2004 Children s Behavioral Health Conference

1. 2004 Children’s Behavioral Health Conference FFT and MST within a System of Care

2. Core Values of a System of Care The system of care should be child-centered, with the needs of the child and family dictating the types and mix of services provided The system of care should be community-based, with the locus of services as well as management and decision-making responsibility resting at the community level. (Stroul, 1988)

3. Why an Evidence-Based Practice? Changing “landscape” of practice in mental health, juvenile justice, social work Push for Accountability…”where is the data?” Increased quality and relevance of research Myths of old being challenged Relevant and valid research to guide practice Emergence of the concept “Best Practices” but…what is a best practice? much more than…”what we already do” More than a theoretical approach

4. “Best practices” are Evidence-Based Programs 1. Systematic Clinical Intervention Programs Integrative in nature (practice, research, theory) Systematic clinical protocols--”clinical maps” Manual driven Model congruent assessment procedures Focus on adherence and treatment fidelity 2. Models that have..strong science/research support 3. Clinically Responsive and Individualized to unique “outcome” needs of the client/family to the unique “process” needs of the family 4. Are able to guide practice with high expectation of success with specific client problems within specific community settings

5. EBPs within a System of Care Examples of FFT and MST within a SOC FFT Many, many systems that use Wraparound processes NY State Office of Mental Health and many other sites MST Many, many systems that use Wraparound processes Nebraska – CMHS project site (Kearney, NE) Ohio – Starke County and many other sites

6. FFT and MST: Common Assumptions & Beliefs Children’s behavior is strongly influenced by their families, friends and communities (and vice versa) Families are key to success Families can live successfully without formal, mandated services Change can occur quickly Professional treatment providers should be accountable for achieving outcomes Science/research can provide guidance

7. Families as the solution Both programs focus on families as the solution Families are full collaborators in treatment planning and delivery with a focus on family members as the long-term change agents Giving up on families, or labeling them as “resistant” or “unmotivated” is not an option MST and FFT has a strong track record of client engagement, retention, and satisfaction The most important group that MST interacts with is the many families that receive the service. MST views families as the key to changing the youth’s behavior because they are, by definition, the most influential system that the youth is a part of. MST assumes that families already do the very best they can, so it serves no purpose to blame or criticize. Instead, MST seeks to determine why the family’s best efforts did not result in a competent, successful youth. MST evaluates the context of the family to better understand the challenges that prevented success. Interventions seek to overcome those challenges, allowing the parent or parent figure to successfully do their job. How we think affects what we do. The words we use communicate how we think. Words like “unmotivated” or “resistant” tend to blame the family member leading to reduced engagement in treatment. MST assumes that behavior makes sense and it is MST’s job to determine how a given behavior fits the situation (e.g., a parent not following through with an intervention may be due to a poorly constructed intervention). MST defines problems in solvable ways.The most important group that MST interacts with is the many families that receive the service. MST views families as the key to changing the youth’s behavior because they are, by definition, the most influential system that the youth is a part of. MST assumes that families already do the very best they can, so it serves no purpose to blame or criticize. Instead, MST seeks to determine why the family’s best efforts did not result in a competent, successful youth. MST evaluates the context of the family to better understand the challenges that prevented success. Interventions seek to overcome those challenges, allowing the parent or parent figure to successfully do their job. How we think affects what we do. The words we use communicate how we think. Words like “unmotivated” or “resistant” tend to blame the family member leading to reduced engagement in treatment. MST assumes that behavior makes sense and it is MST’s job to determine how a given behavior fits the situation (e.g., a parent not following through with an intervention may be due to a poorly constructed intervention). MST defines problems in solvable ways.

8. EVIDENCE-BASED TREATMENTS FOR YOUTH WITH SERIOUS ANTISOCIAL BEHAVIOR (a.k.a. JUVENILE OFFENDERS)

9. 1990 CONSENSUS NOTHING WORKS

10. Support for EBPs as “Best Practice” Surgeon General (1999) mental health Surgeon General (2001) youth violence Research community - model specific research and leading reviews like Kazdin & Weisz (1998) on conduct disorder U.S. Justice Department - OJJDP Blueprints for Violence Prevention - Elliott (1998)

11. 2004 CONSENSUS Four Evidence-Based Practices standout from all others as “model”programs EACH is family based with individualized treatment EACH is consistent with the core values and principles of a System of Care Nurse-Family Partnership (NFP) Functional Family Therapy (FFT) Multisystemic Therapy (MST) Multidimensional Treatment Foster Care (MTFC)

12. HOW ARE THESE EVIDENCE-BASED TREATMENTS DIFFERENT? They focus on different levels of problem severity. NFP - prenatal preventive approach FFT – moderate to severe antisocial behavior, intensive monitoring not needed MST - severe antisocial behavior, imminent risk of out-of-home placement MTFC - severe antisocial behavior, out-of-home placement activated

13. EBPs within a SOC EBPs, FFT & MST specifically, can and do work within a System of Care The key is to determine how the implementation needs to be tailored to each unique system of care

14. Model Overviews Functional Family Therapy (FFT) and Multisystemic Therapy (MST)

15. Functional Family Therapy… a ”Best Practice” Approach Research-based family program for at-risk adolescents and their families Targets youth between 11-18…. Prevention intervention--status/diversion kids Treatment intervention--moderate and serious delinquent youth Short-term, family-based program Mean of 12 sessions over 3-4 months Effective for the range of adolescent problems Violence, drug abuse/use, conduct disorder, family conflict FFT is a “family therapy” approach

16. FFT Research Base (1) 30 years plus research. Progenitor James Alexander, Ph.D Independent replication 130 community sites in 32 states and Europe Statewide evaluated implementation (WA state) Multiple RCT & Comparison Designs 25-60% reductions in recidivism Child welfare—39% reduction in out of home placement and decreased units of service by half Sustainable effects, demonstrated repeatedly From 1 – 5 years after intervention 3 Yr follow up prevention effects for siblings--“ripple effect”

17. FFT Research Base (2) Independent replication 130 community sites in 32 states and Europe Statewide evaluated implementation (WA state) Evaluated training/QA protocol (WA State study—therapist adherence/competency) Low dropout rates (Idaho and WA statewide projects) Lower costs (statewide cost of $2100/family) Juv Justice cost/benefit: $1 spent: $10 saved Changes in family functioning Decrease level of conflict Increase parenting skills/supervision Increase communication Increase in youth skills

18. Functional Family Therapy: Selected Independent Reviews (2000 to 2003) One of Four “Level 1 Model Programs” that Reduce Violence or Serious Delinquency (Youth Violence: A Report of the Surgeon General, January 2001) "Exemplary Program" (Strengthening Americas Families: Center for Substance Abuse Prevention, SAMHSA & OJJDP). Strategies That Work, American Youth Policy Forum: Reducing Juvenile Crime, 6/00). Effective Strategy (Promising Strategies to Reduce Substance Abuse, US Dept of Justice, September 2000). Best Practices of Parent- and Family-Based Interventions (Centers for Disease Control and Prevention, Best Practices of Youth Violence Prevention, A Sourcebook for Community Action, September 2000). Family Strengthening Series, Functional Family Therapy (OJJDP Juvenile Justice Bulletin, December 2000). WA State Institute for Public Policy Model Program Best Practices: “Effective Program (Source Book of Drug and Violence Prevention Programs For Children and Adol, Un. of Medicine and Dentistry of New Jersey, March 2001).

19. From the beginning.. Youth/Families referred to FFT often have: Long histories of system/care involvement Family members involved in various service/justice systems Multiple program failure Multiple system involvement Treatment risk is often marked by: Early Dropout Discouraged Blamed Hopeless Low motivation High discouragement Lack of family support Poor Alliance