Transcript Slide 1

Functional Family Therapy
An evidence-based approach to working with adolescents with
externalizing behavior disorders
Implementing Functional Family Therapy
Webinar #1
Thomas L. Sexton, Ph. D., ABPP
FFT Associates
©FFT Associates. Not intended for Duplication or Distribution
1
Goals of Today’s Training
• Introduction to the Training Program
• Overview of the FFT clinical model & its
value
• Clinical Practice Issues…what will doing FFT
mean for your daily work?
– What can you expect when doing FFT (how long, how
often, where…)
– Your FFT Clinical Work Flow……
Goals of Today’s Training
• Clinical decision making with FFT/CFS
• Measures of Progress & Process
–
FFT Measures…how you will know FFT is working?
• Case conceptualizing—progress notes and session
planning guides
• Training/practicing with FFT/CFS
• Overview of FFT/CFS
• How you will learn FFT/CFS
• Goal for the week
• Next Steps
•
•
•
•
•
Webinar #2 (the clinical model)
Clinical Training #1
Video consultation begins
Practice FFT/CFS
Begin Cases
Learning Resources
• Things to help you along the way:
• Learning Center at the FFT Website
–
www.functionalfamilytherapy.com
• To get started:
–
–
–
FFT Book
Introduction to FFT (on the website)
FFT/CFS help resources
• What you can expect:
–
–
–
–
Number of training activities in the next two weeks—it will
take some time
If you prepare…training will be more relevant and applicable
Your will practice better
You will have more time for the many practice events you will
need to do in the next few weeks
Overview of the Training Process
Learning Functional Family Therapy
• One of biggest challenges is teaching the
FFT clinical model…….Not that it is so
difficult…..It is implementing it into:
• Existing ways a clinician works/trained
• Existing ways an organization works
• Lessons over the last 10 years
• Process of change
• Learning curve
Our Training Philosophy
• Principles:
• Based on adult learning/educational psychological
principles of learning
• Short, relevant, repetitive, and clinically specific
• Goal….
• clinically relevant therapist competence & model
adherence
• Ability to use the model in ways that “fit” clients and context
• High model Fidelity and Clinical relevance
Phases of Training
• Phase 1: Planning, Preparation, &
Implementation
• Phase 2: Clinical Training
• Phase 3: Site Supervisor Training
• Phase 4: Partnership/Site Certification
Training Phases:
• Phase 1: Planning, Preparation, & Implementation
•
•
•
•
Introductory webinars
FFT/CFS training
“fitting” FFT into the work flow
Readiness assessment
• Phase 2: Clinical Training
•
•
•
•
•
•
3 clinical training days
6 site “externship days
6 webinars
45 hours of team consultation
Online discussion forum
FFT/CFS use
Month 1-4 Month 5-9
Month 9-12
Clinical Training
Clinical
(on dayTraining
on site) (on Clinical
day on site)
Training (on day on site)
2 webinars
2 webinars
2 webinars
Training
2 onsite training2days
onsite training days2 onsite training days
Discussion Forum
Discussion
use
Forum useDiscussion Forum use
Active participation
Active
in participation
FFT/CFS inActive
FFT/CFS
participation in FFT/CFS
Training Goals
1. Competent FFT Therapist
•
•
•
Able to adherence to the model consistently
Able to competently practice the model with diverse
families in a way that “fits” their unique situation
Improves outcomes with youth and families
2. Supportive Organization
•
Supports the implementation of FFT through
–
–
–
Clinical procedures
Funding
Staffing time/resources
3. Effective & Efficient FFT services
Training Methods
• On-line Learning
– Way to present material in an interactive way over the
web in “small doses”
• Discussion Forum
– Learning “places” where topics are discussed and where,
over time, the community of FFT therapists take part in
posing questions and answering them
• Traditional Training
– Presentation and interaction with an FFT expert focusing
on the clinical principles and techniques
Training
• Case Consultation
– Small group discussion of specific cases
– Following a “developmental” model that builds from
basic core principles to complex clinical intervention
• Observation/Practice
– Of video tapes (of actual sessions)
– In ongoing practice
Training
• Systematic Case Planning and Quality
Assurance Monitoring
• FFT/CFS
• Ongoing measurement of FFT process and client
progress
• Systematic case planning…..with the FFT progress
notes and session plans
• Case Experience
Learning Resources
• Learning Center
(www.functionalfamilytherapy.com)
• FFT Manual
• Articles/PowerPoint's
• FFT/CFS help/training website
• Weekly Video Case Consultation
• Ask on the discussion forum
• Email us
Questions?
Introduction
What is the need?
Why use FFT?
How does the model work?
Context:
Adolescents Behavior Problems
– Adolescents are not just delinquents….child welfare cases…but,
complicated clinical problems
–
–
–
–
–
drug abuse/use
delinquency
conduct disorder
mental health problems
abuse & neglect
– Require:
• Systematic treatments address specific issues of these kids
and families
• Best research, clinical practice, and system of care
• For practitioners/clinic practices this is the primary
reason for an adolescent to be referred for care
Functional Family Therapy
• Targeting at-risk adolescents and their families….externalizing
behavior disordered youth
• Prevention intervention--status/diversion kids
• Treatment intervention--moderate and serious delinquent youth
• Family Therapy intervention program
• Comprehensive and phasic clinical model (not integrative or eclectic)
• Yet…responsive to client diversity
• Primary focus is on the “in the room” interaction between the therapist and
the family
• Short-term
• 8-13 for moderate cases, 26-30 for more serious cases spread over 3 to 6
months
• Intensity in its quality not quantity
Functional Family Therapy
Clinical Model
Engagement
Reduce within family
risk factors
Early
-negativity/blame
Behavior Change
Generalization
Build within family
Assessment
protective factors
Middle
-behavior
competencies
-hopelessness
-build engagement/
reduce dropout
Build family to context
protective /reduce risk
Late
factors
-interaction
change
Intervention
-peers/school/
-that increase probability of
community
- behavior
Motivation
Behavior Change
Early
Middle
Generalization
Late
Goal
Goal
Goal
Functional Family Therapy
Clinical Model
-phase/intermediate
-phase/intermediate
-phase/intermediateobjectives
objectives
objectives
Skills
Skills
Skills
-therapist
-therapist
-therapistactions
actions
actionsthat
that
thathave
have
havehigh
high
highprobability
probability
probability
of
reaching
those
goals
of
ofreaching
reachingthose
thosegoals
goals
Engagement
Behavior Change
Generalization
Assessment
Intervention
Motivation
Behavior Change
Early
Middle
Generalization
Late
Functional Family Therapy
as an “evidence-based model”
1.
Systematic Clinical Intervention
–
Integrative
• Theory…from within and out of MFT
• Clinical experience
• Research evidence
–
Comprehensive Clinical Model:
• Etiology of problems
• Guiding therapeutic principles of practice
• Phasic change process, mechanisms of change
• Multisystemic foci
1. Systematic Clinical Model
2. Clinical Intervention “Map”
3. Research support
–
Systematic practice
•
Clinical protocol--”clinical map”
4.• Manual
Clinically
responsive & transportable
driven
Changing the problem behavior…
Generalizing
Functional Family
Therapy the change….
by reducing the delinquency
by…
Clinical Model
and family relationships that support it Helping family generalize change across situations…
by…developing individualized change plans
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
community resources
•Problem solving
Assessment
•Conflict management
Engagement Behavior ChangeGeneralization
Goal-Skills
Goal-Skills
GoalSkills
Intervention
Engaging and motivating families to
becoming part of and stay in therapy..
by…
Motivation
Early
•BuildingChange
alliance with
everyone
Behavior
Generalization
•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
Middle
Late
Functional Family Therapy
3. Strong science/research support…
……..Studies spanning 30 years
– Outcome research
–
–
• 5 Clinical Trials/8 Systematic Comparison Studies
Sustainable effects in overall recidivism, intensity of crime, and cost of treatment
•
from 1 – 5 years after intervention (In addition, for FFT 3 Yr follow up prevention effects for
siblings)
•
•
Reductions in post treatment recidivism of between 20% and 65%
Improvements in family functioning, communication, symptom distress,
youth drug use/abuse, out of home placements
Process research
•
•
•
•
Balanced alliance work
Gender interaction studies
Blame and negativity reduction
Support and Structure
Functional Family Therapy (cont’d)
4. Clinically Responsive….to the unique processes of
individual family
•
•
•
•
Respect
Focus on strength and self-reliance
Focus on family functioning/not pathology
Relational understanding of “problems”
– Demonstrated in its wide application in diverse setting/with
diverse clients
Functional Family Therapy?
Family focused approach to change
– Family focused...alliance and involvement with all family members
(Balanced alliance)
– Respectful of individual difference, culture, ethnicity by fitting treatment
to the family
– Aim for Obtainable and lasting change...
•
•
•
Initial focus is motivate the family and prevent dropout by attention to family risk factors
Build relevant family and individual protective factors
With interventions that are specific & individualized
– Long term empowerment
•
Incorporating relevant community resources to maintaining, generalizing,
and supporting family change
Functional Family Therapy
Clinical Model
•
A relational process
–
between two experts…..
•
•
•
Purposeful interactions promote model process goals…
•
•
Client…..-life/experience expert
Therapist….change process expert
therapist is goal directed (specific process outcomes)
In a relational interchange
–
Flexibly-structured…both
•
Contingently directed or….a set of goals….that you pursue depending on the family and
•
Guided by model specific treatment phase goals
the current interactions
Practicing Functional Family Therapy
• How it is delivered
• What you can expect
• Systematic Clinical Decision making
• Ongoing measurement of process and client progress
to better plan and intervene
Core of FFT
A therapy that is both systematic and individualized?
Goal of a therapy is to BOTH…..
• Match to the Family
–
–
Everything is client centered and personal to the life of the client
It is responsive to the unique and multisystemic nature of the client
• Relational “needs”
• Obtainable change for the family
• Unique relational organization
• Match to the Model
–
–
–
Model as primary clinical decision making tool
Model to direct treatment plans….sessions plans
Follow BOTH:
• Core principles clinical procedures
What you can expect
• FFT lasts 8-14/16 sessions
• Conjoint (whole family/major players)
• Delivered weekly (maybe more in E/M, less in
Gen)
• Sessions in each treatment phase occur in a
successful treatment episode
•
•
•
Engagement motivation
Behavior Change
Generalization
• Assessment as short as possible (get to treatment quickly)
• Simultaneous/other Treatments?
Functional Family Therapy
Integrated
ServiceAssessment
Delivery Model
Referral/Initial
Your agency baseline assessment
FFT baseline assessment
A “quick” referral to treatment
Engagement
Behavior Change
Generalization
Assessment
Intervention
Motivation
Early
Behavior Change
Middle
Generalization
Late
Functional Family Therapy
Integrated
Service
Delivery Model
•Weekly
FFT Sessions
•Schedule & hold session in FFT/CFS
•Case Planning—FFT Progress Note
•Measuring therapeutic Process & Client
Progress
Engagement
Behavior
Change
Generalization
•8-10 items
completed
by client online
Assessment
Interventio
n
Motivation
Early
Behavior Change
Middle
Generalization
Late
Functional Family Therapy
Integrated Service Delivery Model
Discharge
•FFT/CFS discharge of client
•Outcome Assessment
Engagement
Behavior Change
Generalization
Referral if necessary
Assessment
Interventio
n
Motivation
Early
Behavior Change
Middle
Generalization
Late
Who is a good client for FFT
• Adolescent
• Mental health issues
• Juvenile justice/conduct problems
• Alcohol and drug problems
• Stable family placement
• With no emergency “needs”
• Acute need for hospitalizations
• Stable meds/psychiatric care
• Use a “rule out” philosophy
Session Delivery
• Where? in the home or in the office
• How long? Approximately 60 minutes
• How frequent? Weekly
– Early may be twice a week
– In the middle phases 1 each week
– Generalization phase…..titrate out session over
time
Session with who?
• Family….FFT is a “conjoint” therapy
– Adolescent
– Parents/Step-parents
– Involved siblings
• Sessions are with the family…..
– No individual session…miss opportunities
What if the cancel/no-show
• Overcome barriers
• Engage/work on the phone
• Make room in your schedule and see them the
next day/ or that day after that
How long Does FFT Last?
• Each phase completed
• 10 to 18 sessions
• Over 4 to 6 months
• What if they come back?
• Same therapist….pick up in generalization phase
Clinical decision making with FFT/CFS
1.Case conceptualizing
• progress notes and session planning guides
2.Measures of Progress & Process
•
FFT Measures…how you will know FFT is working?
Why this way of working helps
• Allows for:
–
–
–
–
•
Individualization
Clinical specification
Inclusion of the family voice
Measurement of phases & goals to provide reliable clinician decision
making
Each of which help improve treatment effectiveness and
efficiency
Model
Specific
Adherence
Session Impact
Youth Symptom
and
Functioning
(immediate family
changes)
(CQP)
(SFSS)
Therapeutic
Alliance
(TA)
Post
Treatment
Family
Functioning
Measure
(Com-R)
Client
Engagement
Baseline
Family
Functioning
(Com-R)
Behavior Change
Generalization
Motivation
Behavior Change
Treatment
Planning
(Progress Notes)
Feedback
-process
-progress
-fidelity
Generalization
Session Planning
(Session
Planning Guide)
Progress Notes
Specific
• What happened
• After each session
• Used by the
therapist to
understand the
case better/plan
• Used by the
Consultant to
help the therapist
learn
Next Session Plan
• Specific session goals
• Specific areas of needed
attention
• Before each session
• Match the
model
specifically to
the
family/situatio
n/needs of the
time
Tools of Clinical Decision Making
• FFT/CFS Feedback
• Your thinking using the FFT progress
note/session plans
• Discussing cases in FFT terms in weekly case
consultation & with your team
FFT Clinical Measurement Inventory
• Resource: FFT CMI Manual (on the web)
• Baseline Assessment
• Family Demographic Information (in CFS)
• Family Functioning (COM-r)
• youth & caregiver form
• Youth Symptom Level (SRFF-full Form)
• Youth & caregiver form
• Sessions Measure (after each session)
• Therapeutic alliance (caregiver, youth, therapist)
• Peabody Alliance Measure (TAQ-r)
• Youth, caregiver & clinicians
• FFT progress (phase specific therapeutic goals)
• Session Impact Scale (SIS E/M; SIS BC; SIS Gen)
• phase based-client perspective of the progress of treatment)
• Symptom Level
• Peabody Symptom and Functioning Scale (SRFF Form A &
B0
• caregiver, youth, therapist
• Discharge Assessment
• Family Demographic Information (in CFS)
• Family Functioning (COM-r)
• youth & caregiver form
• Youth Symptom Level (SRFF-full Form)
• Youth & caregiver form
FFT/CFS System
• How to learn
– Your assignment: using the login info and the on
line help tools….
• Review each on line video and quick guide for each
major function
1.
2.
3.
4.
5.
Entering a Client
Scheduling a Session
Holding a session
Completing measures
Discharging a client
Resources
• FFT Learning Center
– www.functionalfamilytherapy.com
• FFT/CFS
– https://beta.cfsystemsonline.com/login
• Written Manuals
–
FFT in Clinical Practice (Sexton, 2010)
–
FFT Clinical Training Manual (Sexton & Alexander, 2004)
–
FFT Blueprint Manual (Alexander, Pugh, Parsons, & Sexton, 2000)
What’s next?
• This week:
– Read/learn about FFT
– Review the Clinical Measurement Inventory
– Talk in your team about how you will organize
this into your work flow….
–
–
Identify barriers
Identify possible solutions
– FFT/CFS practice
• It will take 4-5 hours of practice!
– Find your questions….for the training!