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)

Too Lax? Too rigid?Optimal adherence

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