functional family therapy international training program clinical training 1 thomas l. sexton,...
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Functional Family Therapy
International Training Program
Clinical Training 1
Thomas L. Sexton, Ph.D., ABPPAstrid van Dam
Functional Family Therapy Associates
What you can expect from us
• Our role• Consultants in learning FFT• Clinical responsibility lies with you• We will communicate anything important
we see/Please do the same
• Training Process
• Supervision Process
Evidence-Based Training & Implementation Model
• Multiple learning styles/formats• Realistic• Cost effective• Comprehensive measurement system
• Youth symptoms, family functioning,
process & progress• Evidence-based practice
• Ongoing measurement of
Process, outcome, & practice• Family Voice• Ongoing evaluation (using CFS)
• Benchmarks for:– Adherence client outcomes,– service delivery– Progress & process
Training Principles
• Based on adult learning/educational psychological principles of learning
• Short, relevant, repetitive, and clinically specific
• Goal….clinically relevant therapist competence & model adherence
• Ability to use the model in ways that “fit” clients and context
• High model Fidelity and Clinical relevance
Month 1-4
Clinical Training (on day on site)
2 webinars 2 onsite training daysDiscussion Forum useActive participation in
FFT/CFS
Month 5-9
Clinical Training (on day on site)
2 webinars 2 onsite training daysDiscussion Forum useActive participation in
FFT/CFS
Month 9-12
Clinical Training (on day on site)
2 webinars 2 onsite training daysDiscussion Forum useActive participation in
FFT/CFS
Months 1-4 Months 5-9Months 9-
12
FFT in Practice
• FFT lasts 8-14/16 sessions• Conjoint (whole family/major players)• Delivered weekly (maybe more in E/M,
less in Gen)• Sessions in each treatment phase
occur in a successful treatment episode• Engagement motivation• Behavior Change• Generalization
• Assessment as short as possible• Simultaneous/other Treatments?
Common Factors Functional Family Therapy
Principles of Good Practice“Common Factors”
-therapeutic relationship-hope/expectation-ritual of practice
Unique Features-Clinical Protocol
-relationally focused process-specific change mechanisms
-for specific problems
Process AssessmentClient Feedback (from each family member) on treatment:
• Impact (are they meeting the FFT phase goals) (SIS EM, SIS BC, SIS Gen)
• Progress (do they experience positive change) (SIS EM, SIS BC, SIS Gen)
• Symptoms (youth symptom level) (Weekly Symptom Measure)
• SIS (EM, BC, Gen) are given every odd number treatment session
• Weekly Symptom Measure is given every even treatment session
• All are given at the END of the FFT Session
Discharge Assessment• Family Functioning (COM)• Youth Symptoms (SFSS-Full)
• Optional:• Youth Mental Health Risk
(SDQ) • Family Functioning (SCORE
15)
• Discharge Assessment is done in the last FFT session
Baseline Assessment• Family Functioning (COM)• Youth Symptoms (SFSS-Full)
• Optional:• Youth Mental Health Risk
(SDQ) • Family Functioning (SCORE
15)
• Baseline Assessment can be done in the first FFT Session or in a separate Assessment
session along with other agency paperwork
Functional Family Therapy Measurement System
Evidence Based Clinical Decision Making Process
Progress Notes• Phase Specific• What happened• After each
session
Next Session Plan• Specific session goals• Specific areas of
needed attention• Before each session
-Used by the therapist to
understand the case better/plan
-Used by the Consultant to help the therapist learn
Match the model specifically to the family/situation/needs of the time
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….
Internal World
Biological Substrate/Learning
History/individual traits
Clinical Symptoms/Behaviors
Family Relational System-patterns
-problem definitions-history
Ecosystemic SystemPeer/school/community/extended family
Ecosystemic SystemPeer/school/community/extended family(Sexton, 2010)
Risk & protective factors
Risk & protective factors
Risk & protective factors
What each
member brings to the table
Risk & protective factors
Basic Unit of Analysis
Family
Child
Mother/Figure
Child
Father/Figure
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.
Comes from……
• 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”– It is their “problem definition”
Functional view of Clinical Problems
Problem is best understood by considering:
1. History that influences how they work today
2. Relational/behavioral “pattern” between the family members• Relational sequences/problem sequences
that answer the question…what do they do
2. Meaning they make of those patterns• Problem definitions & functions
3. Function of the pattern/meaning• Relational outcome that “glues” the
relationship together
Mom/mother figure
Dad/father figure
Adolescent
•Where people come from (relational context)– Types of relationships…with parents/family
•What people are made of….(biological context)• x
•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
The role of history:What people bring to relational systems
Relational Patterns
Mom
Son
Mom
Dad
• 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
• Describe the “what they do” question
Lilly: “Whatever….later, I am going out…., I’all be home…..”
Mom: “Have you done…..are you .”
Mom: “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…”
Lilly: “At least I have friends…later…” she goes out.
Mom: (to her husband)…”I can’t do anything with her…and you don’t help. I would at least like your support
Mom: 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 Lilly…..”
Lilly: (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?”
Lilly: “Fuck off..” the typical argument ensues until Lilly goes to his room
Mom: “What are we going to do..I can’t take this any more…”
Lilly: “I am sorry Mom…but, I can handle it”
Mom: “I just worry about you” (she feels comforted that he understands)
Lilly: “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 wans’t raised right…”
Meaning comes from “problem definitions”
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)
•
Mom/mother figure
Dad/father figureAdolescent
Problem Behavior
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
Problem “definition-what/who the problem is
Emotional Reactions (negativity)-why its an important problem
Behaviors-what should be done about it
Mom/mother figure
Dad/father figureAdolescent
Problem “definitionI have done nothing wrong…what I did was a mistake and wont’ happen again-the problem is you won’t leave me alone-you took everything from me and there is no reason to try
Emotional Reactions (negativity)
-anger-hurt-fear of loss of mom
Behaviors-her role in the problem sequence
Problem “definitionI have done everything I could-I can’t take it because-she is unwilling to work with me-she might have MH problems (depression)-her defiance is the problem-the solution is to “control”
Emotional Reactions -Anger-Hurt-Fear of loss of control
Behaviors-Her role in the problem sequence
Relational Functions• Functional outcomes of these patterns
• Relational “glue” • Stable and consistent
Mom/mother figure
Dad/father figureAdolescent
Clinical Symptoms
Match to…
The “function” of patterns/meaning
Relational “Functions”
Goal..understand and use to match and individualize reframing, themes, behavior change implementation, generalization
strategies
“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
nce
Psychological
Autonomy
high
low
Psychological Interdependencylow high
12
4
5
3 Mid-pointing
P
A
PA
P A
P
A
One-up One-up
Symmetrical
Relational Hierarchy 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
P
A
What can you change….
• Patterns are changeable through skill building
• Meaning is changed through reframing and therapeutic themes
• Functions are stable … so you have to match to them
• Match reframing/theme• Skills• Generalization strageties
Use of Relational Functions
• Matching to the family in– Reframing– Organizing themes– Behavior change implementation– How to generalize, maintain, & support
changes
The “MAP”• The Clinical Protocol
• Goals, Directions
• Pathway of change
• Relational & process focus
Clinical Model
Early Middle Late
Reduce within family risk factors
-negativity/blame-hopelessness
-build engagement/reduce dropout
Build within family protective factors
-behavior competencies-interaction change
-that increase probability of - behavior
Build family to contextprotective connections
-peers-school
-community
Early Middle Late
Assessment
Intervention
Clinical Model
Motivation
Intervention
Assessment
Engagement Behavior Change
Behavior Change
Generalization
Generalization
Early Middle Late
Goals• Alliance between family
with therapist• Family/relationally
based problem problem focus• Reduced family member
negativity/blame• Increased motivation
Goals• Increase behavioral competency of all/family
• Consistent performance of competency in “real” problem situation
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
Problem Behavior
Mom/mother figure
Dad/father figure
Adolescent
• Engage them to change
• Equip them with skills to solve the next “problem”
-• Maintain change over time
Topic of conversation
Intervention point
Goal of therapy
Engagement/Motivation Sessions
Goals• reduce within family
blame• reduce within family
negativity• build therapeutic
alliance• redefine problem as
family focused• increase
hope/expectation for change
Assessment• problem definitions• Problem sequence• How they “function”
or work together
Interventions
• reframing • Develop an
organizing theme that is family
focused• diverting and
interrupting• structuring session
to discuss relevant topics
What does the client “story mean”
•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
“how do they work”Goal: “why” things are so important,
meaningful?What is the pattern in the story?
What does it say about how they work?
Family Story
Relational ReframingStructuring & Supporting
Focus on “them:
Family Story
Relational ThemeFamily Focus to the problem
Everyone is part of the solutionEach member has unique contributions…
Their “challenges”
Initial Presenting Problem Definition-attributional aspect-emotional valence
-related behavioral patterns
Comes from:Each individuals unique
History/experience with problem,
natural attempts to understand/make sense, solve the problem
AdolescentInitial Presenting Problem Definition
-attribution aspect-emotional valence
-related behavioral patterns
MotherInitial Presenting Problem Definition
-attributional aspect-emotional valence
-related behavioral patterns
FatherInitial 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 familyfocused” definition
That is -different from
each individual definition- common to all
- Where all have responsibility- No one has blame
Not compromisingmediating
or negotiating
Family FocusedProblem definition
AccomplishedThrough relentless relational
Reframing
The Outcome:Motivation, negativity reduction,
Family to family alliance, Therapist to family alliance
AccomplishedThrough relentless relational
Reframing
AccomplishedThrough relentless relational
Reframing
Two direction ways to reduce negativity and blame
1. Change the meaning of the behavior of the other
2. Build Responsibility in the “speaker”/”blamer”
By…– Reframing what a client says– Reframing similar ideas according to the
same “theme”– Creating an “organizing them” to describe
their struggle
RelationalProcess of Reframing
Acknowledge
Reframe
ImpactAssess acceptability/fit
Change/continueMaking it fit the client
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
Themes:
1. Hurt behind the anger
2. Protection
3. Anger is loss
4. Speaking out represents
Independence
….as beginning points
tounderstanding of Persons, situations, etc.
1. Meaning-attribution-event-emotion(reduces negativity/blame)
2. Find the Noble Intent
3. Link family members togethermembers togetherIn struggle/problem(builds family focus/Interdependence)
Listen…listen…listen
Acknowledge(identify & acknowledge)
Reframe
Impact
“Build on”/continueBuilding theme that fits
Theme hint(best guess/hypothesis)Description, statement, questionSuggesting alternative theme
ThemeA “new” explanation based on…
1. Changed Meaning
2. Reduced negativity/blamepossibilities for change
3. Linked together in Problem and futuresolution-as all having some-responsibility/ownershipfor the problem and solution
Some examples• Hurt behind the anger• Anger is hurt• Control is protection• Etc.
How would you say it…..(acknowledge & reframe)
• “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”
Reframing
• Identify the Behavior(s) (from problem definition)– (mom): Lilly’s defiance is…..– (lilly): Mom’s controlling is…..
• Acknowledge the importance of each to the person (link their struggle with something important to them)
• ReframeLilly’ defiance is….-Strong willed-ness-Fear of changes-Protection of herself-Fear at losing Mom
Mom’s controlling is…
-Fear of losing her daughter-Protecting her-Struggling with her own perceived inadequacies
Relational 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”
Lilly-responds defiantly
MOM-gets worried
-asks (indirectly)
MOM-jokes, makes fun -tries to get her to
“do it for me”
LillyObviously irritated
-blows off Mom
MOM-hear it as “she doesn’t care”-gets scared
Lilly-responds defiantly
Lilly-responds defiantly
MOM-gets angry
-lectures-withdraws
MOM-gives a
consequence(sever and non specific….takes
away
Lilly-Escalates
defiant response-
When it is a serious even
MOM-escalates
control
When it is a serious even
Lilly-Escalates
defiant response-exhibits
additional When it is a serious
even
“In the room” in Engagement/Motivation
• When clients negatively/blaming reframe
• Over time…reframes become themes
Family Therapist
When the themes about each person link together to provide an alternative explanation of the
“problem” it is an organizing theme
Components of an Organizational/family 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 othe family
members• Complete, includes what is most important to family,
personal, specific in way that is individual
Relational Theme(s)
• Explaining the problem in relational Terms– Involves every one– Identifies the struggle in descriptive
way – Identifies the noble intention– Identifies the challenge of each
MOMProblem “definitionI have done nothing wrong…what I did was a mistake and wont’ happen again-the problem is you won’t leave me alone-you took everything from me and there is no reason to try
Emotional Reactions (negativity)
-anger-hurt-fear of loss of mom
Behaviors-her role in the problem sequence
LillyProblem “definitionI have done everything I couldI can’t take it because-she is unwilling to work with me-she might have MH problems (depression)-her defiance is the problem-the solution is to “control”
Emotional Reactions AngerHurtFear of loss of control
BehaviorsHer role in the problem sequence
Them…..“given all that has gone with you two….both have come a point where your afraid losing each other….That is hard to see given the behavior…..but behind that is this fear…..
Mom….when you are controlling…..really trying to protect your daughter….(maybe not protect way…maybe other ways to protect….but that is the motivation…
Lilly…..Dealing with life being turned upside down…..struggling with the changes…and having a hard time finding her way in that….
Defiance….is kind ward and strange way of dealing but…..it does protect her….and it does help hold in some what to her mom…(and she of course do that different…and, not smart way…) but, is fear of loving you…..
Outcome• Themes….
1. Identify the noble intention
2. Set the goals of therapy
3. Help you stay our of the “weeds” (details)
4. Break negative relational patters
5. Provide positive attribution
6. Build a family focus “(it is all of us”)
7. Set treatment goals
What makes reframing work
1. “feel” the reframe• Therapist able to “be the client” and know what is
important…the noble intention behind the behavior
2. “believe” the reframe• It “is” how you understand them
3. “linked” to everyone else4. Presented in a way that is…
• With acknowledgement• Respectful
Behavior change sessions
Goals• Specify the
behavior change “individualized
plan”
• 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
Parent
Problem Solving
Communication-direct and concrete
communication
Parenting-monitoring and supervising
Where they use:
Work out problems…focus is on
their process of doing so
Adolescent
Targets of FFT Behavior Change
Conflict Management
Events that come up at
home or between them
Single, individualized
“behavior change plan”
Combination of individual skills
“In the room” in Behavior Change
• When clients bring in a problem….have them use the specific behavior change competency in the room
• Apply it in an individualized way to the family…fit it in the problems sequence
• Match relational functions• Goal is that the family use the competency NOT that
problems are solved• Make new behavioral competency linked to the organizing
theme….gives a reason to do it• Over time family increasingly uses the new skill
Family Therapist
Behavior Change Targets
1. Is it Relevant?– What would feel to the family like success– What make a “difference”
2. Is it Obtainable?– Can they do it– Will it derail therapy because it is to hard
3. Does it “fit” them– Relational functions– Organizing them
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
• 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 individualized plan• 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
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”…a way to “prevent” in the future
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 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
Generalization Phase…
In generalization two points of attention
• Within the family:• Relapse prevention • Generalization of competencies• Maintenance of alliance
• Outside the family:• Relationships between family (individual and
whole) and the community
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
Ecosystemic SystemPeer/school/community/extended family
Ecosystemic SystemPeer/school/community/extended family(Sexton, 2010)
Court system involvement
SchoolStruggles
Family changes (joining John’s family)
Peer GroupPressure
Involvement
Identify the external systems and risk factors
that are important for maintaining & supporting change
Why the Generalization phase
families take two “steps” when making changes that are lasting:
1. Families change the relational interactions and adopt alliance-based skills in their daily interactions.
2. Families bring this same attitude and skill set to other naturally occurring issues that confront the family.
• In this step, the successful family becomes consistent over time and learns to handle the emotional discouragement of “relapses.”
Logic of Generalization
• Small changes can have a multisystemic effect
• These changes often don’t happen naturally
• Specific strategies for:• generalizing new skills, • maintaining change, • and supporting those changes with the aid of informal and
formal community support systems helps create the
necessary system change for long term success.
• Reduces:• Revolving door of treatment• Relapse• Future positive changes
• Give a man a fish and you feed him for a day; teach him to fish and he feeds himself for life.” – “learn to dig for the bait” so that they can
have the resources necessary to be self-sufficient in managing the normal challenges of family life.
Generalizing Change
Primary Target
Area/content focused on:
-homework, going out with peers,
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
Discussion focused on:
How to maintain, support, and
generalize new climate, alliance, behavior changes
Medical /medPsych 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
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
Clinical “Art”
• Creativity within the structure
• Therapists as translators
• Family based change through reliable change processes