Functional Family Therapy
Clinical Training Program
Case Conceptualization & Case Planning
Webinar #3
Thomas L. Sexton, Ph.D., ABPP
Functional Family Therapy Associates Inc.
Training Goals
1. Discuss the role of case conceptualization as a
foundation for FFT treatment
2. Identify the critical elements of case planning
• Planning for the case
• Planning for the phase
• Planning for the session
3. Review the role of the Progress Notes & Case
Planning guides in case conceptualization and
planning
What does it take? A therapist that……
• Looks through a “lens”
• Follows a Model……follow the “map”
• Creates and implements a “unique case plan” for each
family
• Use “in the room” experiences to promote change
(change mechanisms)
• Creatively Adapt.....
• Matching to the client
• adapting next response to”
•
•
match client/context
add what was not understood/missed
• Iterative Process….evolves over time
Doing FFT
Thinking FFT
what you do in the room
What you do outside the room
• Case conceptualization
•
Put client story into core principles
• Thinking through the lens
-reframing problems/blame/negativity
-interrupting negative behavioral patterns
-promoting the use of new
behavioral competencies
-generalizing change
Planning
What you do outside the room
1. Case planning
2. Session planning
• Goal (which one is most important)
• Progress (progress in achieving the goal)
Keys to success in FFT
• Model specific Case conceptualization
• Model & client driven planning
• In a way that….
•
•
•
•
•
•
Matches the family process
Matches the families way of functioning
That is relevant and important to them
That helps reduce risk factors
Reduces the likelihood of future behavior problems
Empowers the family to keep changes going
Functional Family Therapy
Case Conceptualization
What lets you make model specific and client center actions that
help
Case Conceptualization
• Understanding the Family through the FFT
“lens”
– Presenting Problem
– How the family functions
• Problem definitions
• Relational patterns
• Relational functions
– The multisystemic context….
• Of the problem
• Of the family
– Risk and protective factors
Example
• Regina (14 years old)
• Referred to mental health center from juvenile court
• History of difficulties
•
•
Early school problems
Hospitalization
• Most recently….
–
–
Drug use (mj)
Drug rehab residential treatment
• Other problems in the family
Initial Questions
• Is this an FFT case?
• How and what “lens” to use in understanding
Regina
• Where to start (in FFT)
• How will therapy proceed?
• What is a possible outcome?
(much of this you know….without any more
information!) by listening with FFT “ear”
Listening with an FFT ‘ear’
Client Story
(Events)
Translating into
Problem Definitions
relational
pattern
(details
of the case….history….purpose for the referral)
Relational
Patterns
(to translate into Family Focused
organizing theme-identify
What is “important” to
the individual
(holistic understanding
/where to intervene)
Context
(multisystemic contextWho is involved)
Relational Function
(to match to client)
Risk & Protective Factors
(what to add to BC)
What to ask yourself ….
•
“What does this tell me about what is important to this person?”
– The answer to this question helps the therapist know what to acknowledge
in reframing.
•
“What does this tell me about their relational patterns and how they link
the family members together?”
–
•
This assessment helps the therapist develop a family-focused way of
understanding how the presenting problem functions.
“What does this tell me about the biological, historical, and relational
things that family members bring to any interaction that will help me
understand why they are reacting this way?”
– This assessment helps the therapist determine where the energy and
emotion might come from and also helps identify what to acknowledge in
the reframing process.
•
“To what cause are they attributing the problem? What is the problem
definition?”
–
This assessment helps the therapist identify the target for blame and form a
target for reframing.
Ecosystemic System
Peer/school/community/extended family
Clinical Symptoms/Behaviors
Internal World
Biological Substrate/Learning
History/individual traits
Family Relational System
Ecosystemic System
(Sexton & Alexander, 2004)
Peer/school/community/extended family
How does the family Function/what role does the problem play
Environmental Context
Ecosystemic system
Risk
Factor
Risk
Factor
Protective
Culture Factor
Risk
Protective
Factor
Peer
Group
Factor
Protective
Factor
Protective
Community Risk
Factor
Factor
School
Adolescent
Dad/father figure
Mom/mother figure
Why are things so important?
•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
Client Story
The “why” things are so important, meaningful, etc.
Anja: “ Regina have you done…””you know you are
Regina: “I can handle it Mom…just keep that bastard away
getting behind”….”you need to take some responsibility”
(escalating the longer she doesn’t answer)
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
Regina: “Whatever….later, I am going out….,
I’ll be home…..”
Regina: “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…”
worry about
you” (she feels
comforted that
he understands)
Anja: “What are we going to do..I can’t take
this any more…”
Relational Patterns
Common/typical “way” they interact
Regina: “At least I have friends…later…” he
goes out.
Anja: (to her husband)…”I can’t do anything
Regina: (comes home 5 hours late.
with him…and you don’t help. I would at least
like your support
Comes in the house and goes
upstairs…on the stairs his mother
comes out of her room…
Stepfather: …continues watching the football
game…worries about his wife…gets angry with
Peter…..”
Anja: is hurt by his comment…goes to her
Stepfather: …When she talks, he continues to
Stepfather: …”I am tired
watch to TV…..he listens quietly and say…”what
do you want me to do…he wasn’t raised right…”
of this…what is the matter
with you…don’t you know
how this hurts your
mother?”
room…watches TV…worries and “feels” bad
about her situation……
Peter: “Fuck off..” the typical argument ensues
until Peter goes to his room
What is the Problem?
“Problems” are embedded in the context
•
–
They are relationally based
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”
Story takes the form of problem
definitions
Problem
“definition
-what the problem is
-why its an important problem
-what should be done about it
Problem “definition
-what the problem is
-why its an important problem
-what should be done about it
Referral Behavior
Adolescent
Dad/father figure
Mom/mother figure
Problem “definition
-what the problem is
-why its an important problem
-what should be done about it
What does this tell you
Family “problems” are relational problems
In their attempt to solve/deal with the problems….
• 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:
– 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)
•
The goal….
Targets of Change
-underlying patterns
of FAMILY behavior
Clinical Symptoms
Adolescent
Reduce the future
Probability of
the “problem behavior”
Dad/father figure
Mom/mother figure
Match to…
Relational Functions
•Functional outcomes of these patterns
•Relational “glue”
•Stable and consistent
Relatedness Assessment
1
Mom
3
Dad
3
3
Adol
1
1
When X relates to Y, the relational pattern (behavioral sequences in the
relationship ) of X’s behavior is characterized by:
high
1
Relational
Independence
Autonomy:
2
3 Midpointing
distance,
Independence,
Disengagement
4
)
5
low
low
Interdependency: closeness, dependency,
enmeshment
high
Case conceptualization in the “real world”
• Given all you have to do…..thinking in this
complex way is very difficult
• In the “real world”…
•
•
What you do out of the room
Aided by the FFT progress notes
–
–
–
Walk you step by step through case conceptualization
Make sure you don’t get lost
Help you overcome your own values and biases
– Happens over time….Iterative
–
–
Not as a stage….but as treatment is going on
Building a “picture of the family” in which you add more
and more
Functional Family Therapy
Case Planning
What to do in the next session, session, phase etc.
Treatment Planning
• Understanding the Change process…the map
of change
– Phases (what is first, second, third….)
– Mechanisms to use in achieving the phase goals
– Family focused/driven outcomes that are
obtainable and relevant
• planning is the way to bring the content and
the process of therapy together
Treatment Plan
Engagement
Reduce within family
risk factors
Early
-negativity/blame
Behavior Change
Generalization
Build within family
Assessment
protective factors
Middle
-behavior
competencies
-hopelessness
-build engagement/
reduce dropout
Build family to context
protective /reduce risk
Late
factors
-interaction
change
Intervention
-peers/school/
-that increase probability of
community
- behavior
Motivation
Behavior Change
Early
Middle
Generalization
Late
Case Planning
• Systematic process that includes
– Next session planning
• Goals of the phase
• “What needs to be done next?”
– Long term goals…..
• Obtainable change
• What matches the family
• The smallest change that will make a differences
Goal
Goal
Goal
Session Plan
-phase/intermediate
-phase/intermediate
-phase/intermediateobjectives
objectives
objectives
Skills
Skills
Skills
-therapist
-therapist
-therapistactions
actions
actionsthat
that
thathave
have
havehigh
high
highprobability
probability
probability
of
reaching
those
goals
of
ofreaching
reachingthose
thosegoals
goals
Engagement
Behavior Change
Generalization
Assessment
Intervention
Motivation
Behavior Change
Early
Middle
Generalization
Late
What therapy changes
1. Most critical issue
solved…and
2. Prepared for the
next “problem”
Individual
Adolescent
Dad/father figure
Mom/mother figure
-cope/deal with in a new way
-empowered with a “way”
To solve future
Long Term Outcome Goals
•
The behavioral outcome goals of therapy are those
that are obtainable and lasting
•
•
•
not healthy families but……..
obtainable behavioral changes
...are those that are:
– obtainable behavioral changes …
– for these people …
– with these resources …
– and these value systems …
– in this context
Case Plan
•
Based on:
•
•
•
the model
matching to the client
Case conceptualization--understanding clients
relationally--understand problems relationally
•
FFT’s Systematic Change Model
•
–
–
–
A model focused yet client/clinically responsive process….
Systematic and flexible…
The therapist “anchor” and “lens”….
The source of therapist creativity
Example
• Regina
– Early goals:
• Alliance-common problem definition, goals & bond
• Shared family focused problem definition
• Reduction in blame/negativity
– Intermediate goals:
• Problem solving
• Conflict management
– Long Term goals
• Family can manage supervision, work out problems
Engagement/Motivation Sessions
Assessment
Goals
•reduce within family blame
•reduce within family
negativity
•build therapeutic alliance
•redefine problem as family
focused
•increase hope/expectation
for change
•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
Behavior change sessions
Assessment
Goals
•Specify the behavior
change “individualized
plan”
•Link BC targets to the
•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)
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
Discussion
focused on:
-homework, going out
with peers, curfew
-specific spot in the
sequence
Targets of FFT Behavior Change
Parenting
-monitoring and supervising
With components of….
to individualize to the family
Parent
Communication
-direct and concrete
communication
Adolescent
Where they use:
Work out
problems…our
focus is on their
process of doing so
Problem Solving
Conflict
Management
Generalization Sessions
Goals
•Generalize the BC
target skills to other areas
•Maintain change
through relapse
prevention
•Access external
resources to support
change
Assessment
•Identify external family
systems to apply BC skills
•Identify contextual
barriers to maintaining the
BC target
•Find areas to generalize
•Identify relapse points
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
Using the FFT Progress Notes
Using the FFT PN
Process/Phase Goals Importance over time
4
3.5
3
2.5
session 1
session 2
session 3
session 4
2
1.5
1
0.5
0
Blame
reduction
Negativity
reduction
Alliance
Family Focus
problem
Using the FFT Session Planning Guides
Using the FFT Session Planning Guides
Using the FFT Session Planning Guides
Keys to success in FFT
• Model specific Case conceptualization
• Model driven planning
• In a way that….
•
•
•
•
•
•
Matches the family process
Matches the families way of functioning
That is relevant and important to them
That helps reduce risk factors
Reduces the likelihood of future behavior problems
Empowers the family to keep changes going
What does it take? A therapist that……
• Looks through a “lens”
• Follows a Model……follow the “map”
• Creates and implements a “unique case plan” for each
family
• Use “in the room” experiences to promote change
(change mechanisms)
• Creatively Adapt.....
• Matching to the client
• adapting next response to”
•
•
match client/context
add what was not understood/missed
• Access change....did it work?
• Questions?
• Next Steps