Blueprints
Model Programs
Functional Family Therapy (FFT)
Program
Background
Many therapies are named to reflect
a theoretical perspective (e.g., behavioral, object
relations) or a primary focus (e.g., multiple systems,
cognitive). Functional Family Therapy (FFT) is named
to reflect a set of core theoretical principles which
represents the primary focus (family), and an overriding
allegiance to positive outcome in a model that understands
both positive and negative behavior as representations
of family relational systems (functional). Thus, Functional
Family Therapy has adopted an integrative stance that
stresses functionality of the family, the therapy,
and the clinical model.
The developers and replicators of Functional Family
Therapy have recognized that solutions require an
integration of high quality science, tested theoretical
principles, and extensive clinical experience in pursuit
of specific functional goals of:
1. Effectively changing the maladaptive behaviors
of youth and families, especially those who at the
outset may not be motivated or may not believe they
can change;
2. Reducing the personal, societal, and economic
devastation that results from the continuation or
exacerbation of the various disruptive behavior
disorders of youth; and
3. Doing so with less cost, in terms of time and
money, than so many of the more expensive (but not
necessarily effective) treatments currently available.
Unlike other therapies, FFT was not developed on college
students, neurotic individuals, or inpatient adults.
Instead, FFT grew out of a need to serve a population
of at-risk adolescents and families that were under
served, had few resources, were difficult to treat,
and were often perceived by helping professions to
be treatment resistant. In many cases these families
entered the "system" angry, resistant, and
unmotivated to change. Essentially the "helping
professions" did not know how to treat this population.
FFT developed out of the awareness that to be successful
in treatment of this population we needed to be culturally
competent, and understand why this group was so treatment
resistant. Thus, FFT attempted to develop ways to
engage these families in order to help them achieve
obtainable change and become more adaptable and productive.
Over the last 30 years, FFT has learned that it is
important to do more than simply stopping bad behaviors.
We know that it is important to motivate families
to change in a positive way by uncovering and developing
the unique strengths of the family in ways that enhance
the families' self-respect while providing specific
ways to improve.
Since its inception in 1969, FFT has accomplished
its primary goals by integrating the most promising
theoretical perspectives, the empirical data available,
and hours and hours of direct clinical experience
with the troubled youth we wanted to help. FFT is
designed to increase efficiency, decrease costs, and
enhance our ability to provide service to more youth
by:
- Targeting risk and protective factors that we
can, in fact, change and then programmatically changing
them;
- Engaging and motivating the families and youth
so they participate more in the change process;
- Entering each session and phase of intervention
with a clear plan and by using proven techniques
for implementation;
- Constantly monitoring process and outcome so we
don't fool ourselves or make excuses for failure;
and
- Believing in the families we see and then believing
in ourselves.
At the time of the inception of Functional Family
Therapy, the majr theoretical perspectives and services
available for treating troubled youth in a family
context were rudimentary, though promising. Early
on, FFT represented an integration of systems perspectives
and behavioral techniques. The systemic background
of FFT emphasized dynamic and reciprocal processes
which needed to be identified in referred families.
This led to early observational research on the interactions
of delinquent and nondelinquent families using a systemic
framework. The behavioral background of FFT provided
not only specific, manualizeable interventions such
as contracting, but it also featured an urgent awareness
of the need for rigorous treatment development-a scientific
imperative to systematically examine the effects of
intervention and develop strategies for identifying
positive change processes. These origins led to a
continuing series of studies involving controlled
outcome evaluations and additional replications. During
the mid-1970's, FFT also began addressing issues of
therapist characteristics and in-session processes
from an integrated clinical/research perspective,
both reflecting and contributing to the training of
therapists for subsequent interventions. In the late
1990's FFT further articulated the clinical change
model adding a comprehensive system of client, process,
and outcome assessment implemented through a computer-based
client tracking and monitoring system (FFT-CSS).
Throughout its development FFT has insisted on step
by step descriptions of the clinical change process
as well as rigorous evaluation of both the process
and outcomes of this work. FFT has also insisted on
integrating high quality science (in regard to evaluation
and research) with sound clinical judgement and experience
and comprehensive theoretical principles. Thus, over
the last 30 years FFT has been a dynamic and evolving
clinical system that retains its core principles while
adding clinical features that further enhance successful
outcomes. In its most recent iteriation, FFT has developed
a functional family assessment system to aid FFT therapists
in targeting and implementing therapeutic change goals
in a way that leads to accountability through process
and outcome evaluation. Thus, FFT has matured into
a clinical intervention model with systematic training,
supervision, and process and outcome assessment components
all directed at enhancing the delivery of FFT in local
communities (see Figure 1).
Brief Description of Intervention
Functional Family Therapy (FFT) is a well documented
family prevention and intervention program which has
been applied successfully to a wide range of problem
youth and their families in various contexts. While
commonly employed as an intervention program, FFT
has demonstrated its effectiveness as a method for
the prevention of many of the problems of at-risk
adolescents and their families. Functional Family
Therapy (FFT) is an empirically grounded intervention
program that targets youth between the ages of 11
and 18, although younger siblings of referred adolescents
are also treated. FFT is a short-term intervention
with, on average, 8 to 12 one-hour sessions for mild
cases and up to 26 to 30 hours of direct service for
more difficult situations. In most programs sessions
are spread over a three-month period of time. Target
populations range from at-risk preadolescents to youth
with very serious problems such as conduct disorder.
The data from numerous outcome studies suggests that
when applied as intended, FFT can reduce recidivism
between 25% and 60%. Additional studies suggest that
FFT is a cost-effective intervention that can, when
appropriately implemented, reduce treatment costs
well below that of traditional services and other
family-based interventions.
As it developed, FFT has been readily adopted
in many contexts due to its clear identification of
specific phases, each of which includes descriptions
of goals, requisite therapist characteristics, and techniques.
The phases of intervention, and their component activities,
have developed in the context of many clinical hours
with many families of various characteristics, coupled
with intensive supervision and clinical case discussion.
As a result, each phase involves clinically rich and
successful interventions that are organized in a coherent
manner and allow clinicians to maintain focus in the
context of considerable family and individual disruption.
The phases consist of:
- Phase 1: Engagement and Motivation. During these
initial phases, FFT applies reattribution (e.g.,
reframing) and related techniques to impact maladaptive
perceptions, beliefs, and emotions. This produces
increasing hope and expectation of change, decreasing
resistance, increasing alliance and trust, reducing
the oppressive negativity within family and between
family and community, and increasing respect for
individual differences and values.
- Phase 2: Behavior Change. This phase applies
individualized and developmentally appropriate
techniques such as communication training, specific
tasks and technical aids, basic parenting skills,
and contracting and response-cost techniques.
- Phase 3: Generalization. In this phase, Family
Case Management is guided by individualized family
functional needs, their interaction with environmental
constraints and resources, and the alliance with
the therapist.
Each of these phases involves both assessment and
intervention components. Family assessment focuses
on characteristics of the individual family members,
family relational dynamics, and the multisystemic
context in which the family operates. The family relational
system is described in regard to interpersonal functions
and their impact on promoting and maintaining problem
behavior. Intervention is directed at accomplishing
the goals of the relevant treatment phase. For example,
in the engagement and motivation phase, assessment
is focused on determining the degree to which the
family or its members are negative and blaming. The
corresponding intervention would target the reduction
of negativity and blaming. In behavior change, assessment
would focus on targeting the skills necessary for
more adaptive family functioning. Intervention would
be aimed at helping the family develop those skills
in a way that matched their relational patterns. In
generalization, the assessment focuses on the degree
to which the family can apply the new behavior in
broader contexts. Interventions would focus on helping
generalize the family behavior change into such contexts.
As a clinical model, FFT has been conducted in varied
clinical settings and as a home-based model. The fidelity
of the FFT model is achieved by a specific training
model and a sophisticated client assessment, tracking,
and monitoring system that provides for specific clinical
assessment and outcome accountability (FFT-CSS). The
FFT Practice Research Network (FFT-PRN) allows clinical
sites to participate in the
development and dissemination of FFT model information.
Evidence of Program Effectiveness
To date, thirteen studies in referenced journals (plus
one in preparation) demonstrate dramatic and significant
positive treatment effects, including follow-up periods
of up to five years. Rates of offending and foster
care or institutional placement have been reduced
at least 25 percent and as much as 60 percent in comparison
to the randomly assigned or matched alternative treatments,
or base rates. One study also demonstrated a positive
three year follow-up effect on siblings. Additional
formal program reports (e.g., county and federal funded
projects) from completed and ongoing replications
reflect similar positive outcomes, and five currently
funded trials (National Institute of Drug Abuse, National
Institute of Alcohol Abuse and Alcoholism, Government
of Sweden) promise additional data regarding generalization
of effects for FFT across more contexts and populations.
Studies have also identified specific FFT based interventions
and direct changes in family functioning which relate
to the outcome findings.
One major factor in the successful evolution of FFT
has been the continuous (29 year) involvement of its
progenitors and many of its co-contributors in various
university settings. This context has not only maintained
a standard of scientific scrutiny, but has also contributed
to the conceptual integrity of the major constructs
and techniques. The prime example of this impact is
the extensive work on reframing in FFT, informed by
other well-developed theoretical perspectives such
as information processing theory, social cognition,
and the psychology of emotion. Laboratory based research
has identified specific components of this critical
technique, which in turn has led to applied research
on cognitive set and attributional processes in referred
adolescent families. Further, investigations have
identified in-session therapist characteristics and
family interaction processes relevant to the phases
of FFT which are predictive of positive change. Most
notable process changes appear to be in family communication
patterns, and especially negative/blaming communications
and "withholding" types of silence. With
respect to therapist characteristics, process and
outcome data demonstrate that FFT therapists must
be first relationally sensitive and focused, then
capable of clear structuring and teaching, in order
to produce significantly fewer dropouts during treatment
and lower recidivism.
More recently, FFT has been widely adopted because
it has evolved an increasingly multicultural perspective,
and has added effective home-based intervention. In
the home-based Clark County, Nevada, Youth and Family
Services program, for example, referred adolescents
are roughly 30 percent African American, 20 percent
Hispanic/Latino (mostly Mexican American), and just
under 50 percent European American with a few American
Indian and Asian American youth. Preliminary data
on the first year of FFT involvement indicate no difference
in reoffense rate among the different ethnic/racial
groups, supporting the generalizability of FFT effects
across cultural/racial groups. The Fayetteville, North
Carolina, program has involved primarily White and
African American families and therapists, including
a significant number of mixed race relationships and
offspring. The two clinical trials being conducted
in New Mexico involve Hispanic/Latino and White youth,
and the home-based program in urban Willow Run, Michigan,
involves a large proportion of African American and
mixed families. (See replication information in later
sections for more details.) As the model has been
increasingly adopted in multicultural contexts, focus
is being placed on issues of culture and ethnicity,
with much of this recent work undertaken in the context
of the multi-site National Institute of Drug Abuse
(NIDA) funded Center for Research on Adolescent Drug
Abuse (CRADA, Howard Liddle, P.I.).
Taken together, 28 years of data and clinical experience
with FFT involving hundreds of therapists and thousands
of families have provided strong empirical support
for this family-based intervention with adolescents.
In addition, the research has demonstrated that intervention
must include a major focus on changing emotional and
attributional, especially blaming, components of family
interaction, then provide a program of specific behavior
change techniques that are culturally appropriate,
family appropriate, and consistent with the capabilities
of each family member.
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