Clinical Model

As early as 1985, research into FFT indicated that it was effective for youth in child welfare settings. For example, Barton, Alexander and colleagues (1985) showed that FFT was associated with a significant reduction in outplacement referrals (11% in FFT vs. 49% in non-FFT) as well as a significant reduction in units of service per family decreased by half (14.7 vs. 6.2). As such, FFT not only led to far better outcomes (fewer out-of-home placements), but was also extremely cost-effective for community agencies. Nonetheless, FFT has been implemented much more frequently in juvenile justice settings. And, where FFT was being implemented in child welfare, the focus tended to be on the acting out behaviors of 11- to 18-year-old adolescents.

Background and Adaptations

Several challenges were addressed to adapt FFT to the complex needs of children and families with a documented history of abuse or neglect. At the organizational level, program developers recognized that the cost of family therapy may be too high to be used with all clients. Moreover, the complexity of evidence-based family therapy requires a level of clinical sophistication that exceeds the skill level of many case planners that serve youth and families in child welfare settings. As such, the first adaptations involved developing a lower cost, less intensive version of FFT for low-risk clients that matched the skill level of case planners, and a higher cost, more intensive version of FFT for higher risk clients. The primary goal was to improve functioning for all child welfare clients by tailoring treatment to the client’s needs. This approach created an infrastructure to provide risk-sensitive, family-focused, culturally sensitive services. The integration of these interventions in a single continuum has the potential to achieve greater effectiveness and economy in preventive services by dynamically delivering the most appropriate, fiscally efficient, least invasive and least restrictive intervention in response to changing family dynamics and situations.

A second adaptation involved integrating a developmental focus into the model to meet the needs of youth across the entire age range (0-18). FFT is a relational approach that matches interventions to the relational configurations of families. With delinquent or substance-abusing adolescents, this often involves accommodating families in which youth have considerable power to engage and motivate family members into the treatment process. However, with younger children in FFT-CW®, it is necessary to implement more “parent-driven” intervention strategies to build skills and create a family context in which youth can flourish.

A third adaptation involved expanding the primary treatment focus from a target youth (e.g., adolescent referred for treatment) to all family members. This has involved developing treatment modules to address the mental health, substance abuse and behavioral needs of parents as well as children.

FFT-CW®: The Clinical Model

FFT-CW®: Low Risk (FFT-LR).
Based on our FFP® model, FFT-LR integrates assessment, supervision and intervention by clarifying the prevention interventionist’s role and how it changes during the course of service delivery. FFT-LR is implemented in three distinct phases: Engagement/Motivation, Support/Monitor and Generalization. During the first phase, the focus is on engaging and motivating youth and families to be a part of a change process by decreasing family conflict and blame and increasing their hope about the possibility for change. Interventionists are also expected to gather information to utilize risk/needs assessments and to complete an assessment of the relational functions (interpersonal payoffs) for maladaptive behaviors. FFT-LR case managers then move into the Support/Monitor phase, where the focus is to identify resources and interventions best suited to youth/families and support linkages to those change programs. Interventionists are expected to utilize their case management skills to maintain and enhance the impact of evidence-based interventions on family members. In the final phase of treatment, the focus is on helping youth/families to generalize change into other systems and to anticipate and plan for potential barriers or challenges that youth and families may face in the future.

FFT-LR impacts youth and families through a family focus. Interventionists meet with families from the beginning and learn to view youth through relational systems, as well as apply assessments, so they can better match families to community-based interventions and monitor participation with programs in a way that enhances the chance for success. Interventionists become stronger advocates of effective services; in turn, they play a more effective part in assessment, referral, monitoring and maintenance of change brought about by effective programs and interventions. Interventionists then work with both families and the community providers to help the family purposefully generalize the skills learned to other systems involved with the family.

FFT-CW®: High Risk (FFT-HR).
FFT-HR uses traditional FFT, an empirically grounded, well-documented and highly successful family intervention for at-risk and juvenile justice involved families. The FFT-HR model includes five phases: (1) Engagement, (2) Motivation, (3) Relational Assessment, (4) Behavior Change and (5) Generalization. Each phase includes specific techniques of intervention, as well as therapist goals and qualities. The intervention involves a strong cognitive/attributional component integrated into systemic skill-training in family communication, parenting skills, conflict management skills and numerous other skills linked to a variety of syndromes and referral problems.

The FFT-CW® model is currently being implemented in all five boroughs of New York City with 25 teams (12 HR, 13 LR).

Preliminary Evidence

The benefit of FFT-CW® approach was observed for 55 families in North Manhattan in a pilot study that demonstrated that 79% of LR and 71% of HR families met all treatment goals; an additional 17% LR and 21% of HR families met at least one treatment goal. Thus, significant improvements were noted for more than 90% of the families in both the LR and HR families. These findings are reflected in the fact that only 2% of families required an out-of-home placement. Moreover, FFT-CW® reduced the length of service for families from around 13 months to just under five months (4.7). From another perspective, FFT-CW® turns a slot over three times for every one slot in alternative services.