Copyright 2010 FFT LLC. An Evidence Based Model

Transcription

1 An Evidence Based Model

2

3 National Survey on Drug Use and Health: SAMSHA, 2009

4 National Survey on Drug Use and Health: SAMSHA, 2009

5 Other than HIV/AIDS, social, behavioral, and environmental factors are the primary causes of adolescent mortality worldwide Blum, 2006

6 Adolescent Mortality CDC, 2006

7

8 Risk Factors Domains Protective Factors Early Aggressive Behavior Individual Self Control Lack of Parental Supervision Family Parental Involvement Parent Substance Abuse Peer Academic Competence Drug Availability School Anti drug Use Policies Poverty Community Cellular to Social Context Strong Neighborhood Attachment Adapted from NIH Publication No (A) Second Edition October 2003

9 Culture Economic Economic Conditions Conditions Family Support Networks FRIENDS FRIENDS Friend s s Family NEIGHBORHOOD NEIGHBORHOOD Built Built Environment Environment Health & Social Services Laws FAMILY FAMILY SES SES Family s s Jobs Immigration Immigration

10 Focus on lining up immediate, intermediate, and long term goals Treatment manuals Well defined theory Description of therapeutic techniques and strategies Road map rather than paint by numbers Flexible Contingent Responsive

11 An Overview of Constructs

12 11 clinical trials Ongoing work Depression Booster Supervision International Implementation Sweden, Netherlands, Norway, England, USA Including Trials New Zealand, Belgium, Chile 25,000 30,000 families served in per year 270 sites worldwide 1500 therapists FFT Book (American Psychological Association) Alexander, Waldron, Robbins

13 At risk and delinquent/drug using preadolescents and adolescents (11 18 years old) and their families Contexts of delivery include Mental health Child welfare Juvenile Justice Youth family social services) Short term intervention 8 13 sessions (up to 30 with very difficult families) 3 6 months

14 Training Supervision Implementation Sustainability Culture Economic Economic Conditions Conditions SES SES FAMILY FRIENDS Basic Research Immigration Immigration Laws NEIGHBORHOOD Built Built Environment Environment Implementation / Dissemination Studies Process Studies Efficacy Studies Effectiveness Studies

15 Relational/Systemic Family First

16 FFT is first and foremost an attitude or philosophy Respect (difference, culture, ethnicity, family form) Non judgmental Strength Based Family focused intervention Pathway to change Involving alliance with and involvement of all family members ( Avoid taking sides) Focus on risk and protective factors Altering ratios to decrease odds of continued problems Interventions are specific (matched) to individuals, relationships, family, and extra familial context

17 The goal of FFT is not to create healthy or normal families according to someone s theory or ideal, but to achieve obtainable changes that will help this family function in more adaptive, acceptable, productive ways with their resources and their value systems in their context THIS REQUIRES RELENTLESS EFFORT TO UNDERSTAND AND RESPECT YOUTH AND FAMILIES ON THEIR OWN TERMS

18 E N G A G M E N T MOTIVATION Relational Assessment and Matching MOTIVATION BEHAVIOR CHANGE GENERALIZATION SESSIONS Pre Treatment Post Treatment

19 Overview: FFT Phases of Change (1) MOTIVATION BEHAVIOR CHANGE GENERALIZATION P H A S E G O A L S : Build Alliance, Reduce Negativity Create Hope Individualized Short / Long Term Positive Changes: Behavior, Attributions, Emotional Reactions Maintain / Generalize Positive Changes, Connect to Positive Community Resources M A J O R A S S E S S M E N T F O C U S Relationships / Interpersonal Functions of Behaviors, Emotions / Attributions Behaviors, Sequences, Skills and Deficits Multiple System Community Links, Extrafamilial Risk / Protective Factors

20 FFT Phases of Change (2) MOTIVATION: RELATIONAL BEHAVIOR CHANGE: STRUCTURING GENERALIZATION: CASE MANAGERIAL M A J O R C L I N I C A L F O C U S & T E C H N I Q U E S Culturally Respectful Relational Focus Positive Reframing Nonblaming Themes Divert Blame Sequencing Direct, Teach, Model Communication Training Parenting Skills Training Conflict Management Relationship Skills Problem Solving Family Case Management Community Resources Building Relapse Prevention, Rehearse of New Skills

21 Culture Economic Economic Conditions Conditions Family Support Networks FRIENDS FRIENDS FAMIL FAMIL Y Friend s s Family NEIGHBORHOOD NEIGHBORHOOD Built Built Environment Environment Health & Social Services Laws SES SES Family s s Jobs Immigration Immigration

22 School Ecosystem Influences Community Peers Intra- Individual Factors Referral Problems Extended Family Problem Family Relational Patterns Repetitive behavioral, emotional, and cognitive patterns Core Motivations Inferred Relational Functions

23 Data is about understanding context and maintaining accountability Context is not only about being relational and systemic, it is also about knowing our roots and foundations. Understanding context is critical for teaching the model Identification of strengths and weaknesses Development of QA / QI plans Many of our cherished clinical assumptions are derived from our own clinical research Accountability is about making sure we stay honest about ourselves and true to the families we serve Be open to constructive feedback

24 Clinical Outcomes Engagement and retention Decreased drug use Decreased externalizing behaviors (conduct problems and delinquency) Out of home placements (incarceration, residential treatment, foster care) Improved family functioning (conflict, parenting) Improved school functioning (attendance and performance) Cost effectiveness ($14 to $17 saved for every $1 spent)

25 Training Supervision Implementation Sustainability Basic Research Implementation / Dissemination Studies Process Studies Efficacy Studies Effectiveness Studies

26 Enhancing Therapist Fidelity to Model How do we help therapists implement FFT with the highest quality and integrity to our core principles? In real world implementation? Therapist Selection Multiple Responsibilities Treatment Philosophy Therapist Availability Costs training, supervision, QA Organizational Commitment/Support

27 Why do we care about fidelity? 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 6 month 12 months 18 months FFT High FFT Low TAU Barnoski et al., 2002

28 Family characteristics? Therapist issues? Training? Supervision? Youth who may be most in need of services and for whom the largest effects could be observed may be getting the least pure implementation

29 Without supervision, adherence, fidelity, and clinical outcomes are negatively affected. Henggeler et al., 1997

30 Phase based Assessment and Intervention

31 E N G A G M E N T MOTIVATION Relational Assessment and Matching MOTIVATION BEHAVIOR CHANGE GENERALIZATION SESSIONS Pre Treatment Post Treatment

32 Specific Interpersonal Skills (1) Relationship skills Warmth,non blaming, humor, interpersonal sensitivity, respect for individual difference (2) Structuring skills provide direction within the sessions, locate and provide resources and materials, provide stepby step structure and behavior change techniques (3) Conceptual skills Assess/understand relational nature of problem; monitor therapy process; Plan and think on your feet (4) Clinical and life experiences Be aware of it, use it, but don t Copyright let it 2010 run FFT LLC

33 Setting the stage for change

34 GOALS: SKILLS: Enhance perception of responsiveness and credibility, demonstrate desire to listen and help Qualities consistent with positive perceptions of clients, persistence, matching

35 FOCUS: ACTIVITIES: Immediate responsiveness, strength based relational focus, individual and cultural characteristics High availability, telephone outreach, language and dress appropriate, proximal services or adequate transportation, contact as many family members as possible. Schedule sessions as frequently as necessary.

36 1 Family members that are living in the home 2 Family member(s) seen as part of the problem or problem sequence according to referral source(s) 3 Family members we think are likely to shut the process down and who probably can! 4 Family members we think are necessary to begin change in the referral youth(s) 5 Important nonfamily members who will participate and are appropriate participants vis à vis retaining a highly influential role with the youth / family (e.g., Grandma)

37 Goals: become SKILLS: Create positive motivational context: less hopelessness and blame (self & other), create hope; engage all major family members and motivate them to part of the change process by: Building balanced alliances Reducing negativity and blame while retaining responsibility, Creating a family focus Relationship and interpersonal skills, nonjudgmental, acceptance and sensitivity to diversity

38 Creating a context for change

39 FOCUS: ACTIVITIES: Relationship process, strength based Interrupt highly negative interaction patterns and blaming Change Focus and Change Meaning Interventions

40 Consistent and contingent responding to disrupt blame and create hope Therapist must accommodate to the family without challenging individuals or relational functions Matching

41 Match to clients: Working hard to respect and understand them, their language, norms, etc In the Motivation Phase it is all about them

42 Change Focus Change Meaning

43 Interrupt/Divert do something to interrupt escalation Pointing Process describing interaction which includes a negative component in the current moment in a strength based way Sequencing describing negative interaction that occurred outside of session in a strength based way Selectively attend to positive elements Strength based relational statements of nobility about one person s efforts towards another person

44 1 Relabel: Provides an alternative, more benign label for a specific behavior, emotion, attribution. 2 Theme hint : Short comment about a possible alternative domain (especially emotional / affective) involved in a negative behavior one that tends to arouse less blaming and negativity. 3 Reframe: Introduces less intense and possibly more benign motives or reasons for the negative Behavior 4 Reframe +: Suggests noble but misguided intent with respect to a family member s

45 5 Theme (Behavioral): Identifies a specific sequence, usually of within-family behaviors, with reframes and/or relabels of most or all of the specific behavioral elements, in a way that suggests non-malevolent (and even possibly noble ) intent or reasons behind all family members behaviors.

46 5 Theme (Relational): Creates/suggests a possible misguided benign, even noble, and sometimes accidental intentions behind longer term relational patterns and/or interpersonal styles. Relational themes often are quite nonspecific with respect to recent behaviors. Often they capture years of relational unhappiness, dysfunction, and negative attributions about self (e.g., as in depression) and others, with recent events being a window into them.

47 by reframing & relabeling sequential negative behaviors and linking them emotionally in a strength based way; This provides a hopeful way to reexamine their lives together in very concrete (behavioral) ways. We don t always understand which themes will work to provide this new perspective when we offer them, but it becomes apparent that family when members take on a new theme their tone changes in clear ways.

48 by reframing and relabeling more global aspects of their history and experiences, often referring to styles rather than specific behaviors, often hypothesizing unintentional mistakes and misperceptions, and using more relational than specific behavioral markers. and linking them emotionally in a strength based way; This provides a hopeful way to reexamine their lives together.

49

50 Issues of the Therapist Not understanding the family members Not understanding her/himself Not being able to avoid rescuing or taking sides and blaming / giving up on some family members

51 The Reframe/Theme fails to acknowledge the problem aspect of that which is to be reframed (thereby seeming to minimize / excuse the behavior) The Reframe/Theme seems to normalize or excuse the problem behavior rather than suggesting a noble but misguided intent He was really tired and that is natural when someone is that tired. The Reframe/Theme unintentionally demeans / implies that someone in the family is a problem He was just trying to let you know he wished you hadn t gone to work. [Implying the parent caused the problem by going to work; before the reframe is offered the therapist needed to assess how the parent feels e.g. in terms of guilt / defensiveness about parent having gone to work]

52 Issues of the Timing / Context of the Reframe Requires base of matching, relational and strength based focus, and pattern of nonblaming. Change follows a sequence Acknowledgement Change focus Change meaning Interrupting negativity is not enough Must also change blaming attributions and emotions

53 Heart and soul of FFT

54 GOALS: SKILLS: Conduct functional relational assessment Develop plans for Behavior Change and Generalization Perceptiveness Understanding relational processes and interpersonal functions of behavior Separating what is from what you hope it to be

55 FOCUS: ACTIVITIES: Intrafamilial and extrafamilial context and capacities (e.g., values, attributions, functions, interaction patterns, sources of resistance, resources, and limitations) Elicit and analyze information pertaining to relational processes Switch from an individual problem focus to a relational perspective Observation Inference about the functions of negative behaviors

56 E N G A G M E N T MOTIVATION Relational Assessment and Matching MOTIVATION BEHAVIOR CHANGE GENERALIZATION SESSIONS Pre Treatment Post Treatment

57 What makes FFT Unique? E N G A G M E N T MOTIVATION Relational Assessment & Matching MOTIVATION Pre Treatment Sessions

58 Family First Focus What are the typical relational patterns? Consistency and stability in the family and in dyads within the family? From the patterns we infer the relational functions of: Relational Connectedness Hierarchy

59 When one family member relates to another, what is the typical relational pattern (behavioral sequences, emotions, beliefs about each other within the relationship) that is characterized by the relative balance of: Closeness / Connection / Interdependency VS. Autonomy / Distance / Rigid Boundaries

60 Autonomy Contact Independence Separating Low levels of psychological intensity Fear of enmeshment? Closeness or connection Enmeshment High levels of psychological intensity Fear of abandonment?

61 Autonomy high 1 2 Autonomy Midpointing 3 4 Contact 5 low low Contact high

62 Relational functions are determined based on inferences derived from sequential patterns not intensity of feelings or what people consciously or unconsciously want. For example, two people may love each other a great deal, but rarely arrange their lives so as to spend very much time together. While they feel intense love, their behavior pattern is of autonomy. Conversely, two people may hate each other intensely, and spend much of their lives trying to find ways to ensure they never see each other again. While they may be consumed with each other in terms of thoughts, if their pattern is one of little or no contact then their function is mutual autonomy.

63 The overall pattern of direct interdependent behavior represents the degree of autonomy, midpointing, or connection.

64 The examples we use are often culture biased in that autonomy and connectedness are normed differently in different cultures, genders, and developmental stages. All these distinctions are made in comparison to other members of each particular culture /comparison group and each family

65 When family members relate to each other, the typical relative balance of overt relational control/influence based on differential resources, power, and role One Up One Down VS. Symmetry (Three primary patterns: Parent 1 up, Parent and Youth Symmetrical, Parent 1 down)

66 Symmetrical Parent 1 1 up Parent 1 1 down

67 Balance of influence in favor of parent Bad versions Parent demands respect, controls coercively but is inconsistent in following through. Youth complains about parent but still depends more on parent than parent does on youth Good version parent is a resource, provides structure and monitoring, youth asks rather than demands, parent justifies position, and youth accepts (even if grumbling).

68 Balance of influence is equal/reciprocal Bad versions Competition, comparing lists of injuries and/or contributions, knocking heads regarding behavioral issue Good version trading responsibilities, lots of negotiation rather than setting rules

69 Balance of influence in favor of youth Bad versions Youth dominates through maladaptive behaviors; Parent complains but can t influence youth to stop Good version youth is a trusted resource, provides positive structure, anticipates and responds without guidance from parent

70 Addressing mediators and referral problems

71 E N G A G M E N T MOTIVATION Relational Assessment and Matching MOTIVATION BEHAVIOR CHANGE GENERALIZATION SESSIONS Pre Treatment Post Treatment

72 GOALS: SKILLS: Facilitate individual and interactive/ relational change Reduce or remove referral behaviors Directive / teaching /structuring skills

73 FOCUS: ACTIVITIES: Individual skills Quality of relational skills Relational problem sequence Compliance with behavior change plans Setting up, leading, and reviewing insession tasks Modeling appropriate behaviors Coaching Assigning homework

74 Develop individualized change plans that match the family and which increase competence in adaptive positive behaviors Eliminate dysfunctional behaviors (drug abuse, delinquency, violence) by changing the processes that support them Change the problem and related behavior(s) by using the therapist directive skills that helps families improve their ability in: Parenting, Youth Compliance, Communication, Managing anxiety, urges, PTSD, etc.

75 Assessment at first is on family relational patterns and behavioral deficits, as well as strengths that can be augmented The new patterns must work for everyone and fit Relational Functions Before the first BC session, have a tentative plan with BC change targets which are informed by, but not exclusively driven by, referral / presenting problems Maintain the new climate of the family (more hopeful, less blaming/negative, more relational, with positively changed attributions about each other)

76 Preparation (Review everything you ve learned about changing behavior) Learning theory (reinforcement, extinction, etc.) Classical Conditioning (often the basis of emotional responses) and Operant Conditioning (overt behavior) Parenting Skills Negotiation / Problem Solving / Conflict Management Modeling Cognitive rehearsal Technical aids (relaxation training, recordings, handouts) Fit all techniques into the relational framework (especially Relational Functions) you already have developed

77 Behavior change technologies (interventions) and therapist persuasion based on alliance, hope, and positivity In sessions Planned using family issues already on the table Spontaneously through an in session incident Using coaching, directing, prompting, teaching, using technical aids As homework Specific task that is accomplishable Clearly presented/understood High expectation of success Model Directly/indirectly demonstrated by the therapist

78 Elements of Successful Communication 1. Source responsibility 2. Directness 3. Brevity 4. Concreteness and behavior specificity 5. Congruence 6. Presenting alternatives 7. Active listening 8. Impact statements

79 Negotiation Want Source Responsibility + Directness Brevity ( you ) ( I ) Assertion Behavioral Specificity/ alternatives Validation Active Listening ( you want ) Affect expression and regulation, validation, relationship building Feel Impact Statements Active Listening ( you feel )

80 Setting rules or expectations is linked to communication skills Replace Don t screw up again tonight with Be home by 5:00 and do not go to Jason s house Replace Clean your room with Put the books on the shelf, put the dirty laundry in the hamper, and at least straighten up your bed. I ll write down a list for you. Replace Get out of my face versus Please wait for a few minutes when I get home before telling what I did wrong, and please tell me only one thing at a time. Noncompliance with rules may be due to unclear rules instead of disregard of rules

81 During disciplining events (by parents) or attempts to change negative parent behaviors (by youth or another parent), brief and specific communication reduce likelihood of getting off track or backing away from plan Replace emotionally based responding with more planned and goals directed responding

82 Conflict management skills Problem solving and negotiation Emotional regulation skills Anger management skills Use of technical aids Contracting Contingency management (formal and informal) Response cost techniques Challenging pathogenic beliefs

83 I want to make some changes in my drinking/drug use What do you think the good things about this decision would be? What do you think the not so good things about this decision would be? I want things to stay just the way they are What do you think the good things about this decision would be? What do you think the not so good things about this decision would be?

84 TRIGGER THOUGHTS/ BEHAVIOR POSITIVE NEGATIVE FEELINGS OUTCOME OUTCOME What sets me up to use? What was I thinking? What did I do then? What good thing happened? What bad thing happened? What was I feeling?

85 Many people develop regular habits about when and where they use drugs and also when they don t use drugs. When are you least likely and most likely to use? Times you are LEAST likely to use: SITUATION/ACTIVITY DAY TIME 1. Treatment at CFAR Tues. 5:00 pm Times you are MOST likely to use: SITUATION/ACTIVITY DAY TIME

86 I might be tempted to use in these circumstances: Things I can do instead of using: a) 1b) 2a) 2b) 3a) 3b) 4a) 4b)

87

88 E N G A G M E N T MOTIVATION Relational Assessment and Matching MOTIVATION BEHAVIOR CHANGE GENERALIZATION SESSIONS Pre Treatment Post Treatment

89 GOALS: SKILLS: Maintain individual and family change Facilitate change in multiple systems Interpersonal and structuring skills Family case manager

90 FOCUS: Assessment of access and utilization of community resources Maintenance of change ACTIVITIES: Accessing appropriate formal and informal community resources Anticipate and plan for future extra stresses familial

91 Desired Outcomes Family stability and independence Family can respond adaptively to new (or relapsed) problems Family linked to positive community resources

92 1. Know the community Have current list of providers/agencies Know the transportation system Know the school system/contacts Know juvenile laws

93 2. Develop contacts have specific referral persons in agencies (schools, mental health agencies, boys/girls clubs) 3. Remember the ethics Confidentiality.Release of information Exceptions Reporting laws

94 1: Engaging Relevant Community Support Prosocial activities Monitoring/supervision Educational services (Always matched to the family) 2: Linking Additional Professional Services Individual Therapy Parent Education Anger management Vocational Training Access to Food and Housing Resources

95 Examples: Parenting classes Social programs/assistance Special school programs Developing vocational opportunities 12 Step programs Community based experiences for families

96 For information about training in FFT contact Holly DeMaranville OR Michael S. Robbins