Evaluating Supervision Models in Functional Family Therapy: Does Adding Observation Enhance Outcomes?

• Author: Charles W. Turner,Hyman Hops,Holly Barrett Waldron,Michael S. Robbins,Janet Brody,Timothy Ozechowski
• Published date: 01 December 2019
• Date: 01 December 2019
• DOI: http://doi.org/10.1111/famp.12399

Evaluating Supervision Models in Functional Family

Therapy: Does Adding Observation Enhance

Outcomes?

MICHAEL S. ROBBINS*

,†

HOLLY BARRETT WALDRON*

CHARLES W. TURNER*

JANET BRODY*

HYMAN HOPS*

TIMOTHY OZECHOWSKI*

This study examined the effects of observation-based supervision Building Outcomes

with Observation-Based Supervision of Therapy (BOOST therapists =26, families =105),

versus supervision as usual (SAU therapists =21, families =59) on (a) youth externa liz-

ing behavior problems and (b) the moderating effects of changes in family functioning on

youth externalizing behaviors for adolescents receiving Functional Family Therapy (FFT).

Exploratory analyses examined the impact of supervision conditions on youth internalizing

problems. In 8 community agencies, experienced FFT therapists (M=1.4 years) received

either BOOST or SAU supervision in a quasi-experimental design. Male (59%) or female

(41%) adolescents were referred for the treatment of behavior problems (e.g., delinquency,

substance use). Clients were Hispanic (62%), African American (19%), Non-Hispanic White

(12%), or Other (7%) ethnic/racial origins. Therapists (female, 77%) were Hispanic 45%,

African American (19%), White Non-Hispanic (30%), or other (4%) ethnic/racial back-

grounds. Analyses controlled for the presence or absence of clinically elevated symptoms on

outcome variables. Clinical outcomes were measured at baseline, 5 months, and 12 mont hs

after treatment initiation. Clients with externalizing behavior above clinical thresholds

had significantly greater reductions in problem behaviors in the BOOST versus the SAU

conditions. Clients below thresholds did not respond differentially to conditions. Supervi-

sors in BOOST had more experience with the FFT model; as such, the observed results may

be a result of supervisor experience. The BOOST supervision was associated with improved

outcomes on problem behaviors that were above clinical thresholds. The findings demon-

strate the importance of addressing client case mix in implementation studies in natural

environments.

Keywords: Family Therapy; Case Mix; Supervision; Externalizing; Implementation

Fam Proc 58:873–890, 2019

*Oregon Research Institute, Eugene, OR.

†

Functional Family Therapy, LLC, Pembroke Pines, FL.

Correspondence concerning this article should be addressed to Michael S. Robbins, Oregon Research

Institute, 1776 Millrace Dr., Eugene, OR 97403. E-mail: mrobbins@ori.org

The authors are indebted to CIBMHS, Aleah Montano, Lisa Weaver, Pam Hawkins, and the therapists

who provided services, recorded sessions, and participated in the supervision process. This work was sup-

ported by NIDA Grant R01 DA029406 to Holly Waldron and Michael Robbins, Co-Principal Investigators.

Dr. Robbins receives compensation from FFT LLC, an organization that disseminates FFT into community

settings. Dr. Waldron receives compensation from LIFFT, Co., an organization that disseminates FFT into

community settings.

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Family Process, Vol. 58, No. 4, 2019 ©2018 Family Process Institute

doi: 10.1111/famp.12399

Functional Family Therapy (FFT; Alexander & Parsons, 1982; Alexander, Waldron,

Robbins, & Neeb, 2013) is an evidence-based treatment for adolescent delinquency

and substance use (Robbins, Alexander, Turner, & Hollimon, 2016). FFT has been widely

disseminated into community settings producing significant improvements for youth with

behavior problems (Baglivio, Jackowski, Greenwald, & Wolff, 2014; Barton, Alexander,

Waldron, Turner, & Warburton, 1985 [Study 1, 2]; Celinska, Furrer, & Cheng, 2013;

Hansson, Johansson, Drott-Engl

en, & Benderix, 2004). Studies have also shown that FFT

is effective in improving (a) youth internalizing symptoms (Celinska et al., 2013; Hansson

et al., 2004) and (b) parent internalizing symptoms/dis tress (Hansson et al., 2004). Recent

studies have yielded mixed findings with respect to adolescent gender, with on e study

showing that girls may have responded more favorably to FFT (Baglivio et al., 2014) and

another showing that no differences in outcomes based on youth gender (Celinska &

Cheng, 2017).

The transportation of evidence-based treatments (EBTs), such as FFT, into practice set-

tings has yielded mixed results, with some estimates suggesting that the outcomes

observed in controlled efficacy trials diminished by as much as 50% (Henggeler, Pickrel, &

Brondino, 1999). The successful implementation of EBTs and the subsequent achievement

of positive outcomes in effectiveness trials are intrinsically linked. Hence, the need to

identify the parameters for successful implementation is widely recognized (Bertram,

Blas

e, & Fixsen, 2015; Fixsen, Naoom, Blas

e, Friedman, & Wallace, 2005; Glasgow, Licht-

enstein, & Marcus, 2003; Kazdin, 2008).

A major determinant of successfully transporting EBTs into community settings is the

integrity of implementation (Fixsen et al., 2005; Glasgow et al., 2003). One of the single

most significant challenges associated with implementation integrity is sustaining treat-

ment fidelity through therapists’ “competent adherence” to the treatment model (For-

gatch, Patterson, & DeGarmo, 2005; Henggeler, Schoenwald, Liao, Letourneau, &

Edwards, 2002; Mihalic & Irwin, 2003). Given adequate therapist training, ongoing super-

vision is the key element for sustaining model fidelity in community agencies (Fixsen

et al., 2005; Schoenwald, Sheidow, & Chapman, 2009).

Based on the accumulated evidence supporting FFT, interest in disseminating the FFT

treatment model has skyrocketed. Currently, the dissemination organization, FFT LLC

(www.fftllc.com), has trained more than 400 local, state, national, and international orga-

nizations. Annually, over 2,500 FFT therapists served nearly 60,000 families around the

globe. To address the key issue of enhancing treatment competence, FFT LLC developed

and implemented a web-based application to monitor highly structured FFT therapist pro-

gress notes, as well as supervisor and client ratings of therapist competence. The process

helps to maximize sustainability for community programs by limiting costs. The impac t of

this supervision process on therapist competence and treatment outcomes is unknown.

By contrast, Miller, Yahne, Moyers, Martinez, and Pirritano (2004) found that supervi-

sion involving active feedback and/or coaching based on supervisor review of therapy ses-

sions to observe therapist behaviors directly results in improved model fidelity. Such

observation-based supervision has been the hallmark in the development of family ther-

apy models and in fidelity monitoring processes in efficacy trials evaluating family ther-

apy (Crits-Christoph et al., 1998; Forgatch et al., 2005). By eliminating this practice, it is

possible that FFT dissemination efforts may have unwittingly omitted an important com-

ponent needed for effective transfer of treatment.

Supervision in Family Therapy

Early meta-analyses found two factors predicting better client outcomes in child and

adolescent psychotherapy (Weisz, Konenberg, Han, & Kauneckis, 1995). The first was the

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