Functional Family Therapy Child Welfare (FFT-CW®) Sylvia Rowlands Michael Robbins

Agenda Context for Evolution of Model Clinical Model Review of Data Principles Intervention Tracks Triage Process Review of Data Q & A

Context for Evolution

The New York Foundling The New York Foundling (“The Foundling”) is recognized as the world industry pioneer in using only evidence-based practices (EBP) to more predictably change the trajectory of children and families in need of social services. The Foundling’s mission is furthering their passion and commitment to help improve the lives of children by partnering with nationally recognized thought leaders who will be instrumental in advancing this field by delivering meaningful value- add and increasing momentum.

NYC 2006

NYC Preventive Services 2006 Case Closing Reasons: City Wide (per 10/2012 Child Stat) Total Cases 8,585 Closed Progress toward goals 57% Closed Child Remanded 6.3% Closed Family Refused Services 7.6% Closed Referred to another PPRS 18% Closed relocated, higher level or service need, whereabouts unknown 13.3% City wide North Manhattan Length of stay 2008 21 months

2007 Foster care placements

In 2006 there were approximately 1700 juvenile delinquent residential placements

Functional Family Therapy Treatment Process Engagement Retention Family functioning Individual Conduct/ Delinquency Drug use HIV Risk School Internalizing Parent distress /drug use Out of Home Placement Incarceration Residential Foster placement

Treatment Population and Parameters Behavior problem or at risk youth/families Age range: 11-18 Service Delivery Contexts Mental health Child welfare Juvenile Justice Schools Short term intervention Average of 12-14 sessions Average between 3-6 months

Global Implementation of FFT 25,000 - 30,000 families 300+ sites/teams 1500+ therapists Belgium, Canada, Chile, Denmark, Egypt, England, Ireland, Netherlands, New Zealand, Norway, Scotland, Sweden, USA

Promise of FFT not Broadly Achieved in Child Welfare Settings Research Child Welfare Paraprofessionals Practice Juvenile Justice 11-18 year olds Challenges Too expensive for all families Too complex for service providers

Key Adaptations for FFT-CW® Family-based model that addresses a range of at risk families Cost-sensitive model that uses a triage process to “match” typical child welfare workers skill sets and families needs “General practitioner” model that addresses full developmental range of youth and problems experienced by family members

Clinical Model

Principles Core to Model Respect-based Relational Accountability Phase-Based

Accountable to families “Attitude” Core Values Family-Based Accountable to families Respectfulness Non-judgmental Strength-based Relational vs. Individual Balanced alliances Matching to individuals, relationships, family, and environment Specific and individualized change Fidelity to model A Philosophy / Belief System about people which includes a core attitude of Respectfulness; of individual difference, culture, ethnicity, family form A change model that is focused on risk and (especially) protective factors – “Strength Based”

FFT Attitude Matching Interventions are specific and individualized to the unique challenges, diverse qualities (cultures, personal experiences), and strengths of all families and family members

RELATIONAL ASSESSMENT High Risk Track BEHAVIOR CHANGE P OO ROO EOO TOO AOO MOO NOO E N G A M T P O S T R E A M N MOTIVATION RELATIONAL ASSESSMENT GENERALIZATION Although we are a family-first model, therapists must be aware of and work to influence multiple systems. This multisystem focus is not limited to generalization. From the outset, therapists must plan and intervene to address multisystemic demands. Over time, the focus increases, but even during initial contacts, therapists must incorporate interventions to address the requirements/needs of other systems (such as juvenile justice or school). The assessment of other systems changes over the course of treatment as cases progress from engagement to motivation to behavior change to generalization. S E S S I O N 1 2 3 4 5 6 7 8 +

Low Risk Track Interventionists Generalize Maintain-Enhance-Gen’lize Any Facility or Previous Work Link to… Gen’l Engage & Motivate Support & Monitor Link to… Gen’l Evidence-Based or other Change Program

Range of Therapist Skills Relational Structuring Conceptual Clinical/Life Experience (1) Relationship skills Warmth (contextually expressed & appropriate), non-blaming, humor, interpersonal sensitivity, respect for individual difference (2) Structuring skills provide direction within the sessions, locate and provide resources and materials, provide step-by-step structure and behavior change techniques (3) Conceptual skills Assess/understand relational nature of “problem;” Monitor therapy process; Plan and “think on your feet” (4) Clinical & “life” experience Be aware of it, “use it,” … but don’t let it run your clinical decision making

Engagement Phase Goals Skills Activities Focus Availability Phone reach out, Frequency Immediate responsiveness Strength-based and relational Superficial qualities Persistence Matching Enhance perception of responsiveness and credibility Goals Skills Activities Focus GOALS: Enhance perception of responsiveness and credibility, demonstrate desire to listen and help SKILLS REQUIRED: Qualities consistent with positive perceptions of clients, persistence, matching FOCUS: Immediate responsiveness, strength based relational focus, individual and cultural characteristics ACTIVITIES: High availability, telephone outreach, language and dress appropriate, proximal services or adequate transportation, contact as many family members as possible. Schedule sessions as frequently as necessary.

Engagement often starts before first contact with family… Timely Response to Referral Working Relationship with Referral Support “Common” Goals

Systems Involvement Over Time Data and sustainability Support of evidence-based practice Involvement in treatment process Minimizing administrative or treatment failures Probation Officer’s Judges/Drug Court Coordinating services School suspension Probation violation Introducing services

Engagement Considerations and Strategies Speed and Availability Flexibility and persistence

Speed, Availability, Flexibility and Persistence Predicts length of service and completion rates Location or time should become an obstacle Adjusting time and methods? When is enough enough?

Engagement Considerations and Strategies Speed and Availability Flexibility and persistence Initial presentation matters Sequential Alliances Get the right people in the room

Working Through Contacts to Engage All Family Members Take time to ask about who is in the family Explore potential barriers Protection (“He is busy”) Protection (“This is not her problem”) Explore potential barriers Conflict (“He does not help at all”) Access family members directly Be aware of “types” that push your buttons 27

Engagement Considerations and Strategies Speed and Availability Flexibility and persistence Initial presentation matters Sequential Alliances Get the right people in the room

Getting the Right People in the Session Hidden fathers or sources of conflict Powerful “extended” family members Avoid sending the message that “You do not matter” Best laid plans can be undermined or blocked by non-engaged members 29

Creating a Context for Change Motivation Phase: Creating a Context for Change Change Focus Change Meaning Strength-based Relational Non-judgmental Respectful Interpersonal Clinical Contingent Responsive Decrease negativity and blame Increase hope Facilitate relational focus Balanced Alliances Goals Skills Activities Focus GOAL: Create positive motivational context: less hopelessness and blame (self & other), create hope; engage all “major” family members and motivate them to become part of the change process by: Building “balanced” alliance - with everyone, Reducing negativity & blame while retaining responsibility, and Creating a family focus for problems and strengths SKILLS: Relationship & interpersonal skills, nonjudgmental, acceptance and sensitivity to diversity, courage and resilience, non-defensiveness FOCUS: Relationship process, strength based ACTIVITIES: Interrupt highly negative interaction patterns and blaming. Change Focus through Diverting and Interrupting, a strength based relational focus, & pointing process and sequencing; Change Meaning through Reframing & themes. Schedule sessions as frequently as necessary  

Family-Level Goals of the Motivation Phase Decrease Negativity and Blame Less negative interactions Less blame More positive attributions More positive body language Instill Hope Hopeful attitude View they have something to gain See potential benefit of therapy or therapist Facilitate Relational Focus Increase family bonding Increased sense of familyness

Therapist-Family Level Goal of the Motivation Phase Balanced Alliance Sense of being heard and understood Sense of being respected Viewed with dignity or nobility

Early Spacing of Sessions The spacing, or number of days between the first, second, and third FFT sessions, depends primarily on: 1 - the severity of risk factors 2 - the immediate availability of protective factors 3 - your over all judgment of how long the family can go without a major disruption. With high risk families we would expect 3 sessions in the first 10 days of FFT Expectation is to have at least one session per week. Sometimes frequency is increased to meet the high demands of severe cases or to deal with a temporary crisis. This is a general rule not a dogmatic requirement. Some agencies may require more intensive contact as a function of funding or referral source. In these circumstances, the timing and frequency of sessions may vary.

Creating a Motivational Context Consistent and contingent responding to disrupt blame and create hope Accommodate to the family without challenging individuals or relational functions Matching Expectation is to have at least one session per week. Sometimes frequency is increased to meet the high demands of severe cases or to deal with a temporary crisis. This is a general rule not a dogmatic requirement. Some agencies may require more intensive contact as a function of funding or referral source. In these circumstances, the timing and frequency of sessions may vary.

In the Motivation Phase it is “all about them” MATCHING (a philosophy as much as “a technique”) is a fundamental requisite for effectively engaging and changing families “Match to” clients: Working hard to respect and understand them, their language, norms, etc In the Motivation Phase it is “all about them”

Assessment of Relational Functions Relational Connectedness Relational Hierarchy

Relational Assessment Phase Elicit and analyze information about patterns Observation Within family patterns Extra-familial patterns Perceptiveness Understanding systems and relationships Formulate relational assessment Plan for behavior change Goals Skills Activities Focus

Relational Connectedness Autonomy Midpointing Autonomy high low 1 2 3 Contact 4 5 Contact low high

Relational Hierarchy The pattern, over time, of relative influence based on power, position, and resources Symmetrical Parent 1 - Down Parent 1 - Up

Improving family interactions and facilitating individual skills Behavior Change Phase Improving family interactions and facilitating individual skills

Behavior Change Phase Goals Skills Activities Focus Facilitating tasks Modeling / Coaching Homework Changing behaviors and interactions Compliance Directive Teaching Structuring Eliminate referral problems Improve family interactions Build skills Goals Skills Activities Focus

Behavior Change Targets Family Interactions Domain-specific modules Family Member Skills

Family Interaction Targets Communication Training Problem Solving Negotiation Contracting Reinforcement (Punishment) Token economy Contingency Management Response Cost Monitoring Developmentally appropriate Family specific Accommodate to functions

Family Member Skill Targets Anger management Assertiveness training Decision making Peer inoculation / refusal skills Effective use of free time Emotional regulation

Domain-Specific Modules Drug Use Truancy Anxiety Depression Trauma Drug Use -Functional analysis of behavior -Coping with urges and craving -Urge Surfing -Decision making Anxiety/Depression -SORC -ABC -Challenging provocative thoughts -Managing negative moods

FFT-CW® and Trauma Strong link between trauma and delinquency Decades of experience working with youth exposed to trauma Creating a safe space for youth and families Blame Negativity Violence Family is a critical source of resilience for its members Loyalty Bonding, Connectedness, Belonging Love Parent involvement necessary for enhancing treatment results

FFT-CW® and Trauma FFT is Consistent with TF-CBT Best Practice Principles (Ford and Cloitre, 2009) Prioritizing Safety Building a relational bridge to engage the youth and caretaker in treatment Maintaining a relational focus Staying strengths-based Focusing on enhancing self-regulation capacities Retaining sensitivity to various family members’ trauma history (including when, how, and if to review trauma history/narrative) Preventing and managing relational strife within the family system

Trauma Considerations Sources or Types Discrete vs. Continuous Within or Outside of the Family Environmental catastrophes Family changes Trauma can be experienced by one family member or the entire family Trauma impacts entire family system Parent’s own trauma experience (past or recent) can negatively impact parenting Emotional availability Extreme emotional responses

Trauma Considerations Process of trauma Distorted ability to appraise environmental and relational cues Maladaptive beliefs World is a dangerous place Parents are vulnerable Talking about something makes it worse

FFT-CW® Strategies Domains addressed Family Skills Building (pulled from TF-based tx) TF-CBT Cognitive Processing Therapy Attachment, Self-Regulation and Competency Figley’s family systems work Not limited to TF-focused specifically DBT CBT for Depression, Anxiety Domains addressed Depression/Anxiety Substance Use

FFT-CW® Strategies Types of skill building Intrusive thoughts Agitation Avoidance Isolation of affect Dissociation Denial Validation/acknowledgement Parentification

Generalization Phase Introduction

Generalization Phase Goals Skills Activities Focus Link to formal and informal systems Plan for future challenges Extend change Exta-familial community resources Interpersonal Structuring Case Management Maintain individual and family change Facilitate change in multiple systems Goals Skills Activities Focus

Triage Training FFT-CW® utilizes a clinical risk rating algorithm (CRF) which uses a specified set of decision rules by which clients are risk stratified and assigned to either a low or high intensity treatment service track (Rowland & Davidson, 2011). The CRF results are used to predict risk and to prioritize the management of the client’s treatment in order to prevent avoidable, life shortening outcomes. The CRF was used in a 2011 – 2015 quasi- experimental, stepped wedge design across all five boroughs of New York City (FFT-CW®, n= 1625 Usual Care: n= 2250).

Implementation Support The CDT model is a strategy or approach for increasing the adoption of evidence based practices (EBP), in everyday human services systems It is focused on EBP programs, models, and interventions It is about implementing (establishing) and sustaining, with model-adherence (fidelity) or integrity

Implementation Support Reinforcing and enhancing organizational capacity to plan, support and sustain Conducting program performance evaluation Coordinating strategies for sustainability (managing turnover) Clarifying and formalizing training protocols with developers Clarifying and developing sustainability strategies with developers

Research Outcomes

Acknowledgements Bill Baccaglini, President and CEO, New York Foundling James Alexander, Developer of Functional Family Therapy, FFT LLC Dana Guyet, formerly New York Foundling, Vice President for FFT-CW® Kate Davidson, formerly New York Founding, assisted in developing the Clinical Rating Form Brian Acevedo and Eric Alter, IT Specialists , New York Foundling Lorraine Castillo, New York Foundling Synia Wong, Director, Division of Policy, Planning, and Measurement Administration for Children's Services, NYC NYF Associate Vice Presidents for the FFT-CW® project Alaine Robertson, Staten Island/Brooklyn Marta Anderson, North Manhattan Stephanie Henriques, Queens Stephanie Stenson, Bronx Hayden Hutchison, Research Assistant, New York Foundling Martie Nees Record, Research Assistant, New York Foundling

FFT-CW® Collaboration Effort Functional Family Therapy LLC (FFT LLC) FFT LLC is responsible for training and supervision in FFT to more than 340 organizations that serve 50,00 families per year nationally and internationally Provided adaptations to FFT that resulted in the FFT-CW® clinical model The New York Foundling (NYF) organization NYF provides a wide array of family services that reaches more than 25,000 children throughout New York City as well as Puerto Rico They contributed the implementation manual and directly provided FFT- CW® services to nearly 3,000 families The Administration for Children’s Services (ACS) of New York City. ACS provided the funds and family referrals to NYF , and the oversight of welfare services to the families receiving FFT-CW® Provided data sets for evaluation Oregon Research Institute (ORI) Received funding from NIDA to evaluate the impact of FFT-CW® versus Usual Care

Objective of the Evaluation To evaluate the efficiency and effectiveness of Functional Family Therapy-Child Welfare® (FFT- CW®, n = 1625) as compared to Usual Care (UC: n = 2250) in providing services for reducing child abuse and neglect To evaluate the success of FFT-CW® and UC in avoiding adverse outcomes for the study samples

Design Considerations Basic Design Stepped Wedge Propensity Matching Challenge of establishing a comparable UC sample for evaluation Balanced by Client’s Borough Balanced by Case Open month Balanced by individual and family risk factors at case open date Domestic violence Mental health Substance abuse History of placement History of prior allegations Balance by Race/Ethnic origin

Selection of Cases Families received services from either FFT-CW® (n = 1625) or UC (n = 2250) UC cases were chosen from clients who entered PPRS service episodes during the same period as the FFT-CW® interventions families (approximately 75 per month) UC clients were selected across all five boroughs of NYC The cases in both samples were opened between June 1, 2011 and May 31, 2014 Enrollment dates permitted us to track clients for 15 months after the case open date

Participants Issues at Referral Gender Race/Ethnicity Families 57.4% Abuse or Neglect 56.9% Child Service Needs 42.8% Child Health and Safety Concern Gender 49% Female Race/Ethnicity 56% Latino-Hispanic 35% African American 3% White, non-Hispanic Families 92% Biological parent CG 3% Grandparent 92% Female primary CG 15-79 Age of primary CG 2.28 Average number of youth in home (33% only child)

Predictors of Adverse Outcomes Covariate B SE Wald df P Exp(B) Substance Abuse 0.61 0.18 12.10 1 .001 1.84 Mental Health 0.46 0.20 5.15 .023 1.59 Prior Allegation History 0.37 0.06 38.53 .000 1.45 Transfer from PPRS 0.82 0.26 10.26 2.28 Constant -2.52 0.12 443.00 0.08

Summary of Efficiency Findings FFT-CW® was associated with more efficient service delivery than UC Higher treatment engagement rates (FFT-CW® = 88.73% vs UC = 83.8%) More rapid initiation of treatment (FFT-CW® = 20 days vs UC = 35 days to third session) Quicker completion of service episode (FFT-CW® = 222 vs UC = 315 days) Fewer staff contacts required with family (FFT-CW® = 27.5 vs UC = 41.3)

Evaluating Efficiency of Service Delivery: Time to Third Session Note: The cell entries are the mean number of days after the case open date to the first, second, or third session.

Evaluating Efficiency of Service Delivery: Number and Type of Contacts Usual Care M (SD) FFT-CW® M SD F p d Family 25.42 (19.50) 21.68 (14.60) 42.37 .000 0.21 Individual 9.38 (10.95) 3.52 (5.42) 395.57 0.64 Phone 10.16 (16.95) 8.62 (10.56) 10.55 .001 0.11 Group 2.59 (4.96) 0.91 (1.40) 176.58 0.43 Note: Cell entries are the means (M) and standard deviations (SD) for the frequency of each contact type within the Usual Care and FFT-CW service modalities.

Summary of Effectiveness Outcomes FFT-CW® was associated with more effective interventions than UC Intake staff identified key risk factors impacting treatment outcomes using the Clinician Rating Form (CRF) Treatment plans were tailored to the family’s pre-service risk into a lower or higher intensity service track Service intensity adjusted after initial contact if warranted (10%) As a consequence… …interventions were more likely to meet all planned objectives for the family (55% vs 32%). …supervision and experience led to continued improvements in fidelity after initial training …higher fidelity of treatment was associated with more favorable outcomes

All Goals Met Note Cell entries are percent of sample that met all goals, met partial goals, or met any goals.

All Goals Met: Mental Health, DV, Substance Use Service Condition Neither Domestic Violence (DV) Substance Abuse (SA) DV + SA UC 30% (70) 21% (24) 44% (55) 18% (22) FFT-CW® 49% (87) 64% (25) 45% (56) 65% (31) Effect Size (df) 0.39 0.91 0.02 0.98

All Goals Met: Risk Level and Fidelity Rating Note: The workgroup fidelity categories were 0-2.5 = 1; 2.5 – 3.0 = 2; 3.0-3.5 = 3, 3.5-6 = 4.

Effectiveness in Avoiding Adverse Outcomes Fewer FFT-CW® than UC families had negative outcomes requiring continued service (13.7% vs 20.7%) Fewer FFT-CW® than UC families transferred to another PPRS at case closing when domestic violence, mental health, and prior allegation risk factors were present (14.3% vs 40.0%) Fewer FFT-CW® than UC families were in service after 12 months (23% vs 56%)

Family Monthly Service Participation Rates After Case Opening df = 0.69

Effectiveness in Avoiding Adverse Outcomes After controlling for pre-existing risk factors: Recurring indicated allegations: families in FFT-CW® had fewer indicated allegations after the case open date than families in UC FFT-CW® had lower rates of out of home placements than UC when families had a current domestic violence safety concern in combination with either: a mental health safety concern or a preservice indicated investigation

Recurring Allegations: Presence of Domestic Violence at Referral Service Condition No Domestic Violence Domestic Violence Combined No Mental Health Mental Health ACS-UC 15% 10% 26% FFT-CW® 14% 4% 13% df 0.02 0.001 0.23 0.35 0.15

Q & A