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Transcript of CIMH FFT Statewide Conference April 23 & 24, 2009 Sacramento, CA FFT National / International New...
CIMH FFT Statewide CIMH FFT Statewide ConferenceConference
April 23 & 24, 2009April 23 & 24, 2009Sacramento, CASacramento, CA
FFT National / International New DataFFT National / International New DataAnd Implementation TrendsAnd Implementation Trends
(And Lessons Learned)(And Lessons Learned)
James F. Alexander, Ph.D.James F. Alexander, Ph.D.
Material based on presentations and data bases provided by Material based on presentations and data bases provided by (in alphabetical order) (in alphabetical order)
Jim Alexander, Malinda Freidag, Amy Hollimon, Helen Midouhas, Jim Alexander, Malinda Freidag, Amy Hollimon, Helen Midouhas, Andrea Neeb, Charles TurnerAndrea Neeb, Charles Turner
Brief History & overview of the Development of FFT Brief History & overview of the Development of FFT James F Alexander, Ph.D., FFT LLC & University of Utah, January,James F Alexander, Ph.D., FFT LLC & University of Utah, January, 20092009
Phase 1: Developing the Evidence Based Model: (1971-1998)Phase 1: Developing the Evidence Based Model: (1971-1998) Integration of prior & current wisdom (theory, clinical, research, training models); Clinical articulation Integration of prior & current wisdom (theory, clinical, research, training models); Clinical articulation
and application in “accountability” contexts. Major contributors: Alexander, Parsons, Barton, and application in “accountability” contexts. Major contributors: Alexander, Parsons, Barton, WaldronWaldron, Mas, , Mas, TurnerTurner, Schiavo, Warburton, Klein., Schiavo, Warburton, Klein.
Research (RCT’s, Effectiveness studies, Change Mechanisms research): Alexander (1973 JCCP) & Research (RCT’s, Effectiveness studies, Change Mechanisms research): Alexander (1973 JCCP) & colleagues ( (esp. Don Gordon, Kjell Hansson, Holly colleagues ( (esp. Don Gordon, Kjell Hansson, Holly WaldronWaldron). ).
FFT designated by the Center for The Study and Prevention of Violence (CSPV; Delbert Elliott, P.I., 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 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.of delinquency, substance abuse, and violence for high-risk youth.
Alexander, Pugh, & Parsons (1998). FFT: Volume 3 in the Elliott Blueprints series.Alexander, Pugh, & Parsons (1998). FFT: Volume 3 in the Elliott Blueprints series. Phase 2: Moving the EBT to large scale dissemination (1999-2007)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 FFT replications supported and guided by the Blueprints initiative (Elliott & Mihalic, Center for the Study & Prevention of Violence - CSPV).Study & Prevention of Violence - CSPV).
FFT received designations as an “Exemplary Program,” “Best Practice,” and “Evidence-Based FFT received designations as an “Exemplary Program,” “Best Practice,” and “Evidence-Based Effective program” (Centers for Disease Control - CDC; Office of Juvenile Justice & Delinquency 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). 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 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. FFT Dissemination strategies. Holly DeMarranville becomes the FFT LLC Communication Director. Tom Sexton provides creative leadership in the FFT dissemination system.Tom Sexton provides creative leadership in the FFT dissemination system.
Mike Robbins & Charles TurnerMike Robbins & Charles Turner emerge as lead Change Mechanisms FFT researchers w/ Jim emerge as lead Change Mechanisms FFT researchers w/ Jim Alexander.Alexander.
Functional Family Probation (FFP) emerges as case management model (UT, WA, NL).Functional Family Probation (FFP) emerges as case management model (UT, WA, NL). WaldronWaldron develops the major NIDA & NIAAA funded FFT programs and trials with Drug-involved Youth develops the major NIDA & NIAAA funded FFT programs and trials with Drug-involved Youth
(with Brody, Ozechowski, (with Brody, Ozechowski, TurnerTurner).). Phase 3: (2007- currentPhase 3: (2007- current):):
Maintain fidelity & competence (e.g., Maintain fidelity & competence (e.g., NeebNeeb, Kellie Armey) & Sustainability (e.g., Helen Midouhas), Kellie Armey) & Sustainability (e.g., Helen Midouhas) Ongoing evaluation/ monitoring (e.g., Amy Hollimon, Kim Mason), new funded RCT’s (e.g., Ongoing evaluation/ monitoring (e.g., Amy Hollimon, Kim Mason), new funded RCT’s (e.g., Waldron, Waldron,
Turner, Robbins ),Turner, Robbins ), Change Mechanism Research (e.g., Change Mechanism Research (e.g., Robbins, TurnerRobbins, Turner), International partners ), International partners (Hansson, S.Scott), additional collaborations (BlueSky Project: Annie E Casey Foundation; JRA, CIMH, (Hansson, S.Scott), additional collaborations (BlueSky Project: Annie E Casey Foundation; JRA, CIMH, PCCD, OCFS, Evidence Based AssociatesPCCD, OCFS, Evidence Based Associates
Reminder: FFT Does Not Operate in a VacuumReminder: FFT Does Not Operate in a VacuumThe Big Picture: Integrating FFT with Other The Big Picture: Integrating FFT with Other
Systems*Systems* PretreatmentPretreatmentSystem Integration System Integration
PhasePhase
PosttreatmentPosttreatmentSystem Integration System Integration
PhasePhase
FFT Direct TreatmentFFT Direct Treatment PhasesPhases
- - EngagementEngagement- MotivationMotivation- Relational > BehavioralRelational > Behavioral AssessmentAssessment- Behavior Change- Behavior Change- Generalization / Ecosystemic - Generalization / Ecosystemic Integration Integration
The Youth / Family Management System(s): The Youth / Family Management System(s): Juvenile Justice, Drug Court, Welfare, Mental Health:Juvenile Justice, Drug Court, Welfare, Mental Health:
(PO’s, Case Managers, Trackers, Contingency Managers)(PO’s, Case Managers, Trackers, Contingency Managers)
Boosters, Boosters, MaintenanMaintenance of links ce of links w/ Youth w/ Youth
Mgt Mgt Systems, Systems, Positive Positive
closeclose
Referral, Referral, PreparatiPreparati
on,on,PretreatmPretreatm
ententLinking Linking w/ Youth w/ Youth
Mgt Mgt SystemsSystems
* Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001 * Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001
AssessmentAssessment AssessmentAssessment AssessmentAssessment
GENERALIZATIOGENERALIZATION, Eco/Multi- N, Eco/Multi-
systemic Linking systemic Linking
BEHAVIOR CHANGEBEHAVIOR CHANGE
SessionsSessions1 2 3 4 5 6 1 2 3 4 5 6
7 >>>> End 7 >>>> End
ENGAGEMENTENGAGEMENT
MOTIVATIONMOTIVATION
Pre-Pre-TreatTreat
--mentment
Reminder: Phases Flow, Reminder: Phases Flow, But are Not Necessarily Linear and SequentialBut are Not Necessarily Linear and Sequential
Post-Post-TreatTreat
--mentment
Note that E Note that E & M can co-& M can co-
occur / occur / blend blend
Note that BC Note that BC & GEN can & GEN can co-occur / co-occur /
blend blend
Note that Note that E&M & BC E&M & BC
are are essentially essentially sequentialsequential
Does Adherence Still Count? Does Adherence Still Count? Supervisor Ratings and Supervisor Ratings and Outcomes in Functional Outcomes in Functional
Family TherapyFamily Therapy
Charles W. Turner, Ph.D.Charles W. Turner, Ph.D.11, Andrea A. , Andrea A. Neeb, M. S. Neeb, M. S. 22, James F. Alexander, Ph.D. , James F. Alexander, Ph.D.
331 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)
Relationship of Adherence to FFT and Relationship of Adherence to FFT and Dropout Rates by Phase of TreatmentDropout Rates by Phase of Treatment
10%
15%
20%
25%
30%
35%
40%
Engage/Motivate Behavior Change Generalization
Treatment Phase
Dro
pout fr
om
Tre
atm
ent .
Low Moderate High
Note: The association of Adherence level to dropout status yielded a 2 (6) = 36.48, p < .001
Supervisor Ratings of Therapists’ Supervisor Ratings of Therapists’ Adherence or Competence by Client Adherence or Competence by Client
OutcomesOutcomes
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
negative minimal satisfactory moderate positive Therapist Rated Treatment Outcome
Super
vior
Rat
ing .. .
Adherence Competence
AdherenceAdherence is the necessary base.is the necessary base.
CompetenceCompetence grows with Practice, Feedback, grows with Practice, Feedback, Sufficient Caseload, System Support. Sufficient Caseload, System Support.
Together they represent Together they represent Model FidelityModel Fidelity - - FFT trains and supervises therapists to do things FFT trains and supervises therapists to do things
adherently adherently andand also competently also competently
Low
Moderate
High
Very High
Very low
Total Total A & CA & C
= Model= Model
FidelityFidelity
CompetenceCompetence
AdherenceAdherence
Therapist InitialTherapist InitialStarting PlaceStarting Place
(For Most)(For Most)
0
1
2
3
4
5
6
0123
123
FidelityFidelity
EffectivenessEffectiveness refers to refers to outcomes outcomes which reflect the complex which reflect the complex intersection of many factors: Individual/Biological, Family, Therapist, intersection of many factors: Individual/Biological, Family, Therapist,
Multi-system & EnvironmentalMulti-system & Environmental
Flexibility
4 category system for 4 category system for Clinical Clinical Adherence:Adherence:
3 category system for 3 category system for Competence:Competence:
Added together, they represent Added together, they represent FidelityFidelity to the to the modelmodel
Four Category system:Four Category system: 3 = Really good, highly phase appropriate (sort of 3 = Really good, highly phase appropriate (sort of
an “I wish I could be that consistently on task” reaction); an “I wish I could be that consistently on task” reaction); 2 = Good. On task enough to be a really solid FFT therapist; 2 = Good. On task enough to be a really solid FFT therapist;
1 = Only fair, but on track; 1 = Only fair, but on track; 0 = Unacceptably low (contraindicated interventions) 0 = Unacceptably low (contraindicated interventions)
Three Category system:Three Category system: 3= Brilliant, creative, matches family and context wonderfully3= Brilliant, creative, matches family and context wonderfully2 = On track, will do the job, it is all we can usually expect, 2 = On track, will do the job, it is all we can usually expect,
1 - Simplistic & limited but on track1 - Simplistic & limited but on track
Within Family Alliance in FFT Across Segments 1 & 2 of Sessions 1 & 2
Positive Change Shows Up (or Not) Early
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
Ses 1-1 Ses 1-2 Ses 2-1 Ses 2-2
Kid Drop
Kid Complete
Mom Drop
Mom Complete
Therapist Rated Outcomes by Therapist Rated Outcomes by Ethnic Origin for Male Ethnic Origin for Male
ParticipantsParticipants
0
5
10
15
20
25
30
35
40
negative minimal satisfactory moderate positive
Treatment Outcome x Ethnic Origin
Per
cent of S
ample
..
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 Therapist Rated Outcomes by Ethnic Origin for Female Ethnic Origin for Female
ParticipantsParticipants
0
5
10
15
20
25
30
35
40
negative minimal satisfactory moderate positive
Treatment Outcome x Ethnic Origin
Per
cent of S
ample
..
Caucasian African American Hispanic 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 Retention Status at the End of Each Treatment Phase Treatment by Treatment Phase Treatment by
Adolescent GenderAdolescent Gender
60
65
70
75
80
85
Engage/Motivate Behavior Change Generalization
Phase of Treatment
Rete
ntion (%
)
..
Male Female
Note: Cell entries are the percent of each gender entering treatment who remain at the end of each phase of treatment. 2 (3) = 7.607, p < .06.
Retention Status at the End of Each Retention Status at the End of Each Treatment Phase by Adolescent Treatment Phase by Adolescent
Race/EthnicityRace/Ethnicity
60
65
70
75
80
85
Engage/Motivate Behavior Change GeneralizationPhase of Treatment
Ret
aine
d (%
) .
.
Caucasian African AmericanHispanic 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 Facility to Community Transition Program 2008 J.F. Alexander, Ph.D. & Helen Midouhas, MSEd., LPC J.F. Alexander, Ph.D. & Helen Midouhas, MSEd., LPC
Presented to Richard Gold Presented to Richard Gold
Youth toFacility(Triggers
FTS contact w/ parent(s)
Case Mgmt (esp Parent[s]), Skill building,Empowerment Training
(Waldron Parent Training Informed), Resource Linking
FFT FFT
MST
MTFC
Facility Entry > Facility Tx Phase > Reintegration Prep > Reentry
OTHERS?
Strength Based & Mental Health Assessment,
Parent Engagementw/ Individual & Family & Ecosystemic focus
(FFT, FFP. MST, Solution informed)
>>>>>>>>> Juvenile Justice System >>>>>>>>>
Resource Specialist:
- Contingency Mgt etc .
Family Transition Program Specialist (FTS)Intake (Youth & Parent[s]) ---- Maintenance --- Triage, Linking
Triage
EntryInto System
In Facility:FTS
NaturalEnvironment
FFT
TransitionFTS
Points of Contact of Ideal Reentry Program: The Integrated FTS >>> Community Based FFT
Model (Gold, PA)
Reentry Coordinator (e.g., FTS Specialist)
makes a conjoint family initial relationship
to establish a future perspective and
balanced alliance
maintain communication, esp with parents
Reentry Coordinator (e.g., FTS Specialist) initiates
A link with a Community Based FFT provider
(or other EBT while youth is still in facility and/or home visits)
to begin family based (FFT) Engagement & Motivation with
youth and parent(s)
FFT or alternativeefficacious &
effective familyBased
Intervention