Functional Family Therapy
International Training Program
Clinical Training 1
Thomas L. Sexton, Ph.D., ABPP
Astrid van Dam
Functional Family Therapy Associates
What you can expect from us
• Our role
• Consultants in learning FFT
• Clinical responsibility lies with you
• We will communicate anything important we
see/Please do the same
• Training Process
• Supervision Process
Evidence-Based Training & Implementation Model
•
•
•
•
Multiple learning styles/formats
Realistic
Cost effective
Comprehensive measurement system
•
•
process & progress
Evidence-based practice
•
•
•
•
Youth symptoms, family functioning,
Ongoing measurement of
Process, outcome, & practice
Family Voice
Ongoing evaluation (using CFS)
Benchmarks for:
– Adherence client outcomes,
– service delivery
– Progress & process
Training Principles
• Based on adult learning/educational psychological
principles of learning
• Short, relevant, repetitive, and clinically specific
• Goal….clinically relevant therapist competence
& model adherence
• Ability to use the model in ways that “fit” clients
and context
• High model Fidelity and Clinical relevance
Month 1-4
Month 5-9
Clinical Training (on day on site) Clinical Training (on day on site)
2 webinars
2 webinars
2 onsite training days
2 onsite training days
Discussion Forum use
Discussion Forum use
Active participation in FFT/CFS Active participation in FFT/CFS
Months 1-4
Months 5-9
Months 9-12
Month 9-12
Clinical Training (on day on site)
2 webinars
2 onsite training days
Discussion Forum use
Active participation in FFT/CFS
FFT in Practice
• FFT lasts 8-14/16 sessions
• Conjoint (whole family/major players)
• Delivered weekly (maybe more in E/M, less in
Gen)
• Sessions in each treatment phase occur in a
successful treatment episode
•
•
•
Engagement motivation
Behavior Change
Generalization
• Assessment as short as possible
• Simultaneous/other Treatments?
Principles of Good Practice
“Common Factors”
-therapeutic relationship
-hope/expectation
-ritual of practice
Common Factors
Functional Family Therapy
Unique Features
-Clinical Protocol
-relationally focused process
-specific change mechanisms
-for specific problems
Functional Family Therapy Measurement System
Baseline
Assessment
Discharge
Assessment
•
Family Functioning (COM)
•
Youth Symptoms (SFSS-Full)
•
Optional:
•
Youth Mental Health Risk (SDQ)
•
Family Functioning (SCORE 15)
Family Functioning (COM)
•
Youth Symptoms (SFSS-Full)
•
Optional:
•
Youth Mental Health Risk (SDQ)
•
Family Functioning (SCORE 15)
•
Baseline Assessment can be done
in the first FFT Session or in a
separate Assessment session along
with other agency paperwork
•
•
Discharge Assessment is done in
the last FFT session
Process Assessment
Client Feedback (from each family member) on treatment:
• Impact (are they meeting the FFT phase goals) (SIS EM, SIS BC, SIS Gen)
• Progress (do they experience positive change) (SIS EM, SIS BC, SIS Gen)
• Symptoms (youth symptom level) (Weekly Symptom Measure)
• SIS (EM, BC, Gen) are given every odd number treatment session
• Weekly Symptom Measure is given every even treatment session
• All are given at the END of the FFT Session
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
Specific
• 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
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….
The “LENS” of FFT
Risk
Risk&&
protective
protective
factors
factors
What each
member
brings to
the table
Ecosystemic System
Peer/school/community/extended family
Clinical Symptoms/Behaviors
Internal World
Biological Substrate/Learning
History/individual traits
Family Relational System
Risk &
protective
factors
(Sexton, 2010)
Risk &
protective
factors
-patterns
-problem definitions
-history
Ecosystemic System
Peer/school/community/extended family
Basic Unit of Analysis
FindingWhat
the “function”
of
is the
the“root
symptom
in the
cause”
relational
system
• Physical
(genetics/brain
Child
Father/
Figure
Child
Mother/Figure
Family
• Relational
patterns
function)
• Coalitions/alliance
• History within
patterns
(trauma/background)
• Relational
“information”
• Learning
History
and its movement
through
• Etc.
the system
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”
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
2. Meaning they make of those patterns
•
Problem definitions & functions
3. Function of the pattern/meaning
•
Relational outcome that “glues” the relationship
together
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)
•x
•The environment in which they live (ecosystemic context)
–Peers/schools/mental health system/community
Adolescent
Dad/father figure
Mom/mother figure
•Interactional Relationships
•Core family/dyad stable relational patterns
Relational sequences/problem sequences
Relational Patterns
• Relational Patterns are common ways of
working
everyone
Dadin families that involveMo
• Problem sequences….are aremcommon
across “content”
• Maintain and support the “problem
behavior”
• Point of intervention and change
• Describe
the “what they do” question
Mo
m
Son
Lilly: “I can handle it Mom…just keep that bastard away from
Mom: “Have you done…..are you .”
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
Lilly: “Whatever….later, I am going out….,
I’all be home…..”
Lilly: “I am sorry Mom…but, I can handle it”
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…”
worry about
you” (she feels
comforted 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 husband)…”I can’t do anything
Lilly: (comes home 5 hours late.
with her…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
Lilly…..”
Mom: 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 wans’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……
Lilly: “Fuck off..” the typical argument ensues
until Lilly goes to his room
Meaning comes from “problem definitions”
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)
•
Problem “definition
Problem “definition
-what/who the problem is
-what/who the problem is
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 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)
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
Match to…
Relational Functions
•Functional outcomes of these patterns
•Relational “glue”
•Stable and consistent
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
Goal..understand and use to match and individualize reframing,
themes, behavior change implementation, generalization
strategies
When X relates to Y, the relational pattern (behavioral sequences in the relationship )
of X’s behavior is characterized by:
high
1
Relational
Independence
2
3 Midpointing
Psychological
Autonomy
4
5
low
low
Psychological Interdependency
high
Relatedness Assessment
3
Mom
4
Biological
Father
Peers
Dad
3
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
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 strageties
Use of Relational Functions
• Matching to the family in
–
–
–
–
Reframing
Organizing themes
Behavior change implementation
How to generalize, maintain, & support
changes
The “MAP”
•
The Clinical Protocol
•
Goals, Directions
•
Pathway of change
•
Relational & process focus
Clinical Model
Reduce within family
risk factors
Early
-negativity/blame
-hopelessness
-build engagement/
reduce dropout
Early
Build within family
Assessment
protective factors
Build family to context
protective connections
Middle
Late
-behavior competencies
-peers
-interaction
change
Intervention
-school
-that increase probability of
-community
- behavior
Middle
Late
Clinical Model
Goals
•Increase behavioral competency of all/family
•Consistent performance of competency
in “real” problem situation
Engagement
Behavior Change
Generalization
Assessment
Intervention
Goals
•Alliance between family
Motivation
with therapist
•Family/relationally
based problem problem focus
•Reduced
family member
Early
negativity/blame
•Increased motivation
Behavior Change
Generalization
Goals
•Generalize new “view” and experience of problem with
new problem that arise
Middle
Late
•Maintain new skill - working together
with new problems
•Support changes by using relevant outside resources
Topic of
conversation
Goal of therapy
•Engage them
to change
•Equip them with skills to solve
the next “problem”
Problem Behavior
Adolescent
Dad/father figure
•Maintain change over time
Mom/mother figure
Intervention
point
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
What does the client “story mean”
•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
Family Story
“how do they work”
Goal: “why” things are so important, meaningful?
What is the pattern in the story?
What does it say about how they work?
Family Story
Relational Reframing
Structuring & Supporting
Focus on “them:
Relational Theme
Family Focus to the problem
Everyone is part of the solution
Each member has unique contributions…
Their “challenges”
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
Two direction ways to reduce negativity and blame
1. Change the meaning of the behavior of the
other
2. Build Responsibility in the
“speaker”/”blamer”
By…
– Reframing what a client says
– Reframing similar ideas according to the same
“theme”
– Creating an “organizing them” to describe their
struggle
Relational
Process of Reframing
Acknowledge
Reframe
Impact
Assess acceptability/fit
Change/continue
Making it fit the client
1. Meaning
-attribution
-event
-emotion
Themes:
Relational
Theme
Process
of
Reframing
A “new”
explanation
on…
1.Acknowledgment
Hurt
behindbased
theof:
anger
Acknowledge
-exhibited emotion
1. Changed Meaning
(reduces negativity/blame) (identify & acknowledge) 2. Protection
-participation, effort
Theme hint
2.(best
Find
the Noble Intent
guess/hypothesis)
Description,
statement, question
alternative
3.Suggesting
Link family
members
theme
together
members together
In struggle/problem
Listen…listen…
(builds
family focus/
Interdependence)
listen
Reframe
Impact
3. Anger is loss
2. Reduced
negativity/
Description
of:
4. -current
Speaking
out represen
blame
behavior/event
takingfor
place
possibilities
change
Independence
between people/
with one person
in the session
3. Linked
in
--reported together
event/behavior
….as
beginning
points
eitherand
between
family
Problem
future
or of one person
solution
“Build on”/continue
all having
some
Building theme that fits -asto
Identification
of:
-responsibility/ownership
understanding
of
-important values,
forPersons,
the problem
and
beliefs,
desiresetc.
situations,
solution
Some examples
•
•
•
•
Hurt behind the anger
Anger is hurt
Control is protection
Etc.
How would you say it…..(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
• 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 willed-ness
-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
Relational Reframing
• Acknowledge (“yes….)
• What they just said is important..frames the
situation/problem/event that is the “target”
• What you “guess” to be important to them
• Reframe (“and….)…what you “add to” the session
• Alternative meaning for what was acknowledged
• what might be “behind” or “the reason”
Lilly
MOM
-gets worried
-asks (indirectly)
-responds
defiantly
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
-Escalates
defiant
response
-exhibits
When it is a serious ev
additional
MOM
-escalates
control
When it is a serious ev
When it is a serious even
MOM
-gives a consequence
(sever and non
specific….takes
away
Lilly
-Escalates
defiant
response-
“In the room” in Engagement/Motivation
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
organizing theme
Components of an Organizational/family Theme
• Frame…
•
•
•
“you are…”
“this is a family….”
Specific behavior/pattern… Problem sequence
• Reframe
–
Explanation…gives different meaning of “how they work” and
“what is going on between them”
•
•
reframes “put together”
New story about what is going on in the family (describes different
reason for problem sequence)
–
–
•
each person….the family…how linked together
“your part….what it means….how it linked with othe family members
Complete, includes what is most important to family, personal,
specific in way that is individual
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
Outcome
•
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”)
7. Set treatment goals
What makes reframing work
1.
“feel” the reframe
•
2.
Therapist able to “be the client” and know what is
important…the noble intention behind the behavior
“believe” the reframe
•
It “is” how you understand them
3. “linked” to everyone else
4. Presented in a way that is…
•
•
With acknowledgement
Respectful
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
“In the room” in Behavior Change
Family
•
•
•
•
•
•
Therapist
When clients bring in a problem….have them use the specific
behavior change competency in the room
Apply it in an individualized way to the family…fit it in the problems
sequence
Match relational functions
Goal is that the family use the competency NOT that problems are
solved
Make new behavioral competency linked to the organizing
theme….gives a reason to do it
Over time family increasingly uses the new skill
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
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
• Building family competencies…so that the risk
patterns central to family change….
•
•
•
•
•
\
Communication
Problem solving/negotiation
Conflict management
Parenting (monitoring supervising)
Promoting new Behavioral competencies
• Not a “curriculum approach”
• Set of principles (in each area) that serve as the
basis of individualized plan
• 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
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”…a way to “prevent” in the future
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
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
• 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 /med
Psych Intervention
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
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