addition to, or instead of other services? FFT Introduction & Planning

39. Staffing • Who will be the practitioners? • How will they be selected? • Will they be full time dedicated to FFT? • What other duties will they have? FFT Introduction & Planning

40. Funding • How will FFT be funded? • Are billing or other requirements compatible? • Are the individuals responsible for billing involved in the planning? • Is there coordination with the County Mental Health Plan? FFT Introduction & Planning

41. Administrative Oversight • Who at the administrative level participated in implementation planning? • Who at the administrative level will be responsible to make sure that FFT is implemented? • How will staff attrition be managed? FFT Introduction & Planning

42. www.cimh.org • Todd Sosna • tmq@verizon.net • (916) 549-5506 • Pam Hawkins • Phawkins@cimh.org • (916) 556-3480 ext. 135 FFT Introduction & Planning