Conflict of Interest

1. Functional Family TherapyInternational Certification ProgramClinical Training 1 Thomas L. Sexton, Ph.D., ABPPIndiana University

2. Conflict of Interest The presenter of this information is required by Indiana University to reveal a potential conflict of interest. He is an owner of a training program that receives income from that activity, his primary writing and scholarly work is in this area, and he promotes this particular model of therapy.

3. 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….

4. The FFT Story Evolution in Theory Evolution Through Practice • Diverse cultures/communities (African American, Hispanic, Vietnamese, Chinese, Haitian, Dutch) • Diverse clients and therapists • Multiple Languages (8 different languages: English, Spanish, Mandarin, Creole, Dutch, Moroccan, Turkish, Sudanese, Russian) • Urban/Rural Evolution through Science • Clinical outcome studies—does it work? • Process studies—what works? How does it work?

5. 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 (FFT/CFS)

6. Both….and Principles of Good Practice “Common Factors” -therapeutic relationship -hope/expectation -ritual of practice Common Factors FFT Unique Features -Clinical Protocol -relationally focused process -specific change mechanisms -for specific problems

7. Early Middle Late Functional Family TherapyClinical Model Engagement Behavior Change Generalization Assessment Goal-Skills Goal-Skills Goal-Skills Intervention Motivation Behavior Change Generalization

8. How we do training In ways that match adult learning theory research • Diverse methods • Sequenced over time • Repeated within increasing specificity Goal: adherence & competency in FFT • Thinking through the lens • Following the map • Creativity within the structure

9. Clinical Outcomes & Model AdherenceWashington State Project • 38%* reduction in felony crime • 50%* reduction in violent crime • $10.67 return for each $1 invested • $2100 per family cost to implement “Adherence to the Model as a vehicle to Meet the needs of the client” * Statistically significant outcome

10. Training Process Phase I: Learning the Clinical Model • Clinical Training • Ongoing Consultation/Supervision • Continuous Quality Improvement (Q-System use) • “practical” training/observation Phase II: Site Clinical Supervisor Training • Site supervisor • Training to prevent model drift • Continuous Quality Improvement (Q-System use)

11. The “LENS” of FFT • Systemic foundation • Common features of many family therapy models • Pragmatic focus on how the family “functions”

12. Lens are….. Explicit or implicit, Principles/theory that explain • clients, therapy, and change, and a systematic • how clients function, • how psychological problems develop, • how to help people change, • and the interrelationship among these factors FFT tries to make these principles explicit, practical, and relevant to clinical change

13. Internal World Biological Substrate/Learning History/individual traits Ecosystemic System Peer/school/community/extended family Change the probably of future behavior problems Point of immediate, relevant, and lasting change Ecosystemic System Peer/school/community/extended family Clinical Symptoms/Behaviors The Multisystemic Focus of Functional Family Therapy Family Relational System Primary entry/ focus Functional Orientation -inside out conceptualization (Sexton, 2010)

14. Child Child Father/ Figure Mother/Figure Family Systemic FoundationBasic Unit of Analysis Finding the “function” of the symptom in the relational system • Relational patterns • Coalitions/alliance within patterns • Relational “information” and its movement through the system What is the “root cause” • Physical (genetics/brain function) • History (trauma/background) • Learning History • Etc.

15. Systemic FoundationRelational Patterns Dad Mom Mom Son Relational Patterns are common ways of working in families that involve everyone Problem sequences….are are common across “content” Maintain and support the “problem behavior” Point of intervention and change

16. Anja: “Peter have you done…””you know you are getting behind”….”you need to take some responsibility” (escalating the longer he does’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: “I am sorry Mom…but, I can handle it” Peter: “Whatever….later, I am going out…., I’all be home…..” Anja: “there is no going out for you….it just ins’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 wans’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…… Peter: “Fuck off..” the typical argument ensues until Peter goes to his room

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

18. 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 Match to… Relational Functions • Functional outcomes of these patterns • Relational “glue” • Stable and consistent

19. 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

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

21. 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?)

22. 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

23. Relational factors…...What to do about relatedness functions • Goal: identify relational functions….use these as “Pathways” to change…ways to implement behavior changes • Match to….relational functions • To do so… • discrepant functions are accommodated • all functions are accepted as legitimate • generally don’t change functions….. • …..change the behavior, affect, and cognitive/attributions related to the expression of the function • goal is to provide alternative ways of expression • Use to match to behavior change intervention…outcome sample

24. Adolescent Dad/father figure Mom/mother figure What people bring to relational systems • Current behavior makes sense in light of … • What people “bring” with them • Where people come from (relational context) • Types of relationships…with parents/family • What people are made of….(biological context) • The environment in which they live (ecosystemic context) • Peers/schools/mental health system/community • Interactional Relationships • Core family/dyad stable relational patterns Relational sequences/problem sequences

25. Core Principles of FFTClinical Problems • Problems are relationally based----change is relationally focused • Family has been functioning for some time….encountered problem that has become “part” of the family….now “functions” as a central part of how they relate • Not what they “want” • Not what they “need” • They way in which they have come to “be” in response to the “problem”

26. 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

27. Core of FFTFamily “problems” are relational problems In their attempt to solve/deal with the problems…. • Family come to therapy with a “definition” of what is the problem • Result of each family members experience and thinking/working to understand their life/problems • Natural part of finding a solution • This definition is usually: • focused on “a person” (attributional component) • has negativity attached (emotional component) • is accompanied by blaming interactions that have become central to the relational patterns of the family (behavioral component)

28. The “MAP” • The Clinical Protocol • Goals, Directions • Pathway of change • Relational & process focus

29. Goals • 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 Goals • Alliance between family with therapist • Family/relationally based problem problem focus • Reduced family member negativity/blame • Increased motivation Goals • 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

30. 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

31. Engagement/Motivation Phase Engagement Goals: lower within family blame and negativity Increase within family alliance family focus to the presenting problem Assessment Early Intervention Outcomes When they Interact and solve problems it is with: • Alliance • Family/relationally based problem problem focus • Reduced negativity/blame • Shared responsibility and ownership Motivation

32. EngagementFor positive participation a discussion that is relevant (about what is important) that involves trust, respect and alliance (e.g., core relational skills, acknowledgement)MotivationNot only to participate in therapy, but to undertake the specific behavior change steps designated by therapist(e.g., Reframing, Theme Developing Skills)

33. 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

34. Implementing Engagement/Motivation Phase Help the family develop a “climate” of working together to solve problem -Individual responsibility for some Part of/role in the problem -new “definition”/understanding of the problem” -reduction in negative feelings blaming New Problem Situation New Problem Situation Goal… Engagement in therapy Motivation to try something new/engage in change Family focused experience/understanding of the problem E/M Phase Functional Family Therapy New Problem Situation New Problem Situation Help the family develop a “climate” of working together to solve problem -Individual responsibility for some Part of/role in the problem -new “definition”/understanding of the problem” -reduction in negative feelings blaming Help the family develop a “climate” of working together to solve problem -Individual responsibility for some Part of/role in the problem -new “definition”/understanding of the problem” -reduction in negative feelings blaming

35. 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…..

36. 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

37. Engagement/Motivation Goals…Developing motivation and alliance • Creating a “family focus” to the presenting problem • Redefine the problem (away from presenting one) • Family enters with “problem definition” that is part of what has them stuck • New problem definition that is less blaming, negative, and individually focused • Create a relational focus--a family focus for the problem… • Each family member has a “part” (responsibility without blame)…everyone involved in some way • Each “part” linked to the challenge that the family currently faces (family focused) • Sets the stage for different solutions (behavior change) ……thus, minimize hopelessness, ready family to take responsibility for trying new skills and making behavioral changes

38. 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 -attributional 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

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

40. Meaning -attribution -event -emotion (reduces negativity/blame) Find the Noble Intent Link family members together members together In struggle/problem (builds family focus/ Interdependence) Relational Process of Reframing Themes: Hurt behind the anger Protection Anger is loss Speaking out represents Independence ….as beginning points to understanding of Persons, situations, etc. 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 Acknowledge Theme hint (best guess/hypothesis) Description, statement, question Suggesting alternative theme Reframe 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 Impact Listen…listen…listen “Build on”/continue Building theme that fits

41. Why Reframes & Themes Work“Respect based” Reframing • Acknowledge (“yes….) • What they just said is important..frames the situation/problem/event that is the “target” • Specifically/directly what happened (“…yes that is what is happened here…) • Identifies a specific event, emotion…behavior that has happened in the room of what has been reported • What you “guess” to be important to them • What you guess to be the most important value/aspect of what happened • Determined from “what they bring to the table” • Comes from what you heard…assumed…guessed about the reason this is so important to them

42. Why Reframes & Themes Work“Respect based” Reframing • 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 • Non-interpretative • Doesn’t explain away…or excuse….DESCRIBES • “theme hint”…just a guess • Based on what you have heard, what you know about them, what is common to adolescents • Over time…. Built a “theme” about the family that is more inclusive than this one event/situation

43. 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

44. Organizing Theme • Frame… • “you are…” • “this is a family….” • Specific behavior/pattern… Problem sequence • Reframe • 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 otherfamily members • Complete, includes what is most important to family, personal, specific in way that is individual

45. Engagement/Motivation Interventions…reframing • 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) • Building Themes…..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

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

47. Outcome • 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”

48. Behavior Change Phase Behavior Change Phase based Treatment Goals: Build behavioral competencies that fit the family 2. Target the most relevant, obtainable, and maintainable competencies 3. Match competencies to relational functions Assessment Middle Intervention Behavior Change Outcomes • Increase behavioral competency of all/family • Consistent performance of competency in “real” problem situation

49. 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 “individualized plan” • LinkBC 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

50. 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 Problem Solving Where they use: Work out problems…our focus is on their process of doing so Conflict Management