Evidence-Based Therapies for Keeping Families Together

Evidence-Based Therapies for Keeping Families Together

By Alana L. Riso & Michael A. Southam-Gerow, Ph.D.
Center for Evidence Based Partnerships in Virginia/Department of Psychology, Virginia Commonwealth University

Evidence-based practice (EBP) was strongly promoted by the American Psychological Association nearly two decades ago (see APA Presidential Task Force on Evidence-Based Practice, 2006). The EBP concept is now an integral part of a recent federal initiative for children and families in need, known as the Federal Family First Prevention Services Act (“Family First;” NCSL, 2022). Our Center for Evidence Based Partnerships in Virginia (CEP-Va) is the state’s technical assistance center for Family First. Family First has the potential to have an enormous impact on families in need. This article presents the background and purpose of Family First and outlines the selection process for its list of EBPs. We provide resources to assist providers and agencies in identifying child and family EBPs for the purpose of referrals, to pursue training, or to apply for state funding through the Family First Act. Finally, we briefly describe the EBPs that were chosen and are administered by our center in Virginia, one of the most active of the 28 states participating in Family First.

The major purpose of Family First is to prevent children from traumatic separations from their family and/or entry into foster care. A federal law, Family First provides states with funding for training practitioners and providing services under specific EBP interventions. The Department of Health and Human Services (HSS), in fulfillment of Family First, created a massive “clearinghouse” (known as the Title IV-E Prevention Services Clearinghouse; NCSL, 2022) which provides transparent reviews of the evidence base for programs and services. The interventions are rated on the quality of evidence supporting their use with child welfare populations. Interventions are rated on a four-point scale: (1) well-supported, favorable effects in two separate comparisons and evidence of an enduring effect, (2) supported, favorable effects in one comparison and evidence of an enduring effect, (3) promising, favorable effects in one comparison, and (4) does not meet criteria, no statistically favorable effects have been demonstrated. States choosing to participate in Family First are required to specify which EBPs from the clearinghouse they will include in their service array. To be eligible for funding for training and services, the EBPs chosen needed to be rated as well-supported, supported, or promising by the clearinghouse. On the clearinghouse website (see https://preventionservices.acf.hhs.gov/program) service providers can find an extensive list of interventions, their level of empirical support, a review of their support, and citations for the major clinical trials for each modality.

Our center (CEP-Va) was selected by the Virginia Department of Social Services (VDSS) to coordinate training and recommend allocation of funding for training in the EBPs from VDSS’s Family First Prevention Plan. Collectively, the EBPs chosen aim to keep families together, given the importance of keeping children out of foster care if at all possible (McIntyre & Keesler, 1986; Miller et al., 2000). Of the eight EBPs chosen by Virginia, we will discuss the six well supported EBPs with a strong emphasis on family-focused interventions: Functional Family Therapy (FFT), Brief Strategic Family Therapy (BSFT), Homebuilders, Multisystemic Therapy (MST), Parent-Child Interaction Therapy (PCIT), and Family Check-Up (FCU).

Functional Family Therapy (FFT)

FFT is an in-home program designed for children and adolescents ages 11 to 18 with change-resistant disruptive behaviors and parents or caregivers who are experiencing hopelessness (Robbins et al., 2016). FFT uses cognitive-behavioral and systems approaches to target behavioral problems in the entire family. The therapy examines the functions of maladaptive behaviors which are viewed as attempts to get relational needs met. Instead of attempting to alter these existing relational needs, each dyad in the family is taught more adaptive means of getting their needs met (Robbins et al., 2016).

FFT typically involves 12-14 weekly one-hour sessions and consists of five phases – engagement, motivation, relational assessment, behavior change, and generalization (Robbins et al., 2016). The engagement phase is focused on establishing high expectations for the program to promote attendance. In the motivation phase, the therapist works to reduce conflict and shifts the family’s attention toward improving their relationships with each other. In the relational assessment phase, the family examines how their behaviors and feelings shape interactions with each other. In the behavior change phase, they are taught behavioral interventions such as listening and anger management skills that reduce maladaptive behaviors. The generalization phase prepares the family to maintain these new adaptive behaviors after the program ends. There is evidence that FFT improves overall family functioning (Hansson et al., 2004) and parental involvement (Stanton & Shadish, 1997).

Brief Strategic Family Therapy (BSFT)

BSFT is a strategic, problem-focused family therapy that targets children and adolescents, ages 6 to 17, with behavior problems such as substance use, minor criminality, and unsafe sexual activity (Horigian & Szapocznik, 2015). Although problematic behaviors, such as substance abuse, may have many causes, BSFT posits that changes in the family unit will have the greatest influence on behavior and development. The program aims to alter maladaptive family interaction patterns contributing to child/adolescent problem behaviors. For instance, BSFT may address oppositional behavior in the child and the failure of parents to set clear boundaries for their children.

BSFT is typically delivered once a week for 60 – 90 minutes over 12-16 sessions in many settings, including at residential treatment facilities, in homes, or in a mental health clinic (Horigian & Szapocznik, 2015). The BSFT structure consists of four intervention techniques: (a) joining, (b) tracking and diagnostic enactments, (c) reframing, and (d) restructuring. Joining involves creating unity among family members and between the family and the therapist. During tracking and diagnostic enactments, the family converses in their typical manner and the therapist studies the family dynamics, identifying adaptive and maladaptive interaction patterns. Reframing involves the therapist taking a more active approach, altering expressions of negative affect in a way that helps the family members understand each other’s intentions more sincerely. For example, an angry statement may be reframed as an expression of concern or hurt. Last, the family will learn to restructure their interactions through skills such as communication redirection, conflict resolution, and behavioral control. Ultimately, BSFT improves family functioning and reduces child and adolescent behavior problems by allowing families to create adaptive interaction patterns.

Homebuilders (HB)

HB is an intensive, in-home program designed for families experiencing significant relational challenges. HB targets families with children ages 0 to 18 in which there is imminent risk of one or more children being removed from the home for placement in foster care, psychiatric hospitals, or correctional settings (Kinney et al., 2017). Therapists are on-call 24 hours a day, for up to six weeks. For example, it is common for HB therapists to come to a family home during times of crisis and work to defuse the situation. Given the intensity of the approach, each HB therapist serves only one or two families at a time.

Although the course of HB can be variable, often a course of treatment begins with individual work with family members for intensive one-on-one therapy (Kinney et al., 1977). As each family member develops some skills, HB moves to family sessions where problems are defined in specific and concrete ways. In this context, the family receives problem-solving and communication training. In addition, the HB therapist connects the family with community resources to help prevent future crises. For example, such work may include providing basic needs such as food, clothing, and shelter. After the family’s crisis has subsided, an HB therapist may refer the family to a long-term treatment program.

Multisystemic Therapy (MST)

MST is a short-term treatment for families of adolescents ages 10 to 17 who exhibit delinquency and severe behavioral problems (Littell, 2005). MST’s strategies stem from strategic family therapy, structural family therapy, and behavioral parent training (van der Stouwe et al., 2014). It is designed to increase family functioning, decrease behavioral problems, and keep children in the home.

MST typically runs for four-to-six months and sessions range from once a week to daily. It is delivered either in-home or in the community through treatment teams consisting of therapists, caseworkers, and clinical psychologists (Littell, 2005). During MST, an assessment is conducted of the child’s behavior, the child’s interactions with the rest of the family, and the family’s interactions with friends and community members. Therapists draft clear, individualized treatment goals, and the family is assigned various tasks to help them accomplish these goals. Tasks may involve collaboration with school personnel, peers, and neighbors. For instance, if a therapist were to discover their client’s passion for soccer, the therapist might prompt the client to ask their high school soccer coach if they can try out for the team. MST is an intensive approach, generally involving multiple contacts with each client during a week. As such, MST therapists hold relatively small caseloads (4-6 cases). 

Parent-Child Interaction Therapy (PCIT)

PCIT is a behavioral approach for parents with young children (ages 2-7) who are exhibiting social, emotional, or behavioral problems (Warren et al., 2022). PCIT aims to help the caregiver develop an effective, authoritative parenting style to improve the caregiver-child relationship and help the child develop emotion regulation and other behavioral skills.

PCIT is typically delivered once a week for 14-16 weeks and consists of two phases: Child-Directed Interaction and Parent-Directed Interaction (Warren et al., 2022). PCIT involves live coaching where the caregiver wears an audio device permitting the therapist to offer real-time guidance. During Child-Directed Interaction, the caregiver learns to follow the child’s lead in play, focusing on maximizing positive attention and decreasing negative attention. Such a skill helps families where behavioral problems have been inadvertently reinforced through negative attention. This phase seeks to reverse that problematic contingency. In Parent-Directed Interaction, the caregiver is taught to use direct and positive commands to address remaining problem behaviors, improving compliance of the child and confidence of the caregiver (Warren et al., 2022).

Family Check-Up (FCU)

FCU is a skills-based intervention in which therapists collaborate with caregivers to improve parenting skills and child behavior (Stormshak & Dishion, 2009). Tested with children ages 2 to 17, FCU involves three sessions: (a) interview, (b) assessment, and (c) feedback. During the interview, the therapist and parents review problem areas, discuss motivation for change, and draft specific treatment goals. The assessment consists of questionnaires and a video of the family executing several interaction tasks which are assessed by the therapist. During feedback, the therapist discusses strengths and challenge areas, employs motivational interviewing, and provides constructive criticism on the video-recorded interaction task. Finally, the therapist recommends specific follow-up services for the family. FCU is linked to improvements in parenting, which decreases child mental illness and problem behavior (Stormshak et al, 2020). 

Conclusion

Virginia provider agencies can apply for funds for training of their staff in these six well-supported EBPs through CEP-Va. Through the awards, hundreds of practitioners will be trained in Virginia. The six EBPs cover a wide range of problem areas and ages, together building a sturdy service array for families with children at risk for out of home placement. In addition to Virginia, prevention plans and funding opportunities for training in EBPs are available in many other states (see https://www.acf.hhs.gov/cb/data/status-submitted-title-iv-e-prevention-program-five-year-plans). Practitioners can also purchase training to become certified in Family First identified treatments with self-paced, virtual, and in-person options. Providers and provider agencies are encouraged to examine their state’s prevention plan for training, referrals, and possible reimbursement for services. These efforts hold the potential to have an enormous impact on family functioning and to prevent traumatic separations of children from their families.

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