presentation provided by coalition for juvenile justice institute for family centered services a...
TRANSCRIPT
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®
Theoretical FrameworkComprehensive 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? With the whole family as defined by the family Meet in their home at days of the week and
times of day that are convenient for the family. Session schedules get the clinician involved during
the most troublesome and difficult times and as they occur.
Provides 24/7 on call crisis support for the family with their known clinical staff. (not a universal on-call system)
Multiple hour sessions several times per week become the norm for creating change.
Provides opportunities for the family to practice functioning differently. These weekly “enactments” are integral to the process (not just talk therapy).
Essential ComponentsThe primary stages or phases of FCT are:
Joining and Assessment Restructuring Value Change Generalization
Typical length of treatment is 6 monthsalthough
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”.
Obstacles ?
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
Assessment
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.
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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.
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.
Phase 2 RestructuringPhase 2 Restructuring
Restructuring
Why do clients or families make changes?
Change Theory : when what we are doing is not longer working….
Reasons folks change vary considerablyBut which reasons are most likely to enable
change that is sustainable?
ConformityCompliancePleasing Avoidance of conflictRemove 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
Phase 4: Generalization
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.
EmotionalBlocks / 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 PracticeRequires involvement of a family system,
however “family” is defined (can be composed of non-related individuals living together as a
family system)
Primary focus is 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.
Competency Based Training Requiring Certification Wheels of Change© Training Program
An intensive 100-hour standardized training process has been in place for FCT (titled Wheels of Change©; WOC) since 2004.
WOC was revised in 2009, was field tested with trainers and management.
Revised version is a competency-based certification process that incorporates 3 phases:
1) an online knowledge and theory based participatory component,
2) field based experience, 3) an observed field testing of the skills needed to
practice the core components of FCT. Certification in Family Centered Treatment
Supervision 6 month peer cohort involving on line video
tested training Video submissions for review of supervision
sessions
Competency based supervision
Standardization - Management and SupervisionAssure implementation of the model for each FCT clientFCT 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 OversightCorporate level clinical review of case
staffing process for each location Management review and response to each
team’s meeting minutesCorporate 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
workerA 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.
TransparencyCustomized 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 www.familycenteredtreatment.com
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.
24.3 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. http://www.journalofjuvjustice.org
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 http://www.safestartcenter.org/pdf/Evidence-Based-Practices-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 1991. Information available at:. http://vcoy.virginia.gov/collection.asp
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. http://www.in.gov/dcs/index.htm
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. http://www.nrepp.samhsa.gov/ReviewPending.aspx
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. http://www.cebc4cw.org/
In summary FCT is more than a Clinical Model of TreatmentEffective 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 www.familycenteredtreatment.com Since 2010 FCT, and specialty uses of FCT, have been presented at the following national conferences: 1st 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 [email protected]
www.FamilyCenteredTreatment.org
www.FamilyCenteredTreatmentFoundation.org
(704) 787-6869
Contact:
Tim Wood, MS, LPC- Executive Director, FCT [email protected]