Agenda

1. Functional Family TherapyInternational Certification ProgramClinical Training 2Thomas L. Sexton, Ph.D., ABPPAstrid van DamFunctional Family Therapy Associates

2. Agenda • Lets see where we stand • Discussion about progress, challenges, setting the days agenda • Integrate CFS into clinical decision making • 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: • 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 • history or biology • peers • bad choices • inability to “just say no” • “mental health” issues • Drug abuse • They are…. • Stuck families

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

7. Problem Behavior (currently defined “prblem” Dad/father figure Adolescent Mom/mother figure What therapy changes 1. Change Climate in 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. Peer Groups Values/Norms Socioeconomic Status Risk and Protective Factors Cultural/Ethnic/Racial “Context” Family 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 • Unique “whole” • Central Family relational patterns problem “fit”/”functions” within • Relational “outcomes” Behavior becomes of worry To parents/the system Community Adolescent Sibling(s) Parent(s) • Biological • Historical • Relational Individual Risk and Protective Factors • Values/customs/relational styles/ • Rules, rituals • Expectations/norms

9. Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions) Adolescent Dad/father figure Mom/mother figure How do families get stuck? Problem “definition -what the problem is -why its an important problem -what should be done about it Emotional Reactions (negativity) Behaviors (interactions) Clinical Symptoms 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: “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…. Anja: “I just worry about you” (she feels comforted that he understands) Peter: “Whatever….later, I am going out…., I’ll be home…..” Peter: “I am sorry Mom…but, I can handle it” 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…” Anja: “What are we going to do..I can’t take this any more…” Peter: “At least I have friends…later…” he goes out. Peter: (comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room… Anja: (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support Stepfather: …continues watching the football game…worries about his wife…gets angry with Peter…..” 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…” Stepfather: …”I am tired of this…what is the matter with you…don’t you know how this hurts your mother?” Anja: is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation…… Figure 7.1 Peter: “Fuck off..” the typical argument ensues until Peter goes to his room

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

12. Relational “Functions”(Relational Assessment) “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 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

13. high 1 2 Relational Independence Autonomy: distance, Independence, Disengagement 4 5 low low Interdependency: closeness, dependency, enmeshment high When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by: 3 Mid- pointing

14. Teenage runaway Teenage runaway Its not the specific behavior…..but the functional-relational pattern it represents….behaviors and their possible interpersonal (relatedness) functions high Substance Abuse Having many jobs and outside activities Being cold, sarcastic, rejecting Being hysterical Relational Independence Autonomy: distance, Independence, disengagement Visible self mutilation “ideal” balanced adult Withdrawing passively Being depressed Double dating Focused/successful professional Giving considerable Nurturance, warm & loving “Positive” Behaviors “Negative” Behaviors Having childhood phobias, Being insecure low low high Contact: closeness, dependency, enmeshment,

15. 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: P A A P P A A P A P Degree to which on person Determines the relationship Degree to which on person determines the relationship 1-up + 1-up Symmetrical Symmetrical: Exchange = Behaviors One-up One-up

16. Implementing Behavior Change • 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 • Foundation is build

17. Clinical modelMatching to…. Artful application means….. • 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 • “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” • 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 • Reframing…a response to a CLIENT statement • Acknowledge(acceptance/support of the intent, the position, the values) of the client….. • not agreement…not empathy…. • Personal not general • Reattribution of that statement (change in meaning) • 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: • Each persons motivate in non negative ways • Links everyone in the family together….to a common problem, challenge, of situation

20. Meaning -attribution -event -emotion (reduces negativity/blame) 2. Challengethem to consider future possibilities/directions (builds hope that there is potential, although unknown Solution) Link family members together In struggle/problem (builds family focus/ Interdependence) Relational Process of Reframing Theme A “new” explanation based on… • Changed Meaning • Reduced negativity/ blame possibilities for change • Linked together in Problem and future solution as all having some responsibility/ownership for the problem and solution 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 Goal: • 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) • Demonstrate Support Show attempts to understanding of Persons, situations, etc Acknowledge Theme hint (best guess/hypothesis) Description, statement, question Suggesting alternative theme Reframe Impact Listen…listen…listen “Build on”/continue Building theme that fits

21. Adolescent Dad/father figure Mom/mother figure Tells what is important -about what you said -about what you didn’t Say -About the problem definition 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 Tells what is important -about what you said -about what you didn’t Say -About the problem definition 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 -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 Clinical Symptoms Tells what is important -about what you said -about what you didn’t Say -About the problem definition -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 Father Therapist Therapist Adolescent -Frame “this is important….” -Acknowledge “this is what is important to you…?” -Reframe Therapist Mother

22. Engagement/Motivation Creating a Family focus... …developing a relational thread Presenting 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 Redefined “problem” 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. • Focus the discussion on what they think is Important • Focus your attention on the process…. • Is there a family focus? • Is negativity and blame lower? • Do you know the sequence? • Match your language to relational functions • Focus on “them”

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

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

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

28. Behavior Change Phase Assessment Intervention Early Middle Late

29. Behavior change sessions • 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) • Goals • Specify the behavior change targets as family prosocial skills: • 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 • Interventions • reframing • Modeling • Teaching • Overcome barriers/adapt

30. Session Goals • Frame and link the family to a specific behavioral competency to help family know what to do • 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 • Engage the family in the behavior change phase activities

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

32. Implementing BC Phase 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 New Problem Situation BC Phase Functional Family Therapy 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 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

33. 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 • Challenge that promotes motivation • Building family competencies…so that the risk patterns central to family change…. • Communication • Problem solving/negotiation • Conflict management • Parenting (monitoring supervising)

34. Promoting new Behavioral competencies • Not a “curriculum approach” • 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 • Implemented within session in ways that match: • Relational functions • Situation • Theme • Individualized change plan

35. Behavior Change… Interventions technologies/targets • 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 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 • 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

38. Targets of FFT Behavior Change: How they go about working together Discussion focused on: -homework, going out with peers, curfew -specific spot in the sequence Parenting -monitoring and supervising Communication -direct and concrete communication With components of…. to individualize to the family Parent Adolescent Conflict Management Where they use: Work out problems…our focus is on their process of doing so 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 • Finding ways to use other things to fit behavior change goals • Staying with it…while responding interpersonally • Monitoring of motivation through out implementation • 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 • Opportunity…through an in session incident • How… • Coaching, directing, teaching, aids • As “homework”…Specific task that is accomplishable..one issue • Clearly presented/understood • High expectation of success….define success as doing it • How… • 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 • Case planning • Progress Notes • Session Planning Guides • Client Feedback (SIS) • Impact you are having • Level of negativity & blame • Level of family focus • Engagement • Motivation • Knowing what to do • Know how to do it

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

44. What Next? Where is behavior change leading?

45. 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 Sessions • Goals • Generalize the BC target skills to other areas • Maintain change through relapse prevention • Access external resources to support change • Interventions • Relapse prevention (if the family is falling back into problem behaviors) • Linking new problem situation to BC skill • Linking family to relevant outside resources

46. Ecosystemic System Peer/school/community/extended family Ecosystemic System Peer/school/community/extended family The Multisystemic Focus of Functional Family Therapy Clinical Symptoms/Behaviors Family Relational System (Sexton, 2010)

47. Generalization Phase…shifting focus • Within the family: • Relapse prevention • Generalization of competencies • Maintenance of alliance • Outside the family: • family--environment interaction(interface)…where the family interacts with the community/environment • Relationships between family (individual and whole) and the community • Use of behavioral competencies in these relationships • In order to use relevant available resources to support changes

48. 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

49. Generalizing Change Behavior Change Built a “competency” to reduce a risk pattern -communication/problem solving/ etc. New area Homework Move competency to a new “content” area Primary Target Going out With friends New area Relationship With sibling Move competency to a new “content” area Area/content focused on: -homework, going out with peers, etc. New area Time with boyfriend

50. Supporting Change Discussion focused on: How to maintain, support, and generalize new climate, alliance, behavior changes Extended Family -monitoring and supervising Community/School -direct and concrete communication Parent Adolescent Area to support changes, add to changes, and places to generalize and extend change Medical Evaluation Psyc Intervention