Happy Birthday Mary

1. The California Institute for Mental HealthFUNCTIONAL FAMIILY THERAPY (FFT) SYMPOSIUM April 28 – 29, 2010Sheraton Gateway Los Angeles Hotel“The Core of FFT”James F Alexander, Ph.D.University of Utah & FFT

2. Happy Birthday Mary

3. The Core of FFT What is our “essence?” … Our “character?” … Our “mission?” … What do we do? … (Actions speak louder than words!)

4. The Core of FFT (2) • Think “comedy” • What is good comedy? What makes comedy “work?” Do we even “need” good comedy - or art or music or poetry or fiction or sports and recreation for that matter? • What does it take to create good comedy? Good art? Good fiction? A 2.42 ERA? A beautiful mural on a building in downtown LA? A meaningful mural on a building in downtown • Can everyone do it? - NO! • Can we afford for only the “special few” to be able to do it? - NO!

5. The Core of FFT (2): What Is FFT? • First, FFT is a person – a person “doing” FFT √ • FFT is a “model;” a framework, a way to “think” and plan, and a guide or map with steps about what to do and when to do it √ • FFT also is a “model,” or framework, for training, monitoring, and maintaining quality > effectiveness; It is a system with feedback and internal correction built in, which also is available to others (yep – the old/new “transparency” thing ) √ • Doing FFT well is determined if not defined by our (and our client families’) ethnicity, religion, gender, social class, political beliefs, intelligence … NOT !!!! … Influenced by? …. Yes. But determined by? NO! • Doing FFT well is determined, if not defined by, our attitudes, our beliefs, our passion, our “heart,” and our stubbornness √ (selective! )

6. What Are These Beliefs? • Something about these people can change • And I can do something to help that change to go in a positive direction • I will do a better job if I follow a plan, a “model,” which has been shown to be effective (“efficacious”) with very troubled families often with great challenges like the ones we see • I (yep, us …. Not just the families) am better off if I do this right! (Not “make,” “force,” “insure,”) Someone is watching, and cares!

7. Oh Yes …. And Then There is the “Doing” Part! • “Style” • Relational/ interpersonal sensitivity, ability to do what is “right” for the other (not just what is “right”). (R&R: READ& REACT) • And to do it in a way that “matches” • “Respectful” in a way that they experience as respectful and appropriate - for them! • Reaches out to them in the domains in which they “live” / exist, can experience productively, and function: • Specifically, “match” them in terms of “where they are” • Affect, Behavior, Cognitions (ABC’s) • Centro De La Familia family based Gang Prevention program for girls • Fathers? (Directors’ attitudes & gender preference) • And “Substance” • Techniques …. Embedded in Phases …. And with structuring skills

8. FFT Phases ( Core Model) Note that E&M & BC are essentially sequential Note that E & M can co-occur / blend Note that BC & GEN can co-occur / blend ENGAGEMENT BEHAVIOR CHANGE GENERALIZATION Eco/Multi- systemic Linking MOTIVATION Pre- Treat-ment Sessions 1 2 3 4 5 6 7 >>>> End Post- Treat-ment

9. FFT Unique Components and Phase Strategy E N G A G E M E N T BEHAVIOR CHANGE MOTIVATION Relational Assessment& Matching MOTIVATION GENERALIZATION, Eco/Multi- systemic Linking Pre- Treat-ment Post- Treat-ment Sessions

10. Within Family Alliance (Factor 1: Collaborative)As A Predictor of Completion / Dropout(Freitag & Alexander, 2010) Mean Alliance Session-Segment

11. “Generic,” Major Syndrome Specific,* or Context Specific** Matching & Techniques *Adol Substance Abuse, Adol PTSD, Sex Offender, Gangs, “mental health” **Child Welfare. Integrated Reentry E N G A G M E N T MOTIVATION BEHAVIOR CHANGE Relational Assessment& Matching Post- Treat-ment Pre- Treat-ment MOTIVATION GENERALIZATION, Eco/Multi- systemic Linking Sessions

12. The Complete FFT Dissemination Model Phases Pretreatment System Integration Phase • FFT CW Direct Treatment • Phases • - Engagement • Motivation • Relational > Behavioral • Assessment • - Behavior Change • - Generalization / Ecosystemic Integration Posttreatment System Integration Phase Assessment Assessment Assessment Referral, Preparation, Pretreatment Linking w/ Youth Mgt Systems Boosters, Maintenance of links w/ Youth Mgt Systems, Positive close The Youth / Family “Management” or Support System(s): Child Welfare, Mental Health, Justice, Drug Court, Welfare, Educational * Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001

13. Assessment by Phase - Generic Pretreatment System Integration Phase • FFT CW Direct Treatment • Phases • - Engagement • Motivation • Relational > Behavioral • Assessment • - Behavior Change • - Generalization / Ecosystemic Integration Posttreatment System Integration Phase Assessment Assessment Assessment Extra-family & Multiple system challenges & positive resources Referral, Preparation, Pretreatment Linking w/ Youth Mgt Systems Boosters, Maintenance of links w/ Youth Mgt Systems, Positive close Evaluate Risk & Protective Factors for Triage; Assess already involved systems Skill deficits & challenges, short and long term change goals (Behaviors, Emotions, & Cognitions) The Youth / Family “Management” or Support System(s): Child Welfare, Mental Health, Justice, Drug Court, Welfare, Educational Relational Functions, Deficits & strengths, safety & initial treatment challenges * Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001

14. Syndrome-Specific Specialization vs Syndrome-informed EM, BC, & Gen • Adolescent substance abuse / use, Adolescent PTSD, Adolescent Sex Offender, Child Welfare, and Integrated Reentry all represent syndromes and contexts commonly encountered by many FFT therapists. • As a result, FFT therapists responsible for the larger range of FFT referrals will be provided as many FFT-specific tools (knowledge & techniques – but only within their “scope of practice” abilities & training) as possible as we move into increasingly diverse treatment contexts. • However, these syndromes and contexts also can represent specialty training tracks offered as packages to specific treatment systems (e.g., institutions with reentry / “aftercare” treatment responsibilities; Drug Courts, Child Welfare Systems, Mental Health systems specializing in PTSD, Dual Dx Depression / Anxiety). In this case, FFT therapists will be trained as teams providing specific FFT “packages.” This training will be more extensive, and will require manualized and evidence-informed versions of FFT, primarily during Behavior Change.

15. Institutions GRYD Risk & Protective Factor Domains (“Ecological Model”) Community, Neighborhood Family Youth

16. Institutions The Moment of Decision – Proximal and Distal Influences Community Family Youth Peers?

17. Institutions Behavioral Styles & Patterns, Skills Attachment issues, Internal sense of “security” The Moment of Decision: Proximal Influences Community Family “Internal” Representation of Family, Community Peers, “Institutions” Peers? Youth Biological Risk & Protective Factors Self Regulation (self soothing, emotional intelligence, impulse control Identity, “Self Concept”

18. Behavior Patterns, Skills Attachment Youth The Moment of Decision: Proximal Influences “Self Concept” “Internal “Representations of Others Self Regulation Biological R & P

19. Stage 1: Usually cancer is relatively small & contained ; seemingly easily treated “non aggressively” • Stage 2: The tumor is larger than in stage 1 ... Sometimes spread into lymph nodes. Aggressive Tx necessary, but with high long term outcomes • Stage 3: cancer is larger ...started to spread … ...cancer cells in the lymph nodes in the area • Stage 4: cancer has spread from where it started to another body organ. Very aggressive interventions necessary, but with low “success” rates nonetheless Cancer Staging (as a metaphor)

20. Stage 1: Risk / Protective factor ratio is low; seemingly easily treated “non aggressively;” low probability of gang entry under current conditions • Stage 2: Risk / Protective factor ratio higher; low but discernable levels of gang-related behaviors appear; attitudes positive re gangs • Stage 3: Clear identification w/ gang mentality; • aggression > violence; 1 major or several less serious but notable criminal behaviors; • Stage 4: Major gang involvement, high offense rate, few or no protective factors, long duration of criminal behaviors, violence and/or heavy economic integration. Gang “Staging”

21. What Are The Risk Factors? (GRYD) • Youth (10-15), four or more risk factors, highest risk • Antisocial Tendencies • Isolates self, Unable to work as part of a socially acceptable group • Rebels against authority • Impulsive Risk Taking • without first considering potential consequences. (“Impulsivity”) • experience s dangerous or illegal acts as thrilling(“Under-arousal?”) • Neutralization (Rationalization; externalization; no guilt) • Justifies actions hurtful to others, • Consistent victimizing and manipulating others; rationalizing that it is acceptable • Unable to show or feel remorse or accept responsibility • Delinquency & Substance Abuse • Frequently involved in illegal behaviors connected to drug use • Negative Peer Influence & Peer Delinquency • Associates w/ friends directly involved in illegal activities

22. What Are The Risk Factors (2)? • Critical Life Events • a traumatic event • in combination with other risk factors may the “the last straw” • Weak Parental Supervision • Lacks parental guidelines • street activities without the knowledge/ supervision of parents. • parents are often physically or emotionally absent • Family Gang Influence • influential family members active in formal gang activity. • family values that affirm and accept gang involvement as normal • Personal” – ADHD, depression, anxiety, etc ( JFA)Separate “trait” / genotype contributions from phenotype (contextually elicited & reinforced components. • JFA Addition – school / vocational involvement; guilt is good, -parents permissive, - do as I say not do as I do. (not as big a problem) – are separate issues