Functional Family Therapy Learning Institute January 22-23,
2015 Miami, FL Clinical Site Supervisor Training
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Introductions Welcome & Introductions
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Agenda Thursday Morning 1. Overview of the FFT Clinical
Supervision Model 2. FFT-CFS as a Clinical Supervision Tool
Afternoon 1. New Research/Adaptations 2. International Applications
of FFT 3. Unique Adaptations of FFT 4. CFS
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Friday Morning 1. Supervision Practice *Directors will meet
separately Afternoon 1. New Supervisor Group 2. Senior Supervisor
Group 3. Ending/next steps
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Clinical Supervision in Functional Family Therapy
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Traditional clinical supervision is often case-focused and not
specifically linked to the adherence and competence in delivering a
specific model of treatment. Development a specific supervision
model that focuses on the development of adherence and competence
in FFT (Sexton, Alexander, & Gilman, 2004). This model of
supervision has been a central feature in the dissemination efforts
of FFT over the last decade. clinical supervision is a central part
of the foundation of a treatment model and functions as a central
piece in a service delivery system that is able to maintain itself
over time To do so.isomorphic to the clinical model
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Clinical Supervision Clinical supervision is more than just a
tool to solve crises or discrete clinical problems (as it is
usually used), It is an essential element in the overall effort to
maintaining the integrity and ultimately the outcomes of FFT.
Supervision is one of the primary ways that fidelity is managed in
clinical trial studies, and it is a common procedure in most
practice settings.
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The role of Clinical Supervision Elements of a successful FFT
project: 1. Comprehensive system of assessment, treatment planning,
and clinical intervention, 2. Quality improvement mechanisms, 3.
Clinical supervision 4. Ongoing data monitoring and feedback
Success of a project depends on the degree to which these elements
are present and work together
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Goals of Clinical Supervision 1. Monitoring model fidelity and
quality of the Practice (quality assurance) In clinical practice,
in service delivery 2. Promoting adherence and competence of the
Therapist (quality improvement) Thinking through the FFT lens
Clinical decision based on FFT principles on the FFT treatment
intervention 3. Managing service delivery context so that it
promotes the model (administrative guidance)
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Guiding Principles of Supervision 1. Model-based/focused
Thinking through he lens, model based clinical decisions 2.
Relationally-based Alliance-based working relationships, Alliance
based motivation Supervision interventions that match to 3.
Multisystemic/multiple domains of attention & action
Integrative in domains of attention (therapist, service delivery
system, context) 4. Phasic based supervision interventions
Assessment (monitoring) and systematic intervention 5.
Evidence-baseddata driven
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Principles of FFT Supervision Other Tx Philosophies,
Principles, &
TechniquesFFTCorePhilosophy,Principles,&Techniques Adherence
Competence
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TherapistCompetence TherapistAdherence KnowledgePerformance
Working Group maturity
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Therapist adherence Adherence is defined in the dictionary as:
to be in accordance with, or follow through or carry out a play
without deviation, or finally, to cling, stick or hold together and
resist separation
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Therapist adherence Adherent FFT therapists stick to the goals
and principles of the model when events, situations, and problems
are presented to them. They cling to the model as the map for
deciding what direction, goal and outcome to pursue. FFT therapists
who demonstrate model-specific adherence : make clinical decisions
in accordance with the principles and conceptual foundations of
FFT, conduct therapy in accordance with the clinical model, and
work with clients guided by the goals of FFT both in general in
specifically to each phase of treatment. adherence is something
between the therapist and the model, something that can be
measured.
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Therapist Competence model-specific adherence is not enough. In
any clinical situation there is more than just a therapist and a
modelthere is the family. Therapists are only effective to the
degree that they match to the client. The match to principle is
what makes FFT effective with different families who live in
different cultures and who are from different
ethnic/racial/religious backgrounds.
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Therapist Competence The dictionary defines competence as: the
ability to apply knowledge, skills, or judgment in practice if
called upon to do so. In FFT this means : the therapist is able to
apply the FFT clinical model, its core theoretical principles and
its specific clinical interventions with a specific family. the
ability of the therapist to match the model to the unique, complex,
and multisystemic nature of the families they treat. competence is
specifically the ability to apply FFT as a matching to
process.
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* Statistically significant outcome Adherence is important
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Ireland (2013)
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Adherence & Competence in Functional Family Therapy
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Supervision Construct Definitions Adherence is the degree to
which the therapist is doing the FFT program (clinical model,
assessment protocol, staffing participation, CFS). Domains of
adherence: Core Principles (client, problems, therapy) Technical
elements Basic clinical elements Service delivery within protocol
Types: General Phase specific
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TherapistAdherence Knowledge Performance Working Group
maturity
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General Model Adherence Low adherence serious weakness in
understanding and applying the core principles of FFT, minimally
using the clinical model in work with clients (following phases of
the model and attempting to achieve the goals of the model in
clinical work). Average therapist has an accurate and broad
understanding of the core principles of FFT, and is using the
clinical model in work with clients (following phases of the model
and attempting to achieve the goals of the model in clinical work).
High adherence therapist that is doing all parts of the model
consistently.
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Therapist Adherence Knowledge Performance Core Principles -
clients -problems -change process Clinical Model Understanding
Clinical Model Application Model Adherence
General characteristics of adherence Does the therapist deliver
the three FFT phases in the appropriate order? Is the therapist
flexible in providing services in a way that meets the familys
schedule? Does the therapist have a theoretical understanding of
the FFT model? Does the therapist utilize the FFT model as their
primary source of clinical decision making? Does the therapist
think about the adolescent in a relational/family focused way? Does
the therapist maintain a balanced alliance with all family members
throughout all phases? Does the therapist demonstrate the following
qualities to the family: Warmth Non-judgmental Non-blaming Humor
Acceptance Sensitivity General relational/counseling skills
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Phase Specific Adherence Adherence to phase goals Adherence
benchmark depends of the goals of model Specific look at
adherence
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Adherence in Engagement/Motivation Is the therapist building a
balanced alliance with the family? Therapists are reframing in an
attempt to reduce negativity and blaming among family members
Therapists acknowledging and reframing client statements in a way
that facilitates the particular phase goals Conducted in a climate
of alliance/support?
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Adherence in Behavior Change The have a specific behavior
change target/individualized family change plan? The behavior
change target is linked to the presenting problem through the
organizing theme Application behavioral skills as behavior change
target
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Adherence in Generalization Therapists specific generalization
targets Generalization phase targets are linked to the generalizing
changes to school, community, and peers. generalization target is
linked to the organizing theme therapist work helps support the
family changes by identifying relevant community resources Matched
to the family
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Competence Competence reflects the skill of the therapist in
doing the clinical model of FFT. Competence includes the ability to
be clinically responsive to individual families (translate the
model to the individual family) while remaining model focused
(goals and skills), consistently practicing the model, and thinking
complexly about clients and the FFT therapy process.
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Competence Low competence a therapist who is attempting to
achieve the goals of each phase and using the skills of each phase
but not doing clinical work in ways that is rigid, not matching to
the family, in a way that reflects simple thinking about the
process, that involves simple application of the skills (e. g.
reframing) that is applied inconsistently. Average competence
indicates that the therapist is thinking somewhat complexly about
the family and process, using skills (e. g. reframing) with
moderate complexity and doing these things most of the time. High
competency therapist has the ability to thinking complexly about
families, the process, do the clinical skills of FFT with high
degree of skill in ways that match to many different kinds of
families in consistent manner.
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Measuring Model Adherence Therapist Adherence Scale (TAM)
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TAM (Therapist Adherence Measure) The is a supervisor-rated
measure of model specific therapist adherence. The TAM based on the
degree to which the clinicians case conceptualization and session
goals are consistent with FFT Model. The TAM has dimensions:
General Model adherence (TAM-G) and Phase specific model adherence
(TAM-G). The supervisor rates both measures during the weekly
clinical staffing using a 5-point Likert scale (1 6) indicating
low, average, and high general model adherence.
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Using the Clinical Feedback System as a Supervision Tool
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Scheduling supervision sessions Individual and group Planning
Supervision Sessions Monitoring Client Progress TAM ratings
Communicating with therapist Monitoring service delivery
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Process of Clinical Supervision A relational change model
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Time low high Adherence Competence Engagement/ Motivation
Adherence/ Competence Maintenance Phases of Supervision (relational
dimension) Outcome Goals Primary focus
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Therapist Presentation of the Case Supervisor Decision making
(knowing what to target) Anchor (source of decisions) Phase of
model Goals of the phase Story of the case - description of family
-description of problem What happened. What next. What is the
adherence issue? What is the competence issue? How can I intervene?
Match to the familyis it working to accomplish goals given
situation? Domain/ Knowledge Performance How: -teach, question,-ask
Impactfeedback -check/readjust assessment -method match (to
domain/person/group) Translation Using what the therapist says To
understand what they do in Sessions and how they Think about cases
Translating back into Intervention that address the primary issue
(adherence/competence) in a way that matches to the therapist
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Organizing Themewhat has been going on with therapist. Orient
..(what phase.sessions etc.) 1. Frame (specifically identify what
it is) 2. Acknowledge (identify this as important) 3. Change
(teach, demonstrate, give an example, practice-can you try.) 4.
Application (apply knowledge to case in question/under discussion)
5. Theme (for where to go/what to work on.. how it is linked to
other casesetc.) Relational Supervision discussion ST ST
Practice/demonstration ST
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What to hear Engagement/Motivation Family Presentation of
Problems (what do they say it is--problem definition) Problem
Sequence Organizing theme (developed to date) Family
focused/involves everyone, thematic, based on problem sequence
(i.e. specifically identifies specific behavior) Alternative
explanation for the problem directly linked to the problem sequence
Developed FROM individual reframing of events/actions Does it work
to: reduce negativity and blame? change the family presenting
problem definition (attribution)
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What to hear Behavior Change Organizing Theme (from engagement
& motivation) and your challenge is. Specific targets (that are
competency based) Implementation strategy (that is matched to
relational functions)
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Framing How to decide what to frame: phase/what you know about
the phase - adherence or competence -knowledge or performance
Prioritizing general to specific core principles to specific
knowledge/solution Framing highlight most central part point out
what is a problem (feedback/problem definition) describe in
respectful way/thematic way
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Changing. Teaching Guided clinical decision making
Demonstrating Planning Group discussion Theme focused/based Case
applicable
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Conducting Clinical Supervision And evidence based
approach
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Group Supervision Supervision Plan Based on CFS review Service
Delivery profile themes Adherence themes (from supervision reports)
Based on current themes of individual and group Identify case that
fits theme Case Discussion Assess fidelity/adherence Identify
intervention point Guided discussion Relational Supervision
Interventions
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Preparation/Supervision Planning Identify the therapists who
are next in line for supervision. Identify 2-3 therapists who did
not receive supervision in the prior supervision. Review Clinician
Progress notes for cases completed since the last clinical
consultation meeting
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Supervision Meeting Ask therapists to be supervised to present
a brief case conceptualization, session goals, and client responses
Complete the TAM (both the TAMG and the phase appropriate TAMS)
Continue with supervision helping the therapist identify next
session plans that are consistent with the FFT clinical model Show
the FFT/CFS screen (using Web-EX to help the therapist identify the
feedback appropriate for the case In a typical consultation session
2-3 therapists receive direct supervision.
