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 1 ©FFT Associates. Not intended for Duplication or Distribution

2. Goals of Today’s Training Introduction to the Training Program Introduction to the Training Program Overview of the FFT clinical model & its value Overview of the FFT clinical model & its value Clinical Practice Issues…what will doing FFT mean for your daily work? 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……

3. Goals of Today’s Training Clinical decision making with FFT/CFS Clinical decision making with FFT/CFS Measures of Progress & Process Measures of Progress & Process – FFT Measures…how you will know FFT is working? Case conceptualizing—progress notes and session planning guides Case conceptualizing—progress notes and session planning guides Training/practicing with FFT/CFS Training/practicing with FFT/CFS Overview of FFT/CFS Overview of FFT/CFS How you will learn FFT/CFS How you will learn FFT/CFS Goal for the week Goal for the week

4. Next Steps Next Steps Webinar #2 (the clinical model) Webinar #2 (the clinical model) Clinical Training #1 Clinical Training #1 Video consultation begins Video consultation begins Practice FFT/CFS Practice FFT/CFS Begin Cases Begin Cases

5. Learning Resources Things to help you along the way: Things to help you along the way: Learning Center at the FFT Website Learning Center at the FFT Website – www.functionalfamilytherapy.com www.functionalfamilytherapy.com To get started: To get started: – FFT Book – Introduction to FFT (on the website) – FFT/CFS help resources What you can expect: 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

6. Overview of the Training Process

7. 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: 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 a clinician works/trained Existing ways an organization works Existing ways an organization works Lessons over the last 10 years Lessons over the last 10 years Process of change Process of change Learning curve Learning curve

8. Our Training Philosophy Principles: Principles: Based on adult learning/educational psychological principles of learning Based on adult learning/educational psychological principles of learning Short, relevant, repetitive, and clinically specific Short, relevant, repetitive, and clinically specific Goal …. Goal …. clinically relevant therapist competence & model adherence clinically relevant therapist competence & model adherence Ability to use the model in ways that “fit” clients and context Ability to use the model in ways that “fit” clients and context High model Fidelity and Clinical relevance High model Fidelity and Clinical relevance

9. Phases of Training Phase 1: Planning, Preparation, & Implementation Phase 1: Planning, Preparation, & Implementation Phase 2: Clinical Training Phase 2: Clinical Training Phase 3: Site Supervisor Training Phase 3: Site Supervisor Training Phase 4: Partnership/Site Certification Phase 4: Partnership/Site Certification

10. Training Phases: Phase 1: Planning, Preparation, & Implementation Phase 1: Planning, Preparation, & Implementation Introductory webinars Introductory webinars FFT/CFS training FFT/CFS training “fitting” FFT into the work flow “fitting” FFT into the work flow Readiness assessment Readiness assessment Phase 2: Clinical Training Phase 2: Clinical Training 3 clinical training days 3 clinical training days 6 site “externship days 6 site “externship days 6 webinars 6 webinars 45 hours of team consultation 45 hours of team consultation Online discussion forum Online discussion forum FFT/CFS use FFT/CFS use

11. Training Month 1-4 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 1-4 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 5-9 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 5-9 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 9-12 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 9-12 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS

12. Training Goals 1.Competent FFT Therapist Able to adherence to the model consistently Able to adherence to the model consistently Able to competently practice the model with diverse families in a way that “fits” their unique situation Able to competently practice the model with diverse families in a way that “fits” their unique situation Improves outcomes with youth and families Improves outcomes with youth and families 2.Supportive Organization Supports the implementation of FFT through Supports the implementation of FFT through – Clinical procedures – Funding – Staffing time/resources 3.Effective & Efficient FFT services

13. Training Methods On-line Learning On-line Learning – Way to present material in an interactive way over the web in “small doses” Discussion Forum 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 Traditional Training – Presentation and interaction with an FFT expert focusing on the clinical principles and techniques

14. Training Case Consultation Case Consultation – Small group discussion of specific cases – Following a “developmental” model that builds from basic core principles to complex clinical intervention Observation/Practice Observation/Practice – Of video tapes (of actual sessions) – In ongoing practice

15. Training Systematic Case Planning and Quality Assurance Monitoring Systematic Case Planning and Quality Assurance Monitoring FFT/CFS FFT/CFS Ongoing measurement of FFT process and client progress Ongoing measurement of FFT process and client progress Systematic case planning…..with the FFT progress notes and session plans Systematic case planning…..with the FFT progress notes and session plans Case Experience Case Experience

16. Learning Resources Learning Center (www.functionalfamilytherapy.com) Learning Center (www.functionalfamilytherapy.com)www.functionalfamilytherapy.com FFT Manual FFT Manual Articles/PowerPoint's Articles/PowerPoint's FFT/CFS help/training website FFT/CFS help/training website Weekly Video Case Consultation Weekly Video Case Consultation Ask on the discussion forum Ask on the discussion forum Email us Email us

17. Questions?

18. Introduction What is the need? Why use FFT? How does the model work?

19. – 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 Systematic treatments address specific issues of these kids and families Best research, clinical practice, and system of care 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 For practitioners/clinic practices this is the primary reason for an adolescent to be referred for care Context: Adolescents Behavior Problems Context: Adolescents Behavior Problems

20. Functional Family Therapy Targeting at-risk adolescents and their families….externalizing behavior disordered youth Targeting at-risk adolescents and their families….externalizing behavior disordered youth Prevention intervention--status/diversion kids Prevention intervention--status/diversion kids Treatment intervention--moderate and serious delinquent youth Treatment intervention--moderate and serious delinquent youth Family Therapy intervention program Family Therapy intervention program Comprehensive and phasic clinical model (not integrative or eclectic) Comprehensive and phasic clinical model (not integrative or eclectic) Yet…responsive to client diversity Yet…responsive to client diversity Primary focus is on the “in the room” interaction between the therapist and the family Primary focus is on the “in the room” interaction between the therapist and the family Short-term Short-term 8-13 for moderate cases, 26-30 for more serious cases spread over 3 to 6 months 8-13 for moderate cases, 26-30 for more serious cases spread over 3 to 6 months Intensity in its quality not quantity Intensity in its quality not quantity

21. Functional Family Therapy Clinical Model EarlyMiddleLate Reduce within family risk factors - negativity/blame -hopelessness -build engagement/ reduce dropout Behavior Change MotivationEngagement GeneralizationGeneralization Build within family protective factors - behavior competencies -interaction change -that increase probability of - behavior Build family to context protective /reduce risk factors-peers/school/communityEarlyMiddleLateAssessment Intervention

22. Functional Family Therapy Clinical Model Motivation Intervention Assessment Engagement Behavior Change Generalization Generalization EarlyMiddleLate Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals

23. Functional Family Therapy as an “evidence-based model” 1. Systematic Clinical Intervention – Integrative Theory…from within and out of MFT Theory…from within and out of MFT Clinical experience Clinical experience Research evidence Research evidence – Comprehensive Clinical Model : Etiology of problems Etiology of problems Guiding therapeutic principles of practice Guiding therapeutic principles of practice Phasic change process, mechanisms of change Phasic change process, mechanisms of change Multisystemic foci Multisystemic foci – Systematic practice Clinical protocol --”clinical map” Clinical protocol --”clinical map” Manual driven Manual driven 1. Systematic Clinical Model 2. Clinical Intervention “Map” 3. Research support 4. Clinically responsive & transportable

24. Functional Family Therapy Clinical Model Motivation Goal-SkillsGoal-Skills Goal- Skills Intervention Assessment Engagement Behavior Change Generalization GeneralizationEarlyMiddleLate Engaging and motivating families to becoming part of and stay in therapy.. by… Building alliance with everyoneBuilding alliance with everyone Reducing negativity and blame while retaining responsibilityReducing negativity and blame while retaining responsibility Creating a family focus for problems to openCreating a family focus for problems to open new solution avenues Assess individual, family, context, andAssess individual, family, context, and how “problem” fits in that system Changing the problem behavior… by reducing the delinquency and family relationships that support it by… developing individualized change plans that “fit the family” and increase competence in.. ParentingParenting CommunicationCommunication Problem solvingProblem solving Conflict managementConflict management Generalizing the change…. by… Helping family generalize change across situations… to become self reliant Maintain change by relapse prevention Support changes by increasing the use of available community resources

25. Functional Family Therapy 3. Strong science/research support… ……..Studies spanning 30 years – Outcome research 5 Clinical Trials/8 Systematic Comparison Studies 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) 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% 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 Improvements in family functioning, communication, symptom distress, youth drug use/abuse, out of home placements – Process research Balanced alliance work Balanced alliance work Gender interaction studies Gender interaction studies Blame and negativity reduction Blame and negativity reduction Support and Structure Support and Structure

26. 4. Clinically Responsive….to the unique processes of individual family Respect Respect Focus on strength and self-reliance Focus on strength and self-reliance Focus on family functioning/not pathology Focus on family functioning/not pathology Relational understanding of “problems” Relational understanding of “problems” – Demonstrated in its wide application in diverse setting/with diverse clients Functional Family Therapy (cont’d)

27. 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 Initial focus is motivate the family and prevent dropout by attention to family risk factors Build relevant family and individual protective factors Build relevant family and individual protective factors With interventions that are specific & individualized With interventions that are specific & individualized – Long term empowerment Incorporating relevant community resources to maintaining, generalizing, and supporting family change Incorporating relevant community resources to maintaining, generalizing, and supporting family change

28. Functional Family Therapy Clinical Model A relational process A relational process – between two experts….. Client…..-life/experience expert Client…..-life/experience expert Therapist….change process expert Therapist….change process expert Purposeful interactions promote model process goals… Purposeful interactions promote model process goals… therapist is goal directed (specific process outcomes) therapist is goal directed (specific process outcomes) In a relational interchange In a relational interchange – Flexibly-structured… both Contingently directed or….a set of goals….that you pursue depending on the family and the current interactions Contingently directed or….a set of goals….that you pursue depending on the family and the current interactions Guided by model specific treatment phase goals Guided by model specific treatment phase goals

29. Practicing Functional Family Therapy How it is delivered How it is delivered What you can expect What you can expect Systematic Clinical Decision making Systematic Clinical Decision making Ongoing measurement of process and client progress to better plan and intervene Ongoing measurement of process and client progress to better plan and intervene

30. Core of FFT A therapy that is both systematic and individualized? Goal of a therapy is to BOTH….. Match to the Family 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” Relational “needs” Obtainable change for the family Obtainable change for the family Unique relational organization Unique relational organization Match to the Model Match to the Model – Model as primary clinical decision making tool – Model to direct treatment plans….sessions plans – Follow BOTH: Core principles clinical procedures Core principles clinical procedures

31. What you can expect FFT lasts 8-14/16 sessions FFT lasts 8-14/16 sessions Conjoint (whole family/major players) Conjoint (whole family/major players) Delivered weekly (maybe more in E/M, less in Gen) Delivered weekly (maybe more in E/M, less in Gen) Sessions in each treatment phase occur in a successful treatment episode Sessions in each treatment phase occur in a successful treatment episode Engagement motivation Engagement motivation Behavior Change Behavior Change Generalization Generalization Assessment as short as possible (get to treatment quickly) Assessment as short as possible (get to treatment quickly) Simultaneous/other Treatments? Simultaneous/other Treatments?

32. Functional Family Therapy Integrated Service Delivery Model Motivation Intervention AssessmentEngagement Behavior Change GeneralizationGeneralization EarlyMiddleLate Referral/Initial Assessment Your agency baseline assessment FFT baseline assessment A “quick” referral to treatment

33. Functional Family Therapy Integrated Service Delivery Model Motivation Interventio n AssessmentEngagement Behavior Change GeneralizationGeneralization EarlyMiddleLate Weekly FFT Sessions Schedule & hold session in FFT/CFS Case Planning—FFT Progress Note M easuring therapeutic Process & Client Progress 8-10 items completed by client online

34. Functional Family Therapy Integrated Service Delivery Model EarlyMiddleLate Motivation Interventio n AssessmentEngagement Behavior Change GeneralizationGeneralization Discharge FFT/CFS discharge of client Outcome Assessment Referral if necessary

35. Who is a good client for FFT Adolescent Adolescent Mental health issues Mental health issues Juvenile justice/conduct problems Juvenile justice/conduct problems Alcohol and drug problems Alcohol and drug problems Stable family placement Stable family placement With no emergency “needs” With no emergency “needs” Acute need for hospitalizations Acute need for hospitalizations Stable meds/psychiatric care Stable meds/psychiatric care Use a “rule out” philosophy Use a “rule out” philosophy

36. Session Delivery Where? in the home or in the office Where? in the home or in the office How long? Approximately 60 minutes How long? Approximately 60 minutes How frequent? Weekly How frequent? Weekly – Early may be twice a week – In the middle phases 1 each week – Generalization phase…..titrate out session over time

37. Session with who? Family….FFT is a “conjoint” therapy Family….FFT is a “conjoint” therapy – Adolescent – Parents/Step-parents – Involved siblings Sessions are with the family….. Sessions are with the family….. – No individual session…miss opportunities

38. What if the cancel/no-show Overcome barriers Overcome barriers Engage/work on the phone Engage/work on the phone Make room in your schedule and see them the next day/ or that day after that Make room in your schedule and see them the next day/ or that day after that

39. How long Does FFT Last? Each phase completed Each phase completed 10 to 18 sessions 10 to 18 sessions Over 4 to 6 months Over 4 to 6 months What if they come back? What if they come back? Same therapist….pick up in generalization phase Same therapist….pick up in generalization phase

40. Clinical decision making with FFT/CFS 1.Case conceptualizing progress notes and session planning guides progress notes and session planning guides 2.Measures of Progress & Process FFT Measures…how you will know FFT is working? FFT Measures…how you will know FFT is working?

41. Why this way of working helps Allows for: 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 Each of which help improve treatment effectiveness and efficiency

42. Treatment Planning (Progress Notes) Session Planning (Session Planning Guide) Client Session Impact (immediate family changes) Therapeutic Alliance (TA) Youth Symptom and Functioning (SFSS) Session Baseline Family Functioning (Com-R) Post Treatment Family Functioning Measure (Com-R) Model Specific Adherence (CQP) Motivation EngagementBehavior Change Generalization Session Feedback -process -progress -fidelity

43. 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 Used by the therapist to understand the case better/plan Used by the Consultant to help the therapist learn Used by the therapist to understand the case better/plan Used by the Consultant to help the therapist learn

44. Tools of Clinical Decision Making FFT/CFS Feedback FFT/CFS Feedback Your thinking using the FFT progress note/session plans Your thinking using the FFT progress note/session plans Discussing cases in FFT terms in weekly case consultation & with your team Discussing cases in FFT terms in weekly case consultation & with your team

45. FFT Clinical Measurement Inventory Resource: FFT CMI Manual (on the web) Resource: FFT CMI Manual (on the web) Baseline Assessment Baseline Assessment Family Demographic Information (in CFS) Family Demographic Information (in CFS) Family Functioning (COM-r) Family Functioning (COM-r) youth & caregiver form youth & caregiver form Youth Symptom Level (SRFF-full Form) Youth Symptom Level (SRFF-full Form) Youth & caregiver form Youth & caregiver form

46. 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

47. Discharge Assessment Discharge Assessment Family Demographic Information (in CFS) Family Demographic Information (in CFS) Family Functioning (COM-r) Family Functioning (COM-r) youth & caregiver form youth & caregiver form Youth Symptom Level (SRFF-full Form) Youth Symptom Level (SRFF-full Form) Youth & caregiver form Youth & caregiver form

48. FFT/CFS System How to learn 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 Review each on line video and quick guide for each major function 1.Entering a Client 2.Scheduling a Session 3.Holding a session 4.Completing measures 5.Discharging a client

49. Resources FFT Learning Center FFT Learning Center – www.functionalfamilytherapy.com www.functionalfamilytherapy.com FFT/CFS FFT/CFS – https://beta.cfsystemsonline.com/login https://beta.cfsystemsonline.com/login Written Manuals Written Manuals – FFT in Clinical Practice (Sexton, 2010) – FFT Clinical Training Manual (Sexton & Alexander, 2004) – FFT Blueprint Manual (Alexander, Pugh, Parsons, & Sexton, 2000)

50. What’s next? This week: 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! It will take 4-5 hours of practice! – Find your questions….for the training!