An Interview with April Gilfort - From Spring 2008 Newsletter

      I recently had the pleasure of interviewing Dr. April Gilfort, Clinical Director of Dominion Ministries, Inc., in Durham, North Carolina. Under her guidance, Dominion Ministries (DM) practices contingency management (CM) techniques in its Substance Abuse Intensive Outpatient Program (SA-IOP) for adolescents and its Multidimensional Family Therapy Program (MDFT). What follows should sound familiar. She confirmed all we had researched for this issue and was clearly following evidence based practice with CM. What is even better about this story is that Dr. Gilfort and DM uses its experience with adolescents and their families to refine their practice of CM. They do consult the literature and follow evidence based treatment models, but evaluation of family outcomes truly drives this program. If you have not been able to wrap your mind around the concept of practice based evidence (as opposed to evidence based practice), read on. This is a chapter in the “how to” manual!

DM’s client population
      This agency’s adolescent population is mainly those who have court ordered treatment. The adolescents come to the agency as a part of their probation; DM communicates treatment progress to the courts with permission from the adolescents as part of the probation agreements. DM can report probation violations (including positive drug screens) to the clients’ court counselors. Eighty percent of the agency’s client population is African American, approximately three to five percent are Latino and the rest are Caucasian. Most are boys and the majority of clients live within Durham city limits.

CM in the MDFT program
      DM began using MDFT about two and one-half years ago and committed to training all therapists who work in the Family Therapy Program in MDFT in December 2007.  The main way DM uses CM is by training caregivers (parents, or whoever else is legally responsible for the adolescent) to set healthy boundaries with their adolescents and to use positive reinforcement as reward for respecting those boundaries. DM’s MDFT program has three phases. In the first phase, therapists work with parents to increase confidence with setting healthy limits for their adolescents. This phase is all about readiness, preparing families to work together towards freedom from drugs. This involves a lot of role playing and planning out ways to reinforce behavior caregivers like. Phase one treatment techniques for the adolescent include working with the therapist to accept respectful limit-setting from their caregivers. The therapist also works with the family unit on how to communicate with each other in respectful ways. In the third phase the therapist helps the family “seal” the positive changes by working with natural supports to maintain the change once therapy has ended.

      Dr. Gilfort offered a helpful example. A grandparent had difficulty getting her granddaughter to respect curfew, which was 7:00 PM. The therapist helped the grandmother examine what would set her up for success in communicating her expectations. Training caregivers to set themselves up for early success is an essential concept in CM. Both caregivers and adolescents need this to build their confidences which will lead to continued practice of their newly acquired skills.  At first the grandmother wanted her granddaughter to come in at 7 PM for an entire week before receiving a reward. As the grandmother and therapist talked, they both decided the granddaughter needed to comply three consecutive days. If she did, the granddaughter could call and ask to stay out later on the fourth evening and the grandmother could grant this extra privilege. If the granddaughter did not comply, the grandmother could deny the privilege and could reward the next time she complied or she could reset the period for compliance (back to the next three consecutive days). When the grandmother and granddaughter reach phase two of this program, they will get coaching from the therapist on how to negotiate new boundaries and rewards.

      Phase two involves the caregivers and adolescents practicing their new skills. With training and early success under their belts, families can learn to set boundaries and decide appropriate rewards together. At this point, expectations (curfews, good grades, etc.) become what Dr. Gilfort calls maturity demands. The caregivers ask their adolescents to rise to the level of maturity of which adolescents are capable. If the adolescent does not live up to this expectation, the caregiver uses positive punishment to reinforce the maturity demand. The caregiver may decide the adolescent needs to spend more time at home studying if he or she received a lower than expected grade (pre-negotiated by caregiver and adolescent) on a test. Dr. Gilfort admits that this three-phase process takes a lot of time, spotted with success and failure, but she says it eventually works. MFDT allows for six months of treatment and fits well with the rocky reality of negotiating healthy limits and rewards.

CM in the adolescent SA-IOP program
      DM also uses CM in a twelve-week SA-IOP program for adolescents. The adolescents receive rewards for the milestones they meet. DM capitalizes on free incentives in this program, the biggest one being stepping down from intensive outpatient services. DM outpatient therapists help the adolescents connect their success in treatment with needing less treatment, which means more free time. Gilfort says the adolescents view the free time as a coveted award. The SA-IOP program also throws celebrations for adolescents as they reach important milestones, especially graduation from the program. DM receives many donations from the community to provide these celebrations. The adolescents may also receive gift cards from time to time. This program also uses positive punishment. The adolescent usually has court orders with which he or she must comply. If he or she has a positive drug screen, DM must contact the court counselor, and the adolescent may have to go to detention, etc.

Maintaining fidelity
      Ms. Gilfort’s goal is to have all therapists trained in MDFT, all supervisors in this program trained to supervise MDFT and for her to become a train-the-trainer for MDFT (currently underway). She also plans for others in her practice to continue to the train-the-trainer level so that there is a less expensive way for her clinicians to get MDFT training if there is turnover. She believes she now has a small core staff committed to practicing MDFT and to staying with the agency.

      Gilfort believes this training, and having all therapists equally trained, encourages fidelity to the MDFT model. Since DM is currently receiving training in MDFT, all therapists are video and audiotaping sessions and getting feedback from experts in MDFT. Gilfort says this type of intensive training really helps her staff maintain fidelity to the model. When I asked her how she plans to insure her therapists maintain their current level of fidelity, she emphasized her commitment to ongoing supervision for her staff by clinical supervisors trained in MDFT. Front line clinicians will continue to get live feedback during sessions, feedback on taped sessions, and guidance from trained MDFT supervisors. Essentially, she is wrapping MDFT training and supervision around every level of DM’s practice. This way, adolescents and their families walk into a unified agency committed to providing the best quality care in every program and at every level.

Financing CM at Dominion Ministries
      When I was interviewing April, I had the sense that DM’s program epitomized best practice. She confirmed my hunch when we talked about how she finances her programs. To truly be an evidence based program, an agency must focus on the best ways to implement their programs. This not only includes policies that encourage fidelity, supportive supervision, and promote evidence based treatment., it also includes a financing program that ensures sustainability and takes full advantage of all ways to draw down dollars for its clients. For all of you who are wondering how you pull it off, here are the secrets. DM:

Solicits donations to support CM,
Capitalizes on free CM, such as less treatment (more free time),
Trains parents to provide appropriate CM that can also be free (extended curfew),
Receives state and county funds for treatment and CM, and relies less on Medicaid (since funding is more restrictive),
Draws down non-UCR dollars from Division funds to pay for training, and
Uses Mental Health Trust Fund dollars to pay for programs

      DM decided what evidence based treatments would best serve its clients and then searched for ways to fund them, rather than looking at its funding options and deciding what it could afford. Think of the familiar saying, “Do what you love and the money will come.” In this case, “Do what you know is best for your clients and you will find a way to finance it.”

      Thank you April! I know your comments will be very helpful to all our readers. Dr. Gilfort welcomes the opportunity to share her experience. Call her at 919-416-1830 if you would like more information about Dominion Ministries’ MDFT or adolescent SA-IOP program.

~submitted by Caroline Moseley