Functional Family Therapy International Training Program Clinical Training 1 Thomas L. Sexton, Ph.D., ABPP Astrid van Dam Functional Family Therapy Associates

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



FFT/CFS

Month 9-12



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

Functional Family Therapy

Clinical Model

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….

The “LENS” of FFT

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



What each

member brings to the table


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


Emotional Reactions (negativity)-why its an important problem



Emotional Reactions (negativity)-why its an important problem


Mom/mother figure


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


-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


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

Relatedness Assessment

Mom

Adol

Dad

42

1

13

3

Mom

Adol

Peers

3

3Biological Father

?

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


MotherInitial Presenting Problem Definition

-attributional aspect-emotional valence


FatherInitial Presenting Problem Definition-attributional aspect-emotional valence


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


Reframing


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



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


-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 Phase

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 Phase

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



The Multisystemic Focus of Functional Family Therapy

Clinical Symptoms/Behaviors

Family Relational System



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

Bringing Creativity to the Structure

• Client Centered– Responsive to clients– Responsive to client needs– “fit” to a client

• Artfully applied– Require clinical creativity and

expertise

Documents

Functional Family Therapy International Training Program Clinical Training 1 Thomas L. Sexton, Ph.D., ABPP Astrid van Dam Functional Family Therapy Associates