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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!