Moving toward the end:
Behavior Change and Generalization
Clinical Training 3
Thomas L. Sexton, Ph. D., ABPP
Functional Family Therapy Associates
Goals
1.
2.
3.
4.
Matching…..
Generalization phase
CFS in Clinical Decision making
and…..
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?
What does successful FFT require
Delivers FFT with Adherence & competency
35.0%
•38%* reduction in
30.0%
felony crime
25.0%
•50%* reduction in
20.0%
violent crime
15.0%
•$10.67 return for
each $1 invested
10.0%
•$2100 per
5.0%
family cost to implement
0.0%
6 month
Adherent
12 months
Non-Adherent
18 months
Control
•Process Focus
•what phase am I in?
•what are the goals of the phase?
•what do I need to assess?
•how do I need to intervene
•to accomplish the goal
•how do I “match to…..”
•what do I need to know about…...
Therapist Reality
“process issues”
Change Process Expert
Family Reality
“alliance/outcome issues”
Life Expert
An example: Lilly
•
14 years old
•
Referred by juvenile justice system
•
Pulled a knife on her mother
•
Marijuana
•
Expelled from school
•
Runaway
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
(joining John’s
fmaily)
Court system
involvement
School
Struggles
(Sexton, 2010)
Peer Group
Pressure Invovement
Ecosystemic System
Peer/school/community/extended family
Youth Defiance
Ecosystemic
System
Drug Problems family
Peer/school/community/extended
Depression
Violent Behavior
Clinical Symptoms/Behaviors
Family Relational Pattern
(Sexton, 2010)
Ecosystemic System
Peer/school/community/extended family
MOM
Lilly
-responds defiantly
-gets worried
-asks (indirectly)
MOM
Lilly
-responds defiantly
MOM
-jokes, makes fun
-tries to get her to
“do it for me”
-hear it as “she doesn’t
care”
-gets scared
Lilly
Obviously irritated
-blows off Mom
MOM
-gets angry
-lectures
-withdraws
Lilly
-responds defiantly
Lilly
-Esclates defiant
response
-exhibits additional
When it is a serious even
MOM
-esclates control
When it is a serious even
When it is a serious even
MOM
-gives a consequence
(sever and non
specific….takes away
Lilly
-Esclates defiant
response-
Problem “definition
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”
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
Emotional Reactions
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
Relatedness Assessment
3
Mom
4
Biological
Father
Peers
Dad
3
2
?
Adol
3
1
1
3
Reframing
•
•
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)
•
Reframe
Lilly’ defiance is….
Strong willedness
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
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
MOM
Organizing/Relational
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
• everything from me and there is no reason to try
-you took
Lilly
Theme
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”
Explaining the problem in relational Terms
•
•
•
•
Involves
one
Emotionalevery
Reactions
(negativity)
Identifies
the
struggle
in
descriptive
way
-anger
-hurt
Emotional Reactions
Identifies
the noble intention
-fear of loss of mom
Anger
Identifies the challenge of each
Hurt
Behaviors
-her role in the problem sequence
•
•
Fear of loss of control
Them…..“given all that has gone with youBehaviors
Her role
in the
problem sequence
gwo….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 wird and strange way of dealing
but…..it does protect her….and it does help hold in
some whay to her mom…(and she of course do that
different…and, not smart way…) but, is fear of loving
you…..
Discussion
focused on:
-drug use
-defiance
Targets of FFT Behavior Change
Parenting
-monitoring and supervising
Communication
-direct and concrete
Parent
communication
Adolescent
Conflict
Management
Where they use:
Work out
problems…our
focus is on their
process of doing so
Problem Solving
Behavior Change Targets
1.
2.
3.
Is it Relevant?
•
What would feel to the family like success
•
What make a “difference”
Is it Obtainable?
•
Can they do it
•
Will it derail therapy because it is to hard now
Does it “fit” them
•
Relational functions
•
Organizing them
•
Lilly BC 1
•
Lilly BC 2
Generalization Phase
Generalization
Phase Based Treatment Goals:
Assessment
Late
Intervention
Generalization
Outcomes
•Increase behavioral competency of all/family
•Consistent performance of competency
in “real” problem situation
1.Generalize
2. Maintain
3. Support
Shifting Focus for the Therapist
•
focus of therapy moves from inside the family to the
“interface” between the family and those systems that
surround it.
•
It requires a shift in direction for the therapist in regard
to clinical assessment and intervention.
•
respond to the “events” in the family with a primary goal of helping
them become ultimately self-sufficient and empowered in their
interaction with the surrounding context.
•
Shift attention away from helping the family solve immediate
problems to a discussion about the role of peer, school, and
extended family and community interactions as they relate to the
family’s ability to continue reducing the probability of future
problems.
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
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.”
Logic of Generalization
•
small changes can have a multisystemic effect
•
These changes often don’t happen naturally
•
Specific strategies for generalizing new skills,
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.
•
Reduces:
• Revolving door of treatment
• Relapse
• Future positive changes
Avoiding the Revolving Door Syndrome
The generalization phase is intended to avoid the familiar
phenomenon of the “revolving door” syndrome
•
Each time a family receives services they learn to
depend on that organization or person as a “needed
resource.”
•
What they don’t rely on is their indigenous
environment of community, extended family, and
friends as a source of natural, reliable, and effective longterm interdependence.
Avoiding the Revolving Door Syndrome
•
When caught in the revolving door syndrome, the
family is inadvertently robbed of the opportunities to
learn to access appropriate support systems.
•
They don’t build new skills or adapt those gained in
earlier phases of therapy,
•
and they feel little sense of efficacy or confidence in
their ability to manage problems independently.
•
“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.
Generalizing Change
Behavior Change
Built a “competency” to
reduce a risk pattern
-communication/problem
solving/ etc.
Going out
Primary Target
With friends
Homework
New area
Move competency to a
new “content” area
Move competency to a
new “content” area
Area/content
focused on:
-homework, going out
with peers, etc.
Relationship
New area
With sibling
Time with
New area
boyfriend
Supporting Change
Discussion focused on:
How to maintain,
support, and generalize
new climate, alliance,
behavior changes
Parent
Adolescent
Extended Family
-monitoring and supervising
Community/School
-direct and concrete
communication
Area to support changes, add
to changes, and places to
generalize and extend change
Medical
Evaluation
Psyc Intervention
Support Change…resources in community
•
Families are multisystemic
•
•
•
Context will impact ability to support change in the long run
Examples:
•
Parenting class
•
Individual therapy
•
Rent assistance
•
Special school program to help with academic issues
Goal:
•
Have the FAMILY do it….you help direct them
•
Becoming self-sufficient in using relevant/necessary community resources to
help
•
Using behavior change competencies to deal with the world around them
Types of Social Support
•
Instrumental support (i.e., financial assistance, help with
transportation, and parenting assistance)
•
Emotional support (i.e., empathy, and caring)
•
Informational support (i.e., help finding the best prices
on food, need-based school assistance, or places to get
rent and utility assistance).
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
Relapse Prevention
Successful relapse prevention requires that the therapist take the initiative and direct
a discussion that helps to:
•
Identify high-risk situations.
•
The discussion should include an analysis of the cues, initiating
situations, family conflicts, and patterns of high-risk situations that
may undermine the family’s ability to continue with their
established changes.
Relapse Prevention
•
Learn alternate ways to respond.
•
The behavior change strageties they learned
•
These include identifying ways to:
•
cope with the negative emotions that arise around these
situations, both for individual family members and the family
as a whole;
•
determining ways to deal with interpersonal conflict by
applying conflict management principles; and
•
discovering strategies to cope with social pressure that may result
from both proximal and distal support systems.
Outcome of Generalization Phase
When successful the family:
•
attributes the change to their effort
•
is realistic about future struggles
•
has a plan for how to continue to apply what they
have learned to new situations
•
continue to maintain a within-family alliance and a
view of the family based on the organizing theme
developed early in therapy.
What is enough change?
•
•
When do you end?
•
What does the say?
•
What specifically to look at?
What gets in the way of ending?
•
What are your barriers?
What are you looking for in the families?
•
Keep it up
•
What they need is to find a way to continue the
changes they made in therapy despite new problems,
the return of old issues, or other risk factors that
may get in the way.
•
This most likely to occur if they know:
•
where to apply skills, what to bring to discussions
(family focus and alliance-based perspective), and
•
how to continue with the “organizing theme” and
direction built in the engagement/motivation and
behavior change phases.
What are you looking for in the families?
•
Handle more and different problems
•
From the family’s perspective, new problems have the
tendency to look different.
•
The more skills that the family needs to employ, the more
the chance of success goes down.
•
Instead of getting endless new lists of skills expand
their existing skills to new problems in a way that seems
manageable.
•
They will be most successful if they can apply the small
steps of behavior change to an increasingly wider range
of issues in daily life.
What are you looking for in the families?
•
Be consistent
•
There will be times and situations where despite their best
efforts, things will be a struggle.
•
They will be most successful in overcoming these situations
if the family focus and behavioral skills are attempted and
maintained, regardless of their total success, in situations
through time.
•
By this means, they would overcome the natural
discouragement of the ups and downs of change.
•
One of the most difficult parts of keeping things up are the
competing “pulls” clients feels from the world around them
What are you looking for in the families?
•
Adapt and adjust when things come up
•
It is not uncommon to see the specific change
strategies used in FFT evolve as the family uses them.
•
Families tend to come up with unique family-based,
alliance-based solutions that include social skills that
fit into the protective factors category.
What are you looking for in the families?
•
Address other bigger issues
• Families continue to face risk factors
• Address those proactively
•
•
•
•
Peers
School & other community issues
Legal requirements
Extended family challenges
What are you looking for in the families?
•
Be realistic
•
Holding the realistic belief that positive change is
possible and they do have the ability to succeed is
important.
•
The belief needs to be realistic, not one that sets
them up for failure by being too positive.
•
If the belief includes knowing that things will
happen again, that it won’t be fun, but, with effort,
there is an alternative, which creates the motivation
to initiate new behaviors and put effort into
persisting at them.