Training Goals

1. Functional Family TherapyClinical Training ProgramCase Conceptualization & Case PlanningWebinar #3 Thomas L. Sexton, Ph.D., ABPPFunctional Family Therapy Associates Inc.

2. Training Goals • Discuss the role of case conceptualization as a foundation for FFT treatment • Identify the critical elements of case planning • Planning for the case • Planning for the phase • Planning for the session • Review the role of the Progress Notes & Case Planning guides in case conceptualization and planning

4. What does it take? A therapist that…… • Looks through a “lens” • Follows a Model……follow the “map” • Creates and implements a “unique case plan” for each family • Use “in the room” experiences to promote change (change mechanisms) • Creatively Adapt..... • Matching to the client • adapting next response to” • match client/context • add what was not understood/missed • Iterative Process….evolves over time

5. Thinking FFT • What you do outside the room • Case conceptualization • Put client story into core principles • Thinking through the lens Doing FFT what you do in the room -reframing problems/blame/negativity -interrupting negative behavioral patterns -promoting the use of new behavioral competencies -generalizing change • Planning • What you do outside the room • Case planning • Session planning • Goal (which one is most important) • Progress (progress in achieving the goal)

6. Keys to success in FFT • Model specific Case conceptualization • Model & client driven planning • In a way that…. • Matches the family process • Matches the families way of functioning • That is relevant and important to them • That helps reduce risk factors • Reduces the likelihood of future behavior problems • Empowers the family to keep changes going

7. Functional Family Therapy Case Conceptualization What lets you make model specific and client center actions that help

8. Case Conceptualization • Understanding the Family through the FFT “lens” • Presenting Problem • How the family functions • Problem definitions • Relational patterns • Relational functions • The multisystemic context…. • Of the problem • Of the family • Risk and protective factors

9. Example • Regina (14 years old) • Referred to mental health center from juvenile court • History of difficulties • Early school problems • Hospitalization • Most recently…. • Drug use (mj) • Drug rehab residential treatment • Other problems in the family

10. Initial Questions Is this an FFT case? How and what “lens” to use in understanding Regina Where to start (in FFT) How will therapy proceed? What is a possible outcome? (much of this you know….without any more information!) by listening with FFT “ear”

11. Listening with an FFT ‘ear’ Client Story (Events) (details of the case….history….purpose for the referral) Translating into relational pattern Relational Patterns (holistic understanding /where to intervene) Problem Definitions (to translate into Family Focused organizing theme-identify What is “important” to the individual Context (multisystemic context- Who is involved) Risk & Protective Factors (what to add to BC) Relational Function (to match to client)

12. What to ask yourself …. • “What does this tell me about what is important to this person?” • The answer to this question helps the therapist know what to acknowledge in reframing. • “What does this tell me about their relational patterns and how they link the family members together?” • This assessment helps the therapist develop a family-focused way of understanding how the presenting problem functions. • “What does this tell me about the biological, historical, and relational things that family members bring to any interaction that will help me understand why they are reacting this way?” • This assessment helps the therapist determine where the energy and emotion might come from and also helps identify what to acknowledge in the reframing process. • “To what cause are they attributing the problem? What is the problem definition?” • This assessment helps the therapist identify the target for blame and form a target for reframing.

13. Internal World Biological Substrate/Learning History/individual traits Ecosystemic System Peer/school/community/extended family Ecosystemic System Peer/school/community/extended family Clinical Symptoms/Behaviors Family Relational System (Sexton & Alexander, 2004)

14. Risk Factor Protective Factor Risk Factor Protective Factor Risk Factor Protective Factor Protective Factor Risk Factor Adolescent Dad/father figure Mom/mother figure How does the family Function/what role does the problem play Environmental Context Ecosystemic system Culture Peer Group School Community

15. Why are things so important? • 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 Client Story The “why” things are so important, meaningful, etc.

16. Anja: “ Regina have you done…””you know you are getting behind”….”you need to take some responsibility” (escalating the longer she doesn’t answer) Regina: “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) Relational Patterns Common/typical “way” they interact Regina: “Whatever….later, I am going out…., I’ll be home…..” Regina: “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…” Regina: “At least I have friends…later…” he goes out. Regina: (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…… Peter: “Fuck off..” the typical argument ensues until Peter goes to his room

17. What is the Problem? • “Problems” are embedded in the context • They are relationally based • 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”

18. Adolescent Dad/father figure Mom/mother figure Story takes the form of problem definitions Problem “definition -what the problem is -why its an important problem -what should be done about it Problem “definition -what the problem is -why its an important problem -what should be done about it Referral Behavior Problem “definition -what the problem is -why its an important problem -what should be done about it

19. What does this tell youFamily “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)

20. 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

21. Relatedness Assessment 1 Mom Mom Dad 3 3 1 3 1 Adol Adol

22. 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

23. Case conceptualization in the “real world” • Given all you have to do…..thinking in this complex way is very difficult • In the “real world”… • What you do out of the room • Aided by the FFT progress notes • Walk you step by step through case conceptualization • Make sure you don’t get lost • Help you overcome your own values and biases • Happens over time….Iterative • Not as a stage….but as treatment is going on • Building a “picture of the family” in which you add more and more

24. Functional Family Therapy Case Planning What to do in the next session, session, phase etc.

25. Treatment Planning • Understanding the Change process…the map of change • Phases (what is first, second, third….) • Mechanisms to use in achieving the phase goals • Family focused/driven outcomes that are obtainable and relevant • planning is the way to bring the content and the process of therapy together

26. Engagement Generalization Behavior Change Motivation Behavior Change Generalization Early Early Middle Middle Late Late Treatment Plan Build within family protective factors -behavior competencies -interaction change -that increase probability of - behavior Reduce within family risk factors -negativity/blame -hopelessness -build engagement/ reduce dropout Build family to context protective /reduce risk factors -peers/school/ community Assessment Intervention

27. Case Planning • Systematic process that includes • Next session planning • Goals of the phase • “What needs to be done next?” • Long term goals….. • Obtainable change • What matches the family • The smallest change that will make a differences

28. Early Middle Late Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Session Plan Engagement Behavior Change Generalization Assessment Intervention Motivation Behavior Change Generalization

29. 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

30. Long Term Outcome Goals • 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

31. Case Plan • Based on: • the model • matching to the client • Case conceptualization--understanding clients relationally--understand problems relationally • FFT’s Systematic Change Model • A model focused yet client/clinically responsive process…. • Systematic and flexible… • The therapist “anchor” and “lens”…. • The source of therapist creativity

32. Example • Regina • Early goals: • Alliance-common problem definition, goals & bond • Shared family focused problem definition • Reduction in blame/negativity • Intermediate goals: • Problem solving • Conflict management • Long Term goals • Family can manage supervision, work out problems

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. 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

35. 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

36. Assessment • Identify external family systems to apply BC skills • Identify contextual barriers to maintaining the BC target • Find areas to generalize • Identify relapse points 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

37. Using the FFT Progress Notes

38. Using the FFT PN

39. Process/Phase Goals Importance over time

40. Using the FFT Session Planning Guides

41. Using the FFT Session Planning Guides

42. Using the FFT Session Planning Guides

43. Keys to success in FFT • Model specific Case conceptualization • Model driven planning • In a way that…. • Matches the family process • Matches the families way of functioning • That is relevant and important to them • That helps reduce risk factors • Reduces the likelihood of future behavior problems • Empowers the family to keep changes going

44. What does it take? A therapist that…… • Looks through a “lens” • Follows a Model……follow the “map” • Creates and implements a “unique case plan” for each family • Use “in the room” experiences to promote change (change mechanisms) • Creatively Adapt..... • Matching to the client • adapting next response to” • match client/context • add what was not understood/missed • Access change....did it work?

45. Questions? Next Steps