Functional Family Therapy Clinical Training Program Organizing Themes & Reframing Webinar #4 Thomas L. Sexton, Ph.D., ABPP Functional Family Therapy Associates

Goals Understand how and where to intervene in FFT sessions in all phases Understand how and where to intervene in FFT sessions in all phases Role of reframing Role of reframing Development of organizing themes Development of organizing themes Role of your creativity Role of your creativity

How do you change the family? Client centered attitudes (validation/respect, regard) Client centered attitudes (validation/respect, regard) Case Plan Case Plan – How and who to engage – What skills to add – How to generalize, maintain and support Plan for the session Plan for the session – Specific goals – What to ask – Specific phase based techniques Finding and using therapeutic “opportunities” Finding and using therapeutic “opportunities” the “events” clients bring into the room the “events” clients bring into the room

Problem Behavior Mom/mother figure Dad/father figure Adolescent Engage them to change Engage them to change Equip them with skills to solve Equip them with skills to solve the next “problem” -cope/deal with in a new way Maintain change over time Maintain change over time Topic of conversation Intervention point Goal of therapy

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

Example Peter is 13 years old. Peter is part Indonesian (his mother was Indonesian) and Dutch (his father was Dutch). He lives with his mother and his stepfather. He has 2 younger twin brothers, five years younger. He lives with his mother and his stepfather. He has 2 younger twin brothers, five years younger. According to the referral, the therapist knew that Peter had “fired” three different therapists in the last year. Each time he found them uninteresting, the sessions “boring” and most of the time was spent talking to his mother. The referral gave a characterization of Peter’s mother, Anja, as “motivated to do anything to help.” “This might be the last chance Peter has to take advantage of the treatments we are offering. If this referral doesn’t work out, placement should be reassessed as a viable option.”

What to do first Involvement in therapy Involvement in therapy Incentive to try something new Incentive to try something new Family focused “problem definition” Family focused “problem definition” Perceive a “credible” helper Perceive a “credible” helper Begins with how you think about the case (case conceputalization) Begins with how you think about the case (case conceputalization)

Where to begin “Problem Definitions” …. Your first opportunity to understand & intervene “Problem Definitions” …. Your first opportunity to understand & intervene Intervening to build engagement & motivation Intervening to build engagement & motivation – Relational Reframing

Relational Reframing Intervening to build engagement & motivation Intervening to build engagement & motivation – Relational Reframing

Relational Reframing When clients negatively/blaming reframe When clients negatively/blaming reframe Over time…reframes become themes Over time…reframes become themes When the themes about each person link together to provide an alternative explanation of the “problem” it is an organzing theme When the themes about each person link together to provide an alternative explanation of the “problem” it is an organzing theme Family Therapist

Relational Process of Reframing How: 1.Frame-point it out Description of: 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 - exhibited emotion -participation, effort Acknowledge Reframe Impact 2.“BAcknowledge why its important its important uild on”/continue Building theme that fits Making the conversation/ Session Relevant -acknowledge what is “wrong” -do something with “what is wrong” that makes it motivating/safe -feel no blame -talk without negativity -not alone in problem

Relational Process of Reframing How: 1.Frame 1.Acknowledge 1.Meaning - attribution -event-emotion (reduces negativity/blame) 2. Challenge them to consider future possibilities/directions (builds hope that there is potential, although unknown Solution) 3.Link family members together In struggle/problem (builds family focus/ Interdependence)Listen…listen…listen Acknowledge Reframe Impact “Build on”/continue Building theme that fits Theme hint ( best guess/hypothesis) Description, statement, question Suggesting alternative theme

Therapist Family Thematic explanation of event, problem, family, situation…that is “real“ for both therapist and client Themes describe problematic patterns of behavior, and/orThemes describe problematic patterns of behavior, and/or relationships, in a way that suggests they may be motivated by positive (but very misguided) intent(s). Organizing themes… describe everyone as linked to the pattern that is Linked to the “problem” mutually constructed … mutuall y acceptedmutually constructed … mutuall y acceptedTells “what is the matter” Content -what is important What is valued Listens for…. the pattern Translate into a theme (not content) That links the individual/problem to family Using REFRAMING Introduce “theme hint” into the conversation Occurs within the interaction Occurs within the interaction Can’t do “reframe outside of the interaction” Can’t do “reframe outside of the interaction”

Frame/Acknowledgement Reframe/reattribute

Reframing is built on Themes Themes describe problematic patterns of behavior, and/or relationships, in a way that suggests they may be motivated by positive (but very misguided) intent(s). Themes describe problematic patterns of behavior, and/or relationships, in a way that suggests they may be motivated by positive (but very misguided) intent(s). Themes provide new “explanations” of problematic and painful patterns that provide Themes provide new “explanations” of problematic and painful patterns that provide – hope for the future and give family members – a reason to “stick with” the difficult change processes which will ensue – Some sense of their “part” or “challenge” Organizing themes…. Organizing themes…. Link family members together Link family members together Explanation of each person, and family struggle Explanation of each person, and family struggle

Functional Family Therapy Reframing is built on Themes anger implies hurt anger implies hurt anger implies loss anger implies loss defensive behavior implies emotional links defensive behavior implies emotional links nagging equals importance nagging equals importance pain interferes with listening pain interferes with listening frightened by differences frightened by differences need to feel OK about self in context of problems need to feel OK about self in context of problems protection protection giving up so much power to someone else giving up so much power to someone else Beginning points to start the reframing process…. Beginning points to start the reframing process….

Why Reframes & Themes Work “Respect based” Reframing Doesn’t explain away but or “make positive” a bad event Doesn’t explain away but or “make positive” a bad event Reframing finds the strength / nobility in the “bad”/problem/behavior Reframing finds the strength / nobility in the “bad”/problem/behavior which is well intentioned but misguided which is well intentioned but misguided while understanding how it is meaningful for that person while understanding how it is meaningful for that person

Example When Peter angrily dismissed Anja, the therapist responded, “This is exactly the point (acknowledgement-framing)…this is the important issue (framing)…..this is the part that gets lost between you (reframe) when you talk like this.” Sensing Anja’s stronger emotional reaction, the therapist responded differently. Each time Anja attributed the whole of the family’s difficulties to Peter’s “problem,” the therapist stopped, looked at Anja and said, “Now I think I understand. This isn’t about you and getting your way, this is about helping him…about you wanting so badly to help (acknowledgement)….it is more about protecting him…(reframe).”

The themes of loss and protection seemed to link Anja and Peter together and help them overcome the emotional struggle each felt in almost every interaction. It really wasn’t that they were “doing” anything different. These themes seemed to resonate for the therapist and suggested “hints.” As hints, there were just guesses by the therapist. Over time, more and more events seem to fit more elaborated versions of loss and protection. Near the end of the session, the therapist said to Anja:

Near the end of the session, the therapist said to Anja: – – “I think this sums it up….what you just said, that it was never about controlling him it was only about helping. You know this is important because it is among your most cherished values. Yet, clearly, you quickly find yourself irritated and waiting for Peter to just leave. Yet at the same time you know, somewhere, that Peter is much less disturbed and actually more impendent than it may seem. His anger is often hurt and a feeling of great loss, loss of his mother.… You know that the biggest issue now is not him but finding a way to become more thick skinned and able to look beyond moments of tension without being derailed.”

Near the end of the session, in response to a strong dismissive reaction by Peter to his mother, the therapist said to Peter: “ I think I understand …maybe now I am getting a better idea. I must say that I have been sitting here all this time trying to figure out how to respond to this type of response you sometimes make to Anja. At first I thought maybe she was right, that you were just disrespectful, but then I listened more carefully. What I actually hear, although it is done with a tone that makes it difficult to hear the real message…but, I think you mean to protect her and at the same time retain your sense of control over your own life. Unfortunately, it seems that your anger is so quick, that it is easy to miss the lessons she is trying to help you with…it is probably even harder to find her good intent….that seems to be how it works in anger….., do you know what I mean….?”

The Outcome Changed relationship Changed relationship Altered perception of the other Altered perception of the other Alliance based therapeutic relationship Alliance based therapeutic relationship Ready for more…”now what do I do…?” Ready for more…”now what do I do…?”

What if….. New “events” enter the room New “events” enter the room They don’t respond They don’t respond You notice little change You notice little change No progress toward goals No progress toward goals How can you adapt? How can you adapt? Reorder importance of the goals? Reorder importance of the goals? What do you need to know? What do you need to know? How can you adapt what you know? How can you adapt what you know?

Only works when…. – Client centered….model focused – Use events….opportunities Opportunities to activate change mechanisms Opportunities to activate change mechanisms Accomplish goals by using events Accomplish goals by using events – Take one step at a time Let the phases build on each other Let the phases build on each other – When you are active – Guide process…lead the family – Act on your guess – Act before you know – Make hypotheses

Some concluding ideas Act before you know Act before you know There is no right “reframe” only a good reframing process There is no right “reframe” only a good reframing process Themes are only as good as they fit Themes are only as good as they fit Organizing themes are the foundation of the rest of FFT Organizing themes are the foundation of the rest of FFT Starting point of behavior change targets Starting point of behavior change targets What to help generalize What to help generalize Organizing these are “built” not “found” Organizing these are “built” not “found” It takes time…it is a process It takes time…it is a process

Question and Answer time Question and Answer time