. FFT . 2008 CIMH FFT Conference The

. FFT . 2008 CIMH FFT Conference The

. FFT . 2008 CIMH FFT Conference The Renewal of FFT James F Alexander, PhD And NOW Core, Classic, EB FFT 1973-1998 Work With Strong Shift to Focus Within Family Community Pretreatment

Posttreatment Primary FocusAnd Family MemberCommunity Resources for System System FFT Treatment Resources Phases and Within Family Behavior To Enhance Booster Sessio Integration Integration Relapse Prevention Outside Fam Success As

Needed Phase Phase Referral, Preparation, Pretreatment Linking w/ Youth Mgt Systems Engagement & Motivation Behavior Change (MultiSystem)

Generalization Boosters, Maintenance of links w/ Youth Mgt Systems, Positive close The Youth / Family Management System(s): Juvenile Justice, Drug Court, Welfare, Mental Health: Based on(POs, Alexander et al, Managers, 1983; Barton etTrackers, al, 1985; Waldron et Case

Phase II FFT Dissemination 2000-2007: Necessary Components 200+ Sites National ConsultantsNational Database National Web Based National QA/QI S Supervisors State International CoordinatorsNational Programs Externship But the CORE of FFT is still

Relationships And we still depend on data to guide what we do FFT Phase III: 2008 + Clarifying, elucidating, refining the clinical model Clarifying, elucidating, refining the Consultation & Supervision Partnering and re-partnering Integrating, specializing & modularizing Manualizing context specific (e.g., cultures) Enhancing our ability to capture data and tracking all of the above

Matching FFT to the Context: Challenges and Lessons Learned Family / Culture / Other (Non EBT) Driven FFT Model Driven Fidelity Accomo- Adaptadation tion Drift What Have We Learned As We Move Into Phase III of FFT?

What Did We Seem To Lose Sight Of? (Back to Basics) Yes, even Tiger Woods sometimes has to go back to his coach and get back to basics Basics #1 FFT Doesnt Begin With the Family FFT Pre-intervention Major PRETREATMENT Tasks* GOALS: Responsive and timely referrals, positive mindset of referring sources,

immediacy ACTIVITIES: Establish relationship with referring sources, be available, maintain a positive attitude, appraise multidimensional (e.g., medical, educational, justice) systems already in place Who Should Attend E & M? Who Are The Major Players? 1 Family member(s) seen as part of the problem or problem sequence according to referral source(s). 2 Family members we think (based on referral info and first calls to the family) are likely to shut the process down - and who probably can!

3 Family members we think are necessary to begin change in the referral youth(s) 4 Important nonfamily members who will participate and are appropriate participants vis-vis retaining a highly influential role with the youth / family (e.g., Grandma) Who Doesnt Need to Be There? - Anyone who doesnt fit above The Spacing of Sessions During E & M 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, and 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. Basics # 1a We need systems that support these fundamental aspects of FFT Basics #2 Change, in FFT, derives from developing A Positive Relational Focus Bonding (especially during E&M) GOAL: 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 MOTIVATION PHASE

GOAL: Create positive motivational context, minimize hopelessness and blame (of self and other), change meaning of family relationships to emphasize possible hopeful experience SKILLS REQUIRED: Relationship & interpersonal skills, nonjudgmental, acceptance and sensitivity to diversity, courage and resilience, non-defensiveness FOCUS: Relationship process, separate blaming from responsibility, strength based

ACTIVITIES : Interrupt highly negative interaction patterns and blaming (Divert and Interrupt). Change meaning through a strength based relational focus, pointing process, sequencing, and Reframing & themes. Schedule sessions as frequently as necessary MATCHING (a philosophy as much as a technique) is a fundamental requisite for effectively engaging and changing families Match to clients: We do what it takes for them to feel you are working hard to respect and understand them, their language, norms, etc Especially during E & M it is all about them AS OF 2008 Data re FFT

Success With Diverse Populations CA 2008 report (presented here) Holly Waldron randomized clinical trials (NIDA) 2006 six month (6000 youth families) nationwide (Upcoming APA Convention presentation) At least with respect to completion rates: FFT is equally effective with Anglo, Latino, and Black/African American Youth families Based on Waldron data, ethnicity/culture matching is best ! Basics #2 In FFT, E&M Really Counts! And Involves Family Bonding, NOT Problem Focus Parent-Youth Alliance in FFT Across Segments 1 & 2

of Sessions 1 & 2 Freidag & Alexander, 20 Major Techniques of E & M Interrupt & Divert 1 - Change Point Process Focus Sequencing, Selectively attend to positive elements of patterns and reports Strength Based . Relational Focus Do something (Take a risk) ---------------------------------------------------

2Change Theme Hints Meanin Relabels Reframes (Acknowledge - then suggest g +) Themes (Relational and Organizing) Painful relational past > Interlocking noble intent Review: The Flow of E & M

Interventions At first, negativity, individual problem focus, blaming, and negative & hopelessness is high At first feelings of hope, positive attributions about self and each other, and a sense of family togetherness are low or absent The Flow of E & M Interventions (2) As E&M progresses, negativity decreases & Relational focus & strength based Attributions Increase,

blaming decreases (but is still present) As negativity, blame, and individual problem focus decreases The Flow of E & M Interventions (2) The FFT therapist can begin to develop Relational Themes and ultimately Organizing Themes This escalates the reduction in negativity and the increase in

positive relational focus, emerging hope Family Bondi ng What is the Difference Between a Reframe and a Relabel to change Relabel ? description, the tone, or meaning of a behavior or feeling

E.g., in response to an angry outburst: With that anger I can see how hurt you are. Or just I can see how hurt you are. Reframe to acknowledge the negative components of a behavior but offer a possible alternative motivation for the behavior That was an angry outburst X, but Im wondering if in addition to yelling you werent also protecting Y by letting him/her know how upset you are about that so s/he can work on bringing it up differently? And Y, my guess is that because the anger was so intense you couldnt hear the reaching out part of what X said.

What Are Reframes? Reframes consist of a simple 3 step process: 1) Identify and make clear the negative aspects of a problem behavior / pattern (the one you are going to attempt to reframe); 2) offer a possible noble* (or benign) but misguided intent or meaning; 3) observe the family for feedback , and based on the family members reactions (affirming or disaffirming) you refine and elaborate the reframe or you apologize for misunderstanding and move on. * Noble intent = to benefit

Summary of Steps in Reframing Acknowledge the negative Reframe: Possible positive / noble but misguided intent, motive, meaning Evaluate the effect of the reframe and Refine or Change Themes - More Comprehensive Than Reframes: Transitional Hope Evoking Meaning of Experiences We develop themes to link the pervasive negative

experiences of the past to a possibly hopeful experience of what they may mean. To do so we offer an alternative meaning (experience of) painful past relationship patterns. This alternative meaning temporarily provides family members with a sense that they are not defined solely by their past bad behavior(s), but by a shared experience that emerged from misfortune, misguided attempts at positive solutions, and sometimes merely the unfortunate events of living with fewer resources than they need or struggling with Summary Of Major Meaning Change Relabeling Techniques attempts to change the label

(meaning, tone, experience) of a behavior or pattern Reframing attempts to also change the perception of the motivation for the behavior Themes attempt to change the experience of relationships (not just behaviors & patterns) Caveat to Basic #2 You can focus on a negative behavior

during E&M - as long as you have a way to relabel, reframe, or create a theme around it. Otherwise Selectively focus on the positive (Robbins) Focus on relationship rather than behavior Turn it into a strength based focus Basic #3: What You Believe Is What Organizes How Well You Will Do FFT Not an FFT Focus Who are they? Primary

Focus: Engage & Motivate around . .... Victims Pain Hurt, Emotional ly Damaged People Not an FFT Focus

Organic Unfixable e.g. Fetal Bad / Evil Alcohol People Pain & mis- Damage perception disperception Their Logic Teach / Structure / Sanctions / Behavior Provide Reduce Remove Change

Rescue Corrective Behavioral Behavioral We are not rescuers or controllers We Empower & Experience Options Options . FFT . (Excerpts from) 2nd Annual Blueprints Conference Denver Colorado, March 16-18, 2008 Afternoon Breakout Session II Holly Waldron, PhD Sabrina Gonzalez, MSW, LSW

Jose Malave, LCSW Issues Of Culture: Elliot, 2008 (today) Fidelity vs Adaptation * Need for local adaptation is over estimated * Adaptations must fit with program rational * Language / cultural adaptations most easily justified Little evidence for race/ethnicity, class, gender differences in school program effects) Most frequent threat is to fidelity

Agency Therapists All you white people love to hear about all this culture stuff ... F Referral Sources Juvenile Justice System: 43% Schools: 31% Newspaper Ads / Flyers: 11%

Self Referred: 10% Other Treatment Agency: 5% Ethnicity Othe r/ Native Mixe Americ d an Anglo

Hispanic Adolescent Marijuana Use at Pre- and Post-Treatment Follow-Up FFT CBT FFT+CBT GROUP 80 Mean Percent Days of Use 70 60 50

40 30 20 10 PreTx 4 Mo F/U 7 Mo F/U 19 Mo F/U (Waldron et al., 2001; 2008) Proportion of Adolescents Abstinent or Using at Minimal Levels (<10% of days) FFT CBT FFT+CBT GROUP 0.7 Proportion of Adolescents 0.6 0.5 0.4 0.3 0.2 0.1 0 PreTx 4 Mo F/U 7 Mo F/U

(Waldron et al., 2001; 2008) 19 Mo F/U Figure C.1. Effects of CBT and IBFT on Marijuana Use (% days) in the Hispanic Sample. Marijuana Use (% days) 65 60 55 50 45 40 35 30 0

3 6 9 12 15 Assessment Point (months) CBT IBFT Note: The individual points represent self-reported days of marijuana use (percent of days) during the past 90 days on the TLFB interview.

18 Figure C.2. Effects of CBT and IBFT on Marijuana Use (% days) in the Non Hispanic Sample. 60 Marijuana Use (% days) 55 50 45 40 35 30 25 20 0 5

10 15 Assessm ent Point (m onths) CBT IBFT Note: The individual points represent self-reported days of marijuana use (percent of days) during the past 90 days on the TLFB interview. 20 Therapist-Client Ethnic Matching and Family Therapy Outcome

Source: Flicker, Waldron, & Turner, 2008; Journal of Family Psychology Why Therapist-Client Ethnic Matching? Ability to communicate in clients primary language and understand cultural background Enhanced therapeutic alliance due to common experience

Less frequent miscommunication and misdiagnosis Therapeutic goals similarly conceptualized Similarity positively influences liking, persuasion, and credibility, processes important to treatment success Ethnically-matched therapists may more accurately identify the impact of cultural issues on problems Ethnic minority clients prefer working with a culturallysimilar therapist (Atkinson & Lowe, 1995; Flaskerud, 1986; Santisteban, Coatsworth et al., 2002; Santisteban, Muir-Malcolm et al., 2002), Simons et al., 1970; Sue, 1988; Sue & Sundberg, 1996; Yeh et al., 1994) Adolescent Marijuana Use by Ethnicity and Ethnic Match 70 60

Mean Change in Use Nonmatched Hispanics 50 Nonmatched Anglos 40 Matched Anglos 30 20 10 Matched Hispanics

0 Pretreatment Follow-Up 1 Assessment Point Follow-Up 2 Ethnicity Findings No significant differences between Anglos and Hispanics on FFT treatment engagement or outcome Hispanic adolescents significantly lower treatment alliances in 1st session

Ethnic Match Findings No significant differences between ethnically matched Anglos and Hispanics on engagement or outcome Ethnic match not related to attendance or treatment satisfaction Non-matched Anglos had most balanced alliance Ethnically matched Hispanics had greater decreases in drug use

Therapist Ethnicity Effects Hispanic therapists had more balanced alliances with families than Anglo therapists Hispanic therapists achieved better substance use outcomes than Anglo therapists Discussion Ethnic match findings, despite highly acculturated Hispanic sample

Relationship between ethnic match and treatment outcome unrelated to acculturation level Therapeutic alliance unrelated to relationship between ethnic match and change in drug use Implications

Evidence that FFT is as or more effective with New Mexican Hispanic families Ethnic match more important for Hispanic families than for Anglo families Findings highlight the need for ethnic diversity among therapists better cross-cultural competence training . FFT

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