Agenda

Functional Family Therapy

International Certification Program

Clinical Training 2

Thomas L. Sexton, Ph.D., ABPPAstrid van Dam

Functional Family Therapy Associates

Agenda

• Lets see where we stand– Discussion about progress, challenges,

setting the days agenda

• Integrate CFS into clinical decision making

• Your goals?

Preparing for Behavior Change Phase

What do you need

– Clear target for change (well specified)– What is the problem?– Where in the problem sequence– In response to which risk factor– Building which protective factor

– Relational Assessment (to match to the family/client)

– Making it relevant– What and how you talk about the goal

– Implementing the plan

Finding the target starts with identifying the problem

• Clinical problems are NOT because of:– the family/youth’s anger– the family/youth’s lack of “motivation”

• We expect them to be discouraged, lack motivation, angry, unhappy with the systems

– history or biology– peers– bad choices– inability to “just say no”– “mental health” issues– Drug abuse

• They are….– Stuck families

What is the problem?

• What they do about what happened• How they handle risk factors (from

in and outside the family)• How they have come to “define”

the problem (over time)• The sequence between each (which

keep them stuck)

What therapy changes

Problem Behavior (currently defined “prblem”

Mom/mother figure

Dad/father figure

Adolescent

1. Change Climate in the family

2. Change the current problem3. Prepared for the

next “problem”

-cope/deal with in a new way-empowered with a “way”

To solve future

Cultural/Ethnic/Racial “Context”

Family

Sibling(s)

Parent(s)

Adolescent

Behavior becomes of worryTo parents/the system

• Biological• Historical• Relational

Individual Risk and Protective Factors

Community

Peer GroupsValues/Norms

Socioeconomic StatusRisk and Protective Factors

• Values/customs/relational styles/• Rules, rituals

• Expectations/norms

• Unique “whole”• Central Family relational patterns

problem “fit”/”functions” within• Relational “outcomes”

FFT….

“The Current Problem”-Cognitive aspect

(Understanding/attributions of the “problem”--definition)

-Emotional response-Behavioral response to the perceived problem

aimed atsolve problem it

How do families get stuck?

Mom/mother figure

Dad/father figureAdolescent

Clinical Symptoms

Problem “definition-what the problem is

-why its an important problem-what should be done about it

Emotional Reactions (negativity)

Behaviors (interactions)









Anja: “ Peter have you done…””you know you are getting behind”….”you need to take some responsibility” (esclating the longer he doesn’t answer)

Peter: “Whatever….later, I am going out…., I’ll be home…..”

Anja: “there is no going out for you….it just isn’t good for you…..you know you can’t say no to those friends of yours…”

Peter: “At least I have friends…later…” he goes out.

Anja: (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support

Anja: is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation……

Stepfather: …continues watching the football game…worries about his wife…gets angry with Peter…..”

Peter: (comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room…

Stepfather: …”I am tired of this…what is the matter with you…don’t you know how this hurts your mother?”

Peter: “Fuck off..” the typical argument ensues until Peter goes to his room

Anja: “What are we going to do..I can’t take this any more…”

Peter: “I am sorry Mom…but, I can handle it”

Anja: “I just worry about you” (she feels comforted that he understands)

Peter: “I can handle it Mom…just keep that bastard away from me…” (he feels better about his Mom….he directs his anger at his step father….). The next night he goes out again….

Stepfather: …When she talks, he continues to watch to TV…..he listens quietly and say…”what do you want me to do…he wasn’t raised right…”

Figure 7.1

Relational Functions• Functional outcomes of these patterns

• Relational “glue” • Current “experience of the relationship for each individual

Why do they stay stuck?

Mom/mother figure


Clinical Symptoms

“GLUE”

The goal….Reduce the future

Probability ofthe “problem behavior”

Targets of Change-underlying patternsof FAMILY behavior

Relational “Functions”(Relational Assessment)

Goal..understand and use…Attempting to change these basic motivational

components of human behavior in just a few sessionsis clinically impossible and ethically inappropriate

“When X relates to Y, the typical relational pattern (behavioral sequence within the

relationship ) is characterized by degrees of:Relatedness….contact vs. distance

(psychological interdependence)Hierarchy….relational control/influence

When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior

is characterized by:

RelationalIndepende

nceAutonomy:

distance,Independenc

e,Disengagem

ent

high

low

Interdependency: closeness, dependency, enmeshment

low high

12

4

5

3 Mid-pointing

Its not the specific behavior…..but the functional-relational pattern it represents….behaviors and

their possible interpersonal (relatedness) functions

RelationalIndependenceAutonomy:distance,Independence,disengagement

high

low

low high

Withdrawing passively

Being cold, sarcastic,rejecting

Substance Abuse

Having childhood phobias,Being insecure

Being depressedDouble dating

Being hysterical

Teenage runaway

Teenage runaway

Contact: closeness, dependency, enmeshment,

Visible self mutilation

“ideal” balanced adult

Having many jobs and outside activities

Giving considerable Nurturance, warm & loving

Focused/successful professional

“Positive” Behaviors

“Negative” Behaviors

P

A

PA

P A

P

A

One-up One-up

Symmetrical

Relational Hierarchy pattern of relationship determination over time

When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized

by:

Degree to which on personDetermines the relationship

Degree to which on person determines the relationship

Symmetrical:Exchange = Behaviors

1-up +

1-up

P

A

Implementing Behavior Change

• Build on Engagement & Motivation progress– Changes in family climate because of

engagement & motivation phase– Negativity lower– Blame reduced– Responsibility increased– A family focus to the problem

• The way is cleared for specific changes in the problem sequence

• Foundation is build

Clinical model

Matching to….

Artful application means…..

• Match to…….guides therapist clinical interventions behavior

– Model sets the process goal….match to helps us individualize how we get to that goal to the unique family in front of us

– Match therapy to family….How those goals are accomplished

Family Frame of Reference: Themes & Organizing Themes

• Themes….that identify the noble intention• “He is independent……and has mistakes”• “Independent but safe• “Parents to help him be so….and

protect him and teach him in the process”

• “Parents with a lot going on……trying to find way to help…..an independent youth”

• Themes function to:– Stay out of the details….break relational

patterns– Reduce negativity & blame– Increase a family focus– Empower the family: Focus on the “Nobel

intention”

Reframes, Themes, & Organizing Themes

• Reframing…a response to a CLIENT statement

– Acknowledge (acceptance/support of the intent, the position, the values) of the client…..

• not agreement…not empathy….• Personal not general

– Reattribution of that statement (change in meaning)

• Theme Hints…..reframing a CLIENT statement to:– Your hypotheses of a theme (theme “hint”)– An existing theme in the conversation

• Relational/ Organizing Theme…..a theme that describes:– Each persons motivate in non negative ways– Links everyone in the family together….to a common problem,

challenge, of situation

RelationalProcess of ReframingAcknowledgment of:

-exhibited emotion-participation, effort

Description of:-current behavior/event

taking place between people/with one personin the session

--reported event/behavioreither between family

or of one person

Identification of:-important values,

beliefs, desires

Goal:1. Build alliance-with the person youare talking directly to

(by being non-blaming)

-with others in family (by seeing you take on “problems” in a way that is direct but safe)

2. Demonstrate Support

Show attempts tounderstanding of

Persons, situations, etc

1. Meaning-attribution

-event-emotion

(reduces negativity/blame)

2. Challenge themto consider future

possibilities/directions(builds hope that there is

potential, although unknownSolution)

3. Link familymembers togetherIn struggle/problem(builds family focus/Interdependence)

Listen…listen…listen

Acknowledge

Reframe

Impact

“Build on”/continueBuilding theme that fits

Theme hint(best guess/hypothesis)

Description, statement, question

Suggesting alternative theme

ThemeA “new” explanation based on…

1. Changed Meaning

2. Reduced negativity/blame

possibilities for change

3. Linked together in Problem and future

solutionas all having some

responsibility/ownershipfor the problem and

solution

Mom/mother figure


Clinical Symptoms

Problem “definition-what the problem is, why its an important problem

-what should be done about it

Behaviors-role in the problem sequence, the part they “play”

-their responsibility









Mother Therapist

-Frame “this is important….”

-Acknowledge“this is what is important

to you…?”

-Reframe (“and it means…(theme hint)

-change the meaning of what was framed

-individual responsibility-linked to the pattern-different intention/

Meaning behind

Tells what is important-about what you said

-about what you didn’t Say

-About the problem definition

Adolescent Therapist



to you…?”

-Reframe (“and it means…(theme hint)

-change the meaning of what was framed

-individual responsibility-linked to the pattern-different intention/

Meaning behind




Father Therapist



to you…?”

-Reframe




Engagement/Motivation

Creating a Family focus...

…developing a relational thread

Presenting Problem

Redefined “problem”

He is manipulative…he just says/gives you the lines you want to hear when we are here…what he really needs is “crack you head open therapy”…responsibility needs to be put with him…I am just tired, I don’t want to be a parent anymore

He is having a very difficult time learning how to be a man (have values and know what is right), I

can’t find a way to get him to do what he needs to do..., I am just really hurt by it all

Making it Relevant

• Issue of content vs process.• Focus the discussion on what they

think is Important• Focus your attention on the

process….• Is there a family focus?• Is negativity and blame lower?• Do you know the sequence?• Match your language to relational

functions• Focus on “them”

How to use the CFS in Clinical Decision making

1. Case planning• Progress Notes• Session Planning Guides

2. Client Feedback (SIS)– Impact you are having

• Level of negativity & blame • Level of family focus • Engagement • Motivation• Knowing what to do• Know how to do it

How to use the CFS in clinical Decision making

3. Symptom Level (youth behavior) (SFSS-weekly)

• Lets you know what to focus on• Helps the conversation be more relevant• Helps you be specific• Lets you know when there are things to

worry about – Runaway

• Discrepancy between family members– Lets you know to focus on the family framing

• Example…..– Case #1

• Organizing theme?• Problem definitions?• Risk Factors• Sequence

Behavior Change Phase

Early Middle Late

Intervention

Assessment

Behavior change sessions

Goals• Specify the

behavior change targets as family prosocial skills:

• Link BC targets to the organizing theme to build relevance and

motivation

• Build compliance

• match to the client

• check if the BC target works to solve conflict

Assessment• Identifying prosocial

family based skill that fits youth/family

problem sequence

• Find barriers to adoption of BC skill

• Determine if the target is being

performed (compliance)

Interventions

• reframing • Modeling• Teaching• Overcome barriers/adapt

Session Goals

• Frame and link the family to a specific behavioral competency to help family know what to do

• Developing relevant skill.– Teach and coach family in using a specific

behavioral competency in the room

• Helping the family adopt the new alliance based protective skills or competencies

• Engage the family in the behavior change phase activities

Discussion focused on:

-homework, going out with peers,

curfew-specific spot in the

sequence

Conflict Management

Communication-direct and concrete

communication

Parenting-monitoring and supervising

Where they use:

Work out problems…our

focus is on their process of doing so

Parent Adolescent

With components of….to individualize to the family

Targets of FFT Behavior Change: How they go about working together

Problem Solving

Implementing BC Phase

BC PhaseFunctional Family Therapy

New ProblemSituation



Target a new skillthat fits the specific problem that

brought them to therapyChanges the Problem sequencecentral to way family functionsUses new “skills” in problems

that come up



that come up



that come up


Techniques of Behavior Change

• Reframing• Helps direct family to shared, family

focused action• Helps link behavior change to organizing

theme…stay focused• Helps reduce negativity that arises• Challenge that promotes motivation

• Building family competencies…so that the risk patterns central to family change….

• Communication • Problem solving/negotiation• Conflict management• Parenting (monitoring supervising)

Promoting new Behavioral competencies

• Not a “curriculum approach”

• Set of principles (in each area) that serve as the basis of assessment of and and target development

• Principles used by the therapist to “construct” a set of targets that match the unique family

• Implemented within session in ways that match:

• Relational functions• Situation• Theme

• Individualized change plan

Behavior Change…

Interventions technologies/targets

• Communication skills training: principles of positive communication…1. Source responsibility2. Directness3. Brevity4. Concreteness and behavior specificity5. Congruence6. Presenting alternatives7. Active listening8. Impact statements

Behavior Change…

Interventions technologies

• Problem Solving…method for adolescent and parents to work together to jointly solve” problems1. Identify a problem….goals of the family in a

specific incident/area/with a specific problem2. Identify the outcome desired3. Agree on what it takes to “do” it

– Sub goals….who has what part– Contracts/negotiations etc.

4. Identify all the ways it can go wrong5. Come back and see if goals are met

accountability

Behavior Change…

Interventions technologies

• Conflict management….for those “problems” that can’t be solved in other ways– Avoid it…..change reaction to early triggers– Principles to use in trying to contain it…

– Present orientation– Issue focused– Adopt a conciliatory set

1. Exactly what is the issue2. Exactly what would satisfy me?3. Is the goal important?4. Have I tried to get what I want through problem

solving?5. How much conflict am I willing to risk to get what

I desire?• Time-out for transitions



curfew-specific spot in the

sequence

Conflict Management

Communication-direct and concrete

communication

Parenting-monitoring and supervising

Where they use:

Work out problems…our

focus is on their process of doing so

Parent Adolescent

With components of….to individualize to the family

Targets of FFT Behavior Change: How they go about working together

Problem Solving

Behavior change interventions require therapist…

– To have a well thought out change plan– Structuring the session to accomplish it – Contingently responding to what happens in the

session…hearing/seeing feedback• Ignoring…some things• Finding ways to use other things to fit behavior change

goals• Staying with it…while responding interpersonally

– Monitoring of motivation through out implementation

• Backing up to engagement/motivation when needed….

– Follow through– Match to….the family relational functions

Behavior Change interventions….

How to implement Behavior Change

In sessions• Planned through teaching/using a client issue• Opportunity…through an in session incident• How…

– Coaching, directing, teaching, aids

– As “homework”…Specific task that is accomplishable..one issue

• Clearly presented/understood• High expectation of success….define success as doing it

– How…• Within couple…as way to strengthen/change couple

Progress Notes-BC Phase

– Problem Sequence– Relatedness Functions– Potential Behavior Change Targets

(Relevance/Obtainable)– Fit of BC Target to Organizing Theme

and Presenting Problems

How to use the CFS in Clinical Decision making

1. Case planning• Progress Notes• Session Planning Guides

2. Client Feedback (SIS)– Impact you are having

• Level of negativity & blame • Level of family focus • Engagement • Motivation• Knowing what to do• Know how to do it

How to use the CFS in clinical Decision making

3. Symptom Level (youth behavior) (SFSS-weekly)

• Lets you know what to focus on• Helps the conversation be more relevant• Helps you be specific• Lets you know when there are things to

worry about – Runaway

• Discrepancy between family members– Lets you know to focus on the family framing

What Next? Where is behavior change

leading?

Generalization Sessions

Goals• Generalize the BC target skills to

other areas

• Maintain change through relapse

prevention

• Access external resources to

support change

Interventions• Relapse prevention

(if the family is falling back into

problem behaviors)

• Linking new problem situation

to BC skill• Linking family to

relevant outside resources

Assessment• Identify external family systems to

apply BC skills• Identify contextual

barriers to maintaining the BC

target• Find areas to

generalize• Identify relapse

points

Ecosystemic SystemPeer/school/community/extended family

Ecosystemic SystemPeer/school/community/extended family(Sexton, 2010)

The Multisystemic Focus of Functional Family Therapy

Clinical Symptoms/Behaviors

Family Relational System

Generalization Phase…shifting focus

• Within the family:• Relapse prevention • Generalization of competencies• Maintenance of alliance

• Outside the family:• family--environment interaction(interface)…where

the family interacts with the community/environment

• Relationships between family (individual and whole) and the community

• Use of behavioral competencies in these relationships

• In order to use relevant available resources to support changes

Maintaining Change

• Change process is a up and down experience– Often the down feels as if it is a failure– Goal is to reframe it as a “normal”

experience in the change process– The goal….despite the current

failure/discouragement to begin the behavior changes again

– Build confidence/efficacy in their ability to maintain changes….by:• Attribute change to the family• Responding to events they bring in by focusing on

relapse prevention

Generalizing Change

Primary Target

Area/content focused on:


etc.

New area

New area

New area

Behavior ChangeBuilt a “competency”

to reduce a risk pattern

-communication/problem solving/ etc.

Move competency to a new “content” area

Move competency to a new “content” area

Going outWith friends

Homework

RelationshipWith sibling

Time withboyfriend


How to maintain, support, and

generalize new climate, alliance, behavior changes

Medical EvaluationPsyc Intervention

Community/School-direct and concrete

communication

Extended Family-monitoring and supervising

Parent Adolescent

Area to support changes, add to

changes, and places to generalize and

extend change

Supporting Change

Scoring the Measures

Agenda

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