What do Families need?

1. Functional Family TherapyInternational Certification ProgramClinical Training 2Thomas L. Sexton, Ph.D., ABPPAstrid van DamFunctional Family Therapy Associates

2. What do Families need? Values and Norms of helps that fit Help out of discouragement and a lack of motivation Help that fits them

3. to successfully deal with diverse families…. • Offer something relevant…different…and helpful • Family based/driven change • focus has to move from need to move away from “outside in” approach • standard “behaviors” with prototypic “models” of what healthy and good functioning is….. • Move toward an “inside out” approach • how they work and change small things in that they help them accomplish the tasks around them in ways that fit them

4. To be successful with youth and their families FFT relies on… • A Clinical “Map” • Systematic process of therapeutic change • Specific goals, objectives, and therapist activities • Mechanisms of change • built on… • Guiding Theoretical Principles • Conceptual, philosophical, and emotional center of the model • Parameters within which FFT occurs • System Support Systematic, model based clinical supervision Accountability Quality assurance methods • Management/treatment responsibility/supervision/clinical decisions FFT based

5. Late Early Middle Functional Family TherapyClinical Model Goals & Phases Remain the constant Alliance based & collaboratively driven Behavior Change Engagement Generalization Assessment Intervention “look & feel” different with each family Behavior Change Generalization Motivation

6. FFT is unique in the EBP World and evidence based treatment that is: Purposefully Creativity Flexibly Structured Model focused and Client Centered Change that is guided by the model….driven by the Family…with respect for how the family “functions” “inside out” approach Requiring a creative therapist Aided by….

7. Bringing Creativity to the Structure • Client Centered • Responsive to clients • Responsive to client needs • “fit” to a client • Artfully applied • Require clinical creativity and expertise

8. Clinical modelMatching to…. • 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 • Match HOW it is done…not WHAT is done!

9. Thinking Through the Lens Therapeutic change process

10. Peer Groups Values/Norms Socioeconomic Status Risk and Protective Factors Cultural/Ethnic/Racial “Context” Family FFT…. “The Current Problem” -Cognitive aspect (Understanding/attributions of the “problem”--definition) -Emotional response -Behavioral response to the perceived problem aimed at solve problem it • Unique “whole” • Central Family relational patterns problem “fit”/”functions” within • Relational “outcomes” Behavior becomes of worry To parents/the system Community Adolescent Sibling(s) Parent(s) • Biological • Historical • Relational Individual Risk and Protective Factors • Values/customs/relational styles/ • Rules, rituals • Expectations/norms

11. Adolescent Dad/father figure Mom/mother figure Individual Behaviors • RELTIONAL PATTERNS • Core family/dyad stable relational patterns • Relational sequences/problem sequences • Relationship defining • Maintains the problem behavior • Promotes certain protective/risk behaviors • “personality” of the family • Central Focus of FFT

12. Relational Patterns

13. 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: “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…. Anja: “I just worry about you” (she feels comforted that he understands) Peter: “Whatever….later, I am going out…., I’ll be home…..” Peter: “I am sorry Mom…but, I can handle it” 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…” Anja: “What are we going to do..I can’t take this any more…” Peter: “At least I have friends…later…” he goes out. Peter: (comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room… Anja: (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support Stepfather: …continues watching the football game…worries about his wife…gets angry with Peter…..” 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…” Stepfather: …”I am tired of this…what is the matter with you…don’t you know how this hurts your mother?” Anja: is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation…… Figure 7.1 Peter: “Fuck off..” the typical argument ensues until Peter goes to his room

14. What problems are NOT! • 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

15. Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions) Adolescent Dad/father figure Mom/mother figure Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions) Clinical Symptoms Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions)

16. Adolescent Dad/father figure Mom/mother figure The goal…. Reduce the future Probability of the “problem behavior” Targets of Change -underlying patterns of FAMILY behavior Clinical Symptoms “GLUE” Relational Functions • Functional outcomes of these patterns • Relational “glue” • Current “experience of the relationship for each individual

17. Relational “Functions” “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 Goal..understand and use… Attempting to change these basic motivational components of human behavior in just a few sessions is clinically impossible and ethically inappropriate

18. high 1 2 Relational Independence Autonomy: distance, Independence, Disengagement 4 5 low low Interdependency: closeness, dependency, enmeshment high When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by: 3 Mid- pointing

19. Teenage runaway Teenage runaway Its not the specific behavior…..but the functional-relational pattern it represents….behaviors and their possible interpersonal (relatedness) functions high Substance Abuse Having many jobs and outside activities Being cold, sarcastic, rejecting Being hysterical Relational Independence Autonomy: distance, Independence, disengagement Visible self mutilation “ideal” balanced adult Withdrawing passively Being depressed Double dating Focused/successful professional Giving considerable Nurturance, warm & loving “Positive” Behaviors “Negative” Behaviors Having childhood phobias, Being insecure low low high Contact: closeness, dependency, enmeshment, (Fear of abandonment?)

20. 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: P A A P P A A P A P Degree to which on person Determines the relationship Degree to which on person determines the relationship 1-up + 1-up Symmetrical Symmetrical: Exchange = Behaviors One-up One-up

21. The Clinical Model “following the map” Therapeutic change process

22. Outcomes • Increase behavioral competency of all/family • Consistent performance of competency • in “real” problem situation Early Middle Late Functional Family TherapyClinical Model Engagement Behavior Change Generalization Assessment Intervention • Outcomes • Alliance between family • with therapist • Family/relationally • based problem problem focus • Reduced family member • negativity/blame • Increased motivation • Outcomes • Generalize new “view” and experience of problem with • new problem that arise • Maintain new skill - working together • with new problems • Support changes by using relevant outside resources Motivation Behavior Change Generalization

23. Individual Dad/father figure Adolescent Mom/mother figure What therapy changes 1. Most critical issue solved…and 2. Prepared for the next “problem” -cope/deal with in a new way -empowered with a “way” To solve future

24. The behavioral outcomes of FFT • The behavioral outcome goals of therapy are those that are obtainable and lasting • not healthy families but…….. • obtainable behavioral changes • ...are those that are: • obtainable behavioral changes … • for these people … • with these resources … • and these value systems … • in this context

25. Engagement/Motivation Sessions • Assessment • problem definitions • Problem sequence • How they “function” or work together • Goals • reduce within family blame • reduce within family negativity • build therapeutic alliance • redefine problem as family focused • increase hope/expectation for change • Interventions • reframing • Develop an organizing theme that is family focused • diverting and interrupting • structuring session to discuss relevant topics

26. What to hear • FFT therapists try to hear something different: • Hear attribution, emotion, and behavioral pattern as central element underlying the “presenting” problem • Hear risk and protective factors embedded in this pattern that increase the likelihood of “clinical problems” • Think….”family relational pattern” • Common/central pattern that is at the foundation of the many different “presenting” problems

27. Comes from:Each individuals uniqueHistory/experience with problem, natural attempts to understand/make sense, solve the problem Accomplished Through relentless relational Reframing Accomplished Through relentless relational Reframing Accomplished Through relentless relational Reframing Adolescent Initial Presenting Problem Definition -attribution aspect -emotional valence -related behavioral patterns Each feels “misunderstood”, blames the other, Thinks the other is the problem, works toward a different solution Goal: Redefine each toward a “common family focused” definition That is -different from each individual definition • common to all • Where all have responsibility • No one has blame Father Initial Presenting Problem Definition -attributional aspect -emotional valence -related behavioral patterns Family Focused Problem definition Initial Presenting Problem Definition -attributional aspect -emotional valence -related behavioral patterns Not compromising mediating or negotiating The Outcome: Motivation, negativity reduction, Family to family alliance, Therapist to family alliance Mother Initial Presenting Problem Definition -attributional aspect -emotional valence -related behavioral patterns

28. Relational Process of Reframing Acknowledge Reframe Impact Assess acceptability/fit Change/continue Making it fit the client

29. Meaning -attribution -event -emotion (reduces negativity/blame) 2. Challengethem to consider future possibilities/directions (builds hope that there is potential, although unknown Solution) Link family members together In struggle/problem (builds family focus/ Interdependence) Theme A “new” explanation based on… • Changed Meaning • Reduced negativity/ blame possibilities for change • Linked together in Problem and future solution as all having some responsibility/ownership for the problem and solution Relational Process of Reframing Acknowledgment of: -exhibited emotion -participation, effort Description of: -current behavior/event taking place between people/ with one person in the session --reported event/behavior either between family or of one person Identification of: -important values, beliefs, desires Goal: • Build alliance -with the person you are 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) • Demonstrate Support Show attempts to understanding of Persons, situations, etc Acknowledge Theme hint (best guess/hypothesis) Description, statement, question Suggesting alternative theme Reframe Impact Listen…listen…listen “Build on”/continue Building theme that fits

30. Engagement/Motivation Phasepurposeful, therapeutic conversations Personal conversation… that is direct… about the most important issues to the family Between family member negativity/blame Therapist Therapist Family Individual Responsibility Time…..

31. Why Reframes & Themes Work“Respect based” Reframing • Acknowledge (“yes….) • What they just said is important..frames the situation/problem/event that is the “target” • What you “guess” to be important to them • Reframe (“and….)…what you “add to” the session • Alternative meaning for what was acknowledged • what might be “behind” or “the reason” • Focus… • Person focused (their part) • Family focused (all of the parts) (“…yes that is what is important here…) • Non-blaming…just an alternative description

32. 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 • 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

33. Organizing Theme • Frame… • “you are…” • “this is a family….” • Specific behavior/pattern… Problem sequence • Explanation…gives different meaning of “how they work” and “what is going on between them” • reframes “put together” • New story about what is going on in the family (describes different reason for problem sequence) • each person….the family…how linked together • “your part….what it means….how it linked with other family members • Complete, includes what is most important to family, personal, specific in way that is individual

34. Engagement/Motivation Creating a Family focus... …developing a relational thread Presenting 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 Reframing Redefined “problem” 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

35. Themes Add to..Elaborate.. Link individuals to family Themes Reframing Opportunity Validation --Reframe Listen--change-incorporate Continue Reframing Opportunity Validation --Reframe Listen--change-incorporate Continue New problem definition -explains problem in family focused way Reframing Opportunity Reframing Opportunity Organizing Theme Individuals linked to family “Braided” reframes Reframing Opportunity Time Dynamic nature of reframing Overtime…the outcome • Negativity decreases • Family focus increases • Motivation increases • Blaming decreases • Attributions change

36. What makes reframing work • “feel” the reframe • Therapist able to “be the client” and know what is important…the noble intention behind the behavior • “believe” the reframe • It “is” how you understand them • “linked” to everyone else • Presented in a way that is… • With acknowledgement • Respectful

37. Adolescent Dad/father figure Mom/mother figure Tells what is important -about what you said -about what you didn’t Say -About the problem definition 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 Tells what is important -about what you said -about what you didn’t Say -About the problem definition 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 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 -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 Clinical Symptoms Tells what is important -about what you said -about what you didn’t Say -About the problem definition -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 Father Therapist Therapist Adolescent -Frame “this is important….” -Acknowledge “this is what is important to you…?” -Reframe Therapist Mother

38. Outcome: Motivation through family focused relational 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”

39. Behavior Change Phase Assessment Intervention Early Middle Late

40. Behavior change sessions • 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) • 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 • Interventions • reframing • Modeling • Teaching • Overcome barriers/adapt

41. Targets of FFT Behavior Change Discussion focused on: -homework, going out with peers, curfew -specific spot in the sequence Parenting -monitoring and supervising Communication -direct and concrete communication With components of…. to individualize to the family Parent Adolescent Conflict Management Where they use: Work out problems…our focus is on their process of doing so Problem Solving

42. Implementing BC Phase Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new “skills” in problems that come up New Problem Situation New Problem Situation BC Phase Functional Family Therapy New Problem Situation New Problem Situation Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new “skills” in problems that come up Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new “skills” in problems that come up

43. 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)

44. 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

45. Behavior Change… Interventions technologies/targets • Communication skills training: principles of positive communication… 1. Source responsibility 2. Directness 3. Brevity 4. Concreteness and behavior specificity 5. Congruence 6. Presenting alternatives 7. Active listening 8. Impact statements

46. Behavior Change…Interventions technologies • Problem Solving…method for adolescent and parents to work together to jointly solve” problems 1. Identify a problem….goals of the family in a specific incident/area/with a specific problem 2. Identify the outcome desired 3. 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 wrong 5. Come back and see if goals are met accountability

47. 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 issue 2. 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

48. 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

49. 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

50. Progress Notes-BC Phase • Problem Sequence • Relatedness Functions • Potential Behavior Change Targets (Relevance/Obtainable) • Fit of BC Target to Organizing Theme and Presenting Problems