1. Functional Family Therapy International Certification Program Clinical Training 2 Thomas L. Sexton, Ph.D., ABPP Astrid van Dam Functional Family Therapy Associates

2. Agenda Lets see where we stand Lets see where we stand – Discussion about progress, challenges, setting the days agenda Integrate CFS into clinical decision making Integrate CFS into clinical decision making Your goals? Your goals?

3. Preparing for Behavior Change Phase

4. What do you need – Clear target for change (well specified) – What is the problem? – Where in the problem sequence – In response to which risk factor – Building which protective factor – Relational Assessment (to match to the family/client) – Making it relevant – What and how you talk about the goal – Implementing the plan

5. Finding the target starts with identifying the problem Clinical problems are NOT because of: Clinical problems are NOT because of: – the family/youth’s anger – the family/youth’s 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 They are…. They are…. – Stuck families

6. What is the problem? What they do about what happened What they do about what happened How they handle risk factors (from in and outside the family) How they handle risk factors (from in and outside the family) How they have come to “define” the problem (over time) How they have come to “define” the problem (over time) The sequence between each (which keep them stuck) The sequence between each (which keep them stuck)

7. What therapy changes Problem Behavior (currently defined “prblem” Mom/mother figure Dad/father figure Adolescent 1. Change Climate in the family the family 2. Change the current problem 3. Prepared for the next “problem” -cope/deal with in a new way -empowered with a “way” To solve future

8. Cultural/Ethnic/Racial “Context” Family Sibling (s) Parent(s) Adolescent Behavior becomes of worry To parents/the system BiologicalBiological HistoricalHistorical RelationalRelational Individual Risk and Protective Factors Community Peer Groups Values/Norms Socioeconomic Status Risk and Protective Factors Values/customs/relational styles/Values/customs/relational styles/ Rules, ritualsRules, rituals Expectations/normsExpectations/norms Unique “whole”Unique “whole” Central Family relational patternsCentral Family relational patterns problem “fit”/”functions” within Relational “outcomes”Relational “outcomes” FFT…. “The Current Problem” -Cognitive aspect (Understanding/attributions of the “problem”--definition) - Emotional response -Behavioral response to the perceived problem aimed at solve problem it

9. How do families get stuck? 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 Emotional Reactions (negativity) Behaviors (interactions) Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions) Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions)

10. Anja: “ Peter have you done…””you know you are getting behind”….”you need to take some responsibility” (esclating the longer he doesn’t answer) Peter: “Whatever….later, I am going out…., I’ll be home…..” Anja: “there is no going out for you….it just isn’t good for you…..you know you can’t say no to those friends of yours…” Peter: “ At least I have friends…later…” he goes out. Anja: (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support Anja: 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 Peter…..” Peter: (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?” Peter : “Fuck off..” the typical argument ensues until Peter goes to his room Anja: “What are we going to do..I can’t take this any more… ” Peter: “I am sorry Mom…but, I can handle it” Anja: “I just worry about you” (she feels comforted that he understands) Peter: “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 wasn’t raised right…” Figure 7.1

11. Relational Functions Functional outcomes of these patterns Functional outcomes of these patterns Relational “glue” Relational “glue” Current “experience of the relationship for each individual Current “experience of the relationship for each individual Why do they stay stuck? Mom/mother figure Dad/father figure Adolescent Clinical Symptoms “GLUE” The goal…. Reduce the future Probability of the “problem behavior” Targets of Change -underlying patterns of FAMILY behavior

12. Relational “Functions” (Relational Assessment) 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

13. When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by: RelationalIndependenceAutonomy:distance,Independence,Disengagementhighlow Interdependency: closeness, dependency, enmeshment lowhigh 1 2 45 3 Mid- pointing 3 Mid- pointing

14. 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, Visible self mutilation “ideal” balanced adult Having many jobs and outside activities Giving considerable Nurturance, warm & loving Focused/successful professional “Positive” Behaviors “Negative” Behaviors

15. 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 X’s 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

16. Implementing Behavior Change Build on Engagement & Motivation progress Build on Engagement & Motivation progress – Changes in family climate because of engagement & motivation phase – Negativity lower – Blame reduced – Responsibility increased – A family focus to the problem The way is cleared for specific changes in the problem sequence The way is cleared for specific changes in the problem sequence Foundation is build Foundation is build

17. Clinical model Matching to…. Artful application means….. 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

18. Family Frame of Reference: Themes & Organizing Themes Themes…. that identify the noble intention Themes…. that identify the noble intention “ He is independent……and has mistakes” “ He is independent……and 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 on……trying to find way to help…..an independent youth” “Parents with a lot going on……trying to find way to help…..an independent youth” Themes function to: Themes function to: – Stay out of the details….break relational patterns – Reduce negativity & blame – Increase a family focus – Empower the family: Focus on the “Nobel intention”

19. Reframes, Themes, & Organizing Themes Reframin g… a response to a CLIENT statement Reframin g… a response to a CLIENT statement – Acknowledge (acceptance/support of the intent, the position, the values) of the client….. not agreement…not empathy…. not agreement…not empathy…. Personal not general Personal not general – Reattribution of that statement (change in meaning) Theme Hints …..reframing a CLIENT statement to: Theme Hints …..reframing a CLIENT statement to: – Your hypotheses of a theme (theme “hint”) – An existing theme in the conversation Relational/ Organizing Theme …..a theme that describes: Relational/ 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

20. 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 Goal: 1.Build alliance -with the person you are talking directly to (by being non-blaming) -with others in family (by seeing you take on “problems” in a way that is direct but safe) 2.Demonstrate Support Show attempts to understanding of Persons, situations, etc 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 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

21. 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 didn’t 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 didn’t 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 didn’t Say -About the problem definition

22. Engagement/Motivation Creating a Family focus... …developing a relational thread …developing a relational thread Presenting Problem Redefined “problem” He is manipulative…he just says/gives you the lines you want to hear when we are here…what he really needs is “crack you head open therapy”…responsibility needs to be put with him…I am just tired, I don’t want to be a parent anymore He is having a very difficult time learning how to be a man (have values and know what is right), I can’t find a way to get him to do what he needs to do..., I am just really hurt by it all

23. Making it Relevant Issue of content vs process. Issue of content vs process. Focus the discussion on what they think is Important Focus the discussion on what they think is Important Focus your attention on the process…. Focus your attention on the process…. Is there a family focus? Is there a family focus? Is negativity and blame lower? Is negativity and blame lower? Do you know the sequence? Do you know the sequence? Match your language to relational functions Match your language to relational functions Focus on “them” Focus on “them”

24. How to use the CFS in Clinical Decision making 1.Case planning Progress Notes Progress Notes Session Planning Guides Session Planning Guides 2.Client Feedback (SIS) – Impact you are having Level of negativity & blame Level of negativity & blame Level of family focus Level of family focus Engagement Engagement Motivation Motivation Knowing what to do Knowing what to do Know how to do it Know how to do it

25. How to use the CFS in clinical Decision making 3.Symptom Level (youth behavior) (SFSS-weekly) Lets you know what to focus on Lets you know what to focus on Helps the conversation be more relevant Helps the conversation be more relevant Helps you be specific Helps you be specific Lets you know when there are things to worry about Lets you know when there are things to worry about – Runaway Discrepancy between family members Discrepancy between family members – Lets you know to focus on the family framing

26. Example ….. Example ….. – Case #1 Organizing theme? Organizing theme? Problem definitions? Problem definitions? Risk Factors Risk Factors Sequence Sequence

28. Behavior Change Phase EarlyMiddleLate Intervention Assessment

29. Behavior change sessions Goals Specify the behavior change targets as family prosocial skills: Specify the behavior change targets as family prosocial skills: 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

30. Session Goals Frame and link the family to a specific behavioral competency to help family know what to do Frame and link the family to a specific behavioral competency to help family know what to do Developing relevant skill. Developing relevant skill. – Teach and coach family in using a specific behavioral competency in the room Helping the family adopt the new alliance based protective skills or competencies Helping the family adopt the new alliance based protective skills or competencies Engage the family in the behavior change phase activities Engage the family in the behavior change phase activities

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

32. Implementing BC Phase BC Phase Functional Family Therapy 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

33. 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 theme…stay focused Helps link behavior change to organizing theme…stay focused Helps reduce negativity that arises Helps reduce negativity that arises Challenge that promotes motivation Challenge that promotes motivation 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)

34. 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 Individualized change plan Individualized change plan

35. Behavior Change… Interventions technologies/targets Behavior Change… Interventions technologies/targets Communication skills training: principles of positive communication… Communication skills training: principles of positive communication… 1. Source responsibility 2. Directness 3. Brevity 4. Concreteness and behavior specificity 5. Congruence 6. Presenting alternatives 7. Active listening 8. Impact statements

36. Behavior Change… Interventions technologies Problem Solving… method for adolescent and parents to work together to jointly solve” problems Problem Solving… method for adolescent and parents to work together to jointly solve” problems 1. Identify a problem….goals of the family in a specific incident/area/with a specific problem 2. Identify the outcome desired 3. Agree on what it takes to “do” it – Sub goals….who has what part – Contracts/negotiations etc. 4. Identify all the ways it can go wrong 5. Come back and see if goals are met accountability

37. Behavior Change… Interventions technologies Conflict management ….for those “problems” that can’t be solved in other ways Conflict management ….for those “problems” that can’t be solved in other ways – Avoid it…..change reaction to early triggers – Principles to use in trying to contain it… – Present orientation – Issue focused – Adopt a conciliatory set 1. Exactly what is the issue 2. Exactly what would satisfy me? 3. Is the goal important? 4. Have I tried to get what I want through problem solving? 5. How much conflict am I willing to risk to get what I desire? Time-out for transitions Time-out for transitions

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

39. Behavior change interventions require therapist… – To have a well thought out change plan – Structuring the session to accomplish it – Contingently responding to what happens in the session…hearing/seeing feedback Ignoring…some things Ignoring…some things Finding ways to use other things to fit behavior change goals Finding ways to use other things to fit behavior change goals Staying with it…while responding interpersonally Staying with it…while responding interpersonally – Monitoring of motivation through out implementation Backing up to engagement/motivation when needed…. Backing up to engagement/motivation when needed…. – Follow through – Match to….the family relational functions

40. Behavior Change interventions…. How to implement Behavior Change In sessions Planned through teaching/using a client issue Planned through teaching/using a client issue Opportunity…through an in session incident Opportunity…through an in session incident How… How… – Coaching, directing, teaching, aids – As “homework”… Specific task that is accomplishable..one issue Clearly presented/understood Clearly presented/understood High expectation of success….define success as doing it High expectation of success….define success as doing it – How… Within couple…as way to strengthen/change couple Within couple…as way to strengthen/change couple

41. Progress Notes-BC Phase – Problem Sequence – Relatedness Functions – Potential Behavior Change Targets (Relevance/Obtainable) – Fit of BC Target to Organizing Theme and Presenting Problems

42. How to use the CFS in Clinical Decision making 1.Case planning Progress Notes Progress Notes Session Planning Guides Session Planning Guides 2.Client Feedback (SIS) – Impact you are having Level of negativity & blame Level of negativity & blame Level of family focus Level of family focus Engagement Engagement Motivation Motivation Knowing what to do Knowing what to do Know how to do it Know how to do it

43. How to use the CFS in clinical Decision making 3.Symptom Level (youth behavior) (SFSS-weekly) Lets you know what to focus on Lets you know what to focus on Helps the conversation be more relevant Helps the conversation be more relevant Helps you be specific Helps you be specific Lets you know when there are things to worry about Lets you know when there are things to worry about – Runaway Discrepancy between family members Discrepancy between family members – Lets you know to focus on the family framing

44. What Next? Where is behavior change leading?

45. 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

46. 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

47. Generalization Phase… shifting focus 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

48. 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: 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

49. 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

50. Discussion focused on: How to maintain, support, and generalize new climate, alliance, behavior changes Medical Evaluation 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

51. Scoring the Measures