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

2. 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

3. Evidence-Based Training & Implementation Model Multiple learning styles/formats Multiple learning styles/formats Realistic Realistic Cost effective Cost effective Comprehensive measurement system Comprehensive measurement system Youth symptoms, family functioning, Youth symptoms, family functioning, process & progress Evidence-based practice Evidence-based practice Ongoing measurement of Ongoing measurement of Process, outcome, & practice Family Voice Family Voice Ongoing evaluation (using CFS) Ongoing evaluation (using CFS) Benchmarks for: Benchmarks for: – Adherence client outcomes, – service delivery – Progress & process

4. 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

5. Month 1-4 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 1-4 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 5-9 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 5-9 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 9-12 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Month 9-12 Clinical Training (on day on site) 2 webinars 2 onsite training days Discussion Forum use Active participation in FFT/CFS Months 1-4 Months 5-9 Months 9-12

6. 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?

7. 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

8. Process Assessment Client 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 Process Assessment Client 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

9. Evidence Based Clinical Decision Making Process 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 -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

10. Functional Family Therapy Clinical Model

11. 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 Family…with respect for how the family “functions” Change that is guided by the model….driven by the Family…with respect for how the family “functions” “inside out” approach “inside out” approach Requiring a creative therapist Requiring a creative therapist Aided by…. Aided by….

12. The “LENS” of FFT

13. Internal World Biological Substrate/Learning History/individual traits Clinical Symptoms/Behaviors Family Relational System -patterns -problem definitions -history Ecosystemic System Peer/school/community/extended family Ecosystemic System Peer/school/community/extended family ( Sexton, 2010 ) Risk & protective factors What each member brings to the table Risk & protective factors

14. 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 (/brain function) Physical (genetics/brain function) History (trauma/background) Learning History Learning History Etc.

15. 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 ” – It is their “problem definition” Functional view of Clinical Problems

16. 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 Relational sequences/problem sequences that answer the question…what do they do 2.Meaning they make of those patterns Problem definitions & functions Problem definitions & functions 3.Function of the pattern/meaning Relational outcome that “glues” the relationship together Relational outcome that “glues” the relationship together

17. Mom/mother figure Dad/father figure Adolescent Where people come from (relational context) Where people come from (relational context) – Types of relationships…with parents/family What people are made of ….(biological context) What people are made of ….(biological context) x 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 The role of history: What people bring to relational systems

18. Relational Patterns Mo m Son 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

19. 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…”

20. 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 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)

21. 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 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

22. Mom/mother figure Dad/father figureAdolescent Problem “definition I 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 Emotional Reactions (negativity) -anger -hurt -fear of loss of mom Behaviors -her role in the problem sequence Problem “definition I 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

23. Relational Functions Functional outcomes of these patterns Relational “glue” Stable and consistent Mom/mother figure Dad/father figureAdolescent Clinical Symptoms Match to… The “function” of patterns/meaning

24. 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

25. When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by: RelationalIndependence Psychological Autonomy highlow Psychological Interdependency lowhigh 1 2 45 3 Mid- pointing 3 Mid- pointing

26. Relatedness Assessment Mom Adol Dad 4 2 1 1 3 3 Mom Adol Peers 3 3 Biological Father ?

27. P A P A P P A A P P A A One-upOne-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 person Determines the relationship Degree to which on person determines the relationship Symmetrical: Exchange = Behaviors P P A A

28. What can you change…. Patterns are changeable through skill building Patterns are changeable through skill building Meaning is changed through reframing and therapeutic themes Meaning is changed through reframing and therapeutic themes Functions are stable … so you have to match to them Functions are stable … so you have to match to them Match reframing/theme Match reframing/theme Skills Skills Generalization strageties Generalization strageties

29. 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

30. The “MAP” The Clinical Protocol The Clinical Protocol Goals, Directions Goals, Directions Pathway of change Pathway of change Relational & process focus Relational & process focus

31. Clinical Model EarlyMiddleLate 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 context protective connections -peers -school -community EarlyMiddleLateAssessment Intervention

32. 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

33. 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

34. 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

35. 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

36. Relational Reframing Structuring & Supporting Focus on “them: Family Story Relational Theme Family Focus to the problem Everyone is part of the solution Each member has unique contributions… Their “challenges”

37. 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 - attribution 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

38. 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

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

40. Relational Process of Reframing Acknowledgment of: - exhibited emotion -participation, effort Description of: - current behavior/event taking place 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 members together In struggle/problem (builds family focus/ Interdependence)Listen…listen…listen Acknowledge (identify & 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

41. 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 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”

42. Reframing Identify the Behavior(s) (from problem definition) 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) Acknowledge the importance of each to the person (link their struggle with something important to them) Reframe Reframe Lilly’ 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

43. Relational 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” What you “guess” to be important to them What you “guess” to be important to them 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”

44. Lilly -responds defiantly MOM -gets worried -asks (indirectly) MOM -jokes, makes fun -tries to get her to “do it for me” Lilly Obviously irritated -blows off Mom MOM -hear it as “she doesn’t care” -gets scared Lilly -responds defiantly

45. Lilly -responds defiantly 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

46. “In the room” in Engagement/Motivation When clients negatively/blaming reframe When clients negatively/blaming reframe Over time…reframes become themes 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

47. Components of an Organizational/family 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 – Explanation…gives 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 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 Complete, includes what is most important to family, personal, specific in way that is individual

48. Relational Theme(s) Explaining the problem in relational Terms Explaining the problem in relational Terms – Involves every one – Identifies the struggle in descriptive way – Identifies the noble intention – Identifies the challenge of each MOM Problem “definition I 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 Emotional Reactions (negativity) -anger -hurt -fear of loss of mom Behaviors -her role in the problem sequence Lilly Problem “definition I 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 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…..

49. 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”) 7. Set treatment goals

50. 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 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 It “is” how you understand them 3.“linked” to everyone else 4.Presented in a way that is… With acknowledgement With acknowledgement Respectful Respectful

51. Behavior Change Phase

52. 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

53. 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 Single, individualized “behavior change plan” Combination of individual skills

54. “In the room” in Behavior Change When clients bring in a problem….have them use the specific behavior change competency in the room 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 Apply it in an individualized way to the family…fit it in the problems sequence Match relational functions Match relational functions Goal is that the family use the competency NOT that problems are solved 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 Make new behavioral competency linked to the organizing theme….gives a reason to do it Over time family increasingly uses the new skill Over time family increasingly uses the new skill Family Therapist

55. 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

56. 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 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) \

57. Promoting new Behavioral competencies Not a “curriculum approach” Not a “curriculum approach” Set of principles (in each area) that serve as the basis of individualized plan 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 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

58. 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”…a way to “prevent” in the future

59. Generalization Phase

60. 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

61. Generalization Phase… 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: Relationships between family (individual and whole) and the communityRelationships between family (individual and whole) and the community

62. 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

63. Ecosystemic System Peer/school/community/extended family Ecosystemic System Peer/school/community/extended family ( Sexton, 2010 ) Court system involvement School Struggles Family changes (joining John’s family) Peer Group Pressure Involvement Identify the external systems and risk factors that are important for maintaining & supporting change

64. 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.”

65. Logic of Generalization Small changes can have a multisystemic effect Small changes can have a multisystemic effect These changes often don’t happen naturally These changes often don’t 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

66. 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.

67. 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

68. Discussion focused on: How to maintain, support, and generalize new climate, alliance, behavior changes Medical /med Psych 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

69. 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

70. 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

71. 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