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Presentation provided by Coalition for Juvenile Justice Institute for Family Centered Services A Partner of The MENTOR Network and flagship provider of
Family Centered Treatment Sustainable Change
Home-based services have become the primary method of public sector intervention for families experiencing functioning difficulties. Most models practiced are, by design or default, client centered, resulting in poor long term outcomes without impacting the family. This EBP model guides families through a change process that challenges the family to demonstrate their value of the changes they have made. Thus Family Centered Treatment enables long term sustainable change rather that short term and performance based.
Origins of Family Centered Treatment® Typically, theories are developed through university based research and the hypotheses are then tried and tested in the field. IFCS did the reverse; tried and tested the strategies in the field, and then through analysis, identified theories that supported the treatment. Out of this research was developed a theoretical model for treatment. Practitioner based model refers to the practice of clinicians using trial and error techniques in the field to determine what works with families. Later after the model developed, the staff practices known to work vetted for theoretical validity and adherence to home based best practices. This model is now known as Family Centered Treatment ®. Family Centered Treatment is based upon what clinicians in the field/on the street did that worked, a.k.a. practitioner based.
Theoretical Framework Comprehensive and intensive home-based model Developed over 20 years Continuously refined through research, experience, and feedback from clients. Although developed from applied success, some of the critical components that provide the theoretical framework are recognizable as derivatives of major models of evidenced based practice such as: Eco-Structural Family Therapy and Emotionally Focused Therapy/ Sensory based Trauma Treatment Salvador Minuchin Sue Johnson
How does it work? WWith the whole family as defined by the family MMeet in their home at days of the week and times of day that are convenient for the family. SSession schedules get the clinician involved during the most troublesome and difficult times and as they occur. PProvides 24/7 on call crisis support for the family with their known clinical staff. (not a universal on-call system) MMultiple hour sessions several times per week become the norm for creating change. PProvides opportunities for the family to practice functioning differently. These weekly “enactments” are integral to the process (not just talk therapy).
Essential Components The primary stages or phases of FCT are: Joining and Assessment Restructuring Value Change Generalization Typical length of treatment is 6 months although the process is individualized for each family to attend to their specific needs and the time frame can decrease or increase dependent upon need. Trauma Treatment is provided at any phase or juncture of treatment when need is indicated
What is meant by “sustainable change”? When achieved, sustainable change helps a family move from making conscious "efforts to change" to establishing a new, accepted "way of living”.
Engaging the family We must connect before we can correct Privilege; not a right to be in their home Treatment and change is their choice Guarantees Respect and dignity integral to the process This process is done “with” them; not “to” or “for” them
Phase 1; Joining FCT clinicians have a clear vision of what the joining phase should look like. This involves respecting the uniqueness of each family and getting to know their world through their point of view It includes a notion that “people are people” and with similar needs as we all possess. This approach requires the clinician to gain understanding for the reasons why the family has made the decisions they did. He/she may even feel if given the same resources and conditions, he/she would have come to the same conclusions as the family. This process allows the clinician to develop an attitude of dignity and respect for the family that eliminates the “one up” position many professionals assume with clients. By doing so, the family opens up and allows the clinician “in”; also known as “joining”.
Assessment Although standardized assessments are utilized (FAD, CANS etc.) the Family Centered Evaluation (FCE) process is specifically designed to be attractive for families that are typically known as highly resistant to engage in treatment. This is accomplished through the use of participatory assessment activities rather than a standard interview process; Ecomaps, Family Life Cycle and Structural Family Assessment. The Family Centered Evaluation (FCE) enables the family to discover unhealthy dynamics on their own, as the activities provide an opportunity for them to pull the pieces together rather than expecting the therapist to dictate what needs are to be addressed. This process permits the family to be in “charge” (empowered) and enables their investment in their process for change. For example; at the end of one of the FCE components, the Structural Family Assessment (SFA), the family is asked to identify goals that represent an honest and real need based upon their own assessment of their level of functioning (what is working and what is not).
Treating the Functions of Behaviors ; not just a behavioral change approach 1. Behaviors are often idiosyncratic and triggered by sensory based perceptions 2. While cognitive ability to understand, articulate and even role play needed behavioral changes may be present, emotional blockages from past pain (trauma) can interfere with the integration of desired changes. 3. To dismiss the client or family member as unwilling or unable to make needed behavioral changes is to place them blame on the client / family. 4. Trauma treatment is needed instead.
Enactment: 2 distinct types Diagnostic Enactment Occurs when you assign a task or allow a spontaneous interaction to occur and make a diagnosis on the area of family functioning needing intervention. Diagnostic Enactment Occurs when you assign a task or allow a spontaneous interaction to occur and make a diagnosis on the area of family functioning needing intervention. Intervention Enactment Occurs when you have selected a intervention and direct the family to practice doing something other than what they typically do. Intervention Enactment Occurs when you have selected a intervention and direct the family to practice doing something other than what they typically do. Highlight and process the alternative outcomes Techniques: Alternative treatment techniques are permissible as long as they are designed at changing the interactions and are not therapist focused: Solution focused, Art Therapy, Narrative, Play Therapy etc. Techniques: Alternative treatment techniques are permissible as long as they are designed at changing the interactions and are not therapist focused: Solution focused, Art Therapy, Narrative, Play Therapy etc. Phase 2 Restructuring
Restructuring Evidence of successful engagement is indicated by the family’s follow through on suggestions or homework. These assignments can include the therapist’s efforts to get the family to vary their ways of interacting with each other outside of their norm. This experiential attempt to behave differently is systematically analyzed by the family and the therapist so the family can learn, refine and attempt a new strategy for interacting differently that works for the family (meets their needs). Once the right strategy is found, the family has the opportunity to practice it with the support and coaching of the therapist. The therapist corrects the family as they slip back into their “old way” of behaving; rapidly accelerating the change process. A potential pitfall with this approach is that the family might have a significant emotional block that prevents them from behaving in the alternative way. When this is discovered, the therapist must process this emotional block to resolve it enough so the family can practice the alternative behavior.
Why do clients or families make changes? Change Theory : when what we are doing is not longer working….
Reasons folks change vary considerably But which reasons are most likely to enable change that is sustainable? Conformity Compliance Pleasing Avoidance of conflict Remove the oversight or external power
If exit or discharge occurs before the client or family “owns” the change what is likely to occur? What happens if discharge or exit occurs before change is “valued”?
Valuing Changes A distinctive feature of FCT Family is guided to experience value conflict concerning the behavioral changes that they have made during treatment. Necessary for changes made during treatment to be sustained. Most models terminate services once compliance is achieved. Ironically it is at this juncture that FCT provides opportunity for the family to examine the reason/function of the behavioral changes, thereby increasing the chance that the behaviors will become internalized and sustainable.
Phase 3: Valuing Changes This stage is distinctive of FCT. FCT clinicians are not satisfied with conformity and compliance; FCT goes beyond to assist the family in developing ownership for their new adaptive behaviors by asking them to examine the reasons for making changes after the behavioral change / restructuring phase. This leads the family to incorporate the changes into their value system; and therefore, the changes are long lasting. This ensures sustainability beyond treatment. Value change is accomplished by the therapist dramatically changing his/her style with the family from highly directive to questioning and shifting responsibility back to them, i.e. “how have you handled this in the past successfully?” “Why don’t you try that?”
Phase 4: Generalization In this final stage of treatment, the family is guided to make explicit their process of addressing and resolving problems. This phase may take up to one month. Families that can effectively identify their problems, explore alternative solutions, implement their ideas/solutions, evaluate the effects and revise their responses, when needed, tend to negotiate through stages of family life well. In this phase therapist must make this process of solution focused self determination (just described) very clear for the family. This must occur in order that the family can use this process to address the expected and unexpected future challenges effectively. The Generalization phase also helps with sustainability by leaving the family with a clear problem solving process to follow when faced with future challenges. This furthers their growth, development and healthy functioning.
The “Power of Giving” is an fundamental component. Positions families to give to others as a method for discovery of their inherent worth and dignity.
Joining and Assessment During this phase the clinician engages the family and gains acceptance and trust. The family centered evaluation is utilized to determine areas of family functioning that need adjustment. Indicator for Transition: The family begins to carry out the clinician’s suggestions and assignments indicating trust in the process. Restructuring The clinician and the family use enactments (experiential practice experiences) to alter ineffective behavioral patterns among family members. This process includes techniques to modify the crisis cycle to more effective and adaptive patterns of family functioning. If emotional blocks, due to past or present trauma, prohibit compliance with practicing new behaviors, the clinician engages the family or specific members into trauma treatment, via emotion change techniques, rather than behavioral approaches. Indicator for Transition: Successful enactments lead to earnest questions by the family members regarding what they can do differently to change/break their maladaptive patterns. These questions are an indicator that the ownership of problems is now seen as a family issue, rather than placing the blame on an individual family member. When the practicing of new interactions begins to produce behavioral changes, the clinician moves to the next phase. Valuing Changes The clinician adjusts their style and methods in order to challenge the intent and reason for the behavioral changes that the family has made. The family evaluates and defines the reasons for their changes. Family members integrate new behaviors into their personal value system, determining changes to sustain based on what is working for them. Indicator for Transition: The family is no longer merely conforming or complying with directions, but is following through on suggestions and expanding upon them to meet their own needs. Although crisis may still continue, the family tells the clinician how they handled the situation using their newfound skills, rather than asking the clinician what to do. Generalization With new skills for dealing with conflict and increased understanding of their own dynamics, the family continues its work, but the treatment is less intense and frequent. The clinician’s focus is continued “practice”, review of what has “worked” previously, and use of “reversals.” Indicator for Transition: New skills have become internalized and new responses to crisis are becoming patterns. Once in this phase the family will be ready for discharge within 30 – 60 days. Emotional Blocks / Trauma Treatment With clinician guidance, the family determines coping and supportive behaviors to address traumatic histories. They are guided to identify and practice effective methods for meeting emotional needs.
Limitations of Practice R equires involvement of a family system, however “family” is defined (can be composed of non-related individuals living together as a family system) Primary focus i s not psychiatric or medical. Nevertheless, FCT can be utilized effectively when illnesses, either medical or psychiatric, are affecting the short or long term functioning of the family system.
What makes Family Centered Treatment work? Standardization of management and clinical practice in all locations
Standardization - Management and Supervision Assure implementation of the model for each FCT client FCT therapists receive an average of 5 hours per week of supervision (combination of peer, individual, field and crisis support) FCT requires a commitment by management to provide: Peer supervision via a weekly team meeting process Weekly supervision of the therapist to assure fidelity to the FCT model – (staff complete standardized forms requiring signatures of the supervisor and therapist) Monthly staffing of each FCT case utilizing a family systems model of review (MIGS – mapping, issues, goals, and strategies) 15 Key treatment related documents that must be produced for each case that are critical to each phase of FCT treatment. Information management system that provides a record review, tracking, and maintenance process producing the data necessary to assure fidelity to the model.
Comprehensive Quality Assurance and Improvement Oversight Corporate level clinical review of case staffing process for each location Management review and response to each team’s meeting minutes Corporate level quantitative and qualitative client record review Corporate level review of dosage (intensity and frequency of treatment provided per assessed and authorized need)
Fidelity Each FCT phase requires specific tools/documents effectively assesses fidelity to FCT per client/family tracked via electronic information management systems enables evaluation of fidelity to the FCT model for each client and worker A consistency checklist: an overview of all the fidelity tools required 15 Individually designed documents to record the distinct aspects related to each phase of the FCT model (Joining/Assessment, Restructuring, Value Change, and Generalization). These records must be used with each client/family and filed in the client record. FCT session planning document for the FCT supervision process, Video review forms to be used during supervision (1 per month by each therapist). Clinical Performance Reviews are conducted to audit the proficiency of staff and teams in FCT case staffings. These audits are random and weekly. Reports are made to the team and the case staffing form (Maps, Issues, Goals, and Strategies – titled MIGS) is reviewed with directions for improvement and assignments given for follow up.
Transparency Customized data requirements from funding sources typically involves the use of assessment instruments that have been validated in the literature, such as CGAS, CFARS, and NCFIS. Specialty Population Outcomes Ex. observed re-offending behaviors of juvenile offenders Such observations are validated in cooperation with collaterals, e.g., probation officers. These instruments and the standardized training are attached documents in the standardization section of this application. Family Centered Treatment Foundation Required monitoring and oversight of providers FCTF is a private non-profit organization devoted to the advancement of family preservation practice provides annual peer reviewed analysis of Family Centered Treatment’s practice based evidence data. These reports are published on the FCT website
Evaluation of outcomes and results
In 2011 /12 for the 2443 discharged FCT clients, 2245 (92%) of them received the “full model” meaning they were engaged in treatment. IFCS considers a family engaged when they have participated in a minimum of 5 sessions.
Synopsis of Research Outcomes* *The following outcomes are derived from “Family Centered Treatment, An Alternative to Residential Placements: Outcomes and Cost Effectiveness” (unpublished manuscript, recommended by peer review for publication and submitted to the Journal of Juvenile Justice on January 24, 2012). Placement Patterns Year One Post-treatment: FCT youth had fewer residential placements, 38% vs. 50%, (p =.002). Frequency of residential placements was lower for FCT youth,.50 vs..63, (p =.03). FCT youth spent less days in residential housing, 64 vs. 91 days, (p =.002). FCT youth spent less time in community detention, conditional on placement, 44.5 days vs. 54 days, (p =.007). FCT youth spent less time in pending placements, 14.6 days vs days, (p =.01). FCT youth spent fewer days in pending placement, conditional on placement, 51 vs. 72, (p =.004).
FCT Site Implementation Successful replication in over 30 sites across 7 states
Family Centered Treatment ® -An Alternative to Residential Treatments for Adjudicated Youth: Outcomes and Cost-Effectiveness. Published in the Journal of Juvenile Justice, a semi-annual, peer-reviewed journal sponsored by the Office of Juvenile Justice and Delinquency Prevention (OJJDP). Articles address the full range of issues in juvenile justice, such as juvenile victimization, delinquency prevention, intervention, and treatment.
The U.S. Departments of Justice and Health and Human Services have jointly released the "Evidence-Based Practices for Children Exposed to Violence: A Selection from Federal Databases." Family Centered Treatment is listed in the matrix of practices identified. Download and read the full document at Matrix_2011.pdf.
FCT is formally designated and listed with the Virginia Commission on Youth 4th edition Collection of Evidence Based Practices for Children and Adolescents with Mental Health Treatment needs. The Virginia Commission on Youth was established by the Virginia General Assembly and represents a legislative response to a two-year study examining the issues related to services to chronic status offenders. Virginia Code directs the Commission "to study and provide recommendations addressing the needs of and services to the Commonwealth's youth and families." Enacted in 1989, the Commission began operations in Information available at:.
FCT is formally designated as a Family Therapy model option eligible for providers as part of the North Carolina Division of Medical Assistance Intensive In Home Service Definition (p.38). North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
As result of the effective work within Maryland, Family Centered Treatment is recognized by Innovations Institute. The Maryland Child and Adolescent Innovations Institute has recognized Family Centered Treatment ®. The Institute for Innovation and Implementation (The Institute) serves as a training, technical assistance, evaluation, policy, systems design, and finance center for the Maryland Children's Cabinet and its member agencies, along with multiple other states, localities, and private organizations. The Institute supports state and local governments and organizations to implement effective systems and practices that are designed to best meet the needs of children and youth with complex behavioral needs and their families. This support is provided through three primary units within The Institute: Policy and Finance; Technical Assistance and Implementation; and Research and Evaluation. These units work in an integrated fashion to assist governmental and other organizational entities to achieve better outcomes for children, youth, and their families.
In 2012, FCT was selected as model of choice to be implemented as part of the state of Indiana Department of Child Services Comprehensive Home Based Services RFP initiative. The purpose of this RFP is to select Comprehensive Home Based Services vendors/providers that can satisfy the DCS need for the provision of Comprehensive Home Based Services that are to be Evidenced Based Models or Promising Practices to all 18 regions and the corresponding 92 local offices in the State.
In 2012, it was announced that FCT had been selected as an intervention for review by SAMHSA's National Registry of Evidence-based Programs and Practices (NREPP). NREPP is a searchable online registry of mental health and substance abuse interventions that have been reviewed and rated by independent reviewers. The purpose of this registry is to assist the public in identifying scientifically based approaches to preventing and treating mental and/or substance use disorders that can be readily disseminated to the field.
Family Centered Treatment has been reviewed and is listed with the California Evidence-Based Clearinghouse for Child Welfare (CEBC). CEBC provides child welfare professionals with easy access to vital information about selected child welfare related programs. The primary task of the CEBC is to inform the child welfare community about the research evidence (http://www.cebc4cw.org/glossary/research-evidence) for programs being used or marketed in California. The CEBC also lists programs that may be less well-known in California, but were recommended by the Topic Expert for that Topic Area.
In summary FCT is more than a Clinical Model of Treatment Effective delivery of FCT is also contingent upon a tripartite approach of management. All levels of management must support the value of effective treatment over business pragmatism. This includes assuring that funding is in place for the: training to ensure that each direct service staff demonstrates theoretical knowledge and field skills competency fidelity measures built into the clinical process and the ensuing monitoring systems rigorous research and data collection systems
Further definition of the FCT model can be accessed on the IFCS or Family Centered Treatment Foundation web site Since 2010 FCT, and specialty uses of FCT, have been presented at the following national conferences: 1 st annual Global Implementation Conference, CWLA, AAMFT, AAAEBP, NAMI, FFTA, Violence Prevention, Research Conference on Family Programs and Policy, Generations United, ACA, NASW, CMHS GAINS (SAMHSA), AMHCA, NAFC, NCJFCJ and the 2011 and 2013 Global Implementation Conferences on Evidence Based Practice Contact information of presenter and FCTF developer
(704) Contact: Tim Wood, MS, LPC- Executive Director, FCT Foundation