Transcript Evidence LA - California Institute for Behavioral Health

Functional Family Therapy
Overview &
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
Topics
•
•
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Functional Family Therapy Model
Effectiveness Research
Training Protocol
Model Adherence
Implementation Plan
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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
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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
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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
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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
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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
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Clinical Model
Engagement
Reduce within family
risk factors
Early
-negativity/blame
-hopelessness
-build engagement/
reduce dropout
Behavior Change
Build within family
protective factors
-behavior
competencies
Middle
-interaction change
-that increase probability of
- behavior
Motivation
Behavior Change
Early
Middle
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Generalization
Build family to context
protective /reduce risk
Late
factors
-peers/school/
community
Generalization
Late
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ClinicalGeneralizing
Model
the change….
Changing the problem behavior…
by reducing the delinquency
by…
and family relationships that support it
Helping family generalize change across situations…
by…developing
individualized change
plans
Engagement
Behavior
Change
Generalization
to
become
self reliant
that “fit the family” and increase competence in..
Maintain change by relapse prevention
•Parenting
Support changes by increasing the use of available
•Communication
Assessment community resources
•Problem solving
•Conflict management
Goal-Skills
Goal-Skills
Goal-Skills
Intervention
Motivation
Early
Engaging and motivating families to
becoming
part
of and stay inGeneralization
therapy..
Behavior
Change
by…
•Building alliance with everyone
•Reducing negativity and blame while retaining responsibility
Middle
•Creating
a family focus for problemsLate
to open
new solution avenues
•Assess individual, family, context, and
how “problem”
FFT Introduction
& Planning
fits in that system
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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
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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 skilltraining
– Communication training, family-specific tasks,
technical aides, basic parenting skills, contracting
and response-cost techniques, problem solving,
conflict management
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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
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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
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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
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FFT Outcomes
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•
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•
•
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
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FFT Research Foundations
Engagement and Retention
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
87%
90%
80%
84%
79%
40.0%
50%
30.0%
20.0%
Idaho
(homebased,
aftercare)
Washington
(homebased,
Probation)
Las Vegas
(clinic
based,
probation)
Miami
(Homebased MH)
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Little Haiti
(Homebased MH)
Traditional
Rates
(Kazdin,
2003)
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Summary of Findings
Demonstrated
Effectiveness
With a range of client
problems
Over time
Across situations
With range of clients
And cost effective
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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)
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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
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FFT Randomized Trials
(Recidivism 6 – 12 months, 30 – 42 months, 24 months respectively)
Relative Effectiveness
Absolute Effectiveness
80.00%
70.00%
FFT
No Treatment
Juv Crt Tx Program
Alternative Tx
60.00%
50.00%
40.00%
30.00%
20.00%
Alternative Tx
Juv Crt Tx Program
10.00%
No Treatment
0.00%
1973
FFT
1977
1998
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WA: Randomized Community-Based Replication
(Washington Institute for Public Policy, 2003)
Client profile
Out of school
Gang involved
Out of home placement (more than one)
Runaway (more than once)
Experienced abuse
46.39%
16.1%
10.51%
14.1%
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%
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Washington State Outcome Study
Crime History
•
Age at first offense
• Before age 12
• Age 12 - 14
• Age 14 - 17
•
13.1%
63.8%
23.4%
Types of Crimes
• Misdemeanors
• Felony
• Weapons charge
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41.5%
56.2%
10.4%
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Washington Statewide
Functional Family Therapy
•38%*
30.0%
reduction in
felony crime
25.0%
•50%*
20.0%
reduction in
violent crime
15.0%
•$10.67 return
10.0%
for each $1
invested
5.0%
•$2100 per
0.0%
6 month
12 months
Adherent
18 months
family cost to
implement
Control
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* Statistically significant outcome as compared
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to the random control condition
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
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FFT Training/Consult
• Maintaining proficiency--year 2 (phase II)
– One FFT therapist attends externship training outof-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)
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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)
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Clinical Services System (CSS)
• Integrated Web-based Information
System
• Informs practice, accountability,
supervision
– Client assessment
– Model adherence
– Client tracking & monitoring
– Outcome assessment
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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
Relational
Assessment
•Progress Notes
•CPQ
•Family Risk/Protective Factors
•Progress Notes
Postassessment—last session
•OQ45 – youth, parent
•YOQ and YOQ-SR
•TOM (Family R&P factors)
•COM
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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
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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
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Model Adherence and Clinical
Outcomes
•38%*
reduction in
felony crime
35.0%
30.0%
•50%*
25.0%
reduction in
violent crime
20.0%
•$10.67 return
15.0%
for each $1
invested
10.0%
5.0%
•$2100 per
0.0%
6 month
12 months
Adherent
Non-Adherent
18 months
family cost to
implement
Control
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* Statistically significant outcome as compared
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to the random control condition
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
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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
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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 peerto-peer assistance
– Web bulletin board
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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
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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
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Implementation Plans
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•
•
•
•
Clients
Integration into agency services
Staffing
Funding
Administrative oversight
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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?
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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?
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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?
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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?
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www.cimh.org
• Todd Sosna
– [email protected]
– (916) 549-5506
• Pam Hawkins
– [email protected]
– (916) 556-3480 ext. 135
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