Functional Family Therapy Clinical Supervision Training Manual

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2 Functional Family Therapy Clinical Supervision Training Manual Thomas L. Sexton, Ph.D. James F. Alexander, Ph.D. Lynn Gilman, M.S. This manual is for use with certified Functional Family Therapy Training. This manual was funded in part by a grant from the Annie E. Casey Foundation.

3 Copyright 2004 FFT LLC All rights reserved. No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.

4 Contents About the Writers...iv Acknowledgments...vi INTRODUCTION...1 SECTION I Evolution of the FFT Clinical Supervision Model...9 SECTION II FFT Clinical Supervision...22 SECTION III Implementing FFT Supervision...69 SECTION IV Conclusions & Afterthoughts...79 References...82

5 About the Authors Thomas L. Sexton, Ph.D., ABPP, is a Professor in the Department of Counseling and Educational Psychology at Indiana University where he is the Director of the Clinical Training Center, Director of the Center for Adolescent and Family Studies, and teaches in the APA accredited Counseling Psychology Program. Dr. Sexton has written in the areas of outcome research and its implications for clinical practice and training. His recent publications include major research articles in the Handbook of Psychotherapy and Behavior Change, the Comprehensive Handbook of Psychotherapy. He is the editor of the new Handbook of Family Therapy. He is also a national expert on family-based treatment interventions for at-risk adolescents and regularly presents workshops nationally and internationally. Along with Jim Alexander, he is the author of the most recent theoretical presentations and developments in Functional Family Therapy. He is one of two national Functional Family Therapy trainers, supervises the FFT externship program, and directs the national and international FFT implementation and dissemination projects. He is a licensed Psychologist, member of the American Psychological Association (APA), the American Counseling Association (ACA), an Approved Supervisor in the American Association of Marriage and Family Therapy (AAMFT), Vice President of Scientific Affairs for Division 43 (Family Psychology) of the American Psychological Association, and a Diplomate in Family Psychology (ABPP). James F. Alexander, Ph.D., is a professor at the University of Utah and a progenitor of Functional Family Therapy (FFT). He is past Director of Clinical Training at the University of Utah and has received numerous honors (Distinguished Contributions to Family Therapy Research, American Family Therapy Academy; Family Psychologist of the Year, Division 43 of the American Psychological Association; Good Housekeeping List of Top U. S. Mental Health Experts; Superior Teaching Award, University of Utah, College of Social & Behavioral Science; APA Division 43 Presidential Citation for Lifetime Contribution to Family Therapy Research; Scientist Exemplar award, American Association for Marriage & Family Therapy Research Conference; Superior Research Award, College of Social and Behavioral Science, University of Utah; Distinguished Alumnus California State University iv

6 Functional Family Therapy Clinical Supervision Training Manual Long Beach; Cumulative Contribution to Family Therapy Research Award, AAMFT). Dr. Alexander has provided over 350 national and international clinical training workshops and conference presentations, has received over 20 clinical research and training grants, almost 100 publications (chapters, books, journal articles) and is past President of Division 43 of the APA. In addition to developing the core elements of FFT, Dr. Alexander has assisted Dr. Thomas L. Sexton in developing the state-of-the-art FFT national dissemination protocol (FFT SDS: Service Delivery System). Lynn Gilman, M.S., is a doctoral student in Counseling Psychology and Assistant Director of the training center in the Department of Counseling and Educational Psychology. Her research interests include training and supervision, particularly the supervision of evidenced-based practice and the link between supervision and client outcome. She is a member of the American Psychological Association and the American Counseling Association. v

7 Acknowledgements The authors would like to thank the Annie E. Casey foundation for their generosity which made publication of this manual possible. We would also like to thank the thousands of families we ve worked with over the years who share their personal struggles with us week in and week out. It is our privilege to learn from them and continuously improve the delivery of our services to at-risk youth and their families. We are also indebted to the team of therapists, supervisors, and mental health facilities who provide Functional Family Therapy at sites across the country. Their dedication to faithfully delivering this model of therapy has contributed to a rich database of information that allows us to study our work with families and fine tune our training of future FFT therapists. Our thanks to Jan Sorby at Sorby Design for her help with the layout and graphics for this manual. The authors also wish to thank Lynn Gilman for her editorial assistance which made completion of this manual possible. Finally, we must thank our own families who provide love and support and tolerate the diversion of our attention to this important work. vi

8 Introduction INTRODUCTION

9 Introduction This manual represents the clinical supervision model of the FFT Service Delivery System (FFT-SDS). The FFT-SDS is a comprehensive service delivery system for use in helping at risk youth and their families. The system includes a well-developed evidence-based family intervention with a long history of clinical application (Functional Family Therapy), a comprehensive client assessment system, an integrated clinical supervision and quality assurance protocol, and a systematic training and dissemination program. The components of the FFT Service Delivery System provide therapists, agencies, and communities the tools necessary for providing a comprehensive treatment program for youth in mental health, juvenile justice, and child welfare systems. Other aspects of the system are detailed in the accompanying clinical, training, and dissemination manuals. This manual, which describes the clinical supervision model, is designed for FFT therapists who have completed Phase I of their clinical training and are moving into the role of clinical site supervisor (Phase II) for the FFT service delivery team at their agency. These therapists have completed phase I of the clinical training and carried cases throughout this training. FFT clinical supervisors are FFT therapists who, through the training process, demonstrated adherence to and competence in the clinical model. FFT clinical supervisors have knowledge of supervision as well as a strong foundation in the clinical application of FFT. For you, the FFT supervisor in training, this manual represents a platform upon which you can develop your competence as an FFT clinical supervisor. It also represents a statement of the responsibility 2

10 Functional Family Therapy Clinical Supervision Training Manual that comes with being a clinical supervisor: monitoring the quality of FFT services and systematically intervening to improve them so that the likelihood of successful outcomes with families improves. Becoming a competent FFT clinical supervisor is a developmental process which is accomplished by first going through the information presented in the manual, then undertaking formal FFT clinical supervision training, undergoing supervised practice, and receiving feedback by FFT trainers as part of phase II of your FFT Site Certification. A preliminary word of caution: like most if not all manuals this manual is not designed, nor should it be used, as a stand alone means to become an independent clinical supervisor of FFT therapists. In a sense, no manual can represent all the components of the successful and highly nuanced change process involved in clinical supervision, any more than a pilot s manual can train someone how to fly an airplane. FFT clinical supervision is a complex and demanding approach to helping build adherence and competence in therapists. Like FFT clinical training, supervision training is also a sophisticated and complex process, and none of us would ever want to shortchange the clients, or underestimate the clinical demands, by shortchanging the training and supervision processes. As you study the manual, please note that like FFT therapy, FFT supervision is demanding of the supervisor s energy and passion. Just as competent delivery of FFT involves training, commitment, and focus, competent supervision requires a focused investment of time, energy and commitment. However, the returns you will receive for this investment are great. As the clinical supervisor you will facilitate the delivery of a clinical model (FFT) that is low cost to deliver, yet produces outcomes that are positive and have a very high benefitto-cost ratio. Furthermore, the outcomes we see are long lasting, and will impact positively myriad others who will intersect with our clients lives for years to come. In designing the manual, we understand that some supervisors, like many therapists, operate from the heart, while others work more from a model or conceptual framework, and still others prefer to base their interventions on intuition or doing what it takes. Thus we understand that clinical supervision training involves a variety of perspectives and avenues for learning. However, as an introduction to FFT supervision, this manual will be primarily conceptual (vs. experiential). Understanding the principles, techniques, and 3

11 Introduction philosophy of FFT supervision is a necessary - necessary but not sufficient - condition for highly effective intervention. Becoming a competent FFT supervisor thus represents a process, not an event, and it involves multiple contexts for learning. This manual represents a first major step, and we ask that you read and interact with the manual in the same way that a potential pilot prepares to learn to fly; study the materials thoroughly, be clear about each major element presented in the manual, and determine (for later interaction with your FFT trainers) which elements you find enlightening, confusing, and/or inconsistent with what you understand about becoming an FFT supervisor. As noted, understanding is not a sufficient condition to becoming a competent FFT supervisor, but it is an essential first step, and helping you successfully negotiate this step is the primary goal of this manual. While the manual describes technique in detail, we must remember that techniques exist to serve the foundational goals of FFT; they are not ends in-and-of themselves. The manual also will discuss intervention concepts. These concepts are presented primarily to provide the guideposts that we follow to attain our goals, all of which center on providing highly effective treatment to diverse populations in need. Finally, we will discuss data and philosophy, but once again not as acontextual academic topics. Instead, data (accountability, quality improvement, and therapist development) and philosophy (strength based, respectful, alliance based, and stage-based-change model) underlie the focus and the passion that carries us through the tough times. They help us sort through the challenges and barriers we encounter when we help guide therapists as they deal with difficult youth and their families, and they help us create the joy and dignity that emerges when we share FFT successfully with troubled youth and families. In sum, as you read this manual we ask that you once again consider your motives for undertaking FFT. Adopting FFT and moving on to become an FFT clinical supervisor is not a means to join the mainstream of clinical interventionists. It is not an easy step and it will require the same dedication and focus on learning a new set of principles and practices that you experienced while learning the clinical model. Becoming an FFT clinical supervisor is a decision to adopt a new set of principles, which: 4

12 Functional Family Therapy Clinical Supervision Training Manual are rigorously and independently empirically studied and validated: the model and its principles work, and do so in diverse contexts with diverse populations stem from multicultural experience and a core belief in respect and working within the culture provide accountability; every session and every family is tracked in order to help therapists and supervisors provide the most responsive and effective intervention are alliance based with an emphasis on alliance with all family members demand creativity ( doing what it takes ) but in the context of carefully articulated structure and principles are delivered relentlessly: FFT therapists simply do not give up Finally, FFT as both a treatment program and a clinical model is family based in all aspects: should you choose to become an FFT clinical supervisor, we consider that you also join the FFT family. We enter into an ongoing partnership in which we together provide continuing feedback and quality improvement, for developing additional funding resources, and for demonstrating treatment effectiveness. With adherence and competent application you can join the team of FFT clinicians who provide effective service to the youth and families who are in such great need. Welcome to FFT Supervision, TLS JFA LG Organization: Using the Manual It will become obvious that this manual is much more than the usual compilation of written material. Instead, you will encounter text and you will encounter printed power-point slides that you will see again during subsequent training experiences. Also you will find references to additional information sources, and contact information. Finally, you will encounter sections of the manual that are more or less relevant for different readers. 5

13 Introduction The manual is organized in three sections. Section I describes the background and empirical foundations of the Functional Family Therapy Clinical Supervision Model. This section will help you understand the place of FFT and its principles within the landscape of clinical supervision approaches. Section II describes the core theoretical principles and specific clinical protocol used as the basis of doing FFT clinical supervision. This section is the nuts and bolts and it is only useful when built upon the core principles (of section I). Finally, Section III describes the implementation of FFT from its delivery within the room with a therapist to the integration of other services and the use of the FFT-Clinical Services System (FFT-CSS). The purpose of this supervision manual is to provide the Functional Family Therapy (FFT) site supervisor with foundational information and basic tools for leadership of an FFT clinical working group. Your new role as a site supervisor requires a shift from relying on your FFT implementation consultant to you becoming the clinical supervisor responsible for the quality assurance and improvement of your team. As such this manual is designed to help you accomplish several goals: Increase your knowledge of the history, development, current status and clinical concepts of FFT Learn the FFT clinical supervision model Gain an advanced understanding of FFT clinical principles to facilitate working group supervision interventions Begin to use the CSS as a clinical supervision tool Develop competence as an FFT site supervisor when used in conjunction with formal training sessions Learning FFT: Primary Objectives of Clinical Supervision Training As you begin your journey of learning FFT we will ask that you adopt three primary objectives: 1) Thinking through the FFT Lens. Successful FFT clinical supervision is built on the same theoretical and philosophical principles that are the foundation of FFT. Many factors contribute to successful supervision of therapists who are dealing with complex and sometimes desperate family situations. Learning to deal with such situations successfully using FFT is about 6

14 Functional Family Therapy Clinical Supervision Training Manual learning how to develop the FFT clinical lens. Learning to guide and supervise therapists using the FFT clinical supervision model similarly requires you to think and work through the same lens. Therapists, like families, are unique at many levels, creating the same challenge for us as supervisors as families do for therapists. That is, we cannot adopt a cookie cutter or one size fits all approach to supervision. At the same time, extensive clinical and research evidence tells us that supervision, just like intervention, must be orderly and follow certain principles and developmental sequences. The FFT lens provides a structure within which we can understand, and develop moment-by-moment clinical strategies to manage the complexities that emerge when an individual family, with its unique qualities, works with a therapist (similarly unique) in a treatment context (which may also be unique). By using a common lens that appreciates and respects the complexities of these individual Figure 1 Personal History Clinical Experience Cultural background Age Cultural Context Gender Unique features/strengths of the Therapist Model focused Objective of Supervision Translated through the.. FFT Lens Guiding principles Clinical model (phases) Thinking through the lens while retaining the unique strengths and characteristics of the therapist Supervision decisions (what you choose to do at each moment) 7

15 Introduction differences, yet examines them in the context of a common framework, FFT supervision can be open and responsive to the range of therapist qualities. This is the same lens you will need to adopt in thinking about cases your therapists work with and as a foundation from which to monitor and intervene to improve the FFT services delivered by your therapists. 2) Openness to learning and commitment to learning a new way of working Like most FFT therapists, most clinical supervisors come to this phase of their training with an experiential history. Each of you has been supervised in a variety of ways. For some, this history provides the foundation for how supervision should happen, for others it is the basis for knowing what not to do. FFT supervision is different than most traditional forms and models used to help clinicians gain competence in family therapy (see section I). To benefit from and enjoy the process of becoming a competent FFT clinical supervisor requires openness to thinking differently about a number of central elements about the supervision process, the therapists you are supervising, the goals of your work, and the information you rely on to accomplish your tasks. To successfully learn requires openness to including the strengths of the therapists and their unique style and the model. For many, at first it feels uncomfortable not relying on your tried and true methods of thinking and acting. However, the good news is that there is a system provided to support your learning (the FFT-SDS: Functional Family Therapy Service Delivery System), and over time the new FFT supervision patterns become automatic and very rewarding. Your contribution to this process is your willingness to be open and honest about who you are, and about your commitment to adopting a new way of practice in a way that works for who you are. Because the FFT model may be new to you does not mean you have to relearn all there is to know about conceptual and clinical supervision. Instead, it means that you have to build upon what you know and create a new and integrated way of working through the FFT Lens. 8

16 Evolution of the FFT Clinical Supervision Model SECTION I

17 1 Evolution of the FFT Clinical Supervision Model FFT is a family-based clinical intervention model that has existed for over 30 years. The model is one that is represented by a core of enduring principles but at the same time a model that is evolving, dynamic, and contemporary. FFT supervision is a relatively new approach that has emerged from a need to help build competence and adherence and ensure model fidelity in the many community agencies engaged in delivering FFT. Both the clinical model and the supervision model continue to be open to new ideas, new research, and new (often underserved) populations in need. In the next section we would like to briefly remind you of the major foundational elements of FFT as a way of helping you understand the need for a unique supervision model. Functional Family Therapy: The Basis of Clinical Supervision FFT cannot adequately be described by any single theoretical label (e.g. behavioral, multisystemic, interpersonal). Instead, FFT is a systematic clinical model that evolved along a path best described as a dynamic process of model integration (Alexander, Sexton, Robbins, 2002). Functional Family Therapy (FFT) is a true family based approach that focuses on the multiple domains of client experience (cognition, emotion, and behavior) across the multiple perspectives within a family system (individual, family, and contextual/multisystemic). In order to understand and intervene successfully across these domains FFT has remained grounded in a relational context. This has allowed FFT to embrace the inherent dialectic 10

18 Functional Family Therapy Clinical Supervision Training Manual tension in family therapy, that is the tension between clinical practice, foundational theory (systems, developmental psychopathology, epidemiology, the sociology of culture, etc.), and rigorous science. FFT has adopted both a client focus based in sound clinical experience (ideographic) while at the same time attending to the common research and theory and change mechanisms (nomothetic) underlying a range of good therapeutic intervention. FFT is unique among family therapy models. It integrates theory and practice while providing specific direction to the processes that go on between therapist and client. In some ways the model is seemingly contradictory. It is more than a paint by the numbers manual or a curriculum based intervention model. Instead, it is a set of integrated theoretical principles and a specific clinical map that is applied by an individual therapist who has unique strengths that they bring to the model in a way that retains its essence while making it uniquely their own. FFT is not about the personality of the model developers, it is not about following a guru, it is not about style, and it is not about blindly following a manual. Instead it is about a therapist with unique and different strengths using clinical skills to accomplish model specific goals and objectives. FFT is not a series or compilation of intervention techniques. Instead FFT is a systematic, theoretically based, clinical model with specific clinical and theoretical principles and a systematic clinical protocol ( map ) that guides therapeutic case and session planning. Since its inception in 1969, FFT has held to the principle of integration of three branches or foundations as essential for a complete, mature, and enduringly effective intervention. The integration of these branches has resulted in the most recent articulations of the FFT model (Alexander & Sexton, 2002; Sexton & Alexander, 2002; Sexton & Alexander, 2003). These three branches of development lay the groundwork for the development of the FFT supervision model. 1. Clinical experience in meeting important clinical needs. FFT grew out of a need to serve a population of at-risk adolescents and families, and we attended to this underserved population in a way that focused on understanding why they presented so many clinical challenges, and why traditional and even mainstream interventions had so little success in helping them. To address this problem with high risk youth and families the early contributors to FFT set out to develop a new set of philosophies and techniques 11

19 Evolution of the FFT Clinial Supervision Model that would lower client resistance, provide the type of interventions that would motivate them, reduce their negativity, and give them hope. FFT has been based on the premise that our job is to take responsibility for motivating families and accept families on their own terms rather than apply a treatment goal which was based on someone else s version of what a family should be, what a culture should be, what a particular spiritual belief or sexual orientation or economic system should be. Early clinical experience showed that it was helpful to provide a plan, or roadmap, for change that matched who the families were, and to provide the tools necessary to navigate the challenges and roadblocks the families faced in the change process. Clinical experience also suggested that long-term change needed to focus not only on stopping the maladaptive behavior, but also on developing the unique strengths of the family in a culturally sensitive way, and enhancing their ability to make future changes. Finally, with this population it became clear that incorporating community resources to help support changes made by the family is essential. The FFT Clinical Supervision model has also grown out of our experience in training and supervising therapists learning FFT over a number of years. In helping therapists learn about FFT we discovered that we focused on different outcomes than traditional supervision and that supervision was for us a relational process that took place over different phases of specific activity. Our supervisory experience suggested that we, as clinical supervisors, needed to help engage and motivate therapists to try something new, to adopt different methods of clinical activity, and to experience supervision as focused, directional and purposeful. 2. The second foundation of FFT is integrated theory (multidisciplinary) and systematic scholarship. The emphasis on understanding, defining, describing, and researching the process of intervention began early in the FFT evolution. This emphasis emerged because it became clear that theoretical development was necessary if traditionally difficult to treat populations were to be well served. With respect to dysfunctional youth at least, clinical interventions of the time provided no vehicle for understanding the relational elements of family functioning or clinical change, clinical accountability, model replication, or understanding the change process. In that early context it was critical that FFT develop a clinical 12

20 Functional Family Therapy Clinical Supervision Training Manual model that could guide practice. Early comprehensive articulations of FFT (Alexander & Parsons, 1982; Barton and Alexander, 1981) relied heavily on the work of early communication theorists (e.g., Watzlawick, Beavin, & Jackson, 1967) and incorporated the notion that behavior serves to define and create interpersonal relationships and that behavior has meaning only in its relational context. At this time the model also relied on the use of specific behavioral technologies such as communication training (Parsons & Alexander, 1973). As the model evolved, cognitive theory, particularly attribution and information processing theories helped explain some of the mechanisms of meaning and emotion often manifested as blaming and negativity in family interactional patterns (Jones & Nisbett, 1972; Kelly, 1973; Taylor & Fiske, 1978). More recently, social constructionist ideas have informed FFT (Sexton & Alexander, 2003) through a focus on meaning and its role in the constructed nature of problems, in interrupting family negativity, and in organizing therapeutic themes (Gergen, 1995; Friedlander & Heatherington, 1998). FFT is now more than an intervention model, it is a comprehensive service delivery system that incorporates four important domains that contribute to its demonstrated success. These four domains stem from a set of theoretical principles to become a comprehensive intervention program including: (1) a clinical core consisting of an integrated set of guiding theoretical principles, a systematic therapeutic program that relies upon phasically based change mechanisms, (2) a well-developed multi-domain clinical assessment and set of intervention techniques, (3) an ongoing research program, and finally (4) systematic training, supervision, and implementation protocols. These components guide therapists in their delivery of FFT. In addition, these components are the anchor that helps ground the therapist in FFT theoretically and practically (Alexander & Sexton, 2002; Sexton & Alexander, 2002; Sexton & Alexander, 2003) The FFT supervision model is based on a foundation of the extensive theory and scholarship of the FFT intervention model. For example, FFT supervision is based on the same guiding theoretical principles as the clinical model. The goals of FFT supervision are clear: adherence to and competent delivery of the FFT clinical model. Thus, the clinical model serves as a standard for assessing the supervisee s status, progress, and the future goals 13

21 Evolution of the FFT Clinial Supervision Model of supervision. When a case is presented in a supervision encounter the FFT model represents how the therapist thinks about the case (the family, the problems they experience), how the therapist understands the change process, and the methods they are using to achieve therapeutic change. FFT-based supervision uses the clinical model (e.g. its theoretical principles, its prescribed phases, therapeutic goals, and therapist behaviors) as the primary yardstick for assessing a therapist. Similarly, the clinical model becomes the basis for determining both the short term and long term goals of supervision. The supervision model is also process and phasically organized around a relational process that focuses on both individual therapists and working groups of therapists using the FFT model. The relational aspect of supervision is the pathway or vehicle to building successful FFT therapists. 3. Finally, FFT is founded on empirical evidence produced by process and outcome studies. FFT has always been informed by the findings of scientific inquiry. The early clinical trial studies (Alexander & Parsons, 1973; Klein, Alexander & Parsons, 1977) focused on questions of efficacy, with pragmatic outcome measures that had both clinical and social relevance (recidivism). These early studies established FFT as an effective approach with a variety of offending adolescents. Process studies attempted to identify the mechanisms by which FFT was successful by indicating, for example, that family negativity significantly impacted engagement and motivation (Alexander et al., 1976) and that the gender of the therapist was differentially related to both the rate and quantity of speech by family members (Mas, Alexander, & Barton, 1985, Mas, Alexander, Turner, 1991, Newberry et al., 1991). These early process studies raised additional questions answered by a second wave of clinical trials focusing on the effectiveness of FFT in different settings with different populations (Barton, Alexander, Waldron, Turner, and Warburton, 1985; Lanz, 1982; Gordon, Arbuthnot, Gustafson, & McGreen, 1988; 1995; Hansson, 1998; Sexton et al., 2000). More recent studies have focused on specific clinical techniques (e.g., Robbins, Alexander, & Turner, 2000), the role of balanced alliance in program retention (Robbins et al., 2003), and therapist model adherence as a primary mediating variable in successful outcomes (Sexton, 2002). The outcome of these studies suggested that FFT is applicable across an even wider client population over diverse settings, with 14

22 Functional Family Therapy Clinical Supervision Training Manual real therapists in local communities. In recent years FFT emerged as a Best Practices because of its integrative and systematic nature along with its repeated demonstrations of successful outcomes with at-risk adolescents and their families which has led to widespread community-based application in many settings with a wide range of clients. There are two reasons that FFT has emerged on the radar of local community providers. These may be many of the reasons that your agency has decided to adopt FFT. First, is a push for accountability by funders, care providers and communities. The second is the increase in the quality and quantity of relevant research to guide practice. There is much more research on aspects of the change process that can impact practice. It is no longer the case that one research finding will contradict another. Now there are clear trends that are well documented in many areas. The extensive process and outcome studies also inform the clinical supervision model of FFT. The knowledge gained about engagement, motivation and the role of gender are at the foundation of the early phases of our supervision model. The importance of alliance is well represented as a key aspect of the supervision process described below. The critical need for therapist model adherence as a primary factor in successful outcome is at the center of the constructs of model adherence and competence, which serve as the centerpiece of FFT supervision. The Evolution of FFT-based Clinical Supervision The initial roots of the FFT supervision model grew from the practice environment and our experience in training and supervising therapists in FFT and from, as noted above, the threads of clinical/supervision experience, research, and extensive dissemination of FFT across the nation. As the FFT clinical model developed and was disseminated to community practice sites it became clear that traditional models of clinical supervision did not provide the necessary framework, specific relational principles, phase based change orientation, and primary focus on model fidelity needed to successfully deliver FFT. We knew that successful implementation of FFT depended upon finding a systematic way of teaching and guiding therapists to replicate FFT. In community settings our needs were quite specific. They required that we develop a process by 15

23 Evolution of the FFT Clinial Supervision Model which the FFT clinical supervisor could help teach and guide therapists, enhancing their ability to replicate FFT as it was intended to be delivered. This process would ensure that the outcomes demonstrated in clinical trial studies could be replicated at local practice sites. Our experience suggested that supervision encompassed more than a focus on therapist development and the provision of a supportive environment. It includes also a teaching component and an emphasis on the interdependent relationship between adherence to the model and development of competence in using the model to treat families within a multisystemic context which includes the therapist, the treatment setting, and the working group of the FFT team. From these experiences we realized a need to identify model specific ways to guide therapists to make the model the primary focus of their clinical decision-making while focusing on adherence to and competence in delivery of the FFT model. The FFT supervision model represents a dramatic change and a new way of thinking about clinical supervision. Rather than a focus on the broad development of the therapist the focus is on delivering a specific clinical model with adherence and competence. Thus, the FFT supervision model grew out of a need for a guiding framework that is clearly articulated and addresses the needs of evidence-based practice. This shift also makes model specific clinical supervision that focuses on the issues of model fidelity, adherence and competent adherence critical. Thus the goal of model specific clinical supervision is replication of a clearly articulated clinical model (FFT). As the site supervisor you are attending to not only the phases, goals, and associated skills of the clinical model but also the phases of the supervision process which will be described in detail in the next section of this manual. Your skills at managing multiple perspectives as an FFT therapist will help prepare you for your new role as a supervision process expert complete with a practice map to overlay on the clinical model. FFT supervision is not a Traditional Supervision Model The larger field of clinical supervision has also evolved over time in terms of the goals, interventions and specificity of the models used in practice. Two major streams of thought and discourse have influenced the development of models of supervision: (1) individual 16

24 Functional Family Therapy Clinical Supervision Training Manual Figure 2 Personal History Gender Research Cultural background Strengths of the Therapist Theory Clinical Experience Model as lens Clinical decision making & intervention (what you choose to do at each moment) Focus now on modelfidelity model adherence model competence implementation therapy and (2) family therapy, each of which contributes to the knowledge base and to the approaches that supervisors use today. Two major challenges in the field have been to distinguish between the overlapping domains of training and supervision and to merge the valuable knowledge that exists within the individual and family therapy literature (Liddle, Becker, & Diamond, 1997). In this brief section we review some of the background of clinical supervision to help you understand that FFT supervision is not traditional clinical supervision but instead a natural evolution of the entire field s thinking about how to help therapists work better with families. This broad context is important to understand as you begin your process of adopting the FFT supervisory lens and think in the domain of the FFT supervisory reality. The supervision and training of family therapy in particular has evolved through several periods emphasizing different issues over the last 30 years. It is now a clinical specialization area as indicated by professional organization designations such as the development of the AAMFT standards for qualifying supervisors. Historical 17

25 Evolution of the FFT Clinial Supervision Model developments in family therapy supervision can be broken down into three major eras: (1) late 1960s to 1970s, (2) 1980s to 1990, and (3) 1990s to present. In the late 60s and through the 70s several influential works were published that charted the direction of thinking in the field. One such work by Cleghorn and Levin (1973) outlined three family therapy skills essential to trainee development: (a) perceptual skills which are the ability to accurately describe the behavioral data of the therapy session, (b) conceptual skills involve the ability to take clinical observations and translate them into meaningful language, and (c) intervention skills that guide in-session therapist behaviors to modify family interactional patterns (Anderson, Rigazio-DiGillio, & Kunkler, 1995). Two other important contributions of the 70s era written by Montalvo (1973) and Haley (1976) changed family therapy supervision by introducing the notion of live supervision to provide immediate feedback to trainees and change the course of a family session as it occurred and by introducing new trainee dimensions to consider. Haley s work articulated four dimensions of training: spontaneous versus planned change, personal growth of the trainee versus theoretical orientation, insight versus action as a cause for change, and self-report of the therapist s work to the supervisor. These works helped organize the thinking about training and supervision across the various models of family therapy. In the late 1970s and through the 1980s, several reviews of the family therapy training literature suggested the need for a more coherent theory of supervision and training. Furthermore, a call for empirical evaluation of the effectiveness of family therapy training was put forth to provide evidence regarding training and supervision processes. Finally, according to these writings the development of supervisors should receive more attention (Anderson, et al, 1995; Liddle, et al, 1997). The most notable concept in family therapy training and supervision literature during the period from the 1980s to the 1990s is the concept of isomorphism. During this time it became clear that therapy models themselves inform the content, process, and methods of training and supervision for that model. This link suggests that the theory of therapy or the thinking about how change occurs acts as a guiding principle for training and supervision as well. For example, since many family therapy models (FFT included) emphasize interactional processes rather than 18

26 Functional Family Therapy Clinical Supervision Training Manual individual dynamics, the nature of supervision reflects that emphasis through the use of group and live supervision methods. Family therapy supervision research and theorizing from the 1990s to date has seen an increase in the systematic articulation of supervision and training specific to many of the major models of family therapy. In addition the influence of integrative models on therapy has extended to an integrative perspective for supervision whereby supervision takes into consideration such ideas as world views, developmental concepts, and issues of gender and cultural diversity (Anderson, et al, 1995). Different approaches to supervision have been categorized based on how directly involved the supervisor is with the raw data of the therapeutic session. At one end of the spectrum is live supervision from behind the mirror which directly involves the supervisor in the session. At the other end of the spectrum is the least direct involvement by the supervisor where case presentations by the therapist to the supervisor provide the data for supervisory intervention. In the middle of the spectrum is the very common training tool of using audio or videotape to bring the clinical data into the supervision session. These different approaches are used in varying degrees for training and supervision purposes. Within the FFT model therapists are trained through a combination of traditional instruction, group supervision including tape review, and live supervision during the externship experience. Supervisor training follows a similar trajectory. Another more recent influence on models of supervision and training emerges from outside the family therapy arena (individual therapy and counselor education) and includes the developmental perspective. In this perspective, supervision models are classified into four types: (1) stage models of trainee development, (2) stage models of supervisor development, (3) process models, and (4) family life cycle models. In the stage models of trainee development basic premises include continuous development of the trainee over time that occurs in stages, a trainee s movement over time from using simple therapeutic constructs to more complex thinking, a move from being dependent on the supervisor to greater autonomy, and the importance of the supervisor-supervisee relationship (Stoltenberg, McNeill, & Crethar, 1994). In the stage model of supervisor development (Hess, 1986) growth of the supervisor takes place by moving through three stages. Stage one finds the supervisor experiencing anxiety over his or her new role with a tendency to 19

27 Evolution of the FFT Clinial Supervision Model focus on client issues rather than supervisory issues. In stage two supervisors become more comfortable examining the supervisorsupervisee relationship as the supervisor begins to gain comfort in the new role. Finally in stage three the supervisor fulfills his or her role as a facilitator of supervisee development. Process models of supervision draw from the work of Piaget, (1968) which focuses on accommodation and assimilation as important learning constructs. These models recognize the level of cognitive development of the trainee along with his or her individual learning style and method of processing information and then attempt to match the teaching to the individual characteristics of the learner. Family life cycle concepts have also been applied to trainee development although less frequently than the other developmental influences. Influences on family therapy supervision beyond the developmental perspective also emerge from the history of individual psychotherapy supervision. The first method of psychotherapy supervision was in the psychoanalytic tradition whereby a student analyst participated in analysis with the supervising analyst. The presumption was that the supervisee learned by gaining self-awareness and by modeling the supervising analyst s methods. Carl Rogers person-centered approach introduced direct observation methods and a more scientifically rigorous methodology for studying the therapy relationship. Truax and Carkhuff (1967) then identified the communication strategies used in Rogers work and training programs were established to teach specific skills. This evolved into the micro-skills training approach which emphasized an instructional approach versus the case-method approach of supervision. Individual models of supervision continued to emerge that were analogous to the accompanying theory of counseling. The criticism of this approach is that the goals, process, and interventions of supervision are actually quite different from an individual counseling session. Therefore, more comprehensive models of supervision became necessary to address the teaching and learning processes inherent in the supervisory relationship, which heralded the emergence of developmental and social role models of supervision. Traditional models of supervision, whether from the family or individual therapy literature, often emphasize therapist development and tend to be case-focused with varying levels of specificity to 20

28 Functional Family Therapy Clinical Supervision Training Manual a particular clinical model. The emergence of empirically supported treatment models demands a richer, more comprehensive, contextually driven form of supervision. Furthermore, many traditional models of supervision rely on a one to one relationship between the supervisor and the supervisee. This manual addresses these concerns by providing a comprehensive model of supervision that is consistent with the guiding principles of the FFT clinical model, which has a proven track record of effectiveness in treating at-risk youth and their families. 21

29 FFT Clinical Supervision SECTION II

30 2 FFT Clinical Supervision In the next section we present the core principles and the phases of the Clinical Supervision model of Functional Family Therapy. It is important to remember that the principles in this section are intended to, along with face to face interactive instruction, prepare you to begin working as an FFT clinical supervisior. In the sections below we focus on your new role, and review the theoretical principles and specific clinical supervision protocol of FFT. Much like the clinical model, the FFT supervision model is constantly evolving and informed by theory, practice, assessment, and research. It is also guided by a core set of principles and relies on trained, competent therapists to replicate the clinical model in practice in a variety of service delivery contexts. Site supervisors act as advocates for the core principles of the FFT model within these varied contexts, which are comprised of therapists, agencies, referral sources, and existing administrative systems. While traditional models of supervision emphasize therapist development and are often case-focused with little specificity to a particular clinical model, the emergence of empirically supported treatment models demands a richer, more comprehensive, contextually driven form of supervision. Furthermore, many traditional models of supervision rely on a one on one relationship between the supervisor and the supervisee. The FFT Supervision model is a response to the demand for model-specific principles of supervision in a way that is consistent with the FFT philosophy of training and implementation. This includes conducting supervision within the context of a relationally focused working group and developing a practice map for supervision. 23

31 Functional Family Therapy Clinical Supervision Training Manual Role of the FFT Site Supervisor As FFT clinical site supervisor you are responsible for the quality of the FFT services delivered at your agency or in your working group. In each of these capacities, the supervisor bases their work on the core principles of the clinical model while operating within the clinical supervision protocol. In your new role of site clinical supervisor you will take on many of the responsibilities the implementation consultant has had during the first year of training at your site. As you step into this new role you are now responsible for: 1. Monitoring model fidelity and quality of the service delivery (quality assurance) in clinical practice of FFT at your community agency and site. 2. Promoting adherence and competence of the therapist (quality improvement) by guiding the FFT therapists in your working group to consistently think through the FFT lens and to make clinical decisions based on FFT principles 3. Managing service delivery context so that it promotes the model and allows for delivery of FFT in a way that the families receive the benefit of high quality services. FFT clinical supervision accomplishes the goals through two basic activities. The first, quality assurance, is a monitoring process. As a quality assurance monitor your job is to constantly watch the adherence and competence of individual therapists in your working group. You will do this in both formal ways through systematic rating mechanisms and informal means through observation in case staffing. Your monitoring responsibility also extends to your agency and requires that you watch that the organizational context (both administrative and structural) consistently support the successful delivery of FFT. This you will do by participating in discussion and decisions about agency support and service delivery systems in which FFT is situated within your site. The information you gather by systematically monitoring therapist and agency model fidelity is the basis of your clinical supervision work. Your second major responsibility is that of quality improvement. Quality improvement is the goal of clinical supervision: improving the ability of the therapist and the site to deliver FFT as it was designed (model adherence) and in ways that successfully meet the needs of individual families (model competence). To improve the 24

32 FFT Clinical Supervision quality of FFT you will use the phases of the FFT supervision model to guide you. Your ultimate goal is high adherence to the model (replicating it at the community site) with high quality. Quality improvement is the result of systematic supervision interventions that take place within a complex relational process between you, individual therapists, and the working group you supervise. YOUR CHANGING ROLE Before we begin on the specifics of the supervision process, we think it is important for you to consider the role change that might occur in your group. You have been a team member-an equal colleague of your other FFT therapists. Your new role will require that you have a different position within the working group, that you focus on different aspects of the cases presented and the service delivered, and that you interact with the administrative context of the FFT team in a new way. This new role carries with it much responsibility. Your new role also means a change from colleague to the quality assurance and improvement leader. This change can bring on many challenges. Most of the challenges are relational ones between you and the team and you and the organizational context of the FFT team. In your new role you are still a team member, but now you have added responsibilities-you have a new set of objectives and goals for your work in the group. Thus, you must establish yourself in this role. Take some time to think about the impact of this change on your existing relationship within the team. This complex set of relationships can be successfully managed. Remember, like FFT therapy, FFT supervision is alliance based. As such, your work with the team needs to remain one based on an experience of working together to accomplish the same goals and objectives. In this way FFT supervision requires two experts to be successful: you as the expert in the supervision process and the therapist as the expert in the case and in their own style. Successful FFT supervisors are able to establish an equal yet different type of relationship based on alliance. Remember, alliance is built when you and the therapist work toward the same goal, agree on the methods to get there, and have a relational bond of support. As you will see in the sections below, building alliance is one of your first objectives as an FFT site clinical supervisor. 25

33 Functional Family Therapy Clinical Supervision Training Manual Core Elements of the FFT Supervision Model The FFT supervision model is built on a set of core theoretical principles and a specific supervision intervention protocol. 1. Core theoretical principles of the supervision model form the foundational basis for the specific activities of the FFT clinical supervisor. The principles are the important background for the more immediate foreground which consists of the specific activities and supervision interventions. However, it is critical that these principles be well understood and remain at the core of all supervision interventions. 2. Supervision Protocol is the systematic phases that the supervision process follows. Each of these phases has specific goals that the supervisor attempts to accomplish. Within each phase particular supervision interventions increase the likelihood of successfully achieving the phase goals. In addition, the FFT clinical protocol model also depicts the systemic and relational nature of supervision. Supervision takes place over time and supervision evolves as a dynamic process. Core Theoretical Principles Like the FFT clinical model, the supervision model is based upon a set of core theoretical and philosophical principles. These principles are the basis for the specific activities of the FFT supervisor. FFT supervision is model focused. The FFT clinical model (its central core principles and clinical protocol) is the primary basis for quality assurance and quality improvement. The clinical model is, therefore, the yard stick by which the therapist is assessed and the outcome goal to which supervision interventions are directed. As an FFT supervisor you supervise to the model; your goal is to promote model specific therapist behaviors in response to the evolving context of the change process between the therapist and the family. Because it is model focused, supervision is based on attention to: - Adherence to the proscribed goals and intervention strategies of the model in addition to the guiding theoretical principles - Competence in the delivery of these goals and strategies 26

34 FFT Clinical Supervision FFT supervision is a relational process between a supervisor, individual therapists, and a working group of therapists. The relational process is reflected in the phasic nature of the supervision model. The foundations of the relational process are: - Respect for the individual and unique differences, strengths, and characteristics of each therapist - Alliance based model of working together that involves therapist and supervisor working in their unique domains to the same end-successful implementation of the FFT model with families and youth. Supervision is multisystemic and requires attention and action in multiple domains: the therapists, the service delivery system, and the working group. The supervision process is a phasic and relational one that unfolds over time. Each phase involves specific interventions that are organized in a coherent manner - Each phase has a set of goals; related change mechanisms that help accomplish those goals, and supervisor interventions most likely to activate those change mechanisms. Supervision is data-based or evidence based. Specific supervision interventions and goals are based on specific monitoring of service delivery patterns of the therapist with specific measures of therapist activities within each phase of FFT (adherence and competence). Monitoring, goal-setting, and ultimately intervening are based on data from multiple perspectives. Throughout the phases of the supervision process there is constant assessment of adherence and competence and the developmental status of the working group. Monitoring, decision-making, and intervening are facilitated by evidence from multiple data sources including: - Data from therapist (self-report) - Data from the CSS (objective) Service delivery profiles Outcomes Adherence measures - Data from your direct observations, particularly during weekly staffings - The supervisor uses data-based information and intervenes systematically to build adherence and competence through case planning, session planning, and case consultation. 27

35 Functional Family Therapy Clinical Supervision Training Manual - Supervision is both individual (e.g. directed at individual therapists) and group focused (e.g. directed at working groups). Thus, it is important for the FFT supervisor to attend to the unique aspects of individuals and the dynamics of the working group. Central concepts of FFT supervision: Adherence and Competence FFT supervision is anchored by two essential constructs: therapist model adherence and competence. A working definition of adherence, competence, and group maturity are important first steps in becoming an FFT supervisor because supervision involves constant monitoring (quality assurance) of both model adherence and competence and systematic intervention aimed at continuously improving supervision goals and interventions (quality improvement). In this section we describe these central concepts. In the next section we integrate these concepts into the relational model of FFT clinical supervision. MODEL ADHERENCE AND COMPETENCE: THE PRIMARY GOALS OF CLINICAL SUPERVISION The role of therapist adherence and competence cannot be overstated. If families are to be helped, FFT must be delivered in the way it was designed to be delivered (adherence), and it must be delivered well, or with a high degree of skill (competence). In fact, if not delivered with adherence and competence, as prescribed by the model described here, it is not really FFT. Adherence to the FFT clinical model and competence in delivering the model are the primary outcome goals of FFT supervision. Adherence, or reproducing the basic clinical and technical elements of the FFT model, is necessary. Without the basic model elements, the work being done does not represent the intervention program, and the potentially positive outcomes, as it was developed. However, basic adherence is not sufficient. Competence, or the quality with which the basic elements of the model are delivered, is also necessary if the therapist is to successfully match the FFT clinical model to the unique, complex, and multisystemic nature of the families they treat. Basic model adherence is a prerequisite to competent application of FFT. In the end, both adherence and competence are necessary however, neither alone is sufficient. 28

36 FFT Clinical Supervision Adherence and competence are interdependent constructs and in reality they both are present as a therapist works successfully with a family and has good outcomes. However, as a clinical supervisor it is important to view these constructs as somewhat independent so that you can assess their levels in order to systematically intervene to improve the quality of FFT. In the discussion below we pull apart these highly interrelated constructs. Later we will bring them back together into an integrated notion that will guide the process of clinical supervision. Adherence and competence are anchored in the FFT clinical model. In fact it is the clinical model that is the primary yard stick for assessing each. There are two important dimension of each: 1. Each dimension has both knowledge and performance components. Clinical knowledge (for either adherence or competence) is an intellectual and working understanding of the core principles and clinical protocol of the FFT clinical model. Performance is the ability to turn that knowledge into practice in a family therapy session. Figure 3 Working Group maturity Context Therapist Competence Knowledge Performance Therapist Adherence 29

37 Functional Family Therapy Clinical Supervision Training Manual Figure 4 2. Both concepts can be viewed as global therapist characteristics (ability over the entire model) and more specifically in regard to specific adherence and competence issues in the specific phase of treatment in which the therapist is working with a specific client. THE IMPORTANCE OF ADHERENCE AND COMPETENCE: THE SCIENTIFIC EVIDENCE The importance of adherence and competence in any specific therapeutic model is intuitive: if you replicate a model that has consistently produced evidence of positive outcomes, your outcomes should also be positive. Current research evidence confirms these intuitive notions. In a recent study (Sexton, et al, 2002), FFT was delivered in a state-wide service delivery system by therapists trained using the same training protocol you and your team received. Those therapists who delivered FFT with high adherence (as rated by their supervisor on a weekly basis) had outcomes (as measured by recidivism one year after intervention, which also represented one year after the adherence ratings were made) that were significantly better than a randomized control group. Those therapists who delivered Therapist Competency Ratings 12 Month Felony Recidivism 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 29% 25% 22% 17% 14% Not competent Marginal Competent Highly Competent Control Group Recidivism Rate 30

38 FFT Clinical Supervision FFT in a manner that was rated as low adherence had outcomes that were worse than traditional services, and of course significantly worse than adherent FFT therapists. For these therapists FFT was delivered in a way such that the families might have been better not receiving family therapy at all. It is important to note that the outcomes measured here were clinically significant ones, measures of arrest 18 months following FFT. These findings suggest that attending to the issues of adherence and competence in FFT service delivery is a critical and central feature of clinical supervision. FFT is not a model from which a therapists can pick and choose various intervention techniques to be applied in a manner that seems correct to them. Instead, FFT is, as noted throughout this manual, an integrated treatment delivery system that must be implemented by the therapist in its entirety, based on its core theoretical principles, in the phasic way outlined. If not delivered in this manner, it is not FFT and the probability of successful outcome goes down. Delivering FFT with adherence and competence is difficult given the complexity of the families and the complex nature of the delivery systems in which you work. It is clinical supervision that is the primary vehicle to developing and maintaining adherence and competence. Model Adherence Therapist adherence is the core building block of successful Functional Family Therapy. Therapist model adherence requires that the therapist understand and perform the basic clinical processes, use the technical elements of the model (assessment protocol, CSS, staffing participation) and deliver FFT services with in the service delivery parameters that support successful FFT. As noted above, model adherence has both knowledge and performance domains. 1. The knowledge domain is the core of model adherence. Without a clear understanding and a working knowledge of the core FFT principles and without an understanding of the clinical protocol (e.g. phases, goals of each phase, areas of assessment) it is unlikely that the therapist will be able to successfully perform the basic clinical elements of FFT. Without a 31

39 Functional Family Therapy Clinical Supervision Training Manual Figure 5 Working Group maturity Context Knowledge Performance Therapist Adherence minimum threshold of adherence based on an understanding of FFT the likelihood of successful outcomes is diminished. The knowledge domain of model adherence includes a basic working knowledge of the core principles of FFT. These principles are an important part of therapist adherence because, while not always apparent in immediate therapist actions, they form the background of all the FFT therapist s clinical actions. The clinical supervisor must listen for these principles in the discussion of cases presented by the therapist. An accurate assessment of these core principles helps systematically target supervision interventions. Understanding Clients. Despite the fact that referrals come to FFT by way of an adolescent s dysfunctional behaviors, therapists must be able to view families as more than these specific behaviors. Families are multisytemic units composed of individuals in a unique and organized family relational system, an ecosystem or community environment, and a broad cultural context - all of which bear on the clinical processes presented to the therapist. It is critical for the therapist to understand the family in a broad context. It also is important to realize that 32

40 FFT Clinical Supervision some aspects of the multisystem environment and processes are changeable, while many more (e.g., neighborhood gangs, poverty, culture) are not changeable by the individual therapist. Therapists also must have the ability to view families as organized in that each is a functioning unit that operates in highly systematic ways. Thus we really don t think in terms of dysfunctional families; instead we see families that function in predictable and organized ways (i.e., they are all functional ), but for many the organization and functioning is chaotic or otherwise associated with undesired outcomes. They must be able to view clients, the families we see, as having strengths. Thus, the first important step in understanding problems is to keep all aspects of our clients in the foreground, rather than allowing their problematic behaviors and maladaptive family functioning to emerge as our primary focus. Understanding Client problems systemically. As a mulitsystemic model FFT acknowledges the clinical importance of serious problems at the level of individual functioning as well as the interactions between the youth, family, school, peer, justice, and neighborhood systems (Liddle, 1995; Szapocznik et al., 1997). However, FFT views these influences as ones that are mediated by the family relational system. This perspective is based on the extensive evidence that the problems of these youth are best understood by looking at their individual behavior in terms of it being nested within the family, which is in turn part of a broad community system (Hawkins, Catalano, & Miller, 1992; Robbins, Mayorga, & Szapocznik, 2003; Szapocznik & Kurtines, 1989). The construct of family risk and protective patterns is a particularly useful way of looking at adolescents with externalizing behavior disorders. Adolescents represent complex clinical profiles of behavior problems including drug use and abuse, antisocial conduct disorder behavior, as well as many of other mental health problems. Using risk and protective factors as an approach to understanding clinical problems is useful because it describes patterns of alterable behavior rather than labeling the youth or family with characteristics that become stable and enduring. When the therapist thinks in terms of family relational patterns, it is not the problem behavior that is the source of family difficult but the way in which it is managed within the 33

41 Functional Family Therapy Clinical Supervision Training Manual family relational system. The therapist is able to focus on the relational patterns that are represented by, and mediate, problematic adolescent behaviors, this in turn increases the likelihood that long term change is initiated and maintained because the patterns that represent the active ingredients of changeable risk and protective factors are changed (i.e., risk decreased, protective factors strengthened). In sum, in order to be therapeutic, FFT therapists view specific presenting clinical problem (clinical syndromes) as relational problems, i.e., as specific behaviors embedded within enduring patterns of behaviors that are the foundation for stable and enduring relational functions within family relationships (Alexander & Sexton, 2002, Sexton & Alexander, 2002). Adherent FFT therapists are able to focus on relational patterns between family members. Adherent therapists are also able to view the serious clinical problems presented by the family as only the tip of the iceberg so to speak. These therapists understand that below the obvious problem/clinical behaviors of a referred youth lie family relational patterns and the functional outcomes of these patterns that bind the family into enduring and problematic cycles. Understanding Therapy and the role of the therapist as fundamentally a relational process. FFT therapists who understand and rely upon the basic core principles of the FFT clinical model view therapy as a purposeful, phasic process that requires the therapist to follow a systematic model that provides a pathway to change with the highest probability of success, while simultaneously responding to the immediate needs/feelings/reactions of the family in the moment. They know that successful therapy requires them to be both systematic and purposeful, while at the same time also being clinically responsive. These therapists understand that the relationship between these two essential therapeutic stances is based on FFT s belief that therapy is a process in which two experts (the therapist and the family) engage in a collaborative, alliance based relationship aimed at alleviating the critical risk factors that increase the likelihood of (i.e. facilitate and maintain) symptomatic behavior. To be successful at FFT, therapists must view themselves as experts on the change process who purposefully influence and direct the process of therapy in particular 34

42 FFT Clinical Supervision directions. The other expert in the process is the family. They know first hand the experiences and patterns that exist in their relationships. Thus we have two experts, with different tasks, who must both do their part for therapy to be successful. This requires a partnership - a cooperation - an alliance based relationship and alliance based motivation to successfully overcome the difficult problems family members face. 2. The performance domain of model adherence requires that the therapist have the ability to put their knowledge of the principles and the FFT model into action with a family. Basic performance of FFT includes the ability to execute the common elements of good counseling and family therapy. Beyond these basic skills, adherent performance requires that the therapist be able to operationalize the core principles by approaching therapy in a way that is alliance based and built on respect and individual understanding of the unique nature of the family. Like the knowledge domain, the performance domain of model adherence is anchored in the FFT clinical model. The therapist needs to have the basic ability to engage and motivate the family, focus on specific, obtainable behavior change targets in ways that match families, and generalize changes within the room and through incorporating community resources. Model Competence Competence is the ability of the therapist to use the FFT clinical model in a way that is clinically responsive to individual families while remaining focused on the goals and skills of the model in a consistent manner and thinking complexly about clients and the FFT therapy process. Thus, competence is the ability of the therapist to successfully apply the FFT clinical model. It is important to note that competence is built on a foundation of adherence. Without adherence, competence is difficult, if not impossible to determine. Similarly, as the skill level of the therapist increases, issues and concerns of adherence fall away and a focus on overall competence becomes the primary focus of supervisory attention. High competence is the goal of all FFT therapists. While both knowledge and performance are important domains, the competence aspect of FFT therapy loads more heavily on the performance domain. This is not 35

43 Functional Family Therapy Clinical Supervision Training Manual Figure 6 Working Group maturity Context Therapist Competence Knowledge Performance to imply that knowledge is unimportant. Instead, the knowledge of high model competence is contained in the ability of the therapist to put what they know into action. 1. Like adherence, competence has both knowledge and performance domains. The knowledge domain of model competence requires that the therapist have a complex understanding of two important aspects of FFT: client problems and the therapy process. Highly competent FFT therapists have the ability to understand the vast array of client problems and issues in very complex and ideographic ways. When highly competent the therapist can place difficult presenting problems into complex relational patterns sorting out the important details of relational functions. Having a complex way of understanding clients and their problems allows the therapist the ability to respond in increasingly contingent ways that match clients. A complex and multidimensional understanding of client problems means the therapist is able to deal with a broader range of presenting concerns while remaining in the relational domain that is FFT. 36

44 FFT Clinical Supervision In order to assess the knowledge aspect of overall therapist competence the FFT supervisor might ask her or himself the following questions: Can the therapist think complexly about behavioral problems in relational ways? - Relational patterns - Relational functions Can the therapist think about the process of FFT and the individual characteristics of the family? - Match to the family - Match to the phase 2. The performance domain of model competence is the more dominate domain in establishing and assessing therapist competence. The performance domain is represented by the ability of the therapist to respond in the room to families in ways that are highly responsive to the individual needs and presentations of the situation. Thus, the performance domain requires that the FFT therapist have a complex ability to respond contingently while staying ultimately focused on the immediate and long-term goals of the model. The complexity of the performance domain is represented by a highly ideographic approach to accomplishing the goals of the FFT model. In other words, the competent therapist always pursues the goals of, for example, engagement/motivation, but from session to session the pathway or route they take may vary widely. Upon closer examination, the way in which the therapist was achieving the goals of engagement/motivation was determined by the immediate needs and requirements of the individual family and unique circumstances with which they were presented. Competence loads more heavily on performance than on knowledge. Group Maturity: The Relational Context of FFT Supervision The process of supervision takes place within a working group of professionals who will become an important support system for the individual FFT therapist. FFT supervision takes places individually (between supervisor and therapist) and within working groups. Working groups are a critical and important feature of community based FFT projects. In many ways the working group at a community 37

45 Functional Family Therapy Clinical Supervision Training Manual practice site is the family to the clinical supervisor. As such, the clinical supervisor must attend to the relational aspects of the group as well as to the adherence and competence levels of individual therapists. Working groups are groups of professionals who comprise the FFT team at a community site. Each has received training in the FFT clinical model, each regularly works with families, and each participates in the weekly team staffing meetings that take place at FFT practice sites. The working group notion is important to the stability, sustainability, and quality of FFT services at a community site because it constitutes a professional support system that is on site and available on a daily basis to provide: a peer group and a source of identity as a member of the FFT treatment team within the local agency a source of therapist support because each member is similarly trained, works in the same clinical model with similar principles and protocols, and have similar struggles a forum for supervision in which cases are regularly presented so that each team member learns from the cases of each team member a source of information for assessing therapist adherence and competence with cases that are presented and, ultimately a source of peer supervision as the group gains adherence and competence and develops into a mature working group. The working group is the psychosocial and relational context in which the supervisor intervenes to improve therapist adherence and competence. In addition, the supervisor must attend to not only the dynamics of the individual therapist, but also the dynamics of the working group. Just as in working with families, the climate, between-group-member alliance levels, and the relational process between group members and between the clinical supervisor and the group become critical issues in successful supervisor. If the working group is ultimately going to be a source of peer support, identity, and model fidelity, it must follow a developmental progression in much the same way that the individual therapist must develop. The study of group dynamics has a long history in the field of counseling and psychology. Group dynamics have often been 38

46 FFT Clinical Supervision characterized as going through phases (e.g. forming, storming, norming, and performing). Because FFT supervision is based on the group working together, the concept of group maturity is particularly useful in understanding the status of the group, and targeting areas of development. Group maturity is a concept initially developed by Hersey (1985) and Blanchard in their work in organizational development (1978). The construct was later applied to families. What we find most useful about this way of understanding group dynamics is that it links group leader behavior with measures of group development. In other words, as a group develops and increases its ability to work together; the group leader changes his or her leadership style to adjust to the maturity level of the group. The details of this model of group development are beyond the scope of this manual. If you are interested in further details consult the resources cited in the reference section. Group maturity is a measure of the developmental level of the working group. Maturity is defined based on the group s ability to: - work together toward a common goal - identify the necessary task and participate in accomplishing that task - take ideas, guidance - generate ideas, solutions Groups with low maturity have yet to develop the ability to work together to do FFT in a way that demonstrates a basic level of adherence and competence. They are unable to identify the critical aspects of the FFT model that are most important for a particular case, for a particular family, within a particular phase. The group is unable to staff cases in a way that helps accomplish FFT goals. Supervision ideas are difficult for the group to accept and they seem unable to generalize FFT specific suggestions to presented cases. Low-level maturity groups require considerable guidance from the clinical supervisor. The guidance for these groups must be concrete, direct, and focused on helping the group stay focused on the common goal of successfully doing FFT. Groups with a moderate level of maturity work as a team, work together in case staffing, can focus on the critical adherence elements of FFT, and offer and take suggestions from the clinical supervisor and the other team members. Case staffings have become 39

47 Functional Family Therapy Clinical Supervision Training Manual more group focused with more individual member initiative. These working groups require suggestions and direction rather than teaching from the clinical supervisor. High maturity working groups work together with high adherence and competence. Staffings follow a model focused agenda with high levels of initiative and participation from the majority of group members. These working groups have developed into a cohesive working unit that is self-sustaining. Clinical supervisors monitor, suggest, and participate in the group with little need for leading and directing. The goal of the clinical supervisor is to help the group develop from low maturity at the initial stages of working together to high maturity levels over time. High maturity level groups are able to sustain FFT with a high degree of model adherence and competence. High maturity groups are essential professional peer supports that maintain the quality of FFT services well beyond that which could be provided by the individual clinical supervisor. Figure 7 Maturity as a dimension of Group context and its relationship to the role of the supervisor Group Maturity High Moderate Low High group maturity = low supervisor directiveness Group maturity ranges from low to high and is based on the groups ability to: work together identify the necessary tasks and participate in accomplishing those tasks take ideas and guidance from the supervisor and other group members generate ideas and solutions Supervisor Directiveness Low Moderate High 40

48 FFT Clinical Supervision THE CHANGING MAKEUP OF THE GROUP. Unlike families, working groups change as team members come and go over time. Thus, group maturity levels change. A high maturity group may, with the loss of old members and the addition of new members, lose some of its ability to function in a professionally and model focused way. Thus, the clinical supervisor constantly monitors the maturity of the group and adjusts supervision interventions accordingly. Systematic Supervision Protocol The Supervision protocol is a map or guide to help the FFT supervisor know where they are and where they are going in the process of supervision. The supervision model is intended to help the supervisor set the agenda for the supervision encounter, identify the specific goals of that encounter, and identify the supervisor s behaviors/interventions that are mostly likely to promote those outcomes. The supervision protocol depicts the relational process of supervision and is intended to also describe how to approach and work with both individual clinicians and working groups in a way that successfully accomplishes the goals of supervision. The supervision model is also phasic. It involves three phases, conducted sequentially, within which there are specific areas of assessment and monitoring of specific supervision goals targeted by systematic supervisor interventions. While the primary responsibilities of the supervisor are quality assurance and quality improvement through the development of therapist adherence and competence, these goals and tasks must be pursued as a process rather than as scattered events. The supervision process must be viewed as a relational one-one that requires different roles for the supervisor and the therapist, each working together to deliver FFT with quality and integrity, and through those roles helping the families they serve to overcome their struggles. As a process guide for the supervisor the supervision model becomes the anchor or primary reality from which the supervisor understands what is occurring and a source of guidance for their next supervision intervention. Consider what happens in a supervision encounter. FFT therapists, who struggle daily with very difficult families, bring in their struggles, emotions, or perception of the families with whom they are working. The supervisor (as noted in the principles) focuses on the relational process of these content 41

49 Functional Family Therapy Clinical Supervision Training Manual presentations. The supervisor responds to the actions of the therapists/group guided by the session specific, phase based goals of the clinical model. This means that the phases of the supervision model must be well understood to the supervisor as the primary part of their lens of working. The supervisor may respond one way in the early stages of supervision and a different way in later phases. Thus, the protocol operates as the map for the supervisor while working with the therapist or while working with a supervision group helping focus on the most important immediate goals of the supervision encounter. Thus, the protocol helps keep the supervisor on target. The phases discussed below are quite specific, direct and prescriptive, and thus can look and feel like a prescribed curriculum. However, they cannot be pursued in a paint by the numbers fashion. Instead FFT supervision is based on the idea that specific goals are pursued in relationally responsive ways. Thus, FFT supervision, like FFT therapy, embraces two seemingly incompatible forces: being systematic and structured while being relational and responsive. When done in this way, the application of the phases and the accompanying strategies is done in ways that are unique to each working group and individual therapist. A number of points are important when using a specific model as the basis of supervision: every action of the supervisor has the potential to be influential and pursue the goals of adherence and/or competence. assessment of therapist adherence and competence is an activity that takes place in each phase of the model. accomplishing within session goals (as defined in the phases) is not linear and straightforward. Instead, it is relational and thus, by definition more circular in a way that feels like one step forward-one back. As a result, the way in which we depict the phases (e.g. as a circular process) is an important one. Accomplishment of the phase goals while structured and directional is neither linear nor direct. while the phases look ordered and structured they happen within the context of conversations between therapist and supervisor. Many times these conversations even seem to go in circles. As such, it is important to note that what happens in session is a discussion about the salient family issues that the therapist faces. The supervisor looks for opportunities to meet the phase goals (e g. build competence). 42

50 FFT Clinical Supervision Figure 8 FFT SUPERVISION MODEL high Adherence Competence Engagement/ Motivation Phases of Supervision Adherence/ Competence Maintenance low Within the context of Group Dynamics and developmental level Time Engagement/Motivation Phase Assessment Therapists understanding of core principles and level of adherence/competence Group development Relational processes Goals/Interventions Engage Reframe Focus on adherence Outcome Supervisory working alliance Motivation to do/practice/be FFT Adherence/Competence Phase Assessment Level of model adherence and competence Use of PRN/CSS Goals/Interventions Target adherence discrepancies first Target competence second Use FFT relational principles to match to therapist Monitor and track therapists with CSS Outcome Model adherence Improved competence Working group is open to change and learning and begins to mature Maintenance Phase Assessment Individual and group level of self-sufficiency Group maturity Goals/Interventions Allow group to meet adherence challenges Be less directive Outcome Stable group that adheres to model with complexity Group that can meet clinical challenges Working group that is cooperative, selfmonitoring, and self-challenging 43

51 Functional Family Therapy Clinical Supervision Training Manual the phases of FFT supervision represent the supervisor reality that guides the supervisor in determining how to respond to what he or she are presented with during the course of the supervision session. Figure 8 depicts the phases of the FFT supervision protocol. In the sections below we describe each phase in more specific detail. Early Phase: Engagement and Motivation You were a member of this team prior to moving into the role of site clinical supervisor so, why the need to engage and motivate? Becoming the official clinical supervisor is a major relational change in your working group. You now have different responsibilities, and relationships with the team as a whole, as well as with individual members. Just like in the FFT clinical model, engagement and motivation is not about having known the client or being family with them, it is about engaging them to participate in a different type of interaction (different from what they usually engage in) and motivating them to work with you in a different way (toward the specific goals of supervision) than they have in the past. As a result, focusing initially on these more relational aspects of the supervision, therapist, and working group relationships is critical to the long-term success of your work. This early engagement/motivation phase has several important goals: alliance building between the supervisor and EACH team member and among team members developing a shared team focus on adherence and competence as the central task of the group and each individual building hope and an expectation for successfully being able to learn FFT and successfully work together as a team to deliver the model with adherence to a diversity of families establishing an FFT focused case staffing structure conducting the quality assurance task of monitoring and tracking therapist adherence and competence as a baseline for quality improvement interventions. The desired outcomes of this early phase of supervision are to have the supervisor build alliances with the individual therapists and the working group to work together and with the supervisor to 44

52 FFT Clinical Supervision Figure 9 Supervision Engagement/Motivation Phase Assessment Therapists understanding of core principles and level of adherence/competence Group development Relational processes Goals/Interventions Engage Reframe Focus on Adherence Outcome Supervisory working alliance Motivation to do/practice/be FFT enhance adherence and competence in FFT. In addition, the supervisor will have a good baseline read on the levels of competence and adherence among the working group members and the domains in which individual therapists may struggle. Finally, the supervisor will have focused on the structure and process of group case discussion that promotes model adherence, complex thinking, and model-focused case processing. As you know, alliance is built as an outcome of the relational process embodied within engagement/motivation. Thus, successful engagement and motivation in supervision is geared to the important internal states that must be developed if therapists and the group are going to be willing to build their abilities and mature as a group. Engagement and motivation are not activities that the supervisor does and is done with. Instead they are developed over the course of early supervision encounters within the conversations with the team about the cases and the FFT model. Engagement is defined as involving the therapist and the working group in the immediate activities of the supervision session such that they become interested and invested in taking part. Engagement comes from small talk, humor, interested questions etc. that involve each team member. Engagement is both a goal (what the supervisor tries to do) and an outcome (the therapist/team is engaged) and can be measured by the level of team involvement in the case staffing meeting. Remember, involvement does not have to mean talking a lot or sharing. Instead it is participation in the process (in a way that fits the individual team member). Motivation is a state that the team develops in which they view the central challenge of supervision as building adherence and 45

53 Functional Family Therapy Clinical Supervision Training Manual competence, where they experience hope that they will be successful, and believe that the supervisor and the group can help them accomplish the goals of model adherence and competence. FFT supervision seeks to develop alliance-based motivation between the supervisor, therapist and working group as a primary means to engagement and long-term motivation. As in the therapy model, in order for engagement and motivation to occur, working groups and individual therapists must experience the supervisor and other working group members as sources of support. As in therapy, motivation comes from not only support but also from feeling challenged to understand FFT better, challenged to apply FFT in creative and successful ways with families, and challenged to, as a working group, develop an expertise in the FFT model. Figure 10 Relationally-based/Alliance-based Alliance Commonly seen as empathy, liking, and support It is complex It has multiple domains Relational bond -relational liking -support -connection -crediability Common goals -going in the same direction Agreed upon means and tasks -agreed upon roles -common process 46

54 FFT Clinical Supervision Successful supervision is based on the alliance that develops where each group member and therapist believes that the supervisor supports and understands his or her position, beliefs and values. As noted in figure 10, alliance is a combination of a supportive relational bond and an agreement on the tasks and the goals of supervision. For FFT supervision, this means that both the therapist and the supervisor know that adherence and competence are the primary goals in supervision. It is important to note that the motivation that results from a supervisory alliance comes from the experience of the therapist/team in discussions with the supervisor rather from any single thing said by the supervisor. Thus, in this early phase of clinical supervision every activity of the clinical supervisor is an opportunity to build alliance between the supervisor and therapist and between group members. When the struggles of the therapist and group are focused on the challenge of learning rather than on FFT or the therapist, a number of important outcomes result. First, it contributes to the reduction of blaming and negative interactions among team members and between the team and the supervisor. This focus on learning is what helps produce hope and a sense of motivation. Second, it helps therapists reattribute the intent and causes of behaviors from malevolent to benevolent and thus alters the emotional attributions associated with the challenges of learning and delivering the model. Third, the group process and learning focused problem definition helps identify potential solutions that may have otherwise been difficult to identify. Finally, this constructed, group focused problem definition helps organize supervision and becomes the major theme that explains the struggles of the individual or the group and thus organizes goal directed behavior consistent with the phase of supervision. Assessment and intervention in Engagement/Motivation Phase of Supervision To be successful the FFT supervisor must have a specific target for their supervision interventions and an understanding of the relational lay of the land. In the early phase of supervision, identification of those targets will come from developing a baseline assessment of the levels of adherence and competence among the therapists in the working group. It is important to remember that 47

55 Functional Family Therapy Clinical Supervision Training Manual there are multiple systems to consider: relational, case-based, and service delivery issues that are a part of any clinical discussion. To be systematic the FFT supervisor must be able to prioritize these issues so that they might systematically intervene in a way that builds individual therapist adherence while developing group maturity level, and helping overcome agency factors that may interfere with or become barriers to successfully implementing FFT. Thus, the clinical supervisor, while primarily focused on the clinical work of the cases, must focus on the mulitsytemic context of the working group. The challenge of the early engagement/motivation phases of clinical supervision is to stay focused on the primary goals of the FFT model. While discussing cases and providing help on cases the supervisor must assess: the relational aspects (degree of engagement and motivation of each therapist) the maturity level of the working group, as well as the levels of adherence and competence of the therapists, and the nature of the surrounding service delivery context. So, while busy engaging the group and individual therapists, the supervisor is taking stock of a wide range of other areas. It is important to note that assessment of each of the domains below occurs within the context of formal and informal group and individual case discussions. The following areas are of particular importance in early phase supervision: Level of Engagement/Motivation for supervision. Initial focus is on the degree to which each therapist and the working group as a whole is engaged with the supervisor and each other in the goal of building adherence and competence in doing FFT. While this may seem obvious, it often is not. During the engagement motivation phase of clinical supervision, therapists often struggle with the core principles of FFT, or with the application of the model, or with completing the supporting technical features of the FFT service delivery system. At these times, therapists, like family members, attribute their struggle to a variety of sources (e.g. the FFT model, the working group, or the supervisor). To be motivated (in a supervisory way) the individual therapist or the working group need to feel as if their views and beliefs about cases they present are accepted and that supervisor and group suggestions are helpful and in the best interest of the therapist and the family they are working with. When therapists struggle, they must experience the supervisor as understanding 48

56 FFT Clinical Supervision of the struggle and the supervisor must demonstrate to the therapist that he or she is capable and competent to be a helpful. Levels of Therapist Model Adherence. Two aspects of model adherence are particularly important in this early stage of supervision: knowledge of the core principles of FFT (how we look at clients, how we think about problems, and how we think of therapy). The supervisor must listen to the case presentations of the therapist and determine the degree to which the therapist understands and is able to act in a way that is consistent with these principles. The supervisor needs to make a global assessment of therapist adherence as well as a more specific assessment of the phase specific goals of FFT (see adherence section above). Carefully identifying the level of therapist adherence, and the degree to which the adherence issues of a particular therapist may be knowledge or performance related, would help focus the way in which the supervisor may intervene to help. In addition, the supervision must assess the degree to which the therapists in the group are using the technical tools built into the FFT service delivery system. The technical tools (e.g. progress notes, CSS, assessment protocol, adequate case loads) are designed to help therapists stay focused and are aimed at promoting adherence and competence. Thus, the consistent use of these tools is essential for successful FFT service delivery. FFT has developed a number of specific instruments in order to systematically assess the quality of FFT delivered at individual sites. These instruments are the supervisor s version of the progress notes used by FFT therapists. These instruments provide systematic assessments of adherence and competence across different domains of supervision (individual supervision encounters about specific cases) and across more global and overall characteristics of therapist behavior. These instruments become the quality assurance tool of the FFT clinical supervisor and form the basis of their supervision interventions. Each instrument is discussed at length in the assessment section of the adherence/competence phase of the supervision model (see pages 65-67). The FFT clinical supervisor uses these instruments throughout each phase of FFT supervision. Group Maturity Level. It is also important to identify the degree to which the working group is able to work in mature ways. As noted above, groups have different degrees of ability to work together, and have different levels of cohesion. The focus here is on within 49

57 Functional Family Therapy Clinical Supervision Training Manual group alliance and maturity in working within the FFT model. Thus, the supervisor must assess the degree to which the group is participating, helping in an FFT focused way, providing feedback, and taking feedback from the FFT supervision. Thus, cohesion may be high, but not in a way that supports the development of adherence and competence in FFT. The maturity of the group will also be reflected in the level of alliance between you and the group. As discussed above, alliance is the degree to which you and the group are working together, the degree to which they accept your role, and the agreement on the purpose and direction of supervision. The maturity level of the group will guide the supervisor in knowing how to deal with the dynamics of the group context of supervision. Service Delivery Context. Focusing on the service delivery context is also a critical feature of FFT supervision. For FFT to be successful it is critical that therapists get good referrals, have the case loads that facilitate immediate responsiveness to clients, have the ability to meet together and staff cases, don t have additional assessment and paperwork requirements that make it difficult to follow through with their use of the FFT-CSS. The FFT supervisor needs to note these potential barriers to successful FFT delivery. Primary Supervisor Activities in Engagement/ Motivation FFT supervision is a relational process between a therapist, a supervisor, and a working group in which the primary goal is successful delivery of FFT with high model fidelity (adherence and competence). The critical issue in the early phases of supervision is the relational aspect of the working relationship. A supervisory relationship is one that is focused on quality assurance and quality improvement as its primary objective. Thus, these early relational elements are focused on establishing an alliance built on these principles. Two particular tools which are discussed below, the case staffing protocol, and reframing can be used to achieve these goals. Additional supervisor activities are discussed in later sections because they are more primary in those phases of clinical supervision. It is, however, important to note, that the supervisor uses many different techniques throughout the supervision process. 50

58 FFT Clinical Supervision STRUCTURING CASE STAFFING The weekly case staffing meetings of FFT teams is a critical part of the successful implementation of FFT. Working groups meet weekly (in addition to the organized supervision and training) to staff cases. Case staffings provide a place for therapists to think through the FFT lens with a like minded group of peers in order to develop a long term case plan and a short term session plan. Case staffings are the primary arena in which FFT supervision occurs so they are a primary tool for supervisors in developing therapist adherence and competence. The process by which case staffings occur, the way in which they are structured, and the nature of the conversation during these meetings can be used by the clinical supervisor to build adherence, competence, and group maturity. Unlike traditional staff meetings, the FFT working group and the supervisor come together to discuss cases and develop session plans based upon the core principles and clinical protocol of FFT. Successful working group staffing focuses on two areas: Case planning and session planning. By using the protocol the team can begin to move the relational process aspect of the case (the primary interest when doing FFT) to the foreground and the content (only a secondary interest) to the background. Case staffings begin with a presentation of the case, broad case planning, input by the team, and the development of a specific next session plan. FFT focused case staffings initially feel very different than traditional staffings. Typically little of the traditional psychosocial history information is presented. Instead, the focus of case planning is on how to understand how this unique problem functions within a unique family relational system. In this way the staffing mirrors the thinking process the therapist must follow to work within FFT. Specific session plans are based in the phase of the model (the phase goals) with unique implementation strategies based on the specific relational structure/functions of the family. It is the role of the FFT clinical supervisor to lead the case staffing meetings. As noted above, each staffing begins with a presentation of the case followed by the development of a plan for the next session. Sometimes the clinical supervisor will ask a therapist to present a case, other times therapists will volunteer. During a case presentation, FFT supervisors listen to the case presentation as a reflection of the reality of the therapist. As such, their presentation should, to some degree or another, map onto the clinical model and 51

59 Functional Family Therapy Clinical Supervision Training Manual Figure 11 SUPERVISION PLANNING PROTOCOL Case Planning: Big Picture 1. How can we understand the family? - Presenting problems - Risk and protective factors - Relational understanding of family 2. How does the problem function in the family relational system 3. What is the major theme/reframe that organizes therapy? 4. Individualized change plan potential outcome sample - Behavior change targets - Behavior change plan 5. What systems are involved that impact maintenance and support of change? Session Planning: Specific Direction 1. What phase are we in? 2. Goals of that phase - Which goals are important for this session? - What progress has been made toward these goals? - What are the process issues to address? (e.g. negativity, blaming, resistance) 3. What do I need to assess? 4. How can I add to or help develop the major theme/reframe? 5. How should I intervene? - Which phase goals are targets for the session? should represent their understanding of the core principles of FFT, the clinical process of FFT, and the clinical decisions to make in response to client issues that reflect their ability to respond in complex and contingent ways. Staffing provides an opportunity for the supervisor to listen to the case presentations, assess the degree of therapist adherence and competence, and, based on the phase of the supervision process, intervene to improve the quality of FFT delivery. The very structure of the staffing is a teaching and supervision intervention. Thus, one of the first agenda items for the clinical supervisor is to focus the working group on adopting the staffing protocol. Through selective responding and suggestion the clinical supervisor keeps the working group focused on the protocol described above. The very act of following these protocols results in therapists and working groups who think through the FFT lens. Over time the group begins to naturally staff cases in this way contributing to increased adherence and competence in their practice. REFRAMING FFT supervision is a relational process between supervisor and therapist in which the supervisor is trying to influence the therapist to change their practice. The work of any therapist is often times experienced as a very personal endeavor and the presentation, discussion, and responses to feedback 52

60 FFT Clinical Supervision are often times felt by therapists as personal in addition to professional. This often triggers high levels of emotion, particularly in FFT because it is a model that is inherently challenging to do well and the work is often with very difficult clients. Thus, there are many times in this process when the therapist struggles. Like clients, when faced with such challenges the therapist often attributes the struggle to FFT as a model, the supervisor, or other issues that divert their attention from the primary goal of building model adherence and competence. Reframing is a useful relationally based way to help focus attention on the struggles of the therapist and help them take responsibility for the difficulty while appropriately validating the fear, pain or other difficulty in a way that offers hope and support for successful resolution. As in therapy, reframing is an effective way for FFT clinical supervisors to respond to therapists. Reframing helps therapists find a way out of the defensive, blaming, and negative emotion that they often confront when struggling with a new model of therapy. When events, emotions, and behavior are reframed an alternative route to emotional expression is created. In addition, an alternative cognitive and attributional set is created that helps redefine meaning events and thus reduces the negativity and redirects the emotionality surrounding them. When done successfully, reframing helps create the alliance base necessary for supervision while refocusing the therapist on the challenges they face in ways that are not blaming. When used in FFT supervision reframing has the very same two central elements as the clinical model: Validation. The validation portion of reframing is a demonstration of understanding and support of what the therapist said, the emotion they expressed, or their struggle in working with a particular concept, issue, or a family. It is important to note that validation is more than reflection, support and empathetic responding. In fact, the validation is a supportive statement because it describes, in non-blaming ways, the event, behavior, or emotion that occurred in very direct and straightforward ways. Alliance develops with the person to whom the therapist speaks because the therapist deals in straightforward yet supportive ways, with the troubling events/behaviors/emotions. Alliance is built with other team members because they see the supervisor talking directly about tough issues, but in a way that 53

61 Functional Family Therapy Clinical Supervision Training Manual supports the therapist. The validation response supports and engages the therapist and the working group. Reframe/reattribution. Validation is followed by a reattribution, which presents an alternative theme or meaning to the event. The alternative meaning or theme must be plausible and believable to the therapist and must focus the struggle back to a challenge for them. The reattribution is helpful because it changes the focus of the behavior from being directed to another person to inside the speaker. There are three general directions that the reattribution aspect of reframing may take. 1. The first targets changing the meaning of a behavior, emotion, or event. Thus, the meaning moves from a negative and blaming meaning to one that describes the behavior, emotion, or event in other ways. This form of reframing helps reduce negativity by changing intent. 2. The second challenges the therapist by suggesting hope through focusing on a different potential direction for change. Challenge oriented reframes do not suggest solutions, but instead suggest a different direction and lend hope. 3. Finally, one can target a reframe toward linking members of the working group together and thus creating a group focus to the emotion, behavior, and event. Check/reevaluate the impact. The reframing statement must be evaluated and its impact must be gauged. The check and reevaluation is a critical component that requires the supervisor to carefully listen to the response of the therapist and/or the working group. The supervisor must listen for what fit and what did not, what was left out, what was/was not emphasized, and what could be added to further match the reframing statement to the therapist. Whatever the therapist s response, the supervisor gains information that is put into a revised and more finely tuned validation and reframe that is delivered next time. Outcomes of Engagement/Motivation Phase of FFT Supervision The engagement and motivation phase of supervision is successful when the individual therapists and team begin to take part in 54

62 FFT Clinical Supervision Figure 12 Reframing as a supervision tool Validation Demonstrated support and understanding for emotion/values/position in personal way Reframe Reattribute meaning of emotion, motivation, intent of behavior/situation Recognize/identify/ describe the event/ bad behavior -the relational part Meaning Change Emotion of self/another Behavior of another Intention of another It s not about the model it s about your struggle Challenge where you go from here your challenge is therefore the thing to change is The task here is Linking so you and he are much alike in therefore both of you it seems that between you It s not just you Check for fit/adjust/reformulate Assess degree to which reframe fits supervisee add supervisee response reformulate changed reframe Purposeful change -the change part supervision, the goals of supervision are shared (e.g. a focus on adherence and competence) and the role of the supervisor is established as someone who is working with the team to assure quality and improve the delivery of FFT. The team comes to trust in the supervisor, they believe that the supervisor has an understanding of their struggles, and the supervisor has the ability to help. They come to know that regardless of what they may have done the supervisor will protect and help them as much as anyone else and that the supervisor will be relentless in their pursuit of adherence and competence. In addition, the working group begins to establish a within group team identity that is apparent in focused staffing meetings where case discussions become open and a collective effort. During this phase the clinical supervisor has also established mechanisms to fulfill the role of quality assurance leader. The supervisor has established/maintained weekly case staffing meetings, 55

63 Functional Family Therapy Clinical Supervision Training Manual structured those discussions in the ways noted above, and started quality assurance monitoring by using the CSS and the weekly supervision ratings (these are discussed in detail on pages and pages 77-80). Through these activities the supervisor has a baseline assessment of the levels of adherence/competence developed through quality assurance monitoring. This baseline will become the springboard for work in the next phase of supervision. Figure 13 SUPERVISION PLANNING PROTOCOL ADHERENCE/COMPETENCE PHASE Assessment Level of model adherence and competence Use of PRN/CSS Goals/Interventions Target adherence discrepancies first Target competence second Use FFT relational principles to match to therapist Monitor and track therapists with CSS Outcome Model adherence Improved competence Working group matures and is open to change and learning 56 Middle Phase: Adherence and Competence As the supervisor establishes the working alliance necessary for successful supervision, he or she shifts the primary focus to adherence and competence. The middle phase of FFT supervision is focused on tracking, monitoring, and systematic intervention to improve the adherence and competence of FFT therapists. Thus, the primary supervision goals are quality assurance and quality improvement. As noted above, quality assurance is a monitoring and tracking based task. Supervisors constantly monitor and assess the level of adherence and model competence. The monitoring occurs during each formal supervision encounter (e.g. staffings) and in each more informal case discussion. Systematically assessing the knowledge and performance issues overall and phase-based adherence and competence form the basis of supervision interventions. Quality improvement is the action of the supervisor to improve the delivery of FFT by the therapist. Quality improvement interventions take place each time the supervisor makes suggestions or gives input to a case discussion, each time the supervisor talks with a therapist, and each

64 FFT Clinical Supervision time the supervisor focuses a working group on specific issues of adherence and competence. Quality improvement may be teaching oriented (discussing a principle/issue of the clinical protocol) or discovery oriented and may take the form of a guided discussion and /or group brainstorming discussion in the working group. Supervisors target issues of adherence first and areas of competence second. The goal of this phase of supervision is for issues of model adherence to decrease and a focus on competence to increase as the primary focus of quality improvement. Quality Assurance Monitoring: Assessment in the middle phase of supervision The quality assurance element of supervision has two purposes. First, it is a way of ensuring that the services delivered by FFT therapists in the working group are replicating the model to make sure the outcomes will be positive. This goal requires systematic assessment of therapist behavior on the specific case level (individual supervision encounter level) and on the global level of both the knowledge and performance domains of adherence and competence. The second purpose is to determine areas in which the supervisor might intervene to improve service delivery quality. Thus, any attempt to intervene and help with a case or with therapist ability must be based on a systematic understanding of the levels of adherence and competence. Before supervisors can systematically improve the adherence and competence of the therapist they need to understand the most important domain to target. It is important to remember (as noted above) that adherence and competence can be assessed at both a global level (the therapist s adherence and/or competence across the basic and common elements of the model) and on an individual case level based on the specific phases of the case they are working with. Global ratings reflect the therapist s overall adherence and competence, while case level ratings reflect adherence and competence of that therapist with that case in that therapeutic encounter. These different perspectives are captured in the two primary supervisor rating tools: the weekly supervision rating and the global rating. Both are discussed later in this manual. 57

65 Functional Family Therapy Clinical Supervision Training Manual IS IT ADHERENCE OR COMPETENCE? The data for monitoring quality comes from the content of the case discussions that occur during formal case staffing and/or individual supervision sessions and during informal interactions with the supervisor. In these settings, therapists present information which demonstrates their knowledge and performance levels with respect to adherence and competence. When listening to case presentations, the supervisor must first determine whether the primary supervision issue they hear is one of adherence or competence. As a therapist presents a case they will describe the family and the struggle of the family, they tell the story of the case. In addition they tend to discuss what happened in recent family sessions. In general the supervisor thinks about the level of adherence first. Adherence is a necessary but not sufficient condition of FFT. Therefore, it is the first area to assess. The clinical model is the yard stick for measuring whether the therapist is thinking about the case through the FFT lens and whether or not clinical decisions are adhering to the core principles of the model, and the appropriate phase goals of the specific case. Once adherence is established, issues of competence move to the forefront of the supervisor s agenda. GLOBAL AND PHASE BASED INDICES OF ADHERENCE Adherence has both knowledge and performance domains and can be thought of in a global and a phasic way. As such it reflects the therapist s overall and phase specific knowledge and basic performance of the model and the primary goals of each phase. When viewed broadly, adherence measures the therapist s overall knowledge of the model. For example within the knowledge domain: Does the therapist have a theoretical understanding of the FFT model? (core principles and basic model protocol) 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? The therapist s understanding of each specific phase of FFT is also important: Knowledge Adherence in Engagement/Motivation 58

66 FFT Clinical Supervision Does the therapist think relationally rather than using diagnostic labels with the family? Does the therapist weave together the reframes into a family theme? Knowledge Adherence in Behavior Change Does the therapist understand the role of problems, patterns and relational functions in regard to the presenting problem of the family? Is the therapist specific about targeted risk factors? Does the therapist have knowledge of relational functions? Knowledge Adherence in Generalization Does the therapist specifically focus on generalizing change across other content areas? Does the therapist focus on both within room (relapse prevention, generalization, and maintenance) and outside of the room (incorporating community resources) issues? The performance domain of model adherence can also be measured with regard to the model in general and the phase specific tasks that need to be followed: 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 maintain a balanced alliance with all family members throughout all phases? 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 demonstrate the following qualities to the family: Warmth Non-judgmental Non-blaming Humor Acceptance Sensitivity 59

67 Functional Family Therapy Clinical Supervision Training Manual Figure 14 Therapist Reality Supervisor Reality Therapist presentation of the case Story of the case Description of family Description of the problem What happened? What s next? Supervisor decision making What is the adherence issue? What is the competence issue? How can I intervene? General relational/counseling skills When the performance domain of adherence is considered specific to the goals of a particular FFT phase the supervisor will evaluate the following areas: Performance Adherence in Engagement/Motivation Does the therapist deliver the FFT Engagement and Motivation Phase within the FFT timeframes? Does the therapist use reframing as a primary skill in engagement/motivation? Does the therapist focus on decreasing negativity and blaming as primary a goal? Performance Adherence in Behavior Change Does the therapist deliver the FFT Behavior Change Phase within the FFT timeframes? Does behavior change begin only after engagement/motivation? Is the behavior change target a small obtainable change? 60

68 FFT Clinical Supervision Does the therapist focus behavior change on specific skill development? Performance Adherence in Generalization Does the therapist deliver the FFT Generalization Phase within the FFT timeframes? Does generalization begin only after successful behavior change? Does the therapist specifically focus on relapse prevention? Does the therapist specifically focus on generalizing change across other content areas? It is important to note that the FFT clinical supervisor will make assessments of the various knowledge and performance domains of model adherence by listening to the therapist present cases and discuss clinical issues. Thus, the ability of the clinical supervisor to listen for and hear indicators of adherence is required. In clinical work, rather than listen to the content the therapist must focus on the process. In supervision work the focus needs to be on the supervisor reality (see figures 14 and 18) and his or her evaluation of adherence and competence. GLOBAL AND PHASE BASED INDICES OF COMPETENCE Once model adherence has been assessed the supervisor turns to the issue of competence. An FFT therapist can certainly be competent in regard to the entire FFT model. This would be reflected by the ability of the therapist to contingently respond to different families in ways that match to them while maintaining the model? More specifically, model competence has, as noted above, knowledge and performance domains. As with adherence, the FFT clinical model serves as a source for markers from which to measure global and phase based therapist competence. Overall competence level is indicated by a continuum: Low competence indicates a therapist who is attempting to achieve the goals of each phase and using the skills of each phase but does clinical work in ways that are rigid, do not match to the family, inconsistently applies skills such as reframing, and reflects simple thinking about the therapeutic process. Average competence ratings indicate that the therapist is thinking somewhat complexly about the family and the process, and using skills with moderate complexity and consistency. High competence ratings indicate the consistent ability to think complexly about families and the process, and a demonstration of the 61

69 Functional Family Therapy Clinical Supervision Training Manual ability to do the FFT clinical skills in a way that matches to many different families. Competence is impossible to achieve without adherence. (See the FFT Weekly Supervision Checklist in the Supervision Tools section of this manual for the adherence and competence rating scales). Within the performance domain, phase-based competence is assessed by considering the following: Competence in Engagement/Motivation Can therapists creatively reframe/create organizing themes? Does the therapist create a balanced alliance will all family members? Is the therapist successful at changing the problem definition to something between people? Does the therapist weave together the reframes into a family theme? Is the therapist successful at applying reframes in a way that matches to each family in their caseload? Competence in Behavior Change Does the therapist develop behavior change goals that are specific to the family? Does the therapist apply behavior change interventions that match to the relational functions of the family? Competence in Generalization Does the therapist apply within family generalization in a way that matches to the family? Does the therapist include/incorporate outside resources? Does the therapist refer families to additional services that match to the family? QUALITY ASSURANCE MEASURES: SPECIFIC ADHERENCE & COMPETENCE MEASUREMENT TOOLS Adherence and competence are complex constructs that change over time. Accurately assessing each is dependent upon the supervisor systematically tracking adherence and competence on standard measures so that trends become apparent over time. In order to facilitate this task, FFT developed standardized measures of adherence and competence. These quality assurance measures are used by the clinical supervisor to determine the profile of therapist adherence and competence. Each instrument measures a different level of therapist behavior from different perspectives. The series of measures 62

70 FFT Clinical Supervision gives the best overall picture of therapist adherence and competence. Because they are standard measures completed at a systematic point in time they promote consistency and reliability over time and across therapists. Since these are the same measures used by each clinical supervisor throughout the country it is possible to compare competency levels across sites. These instruments are contained in the FFT-CSS supervision section so that the information generated from each can be easily used in clinical supervision to capture both the status of adherence and competence as well as tracking the change in each over time. Each instrument provides different types of adherence and competence information, some case specific, some global. The quality assurance measures also provide information from different perspectives, e.g. that of the supervisor and that of the family. Finally, the instruments provide a static view of adherence (in this moment) and when combined with other similar ratings over time, provide trends or profiles of adherence and competence that illustrate a developmental trajectory of model fidelity. In many ways the changing trends of both adherence and competence are probably more informative to the clinical supervisor than are any single data point of either. Descriptions of each measure are as follows: 1. Weekly supervision ratings. Each week, during each staffing the clinical supervisor will make an adherence and competence rating of each therapist that presents a case. The weekly supervision ratings reflect the degree of adherence and competence for that therapist s work in that case in a specific phase. Thus, the weekly supervision ratings are not global but specific to a single case presentation. Both adherence and competence ratings are given (0 to 6 scale). Across the course of a year, 40 to 50 of these rating may be available to the supervisor and a clear trend of improvement, decline, or stagnation becomes apparent. Weekly supervision ratings are a view of adherence and competence from your perspective as the clinical supervisor. 2. Global supervision ratings. 3 times each year the clinical supervisor rates each therapists overall adherence and competence in FFT. The GSR form reflects the overall performance of the therapist across all supervision encounters, from the perspective of the supervisor. 63

71 Functional Family Therapy Clinical Supervision Training Manual 3. Counseling Process Questionnaire. After every other FFT counseling session, therapists administer the CPQ to each family member. The CPQ is intended to provide the family s perspective of their current experience with the therapist. The CPQ is divided into three sections; one related to engagement/motivation, one related to behavior change, and one to generalization. The CPQ is useful because it provides the family s perspective on the therapeutic process. A clinical supervisor would expect questions related to engagement/motivation to be high during the corresponding phase. The family should report high behavior change scores during the BC phase of FFT, and a similar pattern should emerge during generalization. 4. Site Feedback Review. This global review is a measure of the administrative and service delivery context of the site. It is completed once each year. The SFR can be shared with the administration of a working group to help advocate for a service delivery system that is conducive to the successful delivery of FFT. 5. Service delivery tracking, using the FFT-CSS allows the FFT clinical supervisor the opportunity to gain a big picture of how services were delivered to individual families and across an individual therapist s caseload. Each contact and session with a family is entered into the CSS. The report section of the CSS allows therapists to determine the number of contacts, the number of hours of services, and the service delivery patterns (attended sessions, no-shows, cancellations, etc). The service and contact-monitoring feature of the CSS gives supervisors access to an enormously valuable source of information about the work they are doing. This information not only provides documentation but also helps supervisors determine areas of strength and areas where assistance is needed. When used regularly these five instruments, along with clinical observation serve as a solid and systematic approach to the goal of quality assurance (monitoring and tracking adherence and competence) as well as a basis to determine immediate supervision intervention and a way to document change in both adherence and competence over time. 64

72 FFT Clinical Supervision Quality Improvement: The Primary Supervisor Activity in the Middle Phase Based on the profile of therapist adherence and competence gained from clinical supervision and tracked using the quality assurance tools described above, the clinical supervisor has a number of ways in which to attempt to improve the adherence and competence of the therapist. The choice of these interventions depends on whether: (1) the primary issue is one of adherence or competence, (2) whether the domain is one of knowledge or performance, (3) the nature of the maturity of the group (from low to high), and (4) your relational understanding of the individual therapist. There are two primary pathways of intervention to address these areas of quality improvement: Teaching is a way of imparting knowledge that is probably best targeted to issues of adherence and competence that fall within the knowledge domain. Such issues, as noted above tend to be misunderstanding of core principles, or the clinical procedures at either a basic level (adherence) or a complex level (competence) where the issue is one of understanding how to apply principles to a specific family. In both cases, it might be best for the clinical supervisor to specifically focus on the knowledge necessary to improve adherence or competence by discussing the conceptual principle behind an issue related to the core of the therapist s struggle. In a low maturity group, the clinical supervisor may decide to tell or instruct the group. In a moderate level maturity group, the supervisor may focus the discussion on the principle at issue and facilitate a group discussion. In a high maturity group, the supervisor would let the group discuss the conceptual principle. Thus, teaching interventions are targeted primarily at improving the understanding of the therapist Case specific/focused suggestions are a way to improve either adherence or competence through direct suggestions for the specific case under discussion. In other words, the clinical supervisor may suggest a specific course of action, a particular way of reframing, add to the development of an organizing theme, or suggest a relational assessment. All of these specific case focused suggestions are aimed primarily at improving the performance aspect of either adherence or competence. When 65

73 Functional Family Therapy Clinical Supervision Training Manual Figure 15 Supervision interventions Therapist Presentation of the case Story of the case Description of family Description of the problem What happened? What s next? Supervisor Decision Making What is the adherence issue? What is the competence issue? How can I intervene? Basis for determining the issues and what to do Core principles Phase of the model Goals of the phase Match to the family: is it working to accomplish the goals of the situation? Domain Knowledge Performance How Teach Question Guide targeting competence the goal is to help the therapist match to the unique family and apply the FFT model contingently so that it meets the unique requirements of that specific case. USING GROUP MATURITY LEVEL AS A GUIDE The maturity level of the working group can serve as a guide for the clinical supervisor. The manner of presentation of the specific suggestion will depend on the supervisor s assessment of the group maturity level and the relational understanding of the therapist. In a low maturity group, the clinical supervisor is likely to be quite directive and give a suggestion about a potential course of action. It may be that the clinical supervisor acts as if they are the therapist and demonstrates a possible reframe by saying it like they would to a client. In a moderate maturity group the clinical supervisor would likely encourage group involvement and help guide the feedback by both facilitating discussion and participating in the generation of 66

74 FFT Clinical Supervision Figure 16 Group Maturity as a guide for choosing what to do Possible ways to intervene based on group maturity High Moderate Low High adherence/competence Monitor/collaborate Group directed Strong adherence/developing competence Collaborate/suggest Supervisor guided Low adherence/competence Suggest and direct Supervisor directed suggestions. In a high maturity group the supervisor is likely to let the group provide the suggestions. Later Phase: Maintenance As the adherence and competence of the working group and individual therapists grow and the maturity level of the group increases, the clinical supervisor s role once again changes. In this later phase of FFT supervision, the clinical supervisor s goals are to maintain the quality delivery of FFT by each therapist and the group through ongoing monitoring and quality assurance while allowing the working group to continue to develop increased competence across a wider diversity of clients. The supervisor s role in this phase remains an active one as they continue to advance the competency levels and watch for drift in the application of the model. The FFT supervisor has two primary goals in this phase: continuing quality assurance while building advanced levels of competence. Using the tools described above, the supervisor carefully monitors each therapist to identify drift away from the model as soon as it 67

75 Functional Family Therapy Clinical Supervision Training Manual Figure 17 SUPERVISION MAINTENANCE PHASE Assessment Individual and group level of self-sufficiency Group maturity Goals/Interventions Allow group to meet adherence challenges Be less directive Outcome Stable group that adheres to model with complexity Group that can meet clinical challenges Working group that is cooperative, self-monitoring, and self-challenging occurs. The supervisor uses the developed maturity of the group to create peer-to-peer case level supervision. In addition, the supervisor monitors the service delivery context within the agency advocating for the team and a delivery context that supports FFT. The maintenance phase of FFT supervision can continue for some time. It is usually when a team member leaves or when a new member is added that the overall competence and group dynamics change to the degree that the supervisor may need to begin with a renewed focus on the early engagement/motivation and the middle adherence and competence phase goals once again. 68

76 Implementing FFT Supervision SECTION III

77 Implementing FFT Supervision 3 FFT has been implemented as the primary intervention model in over 100 community sites in more than 17 states between 1998 and 2003 (Sexton, 2002). At those sites, approximately 375 therapists helped approximately 10,000 families each year with Functional Family Therapy. The organizations, therapists, and clients at these replication sites represent a very diverse cultural, community, and ethnic range. To date FFT has been used in agencies that primarily serve clients who are Chinese-Americans, African- Americans, White-Caucasian families, and Vietnamese, among others. The agencies in which FFT has been replicated range from community not-for-profit youth development agencies, to drug and alcohol groups, to traditional mental health centers. The therapists at these sites are as diverse as the clients in regard to gender, age, and ethnic origin. At these sites FFT is delivered both as an in-home service and as a traditional outpatient program. Increasingly, FFT is being implemented in school-based settings (Mease & Sexton, in press). An increasing emphasis has been on statewide implementation of FFT in various treatment systems. For example, FFT has worked within the juvenile justice system in Washington State for over 5 years. FFT recently began a project to train all adolescent and family therapists in the New York Mental Health system (over 60 individual sites). Quality on site FFT-based clinical supervision is a central feature of sites that are successful in delivering FFT. It is the clinical supervisor that has the complex task of monitoring and improving model adherence and competence through ongoing quality assurance and improvement. It is the on-site clinical supervisor who monitors the 70

78 Functional Family Therapy Clinical Supervision Training Manual demands of the agency in which FFT is delivered and advocates, when necessary, for service delivery systems that support the FFT model. In this section we focus on how you might think in order to successfully implement the FFT supervision model and meet these challenging goals. Our goal here is to give you an anchor to hold you midst the storm of emotional and behavior experience that occur in family therapy and supervision. We think you will be successful if you can adopt a supervisor reality or a way of thinking about the process that goes on between you and the therapists you supervise that focuses you on the primary goals of supervision (from an FFT perspective) and keeps you grounded in the relational process that is the arena in which supervision encounters take place. The supervisor reality Being a successful FFT therapist requires more than learning the three phases and adopting the core principles. It requires the therapist to engage in FFT in an active, and mulitsystemic manner. Successful implementation requires a willingness on the part of the FFT therapist to struggle with the seeming ambiguity of this model: its structure and flexibility, its relentless model focus and intense client responsivity, its demand to give full attention to what goes on in the room while at the same time working in and with the community. To reiterate, successful implementation of FFT requires that the therapist apply the model with high adherence to the technical and core values of the model so that they can develop competence in delivering it with various families. Creating conditions that foster therapist adherence and competence within the context of the working group is your responsibility. The clinical supervision model is the clinical supervisor s tool to accomplish these tasks. As a clinical supervisor your job is to help therapists adopt both the guiding principles and the clinical map of FFT as their primary sources of clinical decisions. You have to help them adopt the lens of FFT using it to focus their inherent and developed strengths so that precise, high quality and systematic clinical decisions can be made that increase the likelihood of success with families. Successful implementation of the FFT supervision model requires the clinical supervisor to adopt a new reality by 71

79 Implementing FFT Supervision focusing on issues of adherence and competence as the core and anchor of any supervision intervention. It requires the use of the CSS, the various measurement tools described earlier and a dedication to developing and maintaining a philosophy of quality improvement as the primary goal of supervision. Similar to FFT therapy, successful supervision requires two experts who work together in an attempt to help the family. As a result, there are three different realities that exist in FFT therapy: the reality of the therapist, the reality of the family, and the reality of the supervisor. As the supervisor you have impact on the therapist by way of helping ensure the quality of the services delivered to the family. As such you are intimately yet indirectly involved in the services families receive. Thus, FFT supervision involves the reality of the family, the therapist, and the supervisor. Each is different, each has different goals, but all must work together for successful change. Family reality. The reality of the family is one for which the elaborate features and goals of FFT have little direct importance. Families rarely care much about the goals of a family focus or negativity reduction, about relational assessment, or risk factors. Instead, family members are interested in the outcome of this process. Early on they are interested in whether they are heard, whether the therapist is protecting and working with and for them, and whether therapy can make a difference in their lives. In later phases the family focuses on specific skills if they seem relevant and helpful. Thus, the family s reality is one marked by alliance and outcome. Therapist reality. When successfully conducted the therapist delivers FFT by adhering to the model and delivering it with high competence. To do so the therapist must be anchored in a process focused reality while working in intimate, personal, and responsive ways with a family. A process focus requires the therapist to think less about the exact details of who did what to whom and instead focus on the relational and attributional features of what is being presented and on accomplishing the goals of the phase of treatment. For example, the internal dialog of the successful therapist in engagement and motivation is filled with assessment questions regarding the levels of negativity and blame, the degree of family focus, the level of between family and therapist and family to family alliance (the goals of engagement and motivation). The therapist s mind is also 72

80 Functional Family Therapy Clinical Supervision Training Manual filled with attention to reframing, the family s response to a reattribution, deciding on what might be added to the validation portion and how to change the meaning of a behavior, emotion, or intention. In other words, in each phase of FFT the therapist is primarily concerned with the process of therapy rather than the content details of what the family reports. In FFT, the therapist must attend to the realities of the family through accomplishment of the phase goals of the model. Supervisor reality. FFT supervision is model-focused and uses the lens of the clinical model to guide decision-making. FFT supervision has it its own set of goals, objectives, and relational processes that comprise the lens of FFT supervision. When you adopt the supervisor reality of FFT it becomes your primary way of thinking about each supervision encounter. This grounds and anchors you in a way of understanding the supervision process so that you can systematically respond in a way that is purposeful and relationally focused while constantly attending to improving the quality of the therapist s work. Just as in the clinical model, the supervisor must view the supervision encounter from this lens in order to be grounded. Like the therapy model, the supervision lens contains a set of guiding principles as well as a specific phasically based protocol. When successfully conducted the supervisor helps the therapist deliver FFT with strong adherence and high competence. To do this the supervisor must be anchored in a process-focused reality while working in personal and responsive ways with a therapist who has to translate FFT into his/her work with sometimes difficult families. A process focus requires the supervisor to think less about the exact details of who did what to whom and instead focus on the features of adherence (to the clinical and technical aspects of the model) and the relational dynamics with the individual therapist and the working group. A process focus is not intended to suggest that the supervisor not listen or not pay attention. Instead, the content details (exactly what is going on in the case) become background to a foreground of phase based assessment and intervention that is prescribed by the supervision model. In FFT the supervisor must attend to the realities of the therapist through the lens of the supervision model. 73

81 Implementing FFT Supervision Figure 18 Staying on Track: Using the CSS and Case Staffings Learning to focus on therapist adherence and competence amidst the discussion of the complex cases confronted in FFT requires considerable effort. While both FFT as a clinical model and FFT as a supervision model seem simple and straightforward, both are complex. Two challenges are particularly important to FFT supervision: (1) being purposeful and focused in clinical staffings and (2) accurately measuring and using adherence and competence information. SUPERVISION PLANNING AND STAFFING Case staffings provide a place for therapists to think through the FFT lens with a like-minded group of peers in order to develop a long-term case plan and a short-term session plan. As such, the case staffing team becomes a valuable tool in developing adherence and competence if they together discuss cases and plan based upon the 74

82 Functional Family Therapy Clinical Supervision Training Manual core principles and clinical protocol of FFT. As noted above, staffings are the primary tools and contexts of FFT supervision. The clinical supervisor has to help the group think through the FFT lens by directing case planning and session planning discussions. By using the protocol the team can begin to move the relational process aspect of the case (the primary interest when doing FFT) to the foreground and the content (only a secondary interest) to the background. As they listen, the FFT supervisor must assess whether adherence or competence is the major issue, determine if it is a knowledge or performance issue, and respond in a way that matches to the therapist as well as the maturity level of the group. Case staffing begins with a presentation of the case and broad case planning, including input by the team, and the development of a specific next session plan. FFT focused case staffings initially feel very different than traditional staffings. Typically little of the traditional psychosocial history information is presented. Instead, the focus of case planning is on how to understand how this unique problem functions within a unique family relational system. In this way the staffing mirrors the thinking process the therapist must follow to work within FFT. Specific session plans are based in the phase of the model (what are the phase goals) with unique implementation strategies based on the unique relational structure/functions of the family. Just like family therapy sessions, FFT supervision staffings are more successful when the supervisor plans for each meeting. Planning begins by the supervisor identifying the phase of supervision, clearly articulating the goals for the session for each therapist, and determining the specific adherence and competence issues to be addressed. Supervision session plans are usually based on a review of the therapist records (in the CSS), previous weekly supervision ratings, and recent global therapist ratings. It is also important to determine which therapist should present a case. Each therapist should present a case twice each month. Once the staffing begins, the goal is to move from a broad discussion of the case to a specific session plan. As noted above, the FFT case staffing protocol provides guidelines for thinking about a family and their relational dynamics in a way that places the problem behavior in a relational context. Before a case discussion is over, a specific plan must be developed. That plan must lay out a proposed way to accomplish the phase goals for the unique family in question. The clinical supervisor accomplishes this by structuring the conver- 75

83 Implementing FFT Supervision Figure 19 Movement in Staffing Goal Lead therapist/group to think in this way about clients Case Plan (Broad understanding) Issues: Manage time Fit phase Fit/issues/goals Through structuring conversation leading discussion asking, prompting etc. Session Plan (specific direction) sation, leading the discussion, and asking and prompting the working group to participate. CLINICAL SERVICES SYSTEM (FFT-CSS): AN ADHERENCE AND COMPETENCE DEVELOPMENT TOOL As a tool for FFT therapists the FFT-CSS is a an intuitive user friendly web-based program used by community based FFT therapists to record client information (e.g. contact information, demographic information, previous history), client contacts (visits, scheduled visits, phone contacts, etc.), assessment information (individual, family, and behavioral assessment), adherence measures, and outcomes measurements. The goal of the CSS is to increase therapist competence and skill by keeping therapists focused on the relevant goals, skills, and interventions necessary for each of the phases of FFT. The CSS provides immediate real time feedback to therapists on model fidelity, client outcomes, and service delivery profiles. In addition, it provides the site clinical supervisor with specific informa- 76

84 Functional Family Therapy Clinical Supervision Training Manual tion to be used in helping supervise cases and maintain model fidelity. The CSS has two major sections: a clinical section (for FFT therapists) and a supervision section (for FFT clinical supervisors). Supervisors use the CSS to log all supervision sessions (group and individual). In addition, the CSS is designed as a tool that includes all of the quality assurance tools discussed in this manual (e.g. weekly adherence and competence ratings, global therapist ratings, and site feedback reports). Reports of each are easily available. The FFT-CSS is a secure web-based data system. As such we have built in a number of security safeguards. FFT therapists only have access to their own information. Site clinical supervisors only have access to site information. Clinical supervisors receive a special user password that is highly sensitive and should be kept secure. That password only allows access to the working group assigned to the supervisor. In addition, the FFT-CSS has been designed to be HIPAA compliant and web-secure. Further information about these safeguards can be obtained from your FFT implementation consultant. Improvement Plans Quality assurance and improvement are central to the delivery of FFT. Dedication to quality assurance and improvement mean that the site clinical supervisor and the agency for which they work take the responsibility of this role seriously. In most cases the ongoing supervision conducted in weekly staffings and individual supervision (if a part of the agency protocol) are adequate to develop and maintain the quality necessary to produce positive results in families. Unfortunately, despite the best efforts of the clinical supervisor, there may be therapists who do not respond to the interventions of FFT clinical supervision. Their adherence struggles are well documented by the quality assurance measures discussed above. Over time their low adherence begins to have a significant impact on the families they serve. In these cases, the clinical site supervisor and the agency administration has a responsibility to take some action. In these situations the site supervisor may wish to use specific formal and informal quality improvement plans. These plans systematically describe the therapist s challenges, clearly identify areas in which their performance is a problem, and suggest specific methods (e.g. 77

85 Implementing FFT Supervision retraining, additional training, case observation, etc) that might improve the deficit. Whether informal or formal, improvement plans are contracts between the agency and the therapist identifying areas of needed improvement, methods to improve, and a time frame within which demonstrated improvement must occur. Improvement plans occur when necessary model adherence has not been achieved. Informal improvement plans occur when the normal case staffing and individual supervision does not result in improved adherence and competence. Informal plans include: 1. Specific elements identified (what is it?) e.g. Reframing, alliance building, focusing on phase goals etc. 2. What is the problem in this area? Not complete, not primary focus, etc. (knowledge, performance) 3. How are we going to do this how do we make this the focus of your attention? Reading, individual consultation, etc. 4. What is our time frame? When do we need to accomplish change? 1 month, 2 months, etc. 5. When will we reevaluate? Formal improvement plans occur when improvement has not been achieved in any other way. Formal improvement plans are between the agency and the therapist and suggest that the work of the therapist is not meeting the expected level of quality, as defined by the FFT clinical model. The clinical supervisor may suggest to the agency that such a plan is necessary and work with the agency to help identify the important elements. These plans should be written agreements and should include all of the same elements as the informal plans noted above. 78

86 Conclusions & Afterthoughts SECTION IV

87 Conclusions & Afterthoughts 4 It is our hope that this manual has provided you with the foundational material you need to begin to adapt to your new role as a clinical site supervisor. As you embark on the in-person portion of your FFT site supervisor training, it is also our hope that this manual will serve as a reference point for your supervision work whenever you feel the need to anchor yourself in the FFT supervision model. As stated at the beginning of this manual, mastering the knowledge and skills of FFT clinical supervision is a challenging task. You may find yourself struggling in much the same way you struggled through developing your competence as an FFT clinician. This is to be expected. Stick with the model, use the supervision tools available to you (e.g. the CSS, the supervisor rating form, etc) and remember that the follow up supervisor training will provide an opportunity for you to hone your skills. As the clinical site supervisor your new role requires you to run a working group and lead the charge for quality assurance and quality improvement of FFT service delivery. This is no small task. We have asked you to increase your knowledge about FFT in general, to learn a new model of supervision, to facilitate a working group, to use the CSS as a supervision tool, and to apply what you have learned by implementing FFT supervision at your site. In this capacity you take on many of the responsibilities formerly handled by the FFT implementation consultant. It is now your job to (1) monitor model fidelity and quality, (2) promote adherence and competence, and (3) manage the service delivery context that exists at your site. To accomplish these tasks you must become immersed in the core theoretical principles of the supervision model and the specific 80

88 Functional Family Therapy Clinical Supervision Training Manual protocol for conducting FFT supervision. It is important to remember that supervision is a model focused, relational, multisystemic, data-based process. There are a set of goals, assessment tools, interventions, and expected outcomes to guide your practice all of which occur within the context of the working group. Two central concepts are essential to FFT supervision: adherence and competence. Each of these concepts encompasses knowledge and performance domains. Your focus as a supervisor will shift depending upon the domain in which team members struggle and the overall maturity level of your working group. Continuous assessment of these domains drives the supervisor s decision-making and intervention choices. As numerous studies substantiate, therapist adherence and competence has a direct and positive impact on the success of our work with families. The site supervisor is an essential part of ensuring service quality that will help families succeed in therapy. 81

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