Functional Family Therapy
International Training Program
Clinical Training 1
Thomas L. Sexton, Ph.D., ABPP
Astrid van Dam
Functional Family Therapy Associates
FFT is unique in the EBP World
and evidence based treatment that is:
• Purposefully Creativity
• Flexibly Structured
• Model focused and Client Centered
•
Change that is guided by the model….driven by the
Family…with respect for how the family “functions”
• “inside out” approach
• Requiring a creative therapist
• Aided by….
Desired Outcomes
Youth
Family
-prosocial behavior
(school, work, home, peers)
-sense of “working together”
-works collaboratively with family
-”views” problem as solvable challenge
in solving the “normal”
-faces problems with “protective/
problems of life
functional behaviors (communication, Assessment
problem solving, parenting, conflict resolution)
-handles problems with
“new skills” fairly consistently
-uses community resources/
professional services if needed
Early
Middle
Late
Outcomes
-Parents
Empowerment-Developmentally appropriate, consistent
Our goals is to NOT just change youth.Intervention
Parenting, communication, problem solving.
But empower family to manage
conflict management
themselves in the future
Components of the FFT Model
1. Guiding Theoretical Principles
•
•
Conceptual, philosophical, and emotional center of the
model
Parameters within which FFT occurs
2. A Clinical “Map”
•
•
•
Systematic process of therapeutic change
Specific goals, objectives, and therapist activities
Mechanisms of change
3. Measurement, Feedback, & systematic &
individualized treatment planning
–
–
Systematic Training
CFS: Measurement Feedback
Clinical Feedback & Client Vice
Discharge
Assessment
Baseline
Assessment
•
•
•
Family Functioning (COM)
Youth Symptoms (SFSS-Full)
•
Process Assessment
Client Feedback (from each family member)
• Impact
• Progress
• Symptoms
Family Functioning (COM)
Youth Symptoms (SFSS-Full)
Evidence Based Clinical Decision Making
-Used by the therapist
Process
Progress Notes
to understand the case
better/plan
-Used by the Consultant
to help the therapist
learn
• What happened
• After each session
Next Session Plan
• Specific session goals
• Specific areas of needed
attention
• Before each session
Match the model
specifically to the
family/situation/needs
of the time
Functional Family Therapy
Clinical Model
Example
• And example of FFT…..(Neils)
Basic Unit of Analysis
What is the
“root cause”
Child
Father/
Figure
Child
Mother/Figure
Family
• Physical (genetics/brain
function)
• History
(trauma/background)
• Learning History
• Etc.
Topic of
conversation
Problem Behavior
Adolescent
Goal of therapy
•Engage & motivate them
to change
•Equip them with skills to solve
the next “problem”
•Maintain change over time
Dad/father figure
Mom/mother figure
Relational Process…how
do they work? What gets
in the way?
Intervention point
Risk &
protective
factors
What each
member
brings to
the table
Ecosystemic System
Peer/school/community/extended family
Risk &
protective
factors
Clinical Symptoms/Behaviors
Internal World
Biological Substrate/Learning
History/individual traits
Family Relational System
Risk &
protective
factors
(Sexton, 2010)
-patterns
-problem definitions
-history
Ecosystemic System
Peer/school/community/extended family
Risk &
protective
factors
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
Factor Community Risk
Factor
School
Adolescent
Dad/father figure
Mom/mother figure
High Risk
Individual
-temperament
High Risk
School/School/
Educational
Educational
-low ability
-inability to attend-ability
-lack of self-control
-attention/
-Prosocial school history
self-control
Low Risk
School/ Low Risk Individual
Individual -biology
Educational
-healthy biologytemperament
-ability & attention
-social history
-self-control -no significant -capacity
“mental health”
-positive “social”
factors
history
-significant
“mental health”
factors
-biological
predispositions
Low Risk
Family Low Risk
-balanced & productive
Social/Peer
interaction patterns
of behavioral
prosocial peer influence
Family-rangecompetencies
-range/depth ofSocial/Peer
High Risk
-interaction patterns
-alliance based
-peer influence High Risk
Family
-behavioral competencies
emotional climate social skills
-social skills
-negatively escalating
-emotional climate
Social/Peer
& cohesive interaction patterns
-limited behavioral
competencies
-negative emotional climate
-negative peer influence
-poor/poorly developed
social skills
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
3. Meaning they make of those patterns
•
Problem definitions & functions
4. Function of the pattern/meaning
•
Relational outcome that “glues” the relationship
together
5. Risk and protective factors (context)
Functional view of Clinical Problems
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
–
–
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”
The problem is they are “Stuck”
• Families have the capacity to solve problems
• Families can overcome history and the current
context
• It is the relational process …”the space
between them” that gets in the way....and
ultimately gets them stuck
• Stuck in:
•
•
•
•
What they bring
Meaning they make
Behavior patterns
Strategies for working things out
The role of history:
What people bring to relational systems
•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
Adolescent
Dad/father figure
Mom/mother figure
Relational Patterns
the behavioral component
• commonDad
ways of working in families
that involve
Mom
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
Mom
Son
Mom: “Have you done…..are you .”
Lilly: “Whatever….later, I am going
out…., I’all be home…..”
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: “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….
Mom: “I just
worry about
you” (she
feels
Lilly: “I am sorry Mom…but, I can
comforted
handle it”
that he
understands)
Mom: “What are we going to do..I
can’t take this any more…”
Lilly: “At least I have friends…later…”
she goes out.
Mom: (to her stepfather)…”I can’t
do anything with her…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 Lilly…..”
Mom: is hurt by his comment…goes
to her room…watches TV…worries
and “feels” bad about her
situation……
Lilly: (comes home 5 hours
late. Comes in the house and
goes upstairs…on the stairs his
mother comes out of her
room…
Stepfather: …When she talks, he
continues to watch to TV…..he listens
quietly and say…”what do you want
me to do…she 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?”
Lilly: “Fuck off..” the typical argument
ensues until Lilly goes to his room
Problem “definition
Problem
Definitions
-what/who the problem is
Problem “definition
-what/who the problem is
the meaning component
Emotional Reactions
Emotional Reactions
(negativity)
-why its an important problem
(negativity)
-why its an important problem
Problem Behavior
Behaviors
-what should be done about it
Behaviors
-what should be done about it
Adolescent
Problem “definition
Dad/father
figure
-what/who the problem is
Mom/mother figure Emotional Reactions
(negativity)
-why its an important problem
Behaviors
-what should be done about it
Problem “definition
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
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
(negativity)
Emotional Reactions
-anger
-hurt
-fear of loss of mom
-Anger
-Hurt
-Fear of loss of control
Behaviors
-her role in the problem sequence
Behaviors
-Her role in the problem sequence
Adolescent
Dad/father figure
Mom/mother figure
The “function” of patterns/meaning
Clinical Symptoms
Adolescent
Dad/father figure
Mom/mother figure
Relational Functions
•Way they are attached
•Relational “glue”
•Style with which they approach that
relationship
Relational “Functions”
“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
When X relates to Y, the relational pattern (behavioral sequences in the relationship )
of X’s behavior is characterized by:
high
Relational
Independence/
Psychological
Autonomy
1
2
1
2
3 Midpointing
4
3 Midpointing
4
5
5
low
low
Psychological Interdependency
high
high
Psychological
independence
Being cold,
sarcastic,
rejecting
Substance Abuse
Having many jobs and
outside activities
Being hysterical
Visible self mutilation
Teenage runaway
“ideal” balanced adult
Withdrawing
passively
Being depressed
Focused/successful
professional
“Positive”
low
Behaviors
Group
Vacations
“Negative”
Behaviors
low
Teenage runaway
Giving considerable
Nurturance, warm & loving
Having childhood phobias,
Being insecure
Psychological Interdependence
high
Relatedness Assessment
3
Mom
Peers
Dad
3
4
Biological
Father
2
?
Adol
3
1
1
3
Relational Hierarchy
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
P
A
One-up
Degree to which on person
Determines the relationship
A
Symmetrical
Symmetrical:
Exchange = Behaviors
A
P
One-up
Degree to which on person
determines the relationship
Use of Relational Functions
• Matching to the family in
– Reframing
Goal..understand and use to match and individualize reframing,
– Organizing themes
themes, behavior change implementation, generalization
– Behavior changestrategies
implementation
– How to generalize, maintain, & support
changes
What can you change….
• Patterns are changeable through skill
building
• Meaning is changed through reframing and
therapeutic themes
• Functions are stable … so you have to
match to them
• Match reframing/theme
• Skills
• Generalization strategies
The Clinical “Map”
Clinical Model
Engagement
Behavior Change
Generalization
Assessment
Intervention
Motivation
Behavior Change
Early
Middle
Generalization
Late
Relationally-based/Alliance Based
Alliance
Relational “bond” Agreed upon
Alliance
-relational “liking”
means….tasks
•Commonly seen as empathy,
-support
•liking, and--agreed
supportupon roles
-connection
•In therapy it is-common
more…. process
-creditability
•It is complex
•It has multiple domains
•all ofCommon
which are important
Goals
--going in the same
direction
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
•Be supportive
Example
• Example #1 (Briana & GM)
What does the client “story mean”
•Where people come from (relational context)
•What people are made of….(biological context)
•Risk and protective factors of current context (ecological con
Family Story
“the weeds”
“what does it mean”
Multiple problem definitions
A relational process Illustrates how they work to
solve problems
Adolescent
Comes from:
Accomplished
Accomplished
Each individuals
unique
Through
relentless
relational
Through
relentless relational
History/experience
Reframing
Reframing
-attribution aspect
with problem,
-emotional valence
natural attempts to understand/
-related behavioral patterns
Each feels Goal:
make sense, solve“misunderstood”,
the problem
Redefine each toward
Father
blames the
other,
a “common
family
Initial Presenting
Thinks the otherfocused”
is Family
the problem,
definition
Focused
Problem
Definition
Initial Presenting
works toward
a definition
That
is
Problem
-attributional aspect
Problem
Definition
-emotional
valence
different solution
-different from
Initial Presenting
Problem Definition
-related behavioral
patterns
-attributional
aspect
-emotional valence
compromising
-related behavioral Not
patterns
each individual definition
-common to all
-Where all have responsibility
-No one has blame
The Outcome:
mediating
Initial Presentingor negotiating
Motivation, negativity reduction,
Problem Definition
Family to family alliance,
-attributional aspect
-emotional valence
Therapist to family alliance
-related behavioral patterns
Mother
Intervene by:
Relational Story
Reframing
Family
Structuring
& Supporting
(listen
& acknowledge)
Focus on how they work
Develop:
TreatmentTheme
Goals
Relational
Family Focus
to the
• Dads
partproblem
Everyone is part of the solution
Each member •hasMoms
uniquepart
contributions…
Their
• “challenges”
Youth part
Reframing
• Relational process that changes meaning
of others intentions, the problem, their
goals
1. Directed to a specific behavior (from problem
definition & relational sequence)
2. Acknowledge the importance of the event (link
their struggle with something important to them)
3. Reframing by suggesting an alternative
meaning and/or noble intention
Relational
Process of Reframing
Identify & Acknowledge
Reframe
Impact
Change/continue
Making it fit the client
Some examples
•
•
•
•
Hurt behind the anger
Anger is hurt
Control is protection
Etc.
How would you say it…..(identify, acknowledge &
reframe)
“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”
•
Reframing “themes”
•
•
•
•
•
•
•
Hurt…behind the anger
Anger...as protection
Lecturing… as teaching
Nagging....as importantce
Disobeying...as independence
Demanding....as strong willed
Emotional anger....passionate caring
Example
• Example: Reframing (Irish Family)
Developing “Relational” Themes
Family
Therapist
• When clients negatively/blaming reframe
• Over time…reframes become themes
When the themes about each person link together to
provide an alternative explanation of the “problem” it is an
relational theme
Relational 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”)
Relational Theme(s)
Them…..“given all that has gone with you two….both
have
Lilly
come
a point where
afraid losing
each other….That
is hard
Problem
“definition
•MOM
Explaining
theyour
problem
in relational
Terms
everything I could
Problem
“definition
to see given
the behavior…..but behind thatIishave
thisdone
fear…..
– Involves every one
– Identifies the struggle in descriptive way
– Identifies the noble intention
down…..struggling with the
trying
to
protect
your
(negativity)
– Identifies the challengechanges…and
of each having a hard
I can’t take it because
I have done nothing wrong…
-she is unwilling to work with me
what I did was a mistake and wont’ happen again
-she might have MH problems
-the problem is you won’t leave me alone
Lilly…..Dealing
with life being
-you took
everything from you
me and
to try (depression)
Mom….when
arethere is no reason
-her defiance is the problem
turned upside
controlling…..really
-the solution is to “control”
Emotional Reactions
-anger daughter….(maybe
-hurt not protect
-fear of loss of mom
way…maybe other
ways to protect….but
Behaviors
-her role in the problem sequence
that is the
motivation…
Emotional Reactions
time finding
her way in
Anger
that…. Hurt
Defiance….is
ward
Fear of losskind
of control
and strange way of
dealing
but…..it does
Behaviors
Her role
in the problem
protect
her….and
it doessequence
help hold in some what to
her mom…(and she of
course do that
Example
• Reframing Example
• (Philly Family)
What makes reframing & relational themes
work
1.
“feel” the reframe/theme
•
2.
Therapist able to “be the client” and know what is
important…the noble intention behind the behavior
“believe” the reframe/theme
•
It “is” how you understand them
3. “linked” to everyone else
4. Presented in a way that is…
•
•
•
With acknowledgement
Respectful
Specific
Behavior Change Phase
Behavior change sessions
Assessment
Goals
•Specify the behavior
•Identifying prosocial
family based skill that fits
youth/family problem
sequence
change “individualized
plan”
•Find barriers to adoption of
•Link BC targets to the
•Determine if the target is
organizing theme to
build relevance and
motivation
being performed
(compliance)
•Build compliance
•match to the client
•check if the BC target
works to solve conflict
BC skill
Interventions
•reframing
•Modeling
•Teaching
•Overcome barriers/adapt
Targets of FFT Behavior Change
Parenting
Single, individualized
“behavior change
Communication
plan”
-
Events that come
up at home or
between them
monitoring and supervising
direct and concrete
Parent
communication
Adolescent
Where they use:
Work out
problems…focus
is on their process
of doing so
Combination of
Problem Solving
individual skills
Conflict
Management
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
Promoting new Behavioral competencies
• Set of principles (in each area) that serve as the
basis of individualized plan…. Not a “curriculum
approach”
• 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
Example
• Behavior Change Example (Briana)
Generalization Phase
Generalization Sessions
Assessment
Goals
•Generalize the BC
target skills to other
areas
•Identify external family
systems to apply BC skills
•Identify contextual
barriers to maintaining
the BC target
•Find areas to generalize
•Identify relapse points
•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
Generalization Phase…
In generalization two points of attention
•Within the family:
•Relapse prevention
•Generalization of competencies
•Maintenance of alliance
•Outside the family:
•Relationships between family (individual and whole) and
the community
Ecosystemic System
Peer/school/community/extended family
Clinical Symptoms/Behaviors
The Multisystemic Focus of Functional Family Therapy
Family Relational System
(Sexton, 2010)
Ecosystemic System
Peer/school/community/extended family
Ecosystemic System
Peer/school/community/extended family
Family changes
risk(joining
factors
John’s
family)
Court system
Identify
the external systems and
involvement
that are
important for maintaining & supporting
change
School
Struggles
(Sexton, 2010)
Peer Group
Pressure
Involvement
Ecosystemic System
Peer/school/community/extended family
• 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.
Clinical “Art”
•
Creativity within the structure
•
Therapists as translators
•
Family based change through
reliable change processes
Bringing Creativity to the Structure
• Client Centered
– Responsive to clients
– Responsive to client needs
– “fit” to a client
• Artfully applied
– Require clinical creativity and expertise
– In your style and in your way
Contingent nature of phases...
•
“Matching”
Matching means…
– Matching interventions to family presentations
•
•
Change meaning in ways consistent and respectful of all family members
Themes to generate hope
– Working within families’ existing structures
•
•
•
Relational function matching
Changing patterns but not relational functions during Behavior Change
Making sure family links to external resources maintain relational
functions
– done in a manner that fits the developmental,
cognitive, and physical abilities of all family members
FFT-CFS
1. Directory
•
•
•
Your list of clients…access to their information
Add clients, cases
Case feedback….
• Questions