CIMH WebcastCIMH Webcast

Functional Family TherapyFunctional Family Therapy

Andrea A. NeebAndrea A. Neeb

””What really is the difference What really is the difference between a Relabel and a Reframe between a Relabel and a Reframe anyways??”anyways??”

Let’ s talk Relational FunctionsLet’ s talk Relational Functions Behavior Change planning and Behavior Change planning and

examples..”How do we address examples..”How do we address multiple risk factors and still multiple risk factors and still stay within sessions stay within sessions timeframes??”timeframes??”

Introduction to Meaning Change TechniquesIntroduction to Meaning Change TechniquesEngagement & Motivation Phase, FFTEngagement & Motivation Phase, FFT

1 – 1 – RelabelRelabel:: Provides an alternative, more benign “label” for a specific Provides an alternative, more benign “label” for a specific behavior, emotion, attribution.behavior, emotion, attribution.

2 – 2 – Theme hintTheme hint – – short comment about a possible alternative domain short comment about a possible alternative domain (especially emotional / affective) involved in a negative behavior – one that (especially emotional / affective) involved in a negative behavior – one that tends to arouse less blaming and negativity.tends to arouse less blaming and negativity.

3 3 – Reframe– Reframe:: introduces less intense and possibly more introduces less intense and possibly more benign benign motivesmotives or or “reasons”“reasons” for the negative Behavior. for the negative Behavior.

4 – 4 – Reframe +:Reframe +: suggests suggests noble but misguidednoble but misguided intentintent with respect to a with respect to a family member’s negative behavior.family member’s negative behavior.

5 – 5 – Behavioral ThemeBehavioral Theme:: identifies identifies a specific sequence, a specific sequence, usually of within-usually of within-family behaviors, with reframes and/or relabels of most or all of the specific family behaviors, with reframes and/or relabels of most or all of the specific behavioral elements, in a way that suggests behavioral elements, in a way that suggests non-malevolent non-malevolent (and even (and even possibly “noble”) possibly “noble”) intentintent or “reasons” behind all family members’ behaviors. or “reasons” behind all family members’ behaviors.

6 – 6 – Relational ThemeRelational Theme:: creates/suggests possible misguided benign, even creates/suggests possible misguided benign, even noble, and sometimes “accidental” intentions behind noble, and sometimes “accidental” intentions behind longer term relational longer term relational patternspatterns and/or interpersonal and/or interpersonal stylesstyles. Relational themes often are quite . Relational themes often are quite non-specific with respect to recent behaviors. Often they capture years of non-specific with respect to recent behaviors. Often they capture years of relational unhappiness, dysfunction, & negative attributions about self relational unhappiness, dysfunction, & negative attributions about self (e.g., as in depression) and others, with recent events being a window into (e.g., as in depression) and others, with recent events being a window into them.them.

1 – Relabel:1 – Relabel: Provides an alternative, more Provides an alternative, more benign “label” for a specific behavior, emotion, benign “label” for a specific behavior, emotion,

attribution.attribution.

Mom:Mom: “I’ve had it with him … maybe “I’ve had it with him … maybe he he shouldshould go to “DT” (detention) go to “DT” (detention) for a while.” for a while.”

Therapist:Therapist: - To youth: “Sounds like - To youth: “Sounds like your Mom feels she has run out of your Mom feels she has run out of steam to deal with this.”steam to deal with this.”This relabel of Mom’s “feeling” (“I’ve had it with him”) as

representing “running out of steam” tends to come across as less blaming and rejecting, and moves the focus off of a consequence (DT) that we as FFT therapists do not want

to be our main focus or goal. In doing so it allows the therapist to refocus on family relational processes.

2 – Theme Hint –2 – Theme Hint – short comment about a possible short comment about a possible alternative domain (especially emotional / affective) alternative domain (especially emotional / affective)

involved in a negative behavior – one that tends to arouse involved in a negative behavior – one that tends to arouse less blaming and negativity.less blaming and negativity.

E.g., In response to rapidly escalating parent-E.g., In response to rapidly escalating parent-child outbursts:child outbursts:

““OK … please forgive me for jumping here and OK … please forgive me for jumping here and interrupting, but there seems to be lots of interrupting, but there seems to be lots of feelings of loss going on in this familyfeelings of loss going on in this family.”.”Note that this represents a “theme hint” because it is not “developed”

at all – it is merely an assertion which the therapist is focusing NOT on the obvious anger, but is assertively jumping in to impact (actually stop if possible) the outbursts, but s/he does so in a way that:1 – doesn’t take sides2 – doesn’t tell them overtly that their behavior is “wrong” or a “problem to be fixed,” 3 – (hopefully) will change the focus away from the “content” of the angerand instead move them to other thoughts, feelings, memories, etc. ..4 – by “hinting” about a possible “cause” (i.e., loss) for all the anger … even if the therapist isn’t aware (as we often aren’t in early sessions) of any specific content / history involving “loss.”

Reframe:Reframe: introduces less intense and possibly more introduces less intense and possibly more benignbenign motivesmotives or or “reasons”“reasons” for the negative Behavior. for the negative Behavior.

Reframe +:Reframe +: suggests suggests noble but misguidednoble but misguided intentintent with respect to a family member’s with respect to a family member’s

negative behavior.negative behavior.Reframes consist of three simple components:Reframes consist of three simple components:

1)1) Identify and make clear the Identify and make clear the negative aspects negative aspects of a of a problem behavior / pattern (the one you are going to problem behavior / pattern (the one you are going to

attempt to reframe); attempt to reframe);

2) offer a possible benign (Reframe) or perhaps even 2) offer a possible benign (Reframe) or perhaps even noble* noble* (Reframe+) but misguided (Reframe+) but misguided intentintent or or meaning for the behaviormeaning for the behavior; ;

3) based on the family members’ reactions (affirming or 3) based on the family members’ reactions (affirming or disaffirming) you refine and elaborate the reframe … disaffirming) you refine and elaborate the reframe … or you apologize for “misunderstanding” and move on.or you apologize for “misunderstanding” and move on.

* “Noble” intent = to benefit * “Noble” intent = to benefit anotheranother

Mother to Therapist: “This is the third Mother to Therapist: “This is the third time she has run away … she’s just time she has run away … she’s just

out of control”out of control”Therapist: “And Mom … that is unbelievably disruptive to Therapist: “And Mom … that is unbelievably disruptive to

you and the whole family you and the whole family (clearly acknowledges the (clearly acknowledges the disruptive impact), disruptive impact), and I’m sure someone along the line and I’m sure someone along the line has suggested she is just trying to develop and show her has suggested she is just trying to develop and show her independence independence (relabel) … (relabel) … but I’m wondering if there is but I’m wondering if there is something more. As misguided as it is, I wonder if she something more. As misguided as it is, I wonder if she might also be trying to send you a message that ‘Mom, I might also be trying to send you a message that ‘Mom, I see how burdened you are, so I’m trying to grow up fast see how burdened you are, so I’m trying to grow up fast so you don’t have to worry about parenting me as much.’so you don’t have to worry about parenting me as much.’ ((the possible “noble intent” part of the reframethe possible “noble intent” part of the reframe). ). Now Now we all know that this way of doing it won’t work, but I we all know that this way of doing it won’t work, but I wonder if she has been able to tell you how wonder if she has been able to tell you how worried worried she she has been about has been about youryour horrible stress level? It might even horrible stress level? It might even be easier for you both to argue about her (daughter’s) be easier for you both to argue about her (daughter’s) behavior than for either of you to feel the desperation behavior than for either of you to feel the desperation that I’m sure sneaks up on you Mom. that I’m sure sneaks up on you Mom.

What is the Difference Between a Reframe and a Relabel?What is the Difference Between a Reframe and a Relabel? RelabelRelabel – to change the “ – to change the “tonetone,” ,” descriptiondescription, or , or meaningmeaning of a of a

behavior or feeling – but not necessarily address the motivation behavior or feeling – but not necessarily address the motivation behind the negative behaviorbehind the negative behavior In response to an angry outburst: “With that anger I can see how In response to an angry outburst: “With that anger I can see how

agitated you are.” Note that “agitation,” when the word is agitated you are.” Note that “agitation,” when the word is introduced, seems less intense and perhaps even less “negative.” introduced, seems less intense and perhaps even less “negative.” Both anger and agitation represent “feelings,” but “agitation” Both anger and agitation represent “feelings,” but “agitation” tends to take the focus off the negative tends to take the focus off the negative behavioralbehavioral aspect. aspect.

ReframeReframe – to acknowledge the negativity of a behavior but offer a – to acknowledge the negativity of a behavior but offer a possible alternative possible alternative explanationexplanation or or motivationmotivation for the behavior for the behavior ““That was a pretty angry outburst “X”, but I’m wondering if in That was a pretty angry outburst “X”, but I’m wondering if in

addition to expressing your anger you weren’t also protecting “Y” addition to expressing your anger you weren’t also protecting “Y” (Reframe+) by letting her know how sensitive you are about that (Reframe+) by letting her know how sensitive you are about that subject so she can work on bringing it up differently? And “Y,” subject so she can work on bringing it up differently? And “Y,” my guess is that because his agitation (Relabel) was so intense my guess is that because his agitation (Relabel) was so intense you couldn’t hear the reaching out part of what “X” said. you couldn’t hear the reaching out part of what “X” said.

Themes (con’t)Themes (con’t)Like reframes, themes do include the elements of Like reframes, themes do include the elements of

1 – acknowledging painful and even “bad” 1 – acknowledging painful and even “bad” patterns of behavior; patterns of behavior;

2 – suggesting possible “misguided but noble,” or 2 – suggesting possible “misguided but noble,” or at least benign (e.g., based on misunderstanding, at least benign (e.g., based on misunderstanding, etc), intentions ... or they may even be offered as etc), intentions ... or they may even be offered as possibly “unintentional.” possibly “unintentional.”

3 – being open to family member cues that 3 – being open to family member cues that indicate rejection, acceptance, or some other indicate rejection, acceptance, or some other response (confusion), and capturing any movement response (confusion), and capturing any movement towards less negativity and more hopeful reaction towards less negativity and more hopeful reaction with therapist attention and elaboration.with therapist attention and elaboration.

5 – 5 – Behavioral (Sequence) Theme:Behavioral (Sequence) Theme: identifies a identifies a specificspecific sequence, sequence, usually of within-family usually of within-family behaviors, and provides reframes and/or relabels of behaviors, and provides reframes and/or relabels of most or all of the specific behavioral elements, doing most or all of the specific behavioral elements, doing so in a way that suggests so in a way that suggests non-malevolent intentnon-malevolent intent or or “reasons” behind all family members’ behaviors.“reasons” behind all family members’ behaviors.

6 – 6 – Relational Theme:Relational Theme: creates/suggests possible creates/suggests possible misguided benign, even noble, and/or sometimes even misguided benign, even noble, and/or sometimes even “accidental” intentions behind “accidental” intentions behind longer term relational longer term relational patternspatterns and/or interpersonal and/or interpersonal stylesstyles. Relational themes . Relational themes often are quite non-specific with respect to recent often are quite non-specific with respect to recent behaviors. Often they capture years of relational behaviors. Often they capture years of relational unhappiness, dysfunction, and negative attributions about unhappiness, dysfunction, and negative attributions about self (e.g., as in depression) and others. Recent behaviors self (e.g., as in depression) and others. Recent behaviors merely represent a “window” into these more basic (and merely represent a “window” into these more basic (and usually sad!) relationship patterns.usually sad!) relationship patterns.

Major Types of ThemesMajor Types of Themes

Transitioning From E&M to Behavior Transitioning From E&M to Behavior Change & GeneralizationChange & Generalization

Having AttainedHaving AttainedBalanced AllianceBalanced AllianceDecreased Negativity Decreased Negativity

& blame & blame Increased Family Increased Family

bonding bonding Changed (Much more Changed (Much more

Positive)Positive)attributions attributions

Positive BodyPositive Body LanguageLanguage

Hopeful AttitudeHopeful AttitudeSense of Sense of ““Familyness”Familyness”

Overarching Philosophy :Overarching Philosophy :Matching & Strength Matching & Strength

Based RelationalBased Relational

RREELLAATTIIOONNAALL

AASSSSEESSSSMMEENNTT

And And AccomplishedAccomplished

Behavior ChangeBehavior ChangePlanning & Planning &

Behavior ChangeBehavior Change

Generalization, Generalization, Multi-systemic Multi-systemic

Linking Linking

Within Family Relational Functions: Within Family Relational Functions: “Attachment”“Attachment”

When X relates to Y, the relational pattern When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s (behavioral sequences in the relationship ) of X’s

behavior is characterized by:behavior is characterized by:

AutonomyAutonomy::

independenindependencece

separating,separating,Low levels Low levels

of of psychologicpsychological intensityal intensity

(Fear of (Fear of EnmeshmentEnmeshment

?)?)

highhigh

lowlow

Contact: closeness, connection:Contact: closeness, connection: enmeshment, high levels of psychological enmeshment, high levels of psychological intensity (Fear of abandonment?)intensity (Fear of abandonment?)

lowlow highhigh

11 22

44

55

AutonoAutonomymy

Contact/ Contact/ closenesscloseness

MidpointMidpointinging 33

The Second Relational The Second Relational Dimension: Dimension: HierarchyHierarchy

Hierarchy refers to the Hierarchy refers to the pattern, over pattern, over time, of relative influencetime, of relative influence based on based on powerpower, , positionposition, and , and resources resources (as (as

opposed to Relational Connection”)opposed to Relational Connection”)

Parent 1- upParent 1- up Parent 1- down Parent 1- down

Parent Parent SymmetricalSymmetrical

::(Exchange = (Exchange = Behaviors) Behaviors)

Referral & Referral & Ongoing Problem Ongoing Problem

BehaviorsBehaviors

Family Relational PatternsFamily Relational PatternsPatterns that are changed to modify problem behaviors - decrease risk and increase

protective factorsRelational Functions Relational Functions

inferred motivational substrates inferred motivational substrates that serve to motivate and

maintain stability in family (and other) relational

patterns

FFT BehaviorFFT BehaviorChange & Change &

GeneralizationGeneralizationFocusFocus

Intra Individual(Diathesis)Factors & Processes

Extended

Family

Community

Ecosystem Influences

Peer Groups

School

Engagement &Engagement &Motivation, Motivation, AssessmentAssessment

FocusFocus

Review: FFT Steps in the process of change

BEHAVIOR CHANGEBEHAVIOR CHANGE

MOTIVATIONMOTIVATION

FFT Direct Treatment Phases : FFT Direct Treatment Phases : Behavior Change (BC) Behavior Change (BC)

Based on the “AIM Model” (Alexander, Barton, Waldron & Mas, 1983; Alexander, Pugh & Parsons, 1998)*Change the problem and related behavior(s) by using the

therapist skills of Teaching, Modeling, Coaching, providing Technical Aids, and giving Directives & Homework that helps families improve their ability in: Parenting, Youth Compliance, Communication, Problem solving, Conflict management, Managing anxiety, “urges,” PTSD, etc.

* Develop individualized change plans that fit “match”) the family (values, Relational Functions, abilities) and which increase

resources and competence in adaptive positive behaviors* Eliminate dysfunctional behaviors (drug abuse, delinquency,

violence, maladaptive expectations & beliefs, etc) by changing the processes (intra-individual, family relational, multisystemic)

that support them;

Behavior Change Behavior Change Phase StepsPhase Steps

1 – Plan1 – Plan

2 – Review literature / 2 – Review literature / techniques availabletechniques available

3 – Fit Relational Functions3 – Fit Relational Functions

4 – Be clear and specific4 – Be clear and specific

5 – use available “technology”5 – use available “technology”

Syndrome Specific Syndrome Specific “Modules”“Modules”

During Behavior Change During Behavior Change (BC)(BC) By the time you reach Behavior Change (BC), the By the time you reach Behavior Change (BC), the

“meaning?” of major behavioral problem “meaning?” of major behavioral problem syndromes (such as drug abuse, stealing, syndromes (such as drug abuse, stealing, fighting, truancy) has been changed via the fighting, truancy) has been changed via the strength based & relational focus coupled with strength based & relational focus coupled with reframes and themes. We need to have attained reframes and themes. We need to have attained reduction in negativity and blame, experienced reduction in negativity and blame, experienced changed within-family attributions about each changed within-family attributions about each other and themselves, and having the “family other and themselves, and having the “family struggle” rather than an “individual’s problem” struggle” rather than an “individual’s problem” represent the reason we are changing behavior.represent the reason we are changing behavior.

If you think you are ready for BC, but the family If you think you are ready for BC, but the family fails to see the problem behaviors in a different fails to see the problem behaviors in a different light or context, then … you are not ready for light or context, then … you are not ready for BC!BC!

Problem Specific BC (2)Problem Specific BC (2)At the same time you should know quite a bit about At the same time you should know quite a bit about

problem behaviors based on referral info, CSS problem behaviors based on referral info, CSS intake information, and the usual complaints and intake information, and the usual complaints and accusations – which for a while occur despite your accusations – which for a while occur despite your strength based relational focus, reframing, etc.strength based relational focus, reframing, etc.

This can be attained easily without having to focus This can be attained easily without having to focus specifically on the details of problem behaviors specifically on the details of problem behaviors such as drug abuse during E&Msuch as drug abuse during E&M

Then your first task in BC is to insure that you have Then your first task in BC is to insure that you have thought about all you know in relational terms thought about all you know in relational terms (who is present when the behaviors occur, who (who is present when the behaviors occur, who responds when the behavior becomes known, etc).responds when the behavior becomes known, etc).

Planning for Behavior Planning for Behavior Change PhaseChange Phase

Assessment at first is on family Assessment at first is on family relational patterns and behavioral relational patterns and behavioral deficits, as well as strengths that can deficits, as well as strengths that can be augmentedbe augmented

The new patterns must “work” for The new patterns must “work” for everyone and “fit” Relational Functionseveryone and “fit” Relational Functions

Before the first BC session, have a Before the first BC session, have a flexible plan with BC change targets flexible plan with BC change targets which are informed by, but not which are informed by, but not exclusively driven by, referral / exclusively driven by, referral / “presenting” problems.“presenting” problems.

Behavior Change Planning Behavior Change Planning (2)(2)

1 - Review everything you’ve learned about 1 - Review everything you’ve learned about changing behavior: “Learning theory” changing behavior: “Learning theory” (reinforcement, extinction, partial (reinforcement, extinction, partial reinforcement, Classical Conditioning (Often reinforcement, Classical Conditioning (Often the basis of emotional responses) and Operant the basis of emotional responses) and Operant Conditioning (overt behavior). Review classic Conditioning (overt behavior). Review classic texts on parenting, negotiation & problem texts on parenting, negotiation & problem solving, modeling, cognitive rehearsal, solving, modeling, cognitive rehearsal, substance abuse interventions. Use them all, substance abuse interventions. Use them all, but always remember to ..but always remember to ..

2 – Fit all techniques and Behavior Change 2 – Fit all techniques and Behavior Change goals into the relational framework (especially goals into the relational framework (especially Relational Functions) you already have Relational Functions) you already have developeddeveloped

Using Learning Theory Principles to Using Learning Theory Principles to Increase Appropriate BehaviorsIncrease Appropriate Behaviors

Remember that relational functions are a Remember that relational functions are a very powerful motivational component of very powerful motivational component of most important within-family behaviors. most important within-family behaviors. Thus positive reinforcement (e.g., positive Thus positive reinforcement (e.g., positive attention to increase a behavior which attention to increase a behavior which provides an alternative way to meet provides an alternative way to meet relational functions) can be more relational functions) can be more powerful than focusing on the “bad” powerful than focusing on the “bad” behaviors, but it also must “match” the behaviors, but it also must “match” the Relational Functions of all members.Relational Functions of all members. Incorporate relational (e.g., time alone – or Incorporate relational (e.g., time alone – or

time together --depending on the relational time together --depending on the relational function) as well as tangible reinforcers function) as well as tangible reinforcers (snack, book, movie, money, taking out (snack, book, movie, money, taking out garbage)garbage)

Remember that Remember that everyoneeveryone needs to be needs to be recognized and “reinforced.” recognized and “reinforced.”

Behavior Change Behavior Change ExamplesExamples

1. 1. Mother and adolescent daughter came into to Mother and adolescent daughter came into to treatment as a result of daughter’s probation treatment as a result of daughter’s probation violation of curfew. Daughter has been staying violation of curfew. Daughter has been staying in a shelter due to major conflict between in a shelter due to major conflict between herself and mother. Daughter and mother have herself and mother. Daughter and mother have had physical altercations in the past. Daughter had physical altercations in the past. Daughter most recently accused mother’s live in boyfriend most recently accused mother’s live in boyfriend of making inappropriate sexual gestures towards of making inappropriate sexual gestures towards her. Daughter attends school and works at same her. Daughter attends school and works at same resteraunt mother does. Both cannot resteraunt mother does. Both cannot communicate without blaming each other and communicate without blaming each other and verbal abuse. Relatedness is both mother and verbal abuse. Relatedness is both mother and daughter are autonomous. Hierarchy is daughter are autonomous. Hierarchy is symmetrical with neither having influence.symmetrical with neither having influence.

2. 2. Mother refers son for a Youth at Risk Petition Mother refers son for a Youth at Risk Petition which activates a family counseling referral. which activates a family counseling referral. Son is 17 yrs old, has GED, a job, and plays in a Son is 17 yrs old, has GED, a job, and plays in a band, and smokes marijuana on a regular basis, band, and smokes marijuana on a regular basis, which is mother’s chief complaint. Mother is a which is mother’s chief complaint. Mother is a single parent, very actively involved in her single parent, very actively involved in her religion, has 2 other children who are older, one religion, has 2 other children who are older, one who is her other son she is extremely upset with who is her other son she is extremely upset with because he is homosexual, the other is her because he is homosexual, the other is her daughter who is very close to her. Mother is daughter who is very close to her. Mother is fearful of son’s drug use and that he does not fearful of son’s drug use and that he does not respect her. She constantly questions, respect her. She constantly questions, interferes, nags her son. Son lives in garage of interferes, nags her son. Son lives in garage of the home. Mother is highly connected to son, the home. Mother is highly connected to son, son is autonomous. Son is one up.son is autonomous. Son is one up.