functional family therapy international certification program clinical training 1 thomas l. sexton,...

Functional Family Therapy International Certification Program Clinical Training 1 Thomas L. Sexton, Ph.D., ABPP Indiana University

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. 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.

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

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

Common Factors FFT 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

To be successful with youth and their families FFT relies on 1.Guiding Theoretical Principles Conceptual, philosophical, and emotional center of the model Conceptual, philosophical, and emotional center of the model Parameters within which FFT occurs Parameters within which FFT occurs 2.A Clinical Map Systematic process of therapeutic change Systematic process of therapeutic change Specific goals, objectives, and therapist activities Specific goals, objectives, and therapist activities Mechanisms of change Mechanisms of change 3.System Support Systematic, model based clinical supervision Accountability Quality assurance methods Management/treatment responsibility/supervision/clinical decisions FFT based (FFT/CFS) Management/treatment responsibility/supervision/clinical decisions FFT based (FFT/CFS)

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

38%* reduction in felony crime38%* reduction in felony crime 50%* reduction in violent crime50%* reduction in violent crime $10.67 return for each $1 invested$10.67 return for each $1 invested $2100 per$2100 per family cost to implement Clinical Outcomes & Model Adherence Washington State Project * Statistically significant outcome Adherence to the Model as a vehicle to Meet the needs of the client

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

Functional Family Therapy is unique

The LENS of FFT Systemic foundation Systemic foundation Pragmatic focus on how the family functions Pragmatic focus on how the family functions Our inside out approach Our inside out approach

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

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

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

A matter of figure & ground

Systemic Foundation Relational Patterns Mo m Son Dad Relational Patterns are common ways of working in families that involve everyone Relational Patterns are common ways of working in families that involve everyone Problem sequences.are are common across content Problem sequences.are are common across content Maintain and support the problem behavior Maintain and support the problem behavior Point of intervention and change Point of intervention and change

Anja: Peter have you doneyou know you are getting behind.you need to take some responsibility (escalating the longer he doest answer) Peter: Whatever.later, I am going out., Iall be home.. Anja: there is no going out for you.it just inst good for you..you know you cant say no to those friends of yours Peter: At least I have friendslater he goes out. Anja: (to her husband)I cant do anything with himand you dont help. I would at least like your support Anja: is hurt by his commentgoes to her roomwatches TVworries and feels bad about her situation Stepfather: continues watching the football gameworries about his wifegets angry with Peter.. Peter: (comes home 5 hours late. Comes in the house and goes upstairson the stairs his mother comes out of her room Stepfather: I am tired of thiswhat is the matter with youdont you know how this hurts your mother? Peter : Fuck off.. the typical argument ensues until Peter goes to his room Anja: What are we going to do..I cant take this any more Peter: I am sorry Mombut, I can handle it Anja: I just worry about you (she feels comforted that he understands) Peter: I can handle it Momjust 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 saywhat do you want me to dohe wanst raised right

Mom/mother figure Dad/father figure Adolescent 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

Relational Functions Functional outcomes of these patterns Relational glue Stable and consistent Mom/mother figure Dad/father figureAdolescent Clinical Symptoms Match to The goal. Reduce the future Probability of the problem behavior Targets of Change -underlying patterns of FAMILY behavior

Relational Functions 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 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 Xs behavior is characterized by: RelationalIndependenceAutonomy:distance,Independence,disengagement (Fear of Enmeshment?) highlow Interdependency: closeness, dependency, enmeshment (Fear of abandonment?) lowhigh 1 2 45 3 Mid- pointing 3 Mid- pointing

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

P A P A P P A A P P A A One-upOne-up Symmetrical Relational Hierarchy pattern of relationship determination over time When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of Xs behavior is characterized by: Degree to which on person Determines the relationship Degree to which on person determines the relationship Symmetrical: Exchange = Behaviors 1-up + 1-up P P A A

Relational factors...What to do about relatedness functions Goal: identify relational functions.use these as Pathways to changeways to implement behavior changes Goal: identify relational functions.use these as Pathways to changeways to implement behavior changes Match to.relational functions Match to.relational functions To do so To do so discrepant functions are accommodated all functions are accepted as legitimate generally dont 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 interventionoutcome sample

Use of Relational Functions Matching to the family in Matching to the family in Reframing Organizing themes Behavior change implementation How to generalize, maintain, & support changes

Mom/mother figure Dad/father figure Adolescent Current behavior makes sense in light of Current behavior makes sense in light of What people bring with them What people bring with them Where people come from (relational context) Where people come from (relational context) Types of relationshipswith parents/family What people are made of .(biological context) What people are made of .(biological context) The environment in which they live ( ecosystemic 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 What people bring to relational systems

When you know what families bring You can: You can: Better understand what is important Understand family reactions to events Acknowledge and reframe Organizing themes that match to them Find a way to make therapy relevant

When you think relationally Clinical problems are NOT because of: Clinical problems are NOT because of: the family/youths anger the family/youths lack of motivation We expect them to be discouraged, lack motivation, angry, unhappy with the systems 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

Based on the individuals problem definition Based on the individuals problem definition 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 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 Clinical Problems

Family 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 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: 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 )

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

The MAP The Clinical Protocol The Clinical Protocol Goals, Directions Goals, Directions Pathway of change Pathway of change Relational & process focus Relational & process focus

Clinical Model Motivation Intervention Assessment Engagement Behavior Change Generalization Generalization EarlyMiddleLate 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

Engagement & Motivation Phase

Motivation Goals : 1.lower within family blame and negativity 2. Increase within family alliance 3.family focus to the presenting problem Intervention Assessment Engagement Early Outcomes When they Interact and solve problems it is with: Alliance Alliance Family/relationally based problem problem focus Family/relationally based problem problem focus Reduced negativity/blame Reduced negativity/blame Shared responsibility and ownership Shared responsibility and ownership Engagement/Motivation Phase

Engagement For positive participation a discussion that is relevant (about what is important) that involves trust, respect and alliance (e.g., core relational skills, acknowledgement) Motivation Not only to participate in therapy, but to undertake the specific behavior change steps designated by therapist ( e.g., Reframing, Theme Developing Skills)

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

Implementing Engagement/Motivation Phase E/M Phase Functional Family Therapy Goal Engagement in therapy Motivation to try something new/engage in change Family focused experience/understanding of the problem New Problem Situation 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 H 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 New Problem Situation

What to hear FFT therapists try to hear something different : FFT therapists try to hear something different : 1.Hear attribution, emotion, and behavioral pattern as central element underlying the presenting problem 2.Hear risk and protective factors embedded in this pattern that increase the likelihood of clinical problems 3.Think.family relational pattern Common/central pattern that is at the foundation of the many different presenting problems Common/central pattern that is at the foundation of the many different presenting problems

Engagement/Motivation Goals Developing motivation and alliance Creating a family focus to the presenting problem 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 Family enters with problem definition that is part of what has them stuck New problem definition that is less blaming, negative, and individually focused New problem definition that is less blaming, negative, and individually focused Create a relational focus--a family focus for the problem 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 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) Each part linked to the challenge that the family currently faces (family focused) Sets the stage for different solutions (behavior change) Sets the stage for different solutions (behavior change) thus, minimize hopelessness, ready family to take responsibility for trying new skills and making behavioral changes

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 Adolescent Initial Presenting Problem Definition - attributional aspect -emotional valence -related behavioral patterns Mother Initial Presenting Problem Definition - attributional aspect -emotional valence -related behavioral patterns Father 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 Not compromising mediating or negotiating Family Focused Problem definition Accomplished Through relentless relational Reframing The Outcome: Motivation, negativity reduction, Family to family alliance, Therapist to family alliance Accomplished Through relentless relational Reframing Accomplished Through relentless relational Reframing

Two direction ways to reduce negativity and blame Change the meaning of the behavior of the other Change the meaning of the behavior of the other Build Responsibility in the speaker/blamer Build Responsibility in the speaker/blamer

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

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

Relational Process of Reframing Acknowledgment of: - exhibited emotion -participation, effort Description of: - current behavior/event taking place between people/ between people/ with one person in the session --reported event/behavior either 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 to understanding of Persons, situations, etc. 1.Meaning - attribution -event-emotion (reduces negativity/blame) 2.Find the Noble Intent 3.Link family members together together members together In struggle/problem (builds family focus/ Interdependence) Listenlistenlisten Acknowledge Reframe Impact Build on/continue Building theme that fits Theme hint ( best guess/hypothesis) Description, statement, question Suggesting alternative theme Theme A new explanation based on 1.Changed Meaning 2.Reduced negativity/ blame possibilities for change 3.Linked together in Problem and future solution as all having some responsibility/ownership for the problem and solution

Why Reframes & Themes Work Respect based Reframing Acknowledge (yes.) Acknowledge (yes.) What they just said is important.. frames the situation/problem/event that is the target 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, emotionbehavior that has happened in the room of what has been reported What you guess to be important to them 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 heardassumedguessed about the reason this is so important to them

Why Reframes & Themes Work Respect based Reframing Reframe (and.)what you add to the session Reframe (and.)what you add to the session Alternative meaning for what was acknowledged Alternative meaning for what was acknowledged what might be behind or the reason what might be behind or the reason Focus Focus Person focused (their part) Family focused (all of the parts) ( yes that is what is important here) Non-blamingjust an alternative description Non-blamingjust an alternative description Non-interpretative Non-interpretative Doesnt explain awayor excuse.DESCRIBES theme hintjust a guess theme hintjust 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 Over time. Built a theme about the family that is more inclusive than this one event/situation

Some examples Hurt behind the anger Hurt behind the anger Anger is hurt Anger is hurt Control is protection Control is protection Etc. Etc. How would you say it..(acknowledge & reframe) He is independentand has mistakes He is independentand has mistakes Independent but safe Independent but safe Parents to help him be so.and protect him and teach him in the process Parents to help him be so.and protect him and teach him in the process Parents with a lot going ontrying to find way to help..an independent youth Parents with a lot going ontrying to find way to help..an independent youth

Some examples A boys is very angry A boys is very angry A girl is . A girl is . A mother is hopeless. A mother is hopeless. The youth is quiet. The youth is quiet. The family is in chaos.. The family is in chaos.. Acknowledge & Reframe Acknowledge & Reframe

Mom/mother figure Dad/father figure Adolescent Clinical Symptoms 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 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 Mother Therapist -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 Tells what is important -about what you said -about what you didnt Say -About the problem definition Adolescent Therapist -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 Tells what is important -about what you said -about what you didnt Say -About the problem definition Father Therapist -Frame this is important. -Acknowledge this is what is important to you? -Reframe Tells what is important -about what you said -about what you didnt Say -About the problem definition

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

Engagement/Motivation Interventions reframing Reframing a response to a CLIENT statement Reframing a response to a CLIENT statement Acknowledge (acceptance/support of the intent, the position, the values) of the client.. not agreementnot empathy. not agreementnot empathy. Personal not general Personal not general Reattribution of that statement (change in meaning) Building Themes ..reframing a CLIENT statement to: 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: 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

What makes reframing work 1.feel the reframe Therapist able to be the client and know what is importantthe nobel intention behind the behavior Therapist able to be the client and know what is importantthe nobel intention behind the behavior 2.believe the reframe It is how you understand them It is how you understand them 3.linked to everyone else 4.Presented in a way that is With acknolwedgement With acknolwedgement Respectful Respectful

Outcome Themes. 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)

Behavior Change Phase

Behavior Change Phase based Treatment Goals: 1.Build behavioral competencies that fit the family 2. Target the most relevant, obtainable, and maintainable competencies 3. Match competencies to relational functions Intervention Assessment Behavior Change Middle Outcomes Increase behavioral competency of all/family Increase behavioral competency of all/family Consistent performance of competency Consistent performance of competency in real problem situation Behavior Change Phase

Behavior change sessions Goals Specify the behavior change individualized plan Specify the behavior change individualized plan Link BC targets to the organizing theme to build relevance and motivation Link BC targets to the organizing theme to build relevance and motivation Build compliance Build compliance match to the client match to the client check if the BC target works to solve conflict check if the BC target works to solve conflict Assessment Identifying prosocial family based skill that fits youth/family problem sequence Identifying prosocial family based skill that fits youth/family problem sequence Find barriers to adoption of BC skill Find barriers to adoption of BC skill Determine if the target is being performed (compliance) Determine if the target is being performed (compliance) Interventions reframing reframing Modeling Modeling Teaching Teaching Overcome barriers/adapt Overcome barriers/adapt

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

Implementing BC Phase BC Session New Problem Situation New Problem Situation New Problem Situation Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new skills in problems that come up Target a new skill Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new skills in problems that come up Target a new skill that fits the specific problem that brought them to therapy Changes the Problem sequence central to way family functions Uses new skills in problems that come up New Problem Situation

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 Reframing Helps direct family to shared, family focused action Helps direct family to shared, family focused action Helps link behavior change to organizing themestay focused Helps link behavior change to organizing themestay focused Helps reduce negativity that arises Helps reduce negativity that arises Building family competencies so that the risk patterns central to family change. Building family competencies so that the risk patterns central to family change. Communication Communication Problem solving/negotiation Problem solving/negotiation Conflict management Conflict management Parenting (monitoring supervising) Parenting (monitoring supervising) Single, individualized behavior change plan Single, individualized behavior change plan Combination of individual skills Combination of individual skills

Promoting new Behavioral competencies Not a curriculum approach Not a curriculum approach Set of principles (in each area) that serve as the basis of assessment of and and target development Set of principles (in each area) that serve as the basis of assessment of and and target development Principles used by the therapist to construct a set of targets that match the unique family Principles used by the therapist to construct a set of targets that match the unique family Implemented within session in ways that match: Implemented within session in ways that match: Relational functions Relational functions Situation Situation Theme Theme

Discussion focused on: - homework, going out with peers, curfew - -specific spot in the sequence Conflict Management Communication - direct and concrete communication Parenting - monitoring and supervising Where they use: Negotiating/ Problem Solving as a family based resource Parent Adolescent With components of. to individualize to the family Targets of FFT Behavior Change

Behavior Change interventions. How to implement behavior change In sessions Planned through teaching/using a client issue Planned through teaching/using a client issue Opportunitythrough an in session incident Opportunitythrough an in session incident How How Coaching, directing, teaching, aids As homeworka way to prevent in the future

Generalization Phase

Generalization Phase Based Treatment Goals: 1.Reduce within family risk factors 2. Lower within family blame and negativity 3. Increase within family alliance & family focus Intervention Assessment Generalization Late Outcomes Increase behavioral competency of all/family Increase behavioral competency of all/family Consistent performance of competency Consistent performance of competency in real problem situation Generalization Phase

Generalization Sessions Goals Generalize the BC target skills to other areas Generalize the BC target skills to other areas Maintain change through relapse prevention Maintain change through relapse prevention Access external resources to support change Access external resources to support change Interventions Relapse prevention (if the family is falling back into problem behaviors) Relapse prevention (if the family is falling back into problem behaviors) Linking new problem situation to BC skill Linking new problem situation to BC skill Linking family to relevant outside resources Linking family to relevant outside resourcesAssessment Identify external family systems to apply BC skills Identify external family systems to apply BC skills Identify contextual barriers to maintaining the BC target Identify contextual barriers to maintaining the BC target Find areas to generalize Find areas to generalize Identify relapse points Identify relapse points

Generalization Phase shifting focus In generalization two points of attention Within the family: Within the family: Relapse preventionRelapse prevention Generalization of competenciesGeneralization of competencies Maintenance of allianceMaintenance of alliance Outside the family: Outside the family: family--environment interaction(interface)where the family interacts with the community/environmentfamily--environment interaction(interface)where the family interacts with the community/environment Relationships between family (individual and whole) and the communityRelationships between family (individual and whole) and the community Use of behavioral competencies in these relationshipsUse of behavioral competencies in these relationships In order to use relevant available resources to support changesIn order to use relevant available resources to support changes

Ecosystemic System Peer/school/community/extended family Ecosystemic System Peer/school/community/extended family ( Sexton, 2010 ) The Multisystemic Focus of Functional Family Therapy Clinical Symptoms/Behaviors Family Relational System

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. 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 Small changes can have a multisystemic effect These changes often dont happen naturally These changes often dont happen naturally Specific strategies for: Specific strategies for: generalizing new skills, generalizing new skills, maintaining change, 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. 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: Reduces: Revolving door of treatment Revolving door of treatment Relapse Relapse Future positive changes 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. 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 Behavior Change Built 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 out With friends Homework Relationship With sibling Time with boyfriend

Discussion focused on: How to maintain, support, and generalize new climate, alliance, behavior changes MedicalEvaluation Psyc 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 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: Build confidence/efficacy in their ability to maintain changes.by: Attribute change to the family Attribute change to the family Responding to events they bring in by focusing on relapse prevention Responding to events they bring in by focusing on relapse prevention

Clinical Art Creativity within the structure Creativity within the structure Therapists as translators Therapists as translators Family based change through reliable change processes Family based change through reliable change processes

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

Contingent nature of phases...

Matching to. Match to.guides therapist clinical interventions behavior Match to.guides therapist clinical interventions behavior Model sets the process goal .match to helps us individualize how we get to that goal to the unique family in front of us Match therapy to family .How those goals are accomplished Unique solutions within a structure model Unique solutions within a structure model

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

Matching? Matching means Matching means Matching interventions to family presentations Change meaning in ways consistent and respectful of all family members Change meaning in ways consistent and respectful of all family members Themes to generate hope Themes to generate hope Working within families existing structures Relational function matching Relational function matching Changing patterns but not relational functions during Behavior Change Changing patterns but not relational functions during Behavior Change Making sure family links to external resources maintain relational functions Making sure family links to external resources maintain relational functions Ensuring all of this done in a manner that fits the developmental, cognitive, and physical abilities of all family members

Creativity within the Structure Continuous Quality Improvement Progress notes, Session Plans & Process/Outcome Measures FFT/CFS & model specific Feedback

FFT/CFS quality improvement system for Functional Family Therapy Clinical Feedback tool. Clinical Feedback tool. Bring information to youat a glance to help plan sessions Allows client a voice in the progress Lets you know how to match to the family Domains: Domains: Service delivery (the profile of how units of service are delivered in FFT) Treatment planning (case conceptualization and session planning) Model Specific Adherence (treatment fidelity) FFT treatment progress & Process (impact of treatment on client Outcomes ( Client reported outcomes of the FFT treatment episode)

FFT/CFS continuous quality improvement system for Functional Family Therapy Clinical Decisions & Adaptations that match to immediate client needs immediate client needs Promote the most efficient delivery of FFT Promote the most efficient delivery of FFT FFT/CFS Clinical Markers Real Time Feedback Treatment Planning (Progress Notes) Session Planning (Session Planning Guide) Client Session Impact (immediat e family changes) Caregiver Strain Questionnair e-Short Form (CGSQ-SF) TherapeuticAlliance(TA) Youth Symptom and Functioning (SFSS) Session Baseline Family Functioni ng (Com-R) Post Treatment Family Functionin g Measure (Com-R) (Com-R) Model Specific Adherence (CQP) Motivation Engagement Behavior Change Generalization Generalization Session

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practice evolution

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client centered model