An Evidence Based Model for Delinquent, Drug Using Youth and

Their Families

Overview of Model

• The BSFT Model was developed in Miami to meet the needs of Cuban refugees

• Cuban youth were getting into trouble at school and in the community

• Youth were seen at the University of Miami clinic

Overview of Model

• Parents were not included in sessions• Parents wanted communication with therapists

about their troubled youth• Parents were less acculturated than their youth

Overview of Model

How was the model developed?• A basic research study on Cuban values was conducted

by José Szapocznik• The value of family first or Familialismo was identified• A group of Cuban psychologists began to develop a

family intervention, which became known as BSFT

Overview of Model

What is the underlying philosophy?• Replace maladaptive family interactions with adaptive

interactions• Develop competence and mastery• Transform affect to create change opportunities• Facilitate appropriate connections between family

members

Core Components

There are four basic BSFT techniques that are used to address emerging process and create interactional change:• Joining• Tracking• Reframing• Restructuring

Core Components

How frequently do contacts occur?• Sessions are held weekly for 60 -75 minutes• Treatment dosage is 24 weeks• All family members are expected to attend

Population Served• What is the target population for the model?The BSFT model may be used for treatment of children and adolescents 6-17 years old presenting with:

Alcohol and drug useDelinquent behaviorOppositional, defiant behaviorAggressive, violent behavior

Association with deviant peersSexually risky behaviorPoor school attendancePoor academic performance

Population Served

What are the exclusionary criteria?Identified Patients with:• Pervasive Developmental Disorders• Actively Psychotic

Research Evidence

• Reductions in adolescent behavior problems• Drug Use• Delinquency/Conduct Problems• Association with Delinquent Peers

• Improvements in Family Functioning• Superior rates of Engagement/Retention

Outcomes

• Efficacy Trials:Brief Strategic Family Therapy,

Individual Child Psychodynamic Psychotherapy, and a Recreational Attention Control

for Cuban Boys.

Szapocznik et al., 1989

Outcomes

• Both BSFT and Individual Child Psychodynamic Psychotherapy had significant reductions in boys’ emotional and conduct problems at one year follow-up and both conditions had significantly better outcomes than the Recreational Attention Control condition

• Family Functioning deteriorated in the Child Psychodynamic Condition

OutcomesFamily Functioning

FAMILY

CONTROL

CHILD

Baseline Termination Follow-up

Szapocznik & Prado, 2007

Blind Independent Structural Family Systems Ratings

Mea

n Fa

mily

Fun

ctio

ning

Outcomes

Challenge: Bringing whole families to treatmentSolution: BSFT Specialized Engagement

• To improve participation and more importantly to ensure that the critical family members are present in sessions

Outcomes

BSFT Engagement vs. Engagement-as-Usual

0%10%20%30%40%50%60%70%80%90%

100%

Engagement Retention

93%

75%

43%

25%

Family SSSE

Control EAU

Szapocznik et al., 1988

Engagement Retention

75%

93%

Outcomes

Efficacy Trials:• Treatment Outcomes: BSFT vs

TAU (Value-Clarification Group Counseling)with Hispanic drug-using/problematic adolescents and their families

Outcomes

19%

27%

5%

BSFT

11%

GROUP

21%

17%

0% 0%

0% 5%

6%

BSFT GROUP

46%38%

11%

Parent Reports Adolescent Reports

ConductProblems

Antisocial Behaviorwith Peers

14%

43%

19%

50%

17%

57%

Marihuana Use

GROUPBSFT

Reliable ImprovementReliable Deterioration

Santisteban et al., 2003

Reliable change movinginto normal range

Reliable change withinclinical range

IMPACT OF BSFT VS. GROUP COUNSELING ON BLIND, INDEPENDENT STRUCTURAL FAMILY SYSTEMS RATINGS

Poor Family Functioning at Baseline Good Family Functioning at Baseline

BSFT

Group

Baseline Termination

12

13

14

15

16

17

Baseline Termination

14

14.5

15

17

15.5

16

16.5

17.5

BSFT

Santisteban et al., 2003 Szapocznik

& Prado, 2007

Group

OutcomesEffectiveness Trial:480 families randomized to BSFT vs. Treatment as Usual

* 72% referred by Juvenile Justice* 2-3 days/month of drug use

Outcomes

0%10%20%30%40%50%60%70%80%90%

100%

Engaged Retained

73%

44%

89%

60%

TAU

BSFT

Robbins et al, 2011a

Engagement & Retention

Outcomes

-0.1

-0.05

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0 4 8 12Months Post-Randomization

Family Functioning (Parent Report)Full Sample

BSFT

TAU

Outcomes

Robbins et al, 2011a

OutcomesLong Term Outcomes:

4-7 Years Follow-up (280/480)

BSFT youth when compared to TAU youth had lower rates of:

◦ lifetime (IRR = 0.68, 95% CI [0.56, 0.82]) and past year arrests (IRR = 0.53, 95% CI [0.40, 0.72]) than TAU.

◦ lifetime (IRR=0.63, 95% CI [0.49, 0.82]) and past year incarcerations (IRR = 0.66, 95% CI [0.49, 0.89])

Horigian et al., 2015

Staffing Requirements

What are the staffing requirements?• Master’s degree in psychology, mental health counseling,

social work or marriage family therapy with a minimum of two years postgraduate clinical experience

Staffing Requirements

Minimum professional qualifications include:• Ease in working with all members of the family• Basic knowledge of family systems theory and practice• Flexibility including willingness to work evenings and

weekends, when families are available• Willingness to adapt to clients’ cultural characteristics

Staffing RequirementsHow are teams structured?• A standard BSFT team has 4 therapists• One therapist will become BSFT On-Site Supervisor

in Year 2

Staffing Requirements

• What are the caseload requirements?

• A trained BSFT therapist must be full time and can carry a caseload of 8 families for approximately 6 months each.

• Caseloads may be increased if sessions are conducted in the office.

• Each family session runs for approximately 1 to 1½ hours, with additional time required for notes and treatment planning including strategy planning for each session, prior to the session.

Staffing Requirements

Are supervisors required to carry caseloads?• The therapist that acts as the BSFT On-Site Supervisor can

complete approximately 8 cases a year, in addition to their supervisory role.

• With 4 trained therapists at an agency, including the BSFT On-Site Supervisor, the agency can complete an average caseload of 60 cases in a year.

Average Length of Service

• The average length of service is 6 months• Families are required to attend weekly sessions• BSFT Specialized Techniques are used to ensure

Family Engagement and Retention

Training Requirements

• What are the training requirements for new frontline staff ?

• Three 3-day Interactive Workshops• Each workshop will be conducted at the agency site by a

BSFT Model Manager and consists of three days that include interactive lectures, taped demonstration of family therapy sessions, clinical case consultations, and class exercises

Training Requirements

Regular Group Supervision Sessions• Group supervision will commence weekly after the

completion of BSFT Workshop 2. • The supervision is conducted via video conference

and the BSFT Model Manager will provide feedback on pre-submitted recording of therapists’ family sessions.

Training Requirements

Booster Workshops• Starting in the second program year, there will be a

2-day booster workshop conducted every year for the BSFT therapists

• Booster Workshops include live supervision

Training RequirementsTraining for Additional Therapists• If new therapists are added to the BSFT team

after the initial BSFT training, they will need to attend BSFT training and supervision to reach the required level of competence.

• Requests for individuals such as clinical supervisors and directors to observe the workshops/supervision will be accommodated.

Fidelity Monitoring/Quality Assurance Activities

• All BSFT sessions must be recorded• Therapists must review recorded sessions weekly

BEFORE supervision• BSFT Model Managers rate recorded sessions

monthly and issue fidelity reports to therapists and agency leaders

Fidelity Monitoring/Quality Assurance Activities

Is there a model-specific data system? What does it involve?• Agencies are required to complete the BSFT Case

Roster in order to track treatment progress for each family

• The Case Roster is also used to monitor the effectiveness of each therapist

Fidelity Monitoring/Quality Assurance Activities

What technology is required for fidelity monitoring?• Laptop• Monitor• Recording Device

Implementation Support

Site Readiness Process:• Selection of team of BSFT therapists• Creating referral flow• Getting organizational buy-in• Getting stakeholder support

BSFT Implementation Year 1

• BSFT Workshops 1, 2 required before therapists see families

• BSFT Workshop 3 includes live supervision• 2 hour weekly supervision• Monthly implementation conference call• Selection of BSFT On-Site Supervisor

Implementation Support

• BSFT Implementation Year 2 and Beyond• On-Site Supervisor supervises the team• Shared leadership of conference calls between BSFT

On-Site Supervisor and BSFT Model Manager• Annual Booster Workshop• Annual Clinical Consultation

Implementation Support

What resources are available for evaluation?Case Related Data:• Treatment Completion• Treatment Outcomes• Treatment Dosage• Specialized Engagement Outcomes

Thank You