Transcript Document

CIMH FFT Statewide Conference
April 23 & 24, 2009
Sacramento, CA
FFT National / International New Data
And Implementation Trends
(And Lessons Learned)
James F. Alexander, Ph.D.
Material based on presentations and data bases provided by
(in alphabetical order)
Jim Alexander, Malinda Freidag, Amy Hollimon, Helen Midouhas,
Andrea Neeb, Charles Turner
Brief History & overview of the Development of FFT
James F Alexander, Ph.D., FFT LLC & University of Utah, January, 2009
Phase 1: Developing the Evidence Based Model: (1971-1998)

Integration of prior & current wisdom (theory, clinical, research, training models); Clinical articulation
and application in “accountability” contexts. Major contributors: Alexander, Parsons, Barton, Waldron,
Mas, Turner, Schiavo, Warburton, Klein.

Research (RCT’s, Effectiveness studies, Change Mechanisms research): Alexander (1973 JCCP) &
colleagues ( (esp. Don Gordon, Kjell Hansson, Holly Waldron).

FFT designated by the Center for The Study and Prevention of Violence (CSPV; Delbert Elliott, P.I., 1997)
as a “Blueprint Program” (one of only 12 such programs nationally) for the successful treatment of
delinquency, substance abuse, and violence for high-risk youth.

Alexander, Pugh, & Parsons (1998). FFT: Volume 3 in the Elliott Blueprints series.
Phase 2: Moving the EBT to large scale dissemination (1999-2007)

FFT replications supported and guided by the Blueprints initiative (Elliott & Mihalic, Center for the
Study & Prevention of Violence - CSPV).

FFT received designations as an “Exemplary Program,” “Best Practice,” and “Evidence-Based
Effective program” (Centers for Disease Control - CDC; Office of Juvenile Justice & Delinquency
Prevention OJJDP, American Youth Policy Forum, Surgeon General’s Report on Youth Violence 2001).

FFT LLC is established as the dissemination arm of FFT. Doug Kopp becomes CEO and Director of FFT
Dissemination strategies. Holly DeMarranville becomes the FFT LLC Communication Director. Tom
Sexton provides creative leadership in the FFT dissemination system.

Mike Robbins & Charles Turner emerge as lead Change Mechanisms FFT researchers w/ Jim Alexander.

Functional Family Probation (FFP) emerges as case management model (UT, WA, NL).

Waldron develops the major NIDA & NIAAA funded FFT programs and trials with Drug-involved Youth
(with Brody, Ozechowski, Turner).
Phase 3: (2007- current):

Maintain fidelity & competence (e.g., Neeb, Kellie Armey) & Sustainability (e.g., Helen Midouhas)

Ongoing evaluation/ monitoring (e.g., Amy Hollimon, Kim Mason), new funded RCT’s (e.g., Waldron,
Turner, Robbins ), Change Mechanism Research (e.g., Robbins, Turner), International partners
(Hansson, S.Scott), additional collaborations (BlueSky Project: Annie E Casey Foundation; JRA, CIMH,
PCCD, OCFS, Evidence Based Associates
Reminder: FFT Does Not Operate in a Vacuum
The Big Picture: Integrating FFT with Other Systems*
Pretreatment
Posttreatment
FFT
Direct
Treatment
System Integration
System Integration
Phases
Phase
Phase
Assessment
Assessment
Assessment
- Engagement
Referral,
Preparation,
Pretreatment
Linking w/
Youth Mgt
Systems
- Motivation
- Relational > Behavioral
Assessment
- Behavior Change
- Generalization / Ecosystemic
Integration
Boosters,
Maintenance
of links w/
Youth Mgt
Systems,
Positive close
The Youth / Family Management System(s):
Juvenile Justice, Drug Court, Welfare, Mental Health:
(PO’s, Case Managers, Trackers, Contingency Managers)
* Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001
Reminder: Phases Flow,
But are Not Necessarily Linear and Sequential
Note that E&M
& BC are
essentially
sequential
Note that E & M
can co-occur /
blend
ENGAGEMENT
BEHAVIOR CHANGE
GENERALIZATION,
Eco/Multi- systemic
Linking
MOTIVATION
PreTreatment
Note that BC &
GEN can
co-occur / blend
Sessions
1
2
3
4
5
6
7
>>>> End
PostTreatment
Does Adherence Still Count?
Supervisor Ratings and Outcomes
in Functional Family Therapy
Charles W. Turner, Ph.D.1, Andrea A. Neeb, M. S. 2,
James F. Alexander, Ph.D. 3
1
Oregon Research Institute, 2 Functional Family Therapy, Fort Worth, FL,
3 University of Utah, Functional Family Therapy, Salt Lake City
Presented at the Annual Convention of the American Psychological Association,
Boston, MA, August 14, 2008. The research was supported in part by funding from the
National Institute on Drug Abuse (NIDA)
Too Lax?
Optimal adherence
Too rigid?
Relationship of Adherence to FFT and Dropout
Rates by Phase of Treatment
Dropout from Treatment .
40%
35%
30%
25%
20%
15%
10%
Engage/Motivate
Behavior Change
Generalization
Treatment Phase
Low
Moderate
High
Note: The association of Adherence level to dropout status yielded a
c2 (6) = 36.48, p < .001
Supervisor Ratings of Therapists’ Adherence or
Competence by Client Outcomes
Supervior Rating .. .
2.9
2.7
2.5
2.3
2.1
1.9
1.7
1.5
negative
minimal
satisfactory
moderate
Therapist Rated Treatment Outcome
Adherence
Competence
positive
Adherence is the necessary base.
Competence grows with Practice, Feedback,
Flexibility
Sufficient Caseload, System Support.
Together they represent Model Fidelity FFT trains and supervises therapists to do things
adherently and also competently
Fidelity
Very High
Therapist Initial
Starting Place
(For Most)
High
5
4
3
Moderate
2
Low
Very low
6
1
0
Total
A&C
= Model
Fidelity
3
2
1
Competence
3
2
1
0
Adherence
Effectiveness refers to outcomes which reflect the complex intersection
of many factors: Individual/Biological, Family, Therapist, Multi-system &
Environmental

4 category system for Clinical Adherence:
Four Category system:
3 = Really good, highly phase appropriate (sort of
an “I wish I could be that consistently on task” reaction);
2 = Good. On task enough to be a really solid FFT therapist;
1 = Only fair, but on track;
0 = Unacceptably low (contraindicated interventions)

3 category system for Competence:
Three Category system:
3= Brilliant, creative, matches family and context wonderfully
2 = On track, will do the job, it is all we can usually expect,
1 - Simplistic & limited but on track

Added together, they represent Fidelity to the model
Within Family Alliance in FFT Across
Segments 1 & 2 of Sessions 1 & 2
Positive Change Shows Up (or Not) Early
3.1
2.9
2.7
Kid Drop
Kid Complete
Mom Drop
Mom Complete
2.5
2.3
2.1
1.9
1.7
Ses 1-1
Ses 1-2
Ses 2-1
Ses 2-2
Percent of Sample ..
Therapist Rated Outcomes by Ethnic
Origin for Male Participants
40
35
30
25
20
15
10
5
0
negative
minimal
satisfactory
moderate
positive
Treatment Outcome x Ethnic Origin
Caucasian
African American
Hispanic
Other
Note: Values for each bar represent the percent of the males in each
ethnic group that was rated by the therapist as having the indicated outcome.
Therapist Rated Outcomes by Ethnic
Origin for Female Participants
Percent of Sample ..
40
35
30
25
20
15
10
5
0
negative
minimal
satisfactory
moderate
Treatment Outcome x Ethnic Origin
Caucasian
African American
Hispanic
positive
Other
Note: Values for each bar represent the percent of the females in each
ethnic group that was rated by the therapist as having the indicated outcome.
Retention Status at the End of Each Treatment
Phase Treatment by Adolescent Gender
Retention (%) ..
85
80
75
70
65
60
Engage/Motivate
Behavior Change
Generalization
Phase of Treatment
Male
Female
Note: Cell entries are the percent of each gender entering treatment
who remain at the end of each phase of treatment. c2 (3) = 7.607, p < .06.
Retention Status at the End of Each Treatment
Phase by Adolescent Race/Ethnicity
Retained (%)
..
85
80
75
70
65
60
Engage/Motivate
Behavior Change
Generalization
Phase of Treatment
Caucasian
Hispanic
African American
Other
Note: Cell entries are the percent of each racial/ethnic group entering treatment
who remain at the end of each phase of treatment.
Facility to Community Transition Program 2008
J.F. Alexander, Ph.D. & Helen Midouhas, MSEd., LPC
Presented to Richard Gold
Resource
Specialist:
- Contingency
Mgt etc .
Family Transition Program Specialist (FTS)
Intake (Youth & Parent[s]) ---- Maintenance --- Triage, Linking
Facility Entry
Youth to
Facility
(Triggers
FTS contact
w/ parent(s)
>
Facility Tx Phase >
Reintegration Prep
>
Strength Based &
Mental Health Assessment,
Parent Engagement
w/ Individual & Family & Ecosystemic focus
(FFT, FFP. MST, Solution informed)
Case Mgmt (esp Parent[s]), Skill building,
Empowerment Training
(Waldron Parent Training Informed),
Resource Linking
Reentry
MST
FFT 
MTFC
OTHERS?
Triage
>>>>>>>>> Juvenile Justice System >>>>>>>>>
Points of Contact of Ideal Reentry Program:
The Integrated FTS >>> Community Based FFT
Model (Gold, PA)
Reentry Coordinator
(e.g., FTS Specialist) initiates
A link with a
Reentry Coordinator
Community Based FFT provider
(e.g., FTS Specialist)
(or other EBT while youth is
makes a conjoint family still in facility and/or home visits)
initial relationship
to begin family based (FFT)
to establish
Engagement & Motivation with
a future perspective and
youth and parent(s)
balanced alliance
FFT
or alternative
efficacious &
effective family
Based
Intervention
maintain communication, esp with parents
Entry
Into System
In Facility:
FTS
Transition
FTS
Natural
Environment
FFT