Functional Family Therapy Learning Institute January 22-23, 2015 Miami, FL Clinical Site Supervisor Training

Introductions Welcome & Introductions

Agenda Thursday Morning 1. Overview of the FFT Clinical Supervision Model 2. FFT-CFS as a Clinical Supervision Tool Afternoon 1. New Research/Adaptations 2. International Applications of FFT 3. Unique Adaptations of FFT 4. CFS

Friday Morning 1. Supervision Practice *Directors will meet separately Afternoon 1. New Supervisor Group 2. Senior Supervisor Group 3. Ending/next steps

Clinical Supervision in Functional Family Therapy

Traditional clinical supervision is often case-focused and not specifically linked to the adherence and competence in delivering a specific model of treatment. Development a specific supervision model that focuses on the development of adherence and competence in FFT (Sexton, Alexander, & Gilman, 2004). This model of supervision has been a central feature in the dissemination efforts of FFT over the last decade. clinical supervision is a central part of the foundation of a “treatment model and functions as a central piece in a service delivery system that is able to maintain itself over time To do so….”isomorphic” to the clinical model

Clinical Supervision Clinical supervision is more than just a tool to solve crises or discrete clinical problems (as it is usually used), It is an essential element in the overall effort to maintaining the integrity and ultimately the outcomes of FFT. Supervision is one of the primary ways that fidelity is managed in clinical trial studies, and it is a common procedure in most practice settings.

The role of Clinical Supervision Elements of a successful FFT project: 1. Comprehensive system of assessment, treatment planning, and clinical intervention, 2. Quality improvement mechanisms, 3. Clinical supervision 4. Ongoing data monitoring and feedback Success of a project depends on the degree to which these elements are present and work together

Goals of Clinical Supervision 1. Monitoring model fidelity and quality of the Practice (quality assurance) In clinical practice, in service delivery 2. Promoting adherence and competence of the Therapist (quality improvement) Thinking through the FFT “lens” Clinical decision based on FFT principles on the FFT treatment intervention 3. Managing service delivery context so that it promotes the model (administrative guidance)

Guiding Principles of Supervision 1. Model-based/focused – Thinking through he lens, model based clinical decisions 2. Relationally-based Alliance-based working relationships, Alliance based motivation Supervision interventions that “match to…” 3. Multisystemic/multiple domains of attention & action Integrative in domains of attention (therapist, service delivery system, context) 4. Phasic based supervision interventions Assessment (monitoring) and systematic intervention 5. Evidence-based…data driven

Principles of FFT Supervision Other Tx Philosophies, Principles, & TechniquesFFTCorePhilosophy,Principles,&Techniques Adherence Competence

TherapistCompetence TherapistAdherence KnowledgePerformance Working Group “maturity”

Therapist adherence Adherence is defined in the dictionary as: “to be in accordance with,” or “follow through or carry out a play without deviation,” or finally, “to cling, stick or hold together and resist separation”

Therapist adherence Adherent FFT therapists stick to the goals and principles of the model when events, situations, and problems are presented to them. They” cling” to the model as the map for deciding what direction, goal and outcome to pursue. FFT therapists who demonstrate model-specific adherence : make clinical decisions in accordance with the principles and conceptual foundations of FFT, conduct therapy in accordance with the clinical model, and work with clients guided by the goals of FFT both in general in specifically to each phase of treatment. adherence is something between the therapist and the model, something that can be measured.

Therapist Competence model-specific adherence is not enough. In any clinical situation there is more than just a therapist and a model—there is the family. Therapists are only effective to the degree that they “match to” the client. The “match to” principle is what makes FFT effective with different families who live in different cultures and who are from different ethnic/racial/religious backgrounds.

Therapist Competence The dictionary defines competence as: “the ability to apply knowledge, skills, or judgment in practice if called upon to do so.” In FFT this means : the therapist is able to apply the FFT clinical model, its core theoretical principles and its specific clinical interventions with a specific family. the ability of the therapist to match the model to the unique, complex, and multisystemic nature of the families they treat. competence is specifically the ability to apply FFT as a “matching to” process.

* Statistically significant outcome Adherence is important

Ireland (2013)

Adherence & Competence in Functional Family Therapy

Supervision Construct Definitions Adherence is the degree to which the therapist is doing the FFT program (clinical model, assessment protocol, staffing participation, CFS). Domains of adherence: Core Principles (client, problems, therapy) Technical elements Basic clinical elements Service delivery within protocol Types: General Phase specific

TherapistAdherence Knowledge Performance Working Group “maturity”

General Model Adherence Low adherence serious weakness in understanding and applying the core principles of FFT, minimally using the clinical model in work with clients (following phases of the model and attempting to achieve the goals of the model in clinical work). Average therapist has an accurate and broad understanding of the core principles of FFT, and is using the clinical model in work with clients (following phases of the model and attempting to achieve the goals of the model in clinical work). High adherence therapist that is doing all parts of the model consistently.

Therapist Adherence Knowledge Performance Core Principles - clients -problems -change process Clinical Model Understanding Clinical Model Application Model Adherence

TherapistAdherence Knowledge PerformanceExamples:Examples:

General characteristics of adherence Does the therapist deliver the three FFT phases in the appropriate order? Is the therapist flexible in providing services in a way that meets the family’s schedule? Does the therapist have a theoretical understanding of the FFT model? Does the therapist utilize the FFT model as their primary source of clinical decision making? Does the therapist think about the adolescent in a relational/family focused way? Does the therapist maintain a balanced alliance with all family members throughout all phases? Does the therapist demonstrate the following qualities to the family: Warmth Non-judgmental Non-blaming Humor Acceptance Sensitivity General relational/counseling skills

Phase Specific Adherence Adherence to phase goals Adherence “benchmark” depends of the goals of model Specific look at adherence

Adherence in Engagement/Motivation Is the therapist building a balanced alliance with the family? Therapists are reframing in an attempt to reduce negativity and blaming among family members Therapists acknowledging and reframing client statements in a way that facilitates the particular phase goals Conducted in a climate of alliance/support?

Adherence in Behavior Change The have a specific behavior change target/individualized family change plan? The behavior change target is linked to the presenting problem through the organizing theme Application behavioral skills as behavior change target

Adherence in Generalization Therapists specific generalization targets Generalization phase targets are linked to the generalizing changes to school, community, and peers. generalization target is linked to the organizing theme therapist work helps support the family changes by identifying relevant community resources Matched to the family

Competence Competence reflects the skill of the therapist in doing the clinical model of FFT. Competence includes the ability to be clinically responsive to individual families (translate the model to the individual family) while remaining model focused (goals and skills), consistently practicing the model, and thinking complexly about clients and the FFT therapy process.

Competence Low competence a therapist who is attempting to achieve the goals of each phase and using the skills of each phase but not doing clinical work in ways that is rigid, not matching to the family, in a way that reflects simple thinking about the process, that involves simple application of the skills (e. g. reframing) that is applied inconsistently. Average competence indicates that the therapist is thinking somewhat complexly about the family and process, using skills (e. g. reframing) with moderate complexity and doing these things most of the time. High competency therapist has the ability to thinking complexly about families, the process, do the clinical skills of FFT with high degree of skill in ways that match to many different kinds of families in consistent manner.

Measuring Model Adherence Therapist Adherence Scale (TAM)

TAM (Therapist Adherence Measure) The is a supervisor-rated measure of model specific therapist adherence. The TAM based on the degree to which the clinician’s case conceptualization and session goals are consistent with FFT Model. The TAM has dimensions: General Model adherence (TAM-G) and Phase specific model adherence (TAM-G). The supervisor rates both measures during the weekly clinical staffing using a 5-point Likert scale (1 – 6) indicating low, average, and high general model adherence.

Using the Clinical Feedback System as a Supervision Tool

Scheduling supervision sessions Individual and group Planning Supervision Sessions Monitoring Client Progress TAM ratings Communicating with therapist Monitoring service delivery

Process of Clinical Supervision A relational change model

Time low high Adherence Competence Engagement/ Motivation Adherence/ Competence Maintenance Phases of Supervision (relational dimension) Outcome Goals Primary focus

Therapist Presentation of the Case Supervisor Decision making (knowing what to target) Anchor (source of decisions) Phase of model Goals of the phase Story of the case - description of family -description of problem What happened…. What next…. What is the adherence issue? What is the competence issue? How can I intervene? Match to the family…is it working to accomplish goals given situation? Domain/ Knowledge Performance How: -teach, question,-ask Impact…feedback -check/readjust assessment -method match (to domain/person/group) Translation Using what the therapist “says” To understand what they do in Sessions and how they Think about cases Translating back into Intervention that address the primary issue (adherence/competence) in a way that “matches to” the therapist

Organizing Theme…what has been going on with therapist…. Orient …..(what phase….sessions etc.) 1. Frame (specifically identify “what” it is) 2. Acknowledge (identify this as important) 3. Change (teach, demonstrate, give an example, practice-”can you try”….) 4. Application (apply knowledge to case in question/under discussion) 5. “Theme” (for where to go/what to work on.. how it is linked to other cases…etc.) Relational Supervision discussion ST ST Practice/demonstration ST

What to hear Engagement/Motivation Family Presentation of Problems (what do they say it is--problem definition) Problem Sequence Organizing theme (developed to date) Family focused/involves everyone, thematic, based on problem sequence (i.e. specifically identifies specific behavior) Alternative explanation for the problem directly linked to the problem sequence Developed FROM individual reframing of events/actions Does it work to: reduce negativity and blame? change the family presenting problem definition (attribution)

What to hear Behavior Change Organizing Theme (from engagement & motivation) “and your challenge is….” Specific targets (that are competency based) Implementation strategy (that is matched to relational functions)

Framing How to decide what to frame: phase/what you know about the phase - adherence or competence -knowledge or performance Prioritizing general to specific core principles to specific knowledge/solution Framing… highlight most central part point out what is a problem (feedback/problem definition) describe in respectful way/thematic way

Changing…. Teaching Guided clinical decision making Demonstrating Planning Group discussion Theme focused/based Case applicable

Conducting Clinical Supervision And evidence based approach

Group Supervision Supervision Plan Based on CFS review Service Delivery profile themes Adherence themes (from supervision reports) Based on current themes of individual and group Identify case that fits theme Case Discussion Assess fidelity/adherence Identify intervention point Guided discussion Relational Supervision Interventions

Preparation/Supervision Planning Identify the therapists who are next in line for supervision. Identify 2-3 therapists who did not receive supervision in the prior supervision. Review Clinician Progress notes for cases completed since the last clinical consultation meeting

Supervision Meeting Ask therapists to be supervised to present a brief case conceptualization, session goals, and client responses Complete the TAM (both the TAMG and the phase appropriate TAMS) Continue with supervision helping the therapist identify next session plans that are consistent with the FFT clinical model Show the FFT/CFS screen (using Web-EX to help the therapist identify the feedback appropriate for the case In a typical consultation session 2-3 therapists receive direct supervision.