Module 12: Lesson 1

The FST Decision Tree Handout and Red Flags

Checklist TemplateWorksheet

FST Digital Advanced Training Course12 FST Techniques to Become a Family Trauma Expert

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Lesson 1The FST Decision Tree Handout

and Red Flags Checklist TemplateEvaluating Progress and Relapse Prevention are Steps 1-5 and pre-session preparation in Phase V in the FST Treatment Model. Relapse Prevention is the last technique in the FST Advanced Course and the final phase of treatment.

This Lesson #1 worksheet will show you the Pre-Session Preparation for Phase V steps to create both your Decision Tree Handout and Red Flags Checklist Template. These steps are detailed in Chapter 11 (pgs. 323-333) in your Resource Book. This worksheet will serve as your quick reference guide.

In this worksheet you will:

• Learn how to create a decision tree handout and red flags template that you will present to your client or family members in Phase V.

• See the Red Flags Checklist templates used for Tonya’s family in video lesson #1 [Figure 1] and the template used for Dexter’s family in video lesson #2 [Figure 2].

Pre-Session Preparation for Phase VType up and Laminate Final Playbooks and Troubleshooting Checklist; Initiate Any Mid-Week Check-Ins as Needed; Create Decision Tree Handout; Create a Red Flags Checklist Template

Phase V: Evaluate Progress and Relapse PreventionStep 1: Scaling to Assess Overall Progress

Step 2: Mini Scales to Consolidate Healthy Undercurrents

Step 3: Review Decision Tree for Next Steps

Step 4: Co-Create Red Flags Checklist

Step 5: If Graduation: Callbacks and Tune-Ups

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Three Action Steps#1 – �Read�Chapter�11�(pgs.�323-333)� Why?This chapter provides an in-depth outline of the steps needed to create your decision tree and red flag checklist templates. It complements this worksheet as your reference guide.

#2 – �Create�Your�Decision�Tree�HandoutThe ProblemTraditional treatment models often lack the critical step of concretely reviewing the next treatment steps or options before graduation from treatment.

Instead, the individual or family may accomplish the goals of therapy but lack clarity as to the next action steps.

As a result, your clients may end treatment without ever considering the other options available or concrete steps to prevent future relapse. Instead, termination from treatment is often informal and lacks direction.

SolutionTo address these problems, the FST model uses what is called a “Decision Tree Checklist: Five Different Options.” The handout in Table 1 would be copied by you, the FST therapist, and handed to each family member during the next session.

Table 1: Handout of the Decision Tree Checklist: Five Different Options

Option A: Graduation and Red Flags Checklist – Overall, your family and child self-report (and your therapist agrees) a 70% or higher playbook effectiveness on a 0% to 100% rating scale (presented at the beginning of Phase V). It is mutually agreed between you and your therapist that your child and your family are ready for graduation and to finalize your Red Flags Relapse Prevention Checklist along with scheduling the first 30-day callback with your FST therapist.

Option B: Tweak the Current Playbook – If your playbook is not working at a 70% or higher effectiveness (i.e., more practice role-plays/dress rehearsals, more clarification, include key missing extended family members, etc.) a pre-determined number of additional sessions is negotiated with your therapist to work through any identified barriers.

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Pre-Session Preparation Steps ✔ During pre-session preparation, you will study this decision tree handout

carefully. You will pre-determine which of these five options that you are going to recommend to your family as the next step.

✔ The reason for this preparation is that you do not want to be thinking about such an important decision “off the cuff” as the session unfolds. Your decision may change based on new information in Phase V, but it is wise to have a well thought out direction beforehand.

✔ In this way, you are polished and prepared, yet flexible enough to alter these recommendations as needed.

Case exampleAs Figure 1 illustrates, this pre-session preparation and handout was a difference-maker. The mother’s anxiety level in the session dropped because she could now see the next steps and had different options to choose from.

Cynthia, the mother, selected Option B: Tweak the Current Playbook and Negotiate More Sessions. Dexter’s mother realized that her family still needed more role plays on the

Option C: Pick a New Problem and Build Another Playbook – You as a family agree that although the first playbook was successful, other critical wounds still linger and remain (i.e., unresolved grief is a success but still have unforgiveness). It is also agreed that you, as a family, do not yet feel confident or strong enough to complete and implement a second playbook on your own. A specific number of new sessions is then negotiated with your therapist.

Option D: Additional Safety or Misuse of Power Issues Emerge – Additional safety issues emerge or old ones resurface. Healing wounds can act as a cork on a bottle. Once the cork is removed, extreme behavioral problems may reemerge or occur for the first time with your child or teenager. They may be temporary but, you, as the parent or caregiver, still need a behavioral or hybrid contract to weather the storm. A specific number of new sessions is then negotiated to help tweak an existing safety plan or behavioral contract or build a new one.

Option E: Terminate Against Therapist’s Recommendation – The therapist and your family may disagree as to the next steps. Your therapist may advise you that critical work still needs to be done but one or more key family members refuses to go any further. At this point, termination of treatment occurs against your therapist’s recommendation. However, the door is left open to return at any time if relapse occurs, and the family agrees to follow the therapist’s recommendations then.

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disrespect contract. This was also made more evident after Cynthia saw the battle for structure (as illustrated in lesson #2) in which past contracts were not given a chance to work. This was a new narrative or perspective that the family had never thought about before and was supported by the Option B choice.

Based on the evidence from previous sessions, Option B was the best choice. The pre-session preparation allowed me to pondered this decision before the session helped me know how to guide the family. Option B also helped me fight for a new narrative when the mom initially stated that the contract was only working at 20% overall effectiveness. I challenged this perception, in part, based on thinking about the FST Decision Tree before the session.

#3 – �Create�Your�Red�Flags�Checklist�HandoutA final pre-session preparation step is to create a red flags checklist that is customized to the particular family seen in the next session. Simply defined, the purpose of the red flags checklist is to (1) prevent relapse and (2) solidify positive gains. It is also seen as a “protective factor” or handlebar to give your family concrete next steps if the need should arise. It is like

Figure 1: Dexter’s Family Decision Tree

Where do we go from here? We will pick one below: A. Graduate and Red Flags Checklist with Callbacks B. Tweak current playbook and negotiate more sessions C. Pick a new symptom and build another playbook D. Safety or Misuse of Power Issues Emerge E. Terminate Against FST Therapist’s Recommendation

60%50%40%30%10%0% 100%90%80%70%20%

Cynthia for Maxon

x

Adam for Maxon

x

Cynthia for Dexter

x

Adam for Dexter

x

FST Decision Tree

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troubleshooting on steroids. It places you and your family in a place of prevention instead of one of reaction. The red flags checklist is built through Parts I, II, III, and IV:

• Part I: Areas of the Playbook Not Followed – Areas within the playbook at greatest risk for relapse or compromise for your family are listed with the next action steps to get back on track as quickly as possible.

• Part II: Areas of Safety – A reemergence of safety concerns (self-harm, running away, alcohol or drug use, aggression, etc.) and next action steps if these return.

• Part III: Unhealthy Undercurrents or Trauma Symptoms Return – The unhealthy undercurrents and trauma symptoms that your family addressed in treatment are listed, so no one forgets. If any undercurrents or symptoms return, the next action steps are listed to prevent relapse.

• Part IV: First Callback Date – Before the family leaves your office or home session, both therapist and parent get out their calendar to confirm a first date and time (30 days from now at 5 pm) in which the therapist proactively calls the parent to go over the checklist together. This callback will happen again at day 60 and day 90. This callback process and its importance will be outlined in the next chapter.

Table 1 is a template that you can replicate with your future cases. This is the case example of Tonya’s family that was illustrated in your lesson #1 video:

Red Flags ChecklistPart I: Areas of the Wound Playbook Not Followed

• Tonya’s mom feels that she not doing her part (being consistent) and/or Tonya is not following her part of the playbook (respect and going to school) for 3 straight days.

• Sandra (Tonya’s mom) or Mike (Tonya’s dad) say something negative about the other parent to Tonya or each other even one time.

• Mike is not backing up mom around the playbook or Sandra is not backing up Mike around the playbook even one time.

Steps to take if playbook not working for 3 straight days:✓ Mom will call a “check in” meeting with Tonya at the kitchen table to see what the

barriers are and what needs to be done to get back on track✓ After the “check in” meeting, if not back on track, mom will call their FST Counselor

Steps to take if Mom and Dad are not supportive of one another or say something negative:✓ Such an important part of playbook success, one or both parents, or Tonya will call the

FST therapist immediately and to determine if need a tune-up.

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Pre-Session Preparation Steps ✔ As with the Troubleshooting Countermoves Checklist, the FST therapist (you) will

type out the first working draft of the Red Flags Checklist of Part I, II, III, and IV.

✔ During the session, it will be modified with the family’s input. The template, however, will allow the discussion to be laser-focused rather than one of brainstorming and bunny trails.

✔ The Red Flags Checklist is used if there is a decision for graduation or even if the family elects to terminate against the therapist’s recommendation. This is done to provide your family with a bridge back to treatment if they choose to terminate prematurely. Your family may get scared, and you go deeper into wounds or family secrets and terminate prematurely. However, the red flags checklist will still be used. And if it works at all, trust in your treatment grows, and it makes it easier for your family to return.

✔ The red flags checklist can also be used even if your family picks the other decision tree options (Option B, C, or D). In this case, the sample red flags checklist acts like a movie trailer of upcoming attractions. It shows your family what relapse prevention looks like when they are ready for graduation. This will provide your family members with hope and confidence in the FST model and the therapeutic process in general.

Part II: Areas of Safety: If Tonya ever again begins to exhibit one or more of the following safety areas

• Spitting on Mom or anyone.• Showing aggression toward any person.

Steps to take:✓ Mom and dad agree to immediately disable Tonya’s iPhone for a minimum of 4 months.✓ If the above happens a second time, iPhone penalty a minimum of 1 year.✓ Call FST therapist to check in.

Part III: Unhealthy Undercurrents or Trauma Symptoms return• Mom starting to be inconsistent or use empty threats.• A return of Tonya shutting herself in her room for days on end.• Dad or Mom starting to feel resentful (beginning of bitterness) toward one another again.• Mom and dad starting to disagree on parenting issues again.• Tonya starting to lose interest again in outside activities and life in general.

Steps to take:✓ Mom and dad will remind each other of what is missing in private and if corrections are

not made within one week, they will call the FST therapist.

Part IV: Date for First Callback ____________________

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Case ExampleAs Figure 2 illustrates, this hope and confidence is shown in Dexter’s family. In Lesson #2, Cynthia is told that the red flags checklist is a movie trailer of upcoming attractions.

Cynthia understands this fact but loves the process of co-creating a first red flags draft. She states that the process and concrete examples give her confidence that there is a template in place with clear guidelines should early signs of relapse return after treatment ends. The mother especially likes Part II of the playbook or a safety plan around a plan, should Dexter return of previous symptoms of self-harm, aggression, or running away.

Red Flags ChecklistPart I: Areas of the Contract/Playbook Not Followed

• Dexter and/or Maxon do not follow the contract for 3 straight days.• Dexter gives up and becomes disinterested and despondent to the contract/playbook

for 7 days.

Steps to take if the contract/playbook not working for 3 straight days:☐ Mom and Dad will talk to one another to identify what areas of the contract/playbook are

not working, identify barriers and discuss what needs to be done to get back on track.☐ If there is difficulty getting back on track then Mom and/or Dad will call the FST

counselor where all areas of the playbook/contract will be discussed.

Steps to take if Dexter gives up and becomes disinterested to the contract/playbook:☐ Reach out to FST Counselor (Michael) for Tune Up.

Part II: Areas of Safety• Threats or acts of aggression toward anyone.• Threats or acts of self-harm.• Gets upset he will run (still on property)

Steps to take (not really well defined yet need step by step):☐ Step 1 – Call Grandfather.☐ Call FST Counselor.

Part III: Unhealthy Undercurrents or Trauma Symptoms return• Mother and/or Father become inconsistent with rewards and consequences.• Mother and/or Father allow caustic communication to return to the family (includes sparse

communication as to what has been going on with the behavior of the boys for the day).• Family does not use countermoves and button busters.• Family starts to recoil into seclusion (not accessing their village) for a week or longer.

Figure 2: Dexter’s Safety Plan, Parts I-IV

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Final Steps ✔ You will type out this first “working draft” red flags checklist before the session

and then pass it out as a handout using this transition statement (see pages 351-356 in your Resource Book)

The following transition statement is recommended as you pass out the handout:

Now that we have decided on the next steps or which “option” from your decision tree handout let’s create what we call a Red Flags Checklist together. I took the time before our session today to create a template as I did with your Troubleshooting Countermoves Checklist. As we did with your troubleshooting checklist, this red flags checklist template is a working draft. In a moment, we will tweak it as needed. (Hand out a copy of the template to everyone)

As we look at this Red Flags Checklist handout together, I listed potential red flag behaviors that could cause you or your child to relapse. Any relapse will not likely be as bad as before, but if it happens, we still want to address it quickly before it gets out of control like a brush fire. The research shows that your first 30 days puts you at the greatest risk for relapse because your playbook is still brand new.

Therefore, after we create this Red Flags Checklist together, I ask that you tape it to your bathroom mirror right next to your playbook to review each morning as you brush your teeth. Will everyone give me a verbal agreement to review this checklist at least once a day to prevent relapse (get a verbal agreement from each person)

Ok, let’s begin. I will go through each part, starting with Part I, line by line, and ask everyone to either agree and vote to leave as is, tweak it, or change it. If we disagree, I will try to get a consensus. If not, I would like the final vote as your

Steps to take:☐ Mother and/or father to call a check in meeting to evaluate where they are at in

maintaining healthy undercurrents.☐ If not working (see above) Mother and/or father have a village meeting.☐ If corrections are not maintained for 1 week call the FST Counselor.

Part IV: Callbacks and Tune-UpsMichael Coffman MA, LPCC S

Date and Time of 30 Day Callback? ____________Date and Time of 60 Day Callback? ____________Date and Time of 90 Day Callback? ____________

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therapist so we can get the checklist completed promptly. (I reproduced each line on this blank flipchart) Or, (I will type in any changes as we go, using my laptop)

Success MilestonesAfter you complete this worksheet, look for this success milestone in your practice:

✔ Prevention is Worth an Ounce of Cure – Both the decision tree and red flags checklist are a concrete example of “working smarter, not harder.” It is prevention, but the handouts allow both you and your client to end treatment with excellence. These protective factors, before termination, will increase the odds that earlier treatment successes will turn into a new normal for your family. Therefore, the success milestones in to look for are:

• The decision tree is readily accepted by your individual, couple, or family, and they self-report that it is working.

• The red flags checklist prevents your future clients from relapsing at a discernable higher rate than treatment as usual.

• Your confidence grows as you see how both of these techniques work together to provide your clients with a clear roadmap for graduating with success.

Big Ideas: Lesson 1 VideoWhy is Good to Great Relapse Prevention So Needed?

✔ Relapse prevention is Phase V or the last phase of treatment in the FST Model

✔ After an overview of the FST flowchart, I discuss the concept of “It’s Not How You Start It’s How You Finish.” This means that if Phase V of FST treatment is not done well, your client will relapse.

✔ I ground this idea to Prochaska’s Stages of Readiness and how “Maintenance” and “Termination” is critical to your treatment success to prevent what is called recycling back to earlier stages of readiness with a brief example to illustrate this process.

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A Relapse Prevention Example Using a Red Flags Checklist

✔ One of the five relapse prevention techniques, the red flags checklist, is used as a case example to illustrate the importance of good to great relapse prevention

✔ The four-part of the Red Flags Checklist are highlighted from a past Facebook Live talk.

Please Note: Materials that are included in this course may include interventions and modalities that are beyond your authorized practice as a mental health professional, case manager or parent support liaison. As a professional, you are responsible for reviewing your scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.