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Program Profile: Functional Family Therapy (FFT)

Evidence Rating: Effective - More than one study Effective - More than one study

Date: This profile was posted on June 14, 2011

Program Summary

A family-based prevention and intervention program for at-risk youths ages 11 to 18. The program is rated Effective. The treatment group had lower recidivism rates; and when the program was delivered by high-adherent therapists the results were even more significant. The program had a positive effect on youth by reducing risky behavior, increasing strengths, and by improving functioning across key life domains.

Program Description

Program Goals
Functional Family Therapy (FFT) is a family-based prevention and intervention program for high-risk youth that addresses complex and multidimensional problems through clinical practice that is flexibly structured and culturally sensitive. The FFT clinical model concentrates on decreasing risk factors and on increasing protective factors that directly affect adolescents, with a particular emphasis on familial factors.

Target Population
The program is for at-risk youths ages 11 to 18 and has been applied in a variety of multiethnic, multicultural contexts to treat a range of youths and their families. Targeted youths generally are at risk for delinquency, violence, substance use, or other behavioral problems such as Conduct Disorder or Oppositional Defiant Disorder.

Program Components
FFT consists of 8 to 12 one-hour sessions for mild cases and incorporates up to 30 sessions of direct service for families in more difficult situations. Sessions are generally spread over a 3-month period and can be conducted in clinical settings as an outpatient therapy and as a home-based model.

 

FFT integrates several elements (clinical theory, empirically supported principles, and clinical experience) into a comprehensive clinical model. The model has five specific phases: engagement, motivation, relational assessment, behavior change, and generalization.

 

In the engagement phase, therapists concentrate on establishing and maintaining a strengths-based relationship with clients. The goals of this phase are to enhance the perception that the FFT therapeutic process will be responsive and credible, and demonstrate to clients that therapists will listen to, help, and respect them.

 

During the motivational phase, therapists concentrate on the relationship process between adolescents and their family. One goal of this phase is to create a motivational context, so that adolescents and their families will want to continue therapy and not drop out. In addition, therapists concentrate on decreasing the negativity often characteristic of high-risk youths and families, such as hopelessness and low self-efficacy. During this phase, the idea is emphasized and reiterated that a positive experience in therapy can lead to a lasting change.

 

The relational assessment involves analyzing the relational processes of the family, in addition to creating treatment places for the behavior change and generalization phases. The emphasis shifts during this phase from an individual problem to a relational perspective. Therapists work on intrafamily and extrafamily capabilities, such as values, interaction patterns, sources of resistance, and resources.

 

The behavior change phase aims to reduce and eliminate the problem behaviors and accompanying family relational patterns through individualized behavior change interventions (skill training in family communication, parenting, problem-solving, and conflict management). Therapists work to develop change in behavior, while remaining aware of family members’ abilities and interpersonal needs.

 

The goal of the generalization phase is to increase the family’s capacity to adequately use multisystemic community resources and to engage in relapse prevention. The emphases are on relationships between family members and multiple community systems.

 

Key Personnel

FFT can be delivered by a wide range of professionals, including licensed therapists, trained probation officers, and other specialists with a mental health degree and background (e.g., MSW, Ph.D., M.D., R.N., MFT, and LCP).

Evaluation Outcomes

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Study 1 Recidivism
Gordon and colleagues (1988) found that for any 12-month period, the recidivism rate averaged 1.29 offenses for the Functional Family Therapy (FFT) group and 10.29 offenses for the comparison group. The average annual recidivism rates for the groups during the entire follow-up period (27.8 and 51.5 months, respectively) were 5 percent for the treatment group and 25.0 percent for the comparison group.
 
The analysis for adult outcomes reported by Gordon and colleagues (1995) was conducted using data on 45 of the original 54 study participants. Results indicated that the recidivism rate for combined misdemeanor and felony offenses was significantly lower for the treatment group (4.3 percent) than for the comparison group (27.3 percent). For misdemeanors only, the respective recidivism rates differed at the 0.10 level with a treatment rate of 4.3 percent and comparison group rate of 27.3 percent. For felonies only, the difference between the rates for the two groups (4.3 percent and 13.6 percent) was not significant.
   
Study 2
Recidivism
This large-scale trial of FFT conducted by Sexton and Turner (2010) and delivered by community-based therapists found that, when the analysis was collapsed across all therapists, FFT was no more effective in lowering felony recidivism than the supervised probation services that the control group received. However, the therapist level of adherence to the FFT model (low versus high) and the client pretreatment risk and protective level both had moderating effects on recidivism. When adherence to the FFT model was high, FFT resulted in a significant reduction in felony crimes (34.9 percent), a significant reduction in violent crimes (30 percent), and a nonsignificant decrease in misdemeanor crimes (21.1 percent).
 
The study also found that FFT delivered by high-adherent therapists resulted in significantly lower recidivism rates (20 percent) for youths with the highest levels of family and peer risk levels in the sample.

Study 3
Life Domain (LD), Child Behavior Emotional Needs (CB), and Child Risk Behavior (CR)
Celinska and colleagues (2013) found that the LD, CB, and CR scales of the Strengths and Needs Assessment (SNA) showed significantly greater improvements in the FFT group compared with the control group. The findings suggest that FFT had a positive effect on youths in the areas of reducing risk behavior, increasing strengths, and improving functioning across key life domains.
 
Child Strengths (CS), Acculturation (AC), Caregiver Strengths (CRS), and Caregiver Needs (CN)
However, the CS, AC, CRS, and CN scales of the SNA showed no significant differences in improvement between the FFT group and the control group.
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Evaluation Methodology

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Study 1
Gordon and colleagues (1988) used a quasi-experimental design to evaluate Functional Family Therapy (FFT) with lower socioeconomic status juvenile offenders, most of whom had multiple offenses. All 54 participants were white, court-referred juveniles from a rural Southeastern Ohio county who were adjudicated delinquents (guilty of misdemeanors or felonies) or status offenders. Youths who had two offenses before treatment (some of whom were placed outside the home) were assigned to the treatment group. The treatment group (n= 27) consisted of 15 males and 12 females who were court-ordered to a university counseling service as a condition of probation. The comparison group (n= 27) consisted of 23 male and 4 female juveniles who were randomly selected from the group of delinquents who were in court during the same period as the treatment group but were not referred for family therapy. These assignment procedures probably resulted in favor of the comparison group.
 
The participants were all white and were living in an economically depressed community with high rates of unemployment and single-parent households. Status offenses—habitual truancy, unruliness, and running away—accounted for 57 percent of all offenses committed. Misdemeanors accounted for 30 percent of offenses committed and consisted of petty theft, vandalism, criminal trespass, and menacing. Felonies, which accounted for 13 percent of offenses committed, included breaking and entering, grand theft, and rape. Participants in both groups continued to meet with their probation officer one or two times each month. Participants in the treatment group attended a median number of 16 family sessions (range: 7 to 38), lasting an average of 1½ hours each and extending over a mean of 5½ months.
 
The outcome—recidivism rate—was calculated for each group as the percentage of juveniles convicted of one offense or more. The mean follow-up period for measuring recidivism rates was 27.8 months for the treatment group and 31.5 for the comparison group. Since these periods differed slightly, the recidivism rate was annualized to reveal the rate for any 12-month period.
 
Adult recidivism at 5 to 6 years after placement on probation—when participants, generally, were 20 to 22 years of age—was reported by Gordon, Graves, and Arbuthnot (1995).
 
Study 2
The Sexton and Turner (2010) evaluation included a comparison of FFT with probation services. This community-based evaluation was conducted within a statewide juvenile justice system of a large western state. Data collection and group assignments were conducted by an independent state evaluation center. A total of 917 families in 14 counties in both rural and urban settings participated.
 
The participating juvenile offenders had been remanded for probation services and were stratified at the county level and randomly assigned to either FFT or a control group receiving usual probation services. Intervention youths received an average of 12 FFT family-based sessions in their homes over a 3- to 6-month period. FFT was provided by a community-based therapist. Control youth received traditional probation services in their local county with no additional treatment services. Each group included more than 400 adolescents. All participants were followed for 18 months when 1-year posttreatment assessments were collected.
 
Participants’ ages were evenly distributed from 13 to 17 years. Seventy-nine percent were male, and 21 percent were female. Seventy-eight percent of participants were white, 10 percent African American, 5 percent Asian, 3 percent Native American, and 4 percent were not identified. Most of the participants had committed felony crimes (56.2 percent), and many had committed misdemeanors (41.5 percent).
 
Measures included family-focused risk and protective factors sections of the Washington State Juvenile Court Assessment completed by a probation officer. Other measures included a treatment adherence measure and a measure of the youth’s adjudicated felony criminal behavior in the 12-month period following randomization to treatment.
 
The primary outcome measure was the youth’s adjudicated posttreatment felony criminal behavior in the 12-month period following randomization to treatment.
 
A four-step statistical analysis was used. First, preliminary multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA) analyses were conducted to assess potential outside variables that might influence the hypothesis testing. Second, hierarchical linear modeling and logistic regression analyses were used to test the main hypothesis that the FFT condition was associated with a lower level of adjudicated felony recidivism compared with the control group. Third, a secondary hypothesis concerning effects of therapist model adherence (low versus high) was analyzed using logistic regression. Fourth, analyses examined possible interaction effects between pretreatment family and peer risk factors (low family risk, high family risk, and high peer risk) and therapist adherence as predictors of felony recidivism.

Study 3
Celinska and colleagues (2013) used a quasi-experimental design to compare youths receiving FFT with youths who received individual therapy or mentoring. Data on at-risk youth was collected between 2005 and 2007 in the state of New Jersey. The treatment group included youths referred by New Jersey Probation, Family Crisis Intervention Unit, Family Court, and Divisions of Youth and Family Services. Youths in the control group received services through the Youth Case Management program. They were identified to participate in the study by case managers. Eligibility criteria for participation in the study included the following: being between the ages of 11–17; living with a parent or guardian; and having a history of aggressive behavior, destruction of property, or chronic truancy. Youths with alcohol and other drug use or mental health issues were not eligible
 
The sample consisted of 72 youths, of which 36 received FFT and 36 were in the control group. Of the entire study sample, the majority of youths were male (69 percent) and slightly older than15 years. The treatment group receiving FFT was 36 percent African American, 26 percent Latino, 19 percent white, and 8 percent other race/ethnicity. The majority of the treatment group was male (69 percent) and the average age was 15.5 years. The comparison group had similar percentages for race/ethnicity (44 percent African American, 33 percent Latino, 14 percent white, and 8 percent other). The majority of the comparison group was also male (61 percent) and the average age was 15.1 years. There were no significant differences between the groups on demographic characteristics.  
 
Data was collected using the Strengths and Needs Assessment (SNA), which provided a standardized way to collect information on youth functioning across life domains. Primary outcome measures included the following scales: Life Domain Scale, Child Strengths Scale, Acculturation Scale, Caregiver Strengths Scale, Caregiver Needs Scale, Child Behavior Emotional Needs Scale, and Child Risk Behavior Scale.

The goal of the study was to measure effects of FFT relative to services received in the comparison group. A one-way ANOVA test was conducted to test for differences in the duration of treatment and the seven life domain areas the scales represent. The sample size was not large enough to employ other methods.
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Cost

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The Washington State Institute for Public Policy published a report with detailed analysis of fiscal year 2008 costs associated with providing State-funded evidence-based programs in the Washington State juvenile courts (Barnoski 2009). Functional Family Therapy (FFT) was one of these programs. Total cost per youth in Washington State for FFT was $3,134, which included service, quality assurance, administrative overhead, transportation, court oversight, court referral/coordination, case management, and additional court services. The benefits of this program, which included benefits to both crime victims and taxpayers, were calculated to be $36,241 per youth.
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Implementation Information

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There is a three-phase process involved in the training and certification of new sites that wish to implement Functional Family Therapy (FFT). Services are provided by FFT Inc.
 
During phase 1 (Clinical Training), the goal is to evaluate the local context of the site and to create a lasting infrastructure to support the FFT program. Local clinicians receive training and consultation so they can demonstrate strong adherence and competence in delivering the FFT model. Phase 1 is expected to last 1 year, but not longer than 18 months.
 
During phase 2 (Supervision Training), clinicians continue to receive assistance, to create greater self-sufficiency in FFT and to develop competent onsite FFT supervision. This includes attending supervisor trainings and receiving onsite training as well. A Client Services System (CSS) database is also set up to ensure that sites are maintaining and adhering to the FFT model. This phase is expected to be a yearlong process.
 
Finally, in phase 3 (Maintenance Phase), the goal is to ensure that local sites continue ongoing model fidelity. FFT Inc. may review the CSS database to ensure adherence, service delivery trends, and client outcomes. One-day onsite training for continuing education in FFT is also available. This phase is renewed annually.
 
For additional information, please review the information on the FFT Web site: http://www.fftinc.com/index.html.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Gordon, Donald A., Jack Arbuthnot, Kathryn E. Gustafson, and Peter McGreen. 1988. “Home-Based Behavioral-Systems Family Therapy With Disadvantaged Juvenile Delinquents.” American Journal of Family Therapy 16(3):243–55.

Study 2
Sexton, Thomas L., and Charles W. Turner. 2010. “The Effectiveness of Functional Family Therapy for Youth With Behavioral Problems in a Community Practice Setting.” Journal of Family Psychology 24(3):339–48.

Study 3
Celinska, Katarzyna, Susan Furrer, and Chia-Cherng Cheng. 2013. “An Outcome-Based Evaluation of Functional Family Therapy for Youth with Behavioral Problems.” OJJDP Journal of Juvenile Justice 2(2): 23-36.
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Additional References

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These sources were used in the development of the program profile:

Alexander, James F. 2007. Functional Family Therapy Clinical Training Manual, Second Edition. Seattle, Wash.: FFT LLC.

Alexander, James F., Christie Pugh, and Bruce V. Parsons. 1998. “Functional Family Therapy.” In Delbert S. Elliott (ed.). Blueprints for Violence Prevention (Book 3). Boulder, Colo.: Center for the Study and Prevention of Violence, Institute of Behavioral Science, University of Colorado.

Alexander, James F., Christie Pugh, Bruce V. Parsons, and Thomas L. Sexton. 2000. “Functional Family Therapy.” In Delbert S. Elliott (ed.). Blueprints for Violence Prevention (Book 3), Second Edition. Boulder, Colo.: Center for the Study and Prevention of Violence, Institute of Behavioral Science, University of Colorado.

Aos, Steve, Robert Barnoski, and Roxanne Lieb. 1998. Watching the Bottom Line: Cost-Effective Interventions for Reducing Crime in Washington. Olympia, Wash.: Washington State Institute for Public Policy.
http://www.wsipp.wa.gov/rptfiles/98-01-1201.pdf

Barnoski, Robert. 2009. “Providing Evidence-Based Programs With Fidelity in Washington State Juvenile Courts: Cost Analysis.” Document No. 09–12–1201. Retrieved from Washington State Institute for Public Policy Web site:
http://www.wsipp.wa.gov/rptfiles/09-12-1201.pdf

Barton, Cole, James F. Alexander, Holly Barrett Waldron, Charles W. Turner, and Janet Warburton. 1985. “Generalizing Treatment Effects of Functional Family Therapy: Three Replications.” American Journal of Family Therapy 13(3):16–26.

Gordon, Donald A., Karen Graves, and Jack Arbuthnot. 1995. “The Effect of Functional Family Therapy for Delinquents on Adult Criminal Behavior.” Criminal Justice and Behavior 22(1):60–73.

Parsons, Bruce V., and James F. Alexander. 1973. “Short-Term Family Intervention: A Therapy Outcome Study.” Journal of Consulting and Clinical Psychology 2:195–201.

Poirier, Jeffrey M. 2007. “Juvenile Crime and the Economic and Social Benefits of Implementing Effective Delinquency Programs: A Case Study of the District of Columbia.” Policy Perspectives: The George Washington Journal of Public Policy and Public Administration 14:11–41.

Sexton, Thomas L., and James F. Alexander. 2002. Functional Family Therapy: Principles of Clinical Intervention, Assessment, and Implementation. Seattle, Wash.: FFT LLC.

Slesnick, Natasha, and Jillian L. Prestopnik. 2009. “Comparison of Family Therapy Outcome With Alcohol-Abusing, Runaway Adolescents.” Journal of Marital & Family Therapy 35(3):255–77. (This study was reviewed but did not meet CrimeSolutions.gov criteria for inclusion in the overall program rating.)

Waldron, H.B. and C.W. Turner. 2008. “Evidence-based Psychosocial Treatments for Adolescent Substance Abuse: A Review and Meta-analysis.” Journal of Clinical Child and Adolescent Psychology 37(1):238-261.

FFT, Inc. 2010. “Functional Family Therapy.” Accessed July 18, 2011.
http://www.fftinc.com/index.html
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Related Practices

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Following are CrimeSolutions.gov-rated practices that are related to this program:

Targeted Truancy Interventions
These interventions are designed to increase attendance for elementary and secondary school students with chronic attendance problems. The practice is rated Effective for improving attendance.

Evidence Ratings for Outcomes:
Effective - More than one Meta-Analysis Education - Attendance/truancy
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Program Snapshot

Age: 11 - 17

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, Asian/Pacific Islander, Hispanic, White

Geography: Rural, Suburban, Urban

Setting (Delivery): Inpatient/Outpatient, Home, Other Community Setting

Program Type: Family Therapy, Individual Therapy, Probation/Parole Services

Targeted Population: Serious/Violent Offender, Young Offenders, Families

Current Program Status: Active

Listed by Other Directories: Campbell Collaboration, Model Programs Guide, Blueprints for Healthy Youth Development (formerly Blueprints for Violence Prevention)

Program Developer:
James F. Alexander
Research Professor and FFT Clinical Director
FFT LLC
380 South 1350 East, #502
Salt Lake City UT 84112
Phone: 801.550.4131
Fax: 801.581.5841
Website
Email

Program Director:
Doug Kopp
CEO
FFT LLC
1251 NW Elford Drive
Seattle WA 98177
Phone: 206.409.7198
Fax: 206.409.7198
Website
Email

Researcher:
Michael Robbins
Senior Scientist
Oregon Research Institute
1715 Franklin Blvd.
Eugene OR 97403-1983
Phone: 954.552.0779
Fax: 541.484.1108
Website
Email

Training and TA Provider:
Holly DeMaranville
FFT Communications Director
FFT LLC
1251 NW Elford Drive
Seattle WA 98177
Phone: 206.369.5894
Fax: 206.453.3631
Website
Email