Implementation Issues in Functional Family Therapy: A Narrative Analysis of the Evidence

Abstract

Background and Purpose:Currently, functional family therapy (FFT) is indicated as aneffective treatment option for behavioral disorders in youthaged 10–18. While there is a great deal of uptake and support for this intervention, results from systematic reviews, meta analyses, and a recent overview suggest considerable heterogeneityin outcomes. The extant literature has indicated that implementation concerns may be the cause for much of the variability across trials and between outcomes, thus prompting this implementation analysis which is based in part on the Oxford Implementation Index. The purpose of this analysis is to examine the implementation of FFT as it modifies the intervention effects by way of the Index. We present a consideration of dose, delivery, uptake, and context across trials and to understand how these elements, as well those of supervision quality and amount, impact the differential effects found.

Methods:This analysis stems from the published overview of FFT, and all published reviews of FFT which were previously identified were examined. Additionally, search termswere modified and used across relevant databases in orderto update this search and capture any relevant studies that were not reported or included elsewhere. Electronic searches were made of relevant databases, government policyreports, and professional websites. Experts known to have conducted trials of FFT were contacted in order to augment our search of the gray literature, and author calledupon personal and professional resources to locate any studies that were complete but not yet published. This search was designed to be highly sensitive and to capture all relevant studies and publications relating to this project. The included studies were then analyzed in accordance with the Oxford Implementation Index and also with an examination of supervision quality and intensity.

Results:In total, the search yielded 150 records; 48 full texts were retrieved of which 32 were excluded, leaving 16 studies containing 5,320 unique participants included for analysis. There was no evidence of reported harm. Improved training and supervision were associated with better core outcomes. Although there was no apparent dose relationship, it appears that implementation issues are important and also that class and ethnicity were identified for areas of further study.

Conclusions and Implications:

This analysis shed light on whether the effects found for FFT were influenced by differential implementation. Most striking is the possible connection between supervision quality

and quantity with positive outcomes. Unsurprisingly, studies led by the developers of the model rank higher in this area and may indicate that it is the supervision, oversight, and model-specific

training of therapists that allows them to achieve more success with the model. It may be that it is not merely due to supervision and oversight, but to allegiance effects. It is with continued high-quality into the mechanisms of change and implementation of the model that we can better understand how to achieve positive effects across an increasingly heterogenous and disparate population of youth and families in need of treatment.