Functional Family Therapy:evidence based, culturally sensitive, practiced with family voice in every session

Thomas L Sexton, Ph. D. ABPP

Professor Emeritus-Indiana UniversityEditor: Couple & Family Psychology: Research & Practice

Board Certified Family PsychologistFunctional Family Therapy Associates/Care4

• A systematic, evidence-based treatment model for families involved in the child welfare, foster care, behavioral health, and juvenile justice systems

• Family-focused, home-based, Family Therapy, support & case management to successful promote family stability in a wholistic manner

• Provides families across the developmental spectrum a pathway to:• practical help….with their real needs

• engagement in treatment

• develop skills to stabilize and work through daily family issues

• generalize those skills in managing future difficulties as they move toward self-sufficiency.

Functional Family Therapy

Evolution of FFT• An evolving model

• Alexander & Sexton (OJJDP, 1999, Blueprints, 2000, 2004, 8 other coauthored publications)

• Sexton (FFT Clinical Practice, 2010) & 10 other major pubs 2006-2019)

• Upcoming FFT Book & Video Series (APA, 2019)

• This is one of the features that makes FFT unique among evidence based treatments

• Family focus, alliance based foundations

• Matching to the context

• Clinical specificity

• Evidence based clinical decision making

• Relevant and helpful training with an evidence base

• That involves family “voice” in all treatment decisions

Core Philosophy

• Underlying philosophy• Family based/relationally focused

• Collaborative & alliance based (within and with stake holders)

• Family voice…session by session with Care4

• Helping families to be self sufficient

• Therapy goes beyond the therapy room,…help with practical needs

• Trauma informed

• Developmentally specific

• Treatment that ”matches” the uniqueness of the family (risk, culture, community & context)

FFT Clinical Protocol

xEngagement & Motivation Behavior Change Generalization

Goals•Alliance between family

with therapist•Family/relationally

based problem problem focus•Reduced family member

negativity/blame•Increased motivation & hope

Engagement & Motivation Generalization

Goals•Generalize new “view” and experience of problem with

new problem that arise•Maintain new skill - working togetherwith new problems-relapse prevention

•Support changes by using relevant outside resources

Long term goal:Changes in Youth/sibling, &

parent behavior, & family relationship

Sexton & Alexander, 1999; Alexander et al, 2000; Alexander & Sexton 2003, Sexton & Alexander 2003, 2006, 2007)

Goals•Increase behavioral competency of all/family •Consistent performance of competency

in “real” problem situation

Behavior Change

Families

PrimaryClient

PartnerGM

Caregivers

Youth/siblingCaregiver

Youth/siblingDaily living risks, stress of family, couple stress

& safety risks• Common CW referral

• Parent & Parent Education & Safety

focus

Parenting with Alliance & monitoring & supervising for

success• Common JJ & Behavioral

referral• Alliance based working

things out focus

Adult focused• Common BH referral

• Alliance based working things out with extended and

family of choice

Different skills different stages of family development

The type of skills and who they are directed to….depends on the family development phase

Navigating the System

• The goal is to help the family successfully navigate their context getting the support they need and learning how to managing the system in the future so that they become self-sufficient.

• Manage child welfare expectations & monitored

• Safety monitoring

• Legal system navigation & monitoring (probation officer)

• Child welfare system monitoring & navigation

• Family court support (parental rights)/court ordered supervision

• Domestic Violence assessment, monitoring & help

• Practical, daily needs (rent, electricity, food)

Core Components…it takes more than a model

Theoretical Model (lens, map, & art)

Evidence based Training & consultation

Systematic, guided clinical decision making

Comprehensive Measurement &

Real time feedbackSystem(Care4)

Populations Served

• Issues/problems• Families involved in the early childhood, child welfare, foster care behavioral

and physical health, academic and juvenile justice systems, substance abuse/use problems

• Ages• Families with young children to older adolescents & young adults

• Contexts• Foster care, child welfare, juvenile justice, mental health

• Prevention & treatment

• Exclusion criteria• Acute & immediate hospitalization

• Extreme DD

What is the evidence?• Functional Family Therapy has over 40 years of evidence which has shown positive

outcomes including:

• improved communication and reduced conflict,

• reduction in child removal from the home, improved family functioning,

• decreased substance use, and decreased mental health symptoms and behavioral problems (Alexander et al, 2000; Sexton, 2010; Sexton 2016; Sexton, 2018).

• Studies suggest that reductions in re-offense rates of between 20 and 80% 6 to 18 months post treatment with long term maintenance of change over 5 years.

• The Center for Substance Abuse Prevention (CSAP) and the Office of Juvenile Justice and Delinquency Prevention (OJJDP) to identify FFT as a Model program for both substance abuse and delinquency prevention (Alexander, Pugh, Parsons, & Sexton, 2000).

• Research suggests that FFT works in the US and across cultures and countries.

Ireland FFT Study ( (SDQ Total Scores-Youth)

13

14

15

16

17

18

19

Time1 Time 2 Time 3

SDQ

Tot

al D

iffic

ultie

s Sc

ale

Treatment

Control

Mean total scores of treatment and control group on the adolescent version of the Strengths and Difficulties Questionnaire (SDQ) at intake (Time 1), discharge (Time 2), and 3 month follow-up (Time 3; treatment group only).

The Role of model fidelity in clinical outcomes(Sexton & Turner, 2010)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

6 month 12 months 18 months

Adherent Non-Adherent Control

* Statistically significant outcome as compared to the random control condition

38%* reduction in felony crime

50%* reduction in violent crime

$14.67* return for each $1 invested

$2400-2800 per family cost to deliver

Staffing Requirements

• Clinicians • 8 cases

• Site Supervisors• Clinical Site supervisor (3-4 cases)

• Team Structure• 3-8 clinicians

• Teams:• Train together

• Do weekly consultation together

• Case plan together

• Become an self sufficient FFT team

• ** Consultants & Model developer see cases and work with FFT…you have to know it to teach it!

Guided Practice & Experience

Theory into practice

Evidence-based Treatment Planning

Core & Specialized Knowledge

Core principles of FFT

FFT Training

CQI & outcome measurement

Evidence-Based Training & Implementation

• Multiple components, learning styles/formats1. Knowledge

2. Translation of knowledge into practice

• Designed to be:• Realistic…fits your work flow

• Cost effective, accessible & responsive

• Implementation with:• Comprehensive measurement system

• Evidence-based practice • Ongoing measurement of

Process, outcome, & practice

• Family Voice

• Ongoing evaluation (using Care4)

Training: Evidence based, clinically applicable, & responsive training

1. On-line Learning—FFT-Adapt Courseware

2. Traditional Training

3. Case Consultation…weekly by video (with Care4)

4. Practice….on site visits with actual sessions to help translate knowledge into practice

5. Clinician, site supervisor & advanced training modules

6. Systematic Case Planning and Quality Assurance Monitoring

• FFT-Clinical Feedback System

• Ongoing measurement of FFT process and client progress

FFT-Adaptware

FFT-Adaptware

Training Roadmap

Knowledge

Adaptware

Case Planning & observed sessions by the team

Practice Visits

Clinical Training 1

Case Planning & observed sessions by the team

Practice VisitsCase Planning & observed

sessions by the team

Knowledge & Case Focused

Clinical Training 2

Practice Visits

Certification

Practice Visits

Video, text & practice/200

pages, 20 hours of video

Live supervised & guided family

session—on site

Years 2 & 3

• Year 2: Advanced Team Training & Site Supervisor Training

• FFT site supervisor training• 4 days supervisor training

• 3 onsite team visits

• Advanced training (team)• Use of Care4 to demonstrate fidelity & positive outcomes

• Year 3: Certification & Maintenance Training• Use of Care4 to demonstrate fidelity and positive outcomes

• Training & live family site visit

• Monthly therapist & supervisor webinars

Responsive Training

• Therapist begins in 1-2 days after registration

• All training on site…not travel for therapists (except for site supervisors-year 2)

• Guided Clinical Practice (on site/live family supervised sessions)

• Replacement Training (within 2 days)

• Replacement Training Cost Sharing

Implementation Support

• Collaborative process (we help the the agency fit the model to the agency & context)

• Ongoing fidelity reports & feedback to Agencies

• Monthly Organization calls

• Extra help for individual therapist

• Network wide collative learning communities

• Measurement & Reporting for evaluation

• Comprehensive measurement (baseline, session by session & discharge) with comprehensive case reports

• real time access to all of “your data”

• real time clinical impact reports

• training & adherence summaries

• Connections, Local EHR integration & geo location (by Jan, 2020)

• Ongoing Implementation Support (for the life of the project)

Treatment Planning

Measurement(client feedback about impact, progress & behavior)

Not just being evidence base….but, practicing with evidence

xEngagement & Motivation Behavior Change Generalization

Precision Behavioral Health…Using Client based evidence to improve decision

makingClient

FeedbackFFT Clinical

Phase Goals

Evidence based treatment, systematic treatment planning

Intervene TherapistReflection

Plan Feedback

Evidence-Based Clinical Decision Making

Functional Family Therapy Sessions

Care4 (desk & mobile)

Supervision

Clinical Measures

The tools systematically monitor & evaluate the following areas at the initiation of treatment (baseline), during treatment, and at the end of treatment (discharge):

•Child, youth & adult functioning (MH & substance abuse screening)•Family Functioning (risk & protective factors)•Family Stability & caregiver/parental strain•Family Risk Assessment (family Risk level for domestic violence)•Trauma exposure & symptoms•Treatment Impact•Therapeutic Alliance•Therapeutic Progress

• Family Voice on….• Impact• Progress• Symptoms

• Therapist view on:• Impact• Progress• Symptoms

Core session by session indicators

Reports (trend & item feedback)

Clinical Reports1. Treatment Impact Report

2. Family Stability Report3. Family Outcome report

4. Fidelity Report

Administrative Reports1. Member Activity

2. Group Activity3. Case Status (open closed cases)

4. Fidelity Report (supervision)5. Other specialized

Fidelity…a CQI process

• Treatment fidelity, model adherence are part of our Continuous Quality Improvement Protocol that is central to effective outcomes in Functional Family Therapy.

• TAM-Therapist Adherence Measure

• SAM-Supervisor Adherence Measure

• Site Fidelity Assessment

• Adherence & Learning Summary-every 6 months

• If necessary, improvement plans can be developed.

• The FFT fidelity measures are integrated into the Care4 online system which allows for real time access to the current status of the case and current therapist and team adherence for evidence based supervisors, and for ongoing quality improvement.

• Thomas Sexton• thsexton@mac.com