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James F Alexander, PhD

FFT Founder and Principle Investigator

Functional Family Therapy


An integrative model for working with at
risk adolescents and their families

Sweden Presentations May, 2007


FFT LLC
The FFT Perspective
Strengths, resources, abilities
•less apparent
•resources many times not currently in use
in the presenting “problem” situation)
•Abilities that have carried the client successfully
• through
difficult times/situations in the past
•“Protective Factors”

Clinically significant/Problematic
•most apparent
•weaknesses, challenges, deficits
•Past “history”
•Diagnosis
•“Risk Factors”
Successful FFT therapists see
whole person (the sum total)
•“noble intent” behind all “bad” behavior
•Respectful attitude
•Working with ”(“empower”)
•Rather than working on (“manage”)
So Where are Risk & Protective
Factors We Address in FFT?

1.In the adolescent/parents

2.In the family (This is our initial focus)

3.In the social/environmental context


…. And “in” the attitude we bring to
the way we view them (FFT lens)
How Do We Maintain the Appropriate Focus?
As a First Step We View Families and Clinical Problems
Through The FFT Lens

Personal History
Cultural context
Clinical Experience
Other & Agency Tradition Age
Intervention
models Expectations of
Referral agencies,
Gender
etc
Translated through the ..

FFT “Lens”
•See families in relational,
•strength based, non-judgmental ways

Clinical decisions
(what you choose to do at each moment)
Family “problems” are relational
The family’s experiences lead them to enter
therapy with a “definition” of what is the
problem

• This definition is usually:


– focused on “a person” (attribution
component)
– has negativity attached (emotional
component)
– is accompanied by blaming interactions
that have become central to the relational
patterns of the family (behavioral
component)
So …..
What characterizes many (if not most) of
the youth & families we want to help In FFT?

Narcissistic, Depressed, Un (anti)-


Comorbid, Hopeless, motivated,
Hx of Betrayal, criminal / drug
Abuse involvement

Limited Resentful, History of


Resources disrespectful, Failure, High
Angry probability of
re-occurrence
“In your heart” how do you find yourself reacting to each family member?
Who are they?
“Victims” “Hurt,” “Organic” “Bad / Evil
“Emotionally E.g. Fetal People”
Damaged” Alcohol “Unfixable”
People
Primary
Focus: Pain Pain & mis- “Damage” Their
Engage & perception Æ dis- “Logic”
Motivate perception
around .....

Behavior Teach / Structure / Sanctions /


Change Goals “Rescue” Provide Reduce Remove
Corrective Behavioral Behavioral
Experience & Options Options
Beh’l Options

We are not “rescuers” or “controllers” – We Empower


If rescue or control is necessary
Not An FFTresources
we refer to more appropriate Focus
THE FFT CLINICAL MODEL:
Phases of FFT
Engagement Behavior Change Generalization
Goal Goal Goal
Relational s
Assessment Behavioral sAssessment s Assessment
Multisystems
E & M Relationally based Behavior Change Ecosystemic
Interventions Interventions Case Management
Skills Skills Skills

Motivation Behavior Change Generalization

Early Middle Late


Phase Task Analysis (PTA: Sexton, 1997)
The Phase Based FFT Model:
Effective intervention involves….
following this Systematic Change Model
• The process of therapy is one in which you
understand phasic change and relentlessly
pursue phase goals while working flexibly
within the structured FFT phases…

• responding contingently and respectfully to


what you are presented with…in a way
consistent with principles of understanding
and matching families on their terms,

• understanding therapeutic intervention from


a family system perspective
Reducing / eliminating the problem behavior(s)
and modifying the family relationships that support it
In Terms of the Phasic FFT Model
by…developing individualized change plans
that “fit the family” and increase competence in..
•Parenting
•Communication
Engagement
•Problem solving Behavior Change Generalization
•Conflict management (etc)
GeneralizingGoal
(Multi-systemic focus)Goal Goal
- Helping family generalize change Assessment
& to become self reliant
- Maintaining change by relapse prevention
-Supporting changes by increasing the
Intervention
Skills community resources
use of available Skills Skills
Engaging and motivating families to
Motivation becoming
Behavior part of and
Change stay in therapy..
Generalization
by…
•Building alliance with everyone
Early Middle •Reducing negativity
Lateand blame
while
Time retaining responsibility
•Understanding systemically and
Creating a family focus
Why is FFT Effective? (2):The Foundation of FFT is
Respect For Diversity and Cultural Competence
The outcome goals of FFT are
• not “healthy” families according to
someone’s theory or ideal, but……..
• obtainable changes that will help
• this family function in more
– Adaptive, acceptable, productive ways
– with these resources …
– and these value systems …
– in this context
THIS REQUIRES

RELENTLESS EFFORT
TO UNDERSTAND AND RESPECT
THESE YOUTH AND FAMILIES ON THEIR OWN TERMS
Where do we start?
Why “FAMILY FIRST?”
.24
Self-Control Academic
Self-Efficacy .19
.70

Family .59 Family .40 Family .88 Substance


Bonding Super- and Peer
vision Norms Use

.14
Social and
Community
Prevention (N=8,576)
(CSAP)
Ecosystem
School Influences Community

Clinically
Peer Extended
Groups Family
Significant
Behavior
Intra Individual
(Diathesis)
Factors & Processes

How do we accomplish our focus


on “Family First?”
In order to address and intervene successfully with the
Individual and Ecosystemic nature of clinical problems
Ecosystem
School Influences Community

Clinically
Peer Extended
Groups Family
Significant
Behavior
Intra Individual
(Diathesis)
Factors & Processes

Family
First

How Does FFT approach these factors?


How Do We Understand These Family First Factors?
Clinically
Significant
Behavior
Family Relational Patterns
•Common behavior patterns, attitudes, and emotions that surround
clinically significant problems

Relational Functions
(inferred)
that serve to motivate and maintain stability
in family relational patterns

Theory specific / hypothesized constructs for understanding clinical


problems: e. g. attachment bond disorders, traumatic events, reinforced
behavior, cognitive thinking errors, archetypes, object introject processes
Understanding the problem/family/context
as the organizing framework for change
• Begins with relational assessment (relatedness and hierarchy functions) –
BEGINS IMMEDIATELY

• Client/problem assessment -
• of the problem…. problem sequence MORE IMPORTANT AFTER A
FEW SESSIONS – AFTER SUCCESSFUL STRENGTH BASED
RELATIONAL FOCUS HAS BEEN ESTABLISHED & AFTER
SUCCESSFUL THEMES AND ORGANIZING THEMES
• functioning of individual, family, and role of context
• Risk and protective factors

• …thus…. a multisystemic assessment/understanding of:


• Relationships MOST IMPORTANT
• Problem behaviors and sequences BECOMES MORE IMPORTANT
DURING BEHAVIOR CHANGE
• Environmental social/cultural context ESPECIALLY IN
GENERALIZATION
Ecosystem
School Influences Community

Peer Extended
Groups Family
Clinically
Intra Individual
(Diathesis) Significant
Factors & Behavior
Processes
Family Relational Patterns
•Common behavior patterns that surround clinically significant problems
•Risk and protective patterns that increase/decrease likelihood of
clinically significant behaviors

Relational Functions
(inferred) FFT Behavior
Change &
that serve to motivate and maintain stability Generalization
in family relational patterns

Using Relational Assessment in the process of change


Finally, successful FFT Therapists reflect
specific interpersonal qualities

(1) Relationship skills


Warmth (contextually expressed), non-blaming, humor
interpersonal sensitivity, respect for individual difference
(2) Structuring skills
provide direction within the sessions, match to the clinical
model, locate resources out of the session
These Relationship and Structuring skills count for more than
the “intellectual knowledge” about the model – yet without the
model knowledge base we have no guiding principles or a means
to be accountable to our families and our treatment systems
(3) Conceptual skills
-to assess/understand relational nature of “problem”
-to monitor therapy process
-to plan and “think on your feet”
(4) Clinical & “life” experience (Be aware of it, “use it,” … but don’t let it
run your clinical decision making)
The Skill and Commitment to Adherence and Competence

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
10,0% $1 invested

5,0% •$2100 per


family cost to
0,0% implement
6 month 12 months 18 months
Adherent Non-Adherent Control

* Statistically significant
outcome
Functional Family Therapy

• Engagement and Motivation


Engagement Phase

Motivation
Implementing phases across sessions
When does FFT
begin? Before
the first clinical And before, between, and
contact after sessions,
Engagement/ PLAN, THINK, CONSULT
Motivation CSS & TEAM

Behavior Change

Generalization

1 2 3 4 5 6 7 8 9 10 11 12
Sessions
Engagement and Motivation
Phase
Engagement Our Goal
To engage and motivate families to
becoming part of and stay in therapy..
Assessment
by…

Building
Intervention “balanced” alliance - with everyone

Reducing negativity & blame while


Motivation retaining responsibility

Creating a family focus for problems to open


new solution avenue
Engagement

ENGAGEMENT &
MOTIVATION
Motivation PHASE:
Engagement
For positive participation - involves
building trust, respect, alliance

Motivation
Not only to participate in therapy, but
to undertake the specific behavior change
steps designated by therapist
The “Staying Power” of
Motivational Forces
Hype,
“Understanding”

SHAME

Fear / Punishment Positive Alliance, Hope


Introduction to E & M Techniques
Engagement/Motivation Interventions
Engagement
Interrupt & Divert
-negative interaction patterns
Intervention -blaming
(stay busy)
Motivation

Change meaning through


establishing a nonblaming relational focus
Includes refocusing “Individual” issues as “Relational” issues,
Sequencing / Pointing Process, Theme Hints,
REFRAMING and providing THEMES

And MATCHING – Always MATCHING


MATCHING (a philosophy as much as
“a technique”) is a fundamental requisite
for effectively engaging and changing
families
“Match to” clients:
We do what it takes for them to feel you
are working hard to respect and
understand them, their language,
norms, etc
Especially during E & M it is “all about them”
What is our initial focus? Who is …
• negative?
-hopeless?
-seeing “no solutions”?
-resisting?
• In Engagement and Motivation, we initially
understanding phasic change.
• organize our energy on who is…..
--the most likely (and able) to prevent
positive change from being initiated
Then make your focus relational ASAP
Levels of “Process” Techniques in E&M
(in context of high negativity & blaming)
“Make it Relational” & emphasize strength/positivity
by”
1 - Jumping into escalating hostility ASAP -
somehow!
2a-“Pointing Process” (sequences in session) in non-
blaming way, find way to “see the strength” in the
process
2b- Sequencing (sequences outside the session)
3 – Offering a “Theme Hint”
4- Beginning a process of Reframing
5- Beginning to develop Positive Themes
-Jump into escalating “denial” somehow. (“OK, so you all seem to be in
agreement here. Is this new – did this referral bring you all together or
have you always been pretty much on the same page?”)
The Flow of E & M
Interventions

At first, negativity,
individual problem focus,
blaming, and negative
& hopelessness is high

At first feelings of hope,


positive attributions about
self and each other,
and a sense of “family togetherness”
are low or absent
As E&M progresses,
negativity decreases

&

Relational focus &


strength based
Attributions Increase,
blaming decreases
(but is still present)
As negativity, blame, and
individual problem focus
decreases…

The FFT therapist can begin to


develop Relational Themes –
and ultimately Organizing
Themes

This escalates the


reduction in negativity
and the increase in
positive relational
focus, emerging hope
The Data: Impact of Therapist response to
Negativity: The Frame-Reframe Continuum:

THEME
+
REFRAME
Negativity Continues
THEME “HINT”
(56 - 70+%)
= NONBLAME SEQUENCE,
(MAKE IT RELATIONAL)
PROMPT

- FRAME
REFLECT Negativity begins
To shift (-> 35%)
What is Reframing?
Reframing is an Interpersonal Process in
which the interventionist usually takes the
lead …

… in suggesting that a problem behavior,


while “bad” (or worse), may not necessarily
only have a malevolent motive; instead it
could also include a more positive (but very
misguided) intent.
Reframing Steps
• Acknowledge the negative
• Reframe intent, motive,
meaning
• Evaluate the effect of the
reframe
• Refine/Change
Reframing…a relentless process

Therapist Family

Tells
Listens for….
“what is the matter”
-attribution of cause (who, what)
-who, what, why
-position…values
-what it means, how I
-metaphors
Feel about it-what I attribute
Responds with….
the cause to be
Family/relationally
focused reattributing
Validate-reframe

“Explanation” of event, problem, family, situation…


that is “real“ for both therapist and family member(s)
What are Reframing Themes?
• Themes describe problematic patterns of behavior,
and/or relationships, in a way that suggests they may be
motivated by positive (but very misguided) intent(s).
• Themes provide new “explanations” of problematic and
painful patterns that provide
– hope for the future and give family members
– a reason to “stick with” the difficult change processes
which will ensue
• Hear themes….. …think thematically… respond to
themes, and remember that themes can have origins in
experiences that might have occurred long ago (e.g.,
eating difficulties in infancy, parents not knowing how to
balance work and family, kids not understanding how
desperate things were for Mom and / or Dad)
Dynamic nature of reframing…Developing Themes
Relational Themes
Strength Add to..Elaborate..
based Link individuals to family
focus
New problem
Interrupt
But don’t “control” Reframing definition
-explains problem in
Negativity Opportunity family focused way
Validation --Reframe
Listen--change-
incorporate
Continue Organizing Theme
Individuals linked to family
“Braided” reframes

Reframing Over time…the outcome


Relational Opportunity Relational •Negativity & blame decreases
Strength Strength •Family focus increases
based based •Motivation increases
•Attributions change
focus Time focus
Organizing Themes
• Everyone’s “responsibility” is clear, but no one is
to “blame.” The family has become victim to an
unfortunate (sad, tragic) “way of being” over time.
• They usually “wanted the right thing” but they
didn’t know how to do it; they were misguided, in
too much pain, too damaged.
• Often they didn’t even recognize their part in the
process.
• Previous attempts to solve the family’s problems
in fact made things worse, and created
defensiveness and/or hopelessness in everyone.
Organizing Themes (2)
• As family members “see themselves in the same boat”
they are more likely to experience temporary hope,
compassion, openness.

• This is marked by:


– Spontaneous positivity
– Change in attributions
– Reduction in blame
– Nonverbal and verbal cues of “hope” and “familyness”

• And it signals a possibility that you can move into


Behavior Change quickly
– Focusing on less volatile issues
– Remembering Relational Functions – and “protecting”
them while changing the negative / destructive ways
they were expressed in the past
Engagement/Motivation
Outcomes of these goals…
Family motivated to come back…reduce
dropout
because they…
– Different “experience” in therapy
– Not the same as home
– Lower negativity
– Decrease hopelessness
– A family-relational focus of the problem
– Worked with someone who helped who
• overcome obstacles to therapy
• was a credible helper
How Do We Understand Families?

• We need to understand and work with what


“drives” them (what they bring to us)

…. And be able to use that knowledge to tailor


our interventions during every phase so that
the youth and family can and will follow
them, change in a positive direction, and be
able to maintain those positive changes

Family (Relational) Assessment is our


Primary Focus
Relational “Functions”
“When one family member relates to another, the
typical relational pattern (behavioral sequence, emotions,
beliefs about each other within the relationship) is
characterized by degrees of:

Relatedness….
contact/closeness vs. distance / autonomy
(psychological interdependence)

Hierarchy….
overt relational control/influence –
based on differential resources, “power,” role
Attempting to change these basic motivational components of
human behavior in just a few sessions is clinically impossible and
(arguably) inappropriate ethically
Understanding the problem/family/context
• Conceptualize the family as a relational and social context through
• Relational assessment (relatedness and hierarchy
functions) – BEGINS IMMEDIATELY

• Client/problem assessment
• of the problem…. problem sequence MORE IMPORTANT
AFTER A FEW SESSIONS – AFTER SUCCESSFUL STRENGTH
BASED RELATIONAL FOCUS HAS BEEN ESTABLISHED &
AFTER SUCCESSFUL THEMES AND ORGANIZING THEMES
• functioning of individual, family, and role of context
• Risk and protective factors

• …thus…. a multisystemic assessment/understanding of:


• “Relationships MOST IMPORTANT
• Problem” behaviors and sequences BECOMES MORE
IMPORTANT DURING BEHAVIOR CHANGE
• Environmental social/cultural context ESPECIALLY IN
GENERALIZATION
Relationship Patterns…. Again, Family First
…”the space between”
•organized., repetitive
behavioral sequences that
come to “define” the
Behavior Sequences relationship
•Stable over time…
•Rules…roles….that define
the ways of typically being
together

Relational Functions
“outcome” of pattern for the individual
•“motivator” of future behavior in that relationship
•Glue” that holds the behavior within relationship together
1 - Relational Connection, Interdependency
When X relates to Y, the overt relational pattern over time
(behavioral sequences in the relationship) of X’s behavior is
characterized by: My connection
My “sense” of psychological with you seems to
& emotional well being seems to reflect both autonomy
not “centered” on you &
High Connection;
(Autonomy):
Autonomy & there seems to be a
Most of my “connection” is
High balance (or conflict) of
“invested” elsewhere
Interdepen- both
dency

My “sense” of psychological
& emotional well being
depends heavily on you :
Walling Off There is considerable intensity &
investment in you; I’m “centered”
Pulling In on you a great deal
Interpersonal Relatedness Functions:
When X relates to Y, the relational pattern (behavioral
sequences in the relationship ) of X’s behavior is
characterized by:
high
1 2 33 Mid-
Mid-
Autonomy:
distance
pointing
pointing
independence
separating, 4
Low levels of
psychological
intensity
(Fear of
Enmeshment?) 5
low

low Contact: closeness, dependency, high


enmeshment, high levels of psychological
intensity (Fear of abandonment?)
Its not the specific behavior…..
but the functional-relational pattern it represents…. behaviors and
their possible interpersonal (relatedness) functions
high Adol Substance Abuse
Having many jobs and (pseudo-individuation)
Autonomy: Being cold,
outside activities Borderline
distance sarcastic,
Visible self mutilation
independence rejecting Teenage runaway
“Ideal” balanced adult
separating,
Withdrawing Being depressed
Low levels of passively
psychological Double
Teenage runaway
intensity Focused, dating
(Fear of successful
Enmeshment?) Giving considerable
Nurturance, warm & loving

Having childhood phobias,


low Being insecure

Contact: closeness, dependency, enmeshment,


“Positive” “Negative”
Behaviors Behaviors
Hierarchy refers to the pattern, over time, of relative
influence based on power, position, and resources.

Parent Parent
up(+) down(+)

Parent
Symmetrical:
Parent up (Exchange = Parent down
Behaviors)
Relational factors: Hierarchy
Functions - Hierarchy:
PARENT VERY 1-UP (1
UP+)
Balance of influence very much “in favor” of parent
• “Bad” versions – Parent is perping kid & kid
can’t escape, Parent smothers and over-
controls kid who complains loudly but can’t
influence parent to stop
• “Good” version – parent is a trusted resource,
provides high rate of structure & monitoring
Relational factors: Hierarchy

PARENT UP
Balance of influence “in favor” of parent
• “Bad” versions – Parent demands respect,
“controls” coercively but is inconsistent in following
through. Youth complains about parent but still
depends more on parent than parent does on youth

• “Good” version – parent is a resource,


provides structure & monitoring, youth asks rather
than demands, youth ‘requires” parent justify
position, but accepts it (even if grumbling).
Relational factors: Hierarchy

PARENT SYMMETRICAL WITH


YOUTH
Balance of influence is
equal/reciprocal
• “Bad” versions – Competition, comparing
lists of injuries and/or contributions,
“knocking heads” re some behavioral issue
• “Good” version – “trading”
responsibilities, lots of negotiation rather
than setting rules
Relational factors: Hierarchy

PARENT DOWN
Balance of influence “in favor” of
youth
• “Bad” versions – Youth is determining
parent’s behavior more than parent is
determining youth’s; Parent complains but
can’t influence youth to stop
• “Good” version – youth is a trusted
resource, provides positive structure,
anticipates and responds without guidance
from parent
Relational factors: Hierarchy

PARENT DOWN +

Balance of influence very much in favor of


youth
• “Bad” versions –Youth is perping parent &
parent can’t/won’t escape; youth over-controls
parent who complains loudly but can’t influence
youth to stop; parent is “resigned” and uses PO
as “complaint resource”
• “Good” version –Youth “takes care of” parent,
provides resources and high rates of structure &
monitoring
Assessing Relational Functions:
Additional considerations
• (1) functions are sometimes not obvious,
can be indirect (triangles)
• (2) functions are relationship specific (a
parent can have different relational
functions with different kids; a youth can
have a different relational functions with
each parent (boyfriend, extended family
members, etc)
• (3) family members often mis-report
(look at where the patterns typically end up… not what
they want [intend] but where they stand relative to one another….
“when the dust settles”)
Behavior Change
Phase
The FFT Clinical “Map”...systematic
Changing the problem behavior
by using the therapist skills of….
•Teaching, modeling, coaching,
•providing technical aids, and giving
directives that help families improve
their ability in
•Parenting &Behavior
“Youthing”Change
•Communication
•Problem solving
Assessment
•Conflict management
•Positive Compliance

Intervention

Changing the youth’s problem behavior by


Behavior
eliminating the dysfunctional Change
behaviors
(drug abuse, delinquency, violence, etc)
and changing the processes that support it
by…developing individualized change plans
that “fit the family” (values, relational functions, abilities),
and increase competence
Behavior Change Phase…

Goal:
•develop and implement individual change plan that targets
presenting problem by reducing family risk and building family
protective factors…

Desired outcomes are improved...


•Developmentally appropriate
•Monitoring and supervision
•Consequences/rewards/punishments
•Parenting skills
•Communication skills (parents & adolescent)
•Family conflict management
•Problem solving
•Compliance (by all family members)
58
Behavior change…targets and implementation
Client
Assessment
Problem and other
OQ Sequences
YOQ/YOQ-SR

Relational
Implementation
Target(s) •Match to…
to…
Assessment
•Communication •How to present/do
•Problems solving •Reframe to use as
•Sequence interruption context

Organizing
Theme(s)
Specific Session Intervention Plan
Get it started
Keep it on track
Follow-up

59
Behavior Change interventions….
How to implement:
• Apply…
– Behavior change technologies (interventions) and therapist
persuasion based on alliance, hope, and positivity

– In sessions
• Planned through teaching/using a client issue
• Opportunity…through an in session incident
• How…
– Coaching, directing, teaching, using technical aids

– As “homework”
• Specific task that is accomplishable
• Clearly presented/understood
• High expectation of success

– Model
• Directly/indirectly demonstrated by the therapist
Behavior Change
Technical Aids (examples)
• tape recordings, therapist handouts

• reminder cards / post-it notes /charts, notes,


message centers on refrigerators

• school-home feedback systems

• answering machines, e-mail, instant messages, text


message

• pictures, “corny sayings,” symbols

• Interactive rituals (games, relaxation training)

61
Communication skills training: Elements 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
Communication flow chart

Assertion Validation
Behavioral Active
Want Specificity/ Listening
Negotiation
alternatives (“you want…”)

Source
Directness
Responsibility + Brevity
(“you”)
(“I”)

Affect expression & Impact Active


regulation, Feel Statements Listening
(“you feel…”)
validation,
relationship building
Validation, Relationship
Building
• FEELING WORD(S) • NO FEELING WORD(S)
• Paraphrase • Ask if feeling exists

• Synonym • Guess about feeling

• Ask for more feeling


info
• Avoid being defensive
• Avoid being defensive
Behavior Change Intervention Technology:
Conflict management
– Avoid it
– Change reaction to early steps in the process
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?
– Contain it…
• Present orientation
• Issue focused
• Time - out for transitions
Behavior Change…

Problem solving
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

66
Problem Solving (Continued)
(Parent Perspective)
• 1 - Identify ONE “problem” (behavior, situation)
• 2 - Use principles of Positive Communication
(e.g., Behavioral Specificity)
• 3 - Impact Statements (but no personal attacks)
• 4 - Ask / “Invite” youth re if s/he .....
– understands how it is a problem for you (validate)
– wants to let you know “why” the problem occurred (in
her/his own terms)
– has suggestions about how to solve the problem
– Prefers that you resolve it yourself
Behavior Change
Interventions technologies
Review & Additional Basic Parenting
Principles/techniques
1. Contracting & Monitoring, Contingency Management w/
younger adolescents
2. Response-cost techniques / Action-related
consequences / Time-out
3. Relationship building & Conflict Management
4. Challenging “Pathogenic Beliefs” (and linking them to
interpersonal functions and reframes / themes)
Behavior change interventions require
therapist…
• To have a well thought out change plan
• Structure the session to accomplish it
• Contingently respond to what happens in the
session…hearing/seeing feedback
• Find ways to be flexible (creative) in order to meet
behavior change goals:
» Ignoring some things
» “Staying with it”…while responding interpersonally

• Monitor motivation throughout implementation


(Backing up to engagement/motivation when needed)
• Follow through
Remember that resistance
•indicates that one or more members do not
experience that the therapeutic process will benefit
them

OR

•Our interventions did not “fit” Interpersonal


Functions

OR

•We were sloppy!


Generalization Phase

Assessment
Intervention

Early Middle Late


The FFT Clinical “Map” ...systematic
Desired Outcomes…
•family stabilizing changes
•family using necessary community resources on their own
Engagement •family Behavior Change
acting with self-reliance
•incorporate community systems intoGeneralization
treatment
Assessment

Intervention

Motivation Behavior Change


Generalization
Early Middle Late
Time
Using Reframing in Generalization

• Maintain
Validate motivation when
the “felt need” is
gone using
Reframe reframing

• Redefine
challenge as
Assess acceptability/fit keeping going
despite the fact
feel better
Change/continue
• Link to
organizing
theme
Generalization Phase
Supporting Change
Relevant Community
Support
•Prosocial activities
•Monitoring/supervision
•Educational services
Generalization Phase •Matched to the family
Functional Family Therapy
Additional Professional
Services
•Individual Therapy
•Parent Education
•Anger management
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
Generalization Phase…
relapse prevention
1. Identify situations where problem may
occur
2. Identify strategies to use when problem
reoccurs
3. Predict the problem to recur

….in order to build confidence that new skills


will work in similar/different situations over
time
Support Change…resources in community

• Families are multisystemic


– Context will impact ability to support change in the long run
• Supporting change is aimed at:
– Becoming self-sufficient in using relevant/necessary community
resources to help
– Using behavior change competencies to deal with the world
around them

• 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
Generalization phase…
…Supporting change..Family Case
Manager role
• FFT therapist role in
generalization…family case manager

• 1. Know the community


• Have current list of providers/agencies
• Know the transportation system
• Know the school system/contacts
• Know juvenile laws
Generalization phase…
…Family Case Manager role

2. Develop contacts
– have specific referral persons in
agencies (schools, mental health
agencies, YMCA, boys/girls clubs)

3. Remember the ethics


– Confidentiality….Release of information
– Exceptions
– Reporting laws
FFT Phases of Change

ENGAGEMENT BEHAVIOR GENERALIZATION


- MOTIVATION CHANGE

P H A S E G O A L S:
Create Therapeutic Individualized Maintain &Generalize
Alliance, Short & Long Term Positive Changes,
Positive Changes: Connect & Use
Reduce Negativity & Positive
Behavior, Attributions,
Hopelessness Emotional Reactions Community Resources

M A J O R A S S E S S M E N T F O C U S
Relationships and the Values, MULTIPLE SYSTEM-
Interpersonal Function Behaviors, COMMUNITY LINKS,
of Behaviors, Sequences, Extrafamilial Risk &
Emotions & Attributions Skills & Deficits Protective Factors
FFT Phases of Change (cont)

ENGAGEMENT BEHAVIOR GENERALIZATION:


-MOTIVATION: CHANGE: CASE
RELATIONAL STRUCTURING MANAGERIAL

M A J O R C L I N I C A L F O C U S
&T E C H N I Q U E S
Direct,Teach,Model: “Family Case
Culturally Respectful
Communication Management”
& Appropriate bh’s,
Training, (Develop Commun-
Positive Reframing,
Parenting Skills ity Resources),
Nonblaming Themes,
Training, Relapse
Relational Focus,
Conflict Management, Prevention,
Divert Blaming,
Relationship Skills, Rehearse New
Sequencing
Problem Solving Skills For Future
•It isn’t just a set of skills”
•It isn’t just “an intervention”
•(e. g. the right reframe) •Process Focus
•It is a systematic system of: •what phase am I in?
•what are the goals of the phase?
•Understanding, deciding,
•what do I need to assess?
and….doing from within •how do I need to intervene
the model •to accomplish the goal
•how do I “match to…..”
•what do I need to know about…...

Therapist Reality
“process issues”
Change Process Expert
•Experienc
FamilyeReality
in the room
•how do I feel about….?
“alliance/outcome issues”
•how does this fit with
Life
what Expert
I think about…
•does this make sense to me?
•what does this mean I will
have to do?
Case Planning

1. Case Plan

– based on:
– what you know about individuals
(parents/adolescent), family, context from both
relational and risk and protect factor
perspective…how to match to
– Individualized change plan matched to clients
relational needs, problem, and context
2. Session Plan
• based on:
– Goals of the phase, ways to get there that match
client, thread of reframes used to organize the
problem
Case Planning Protocol (“Big Picture”)
1. How can we understand the family?
– Presenting problems, possible underlying strengths and
motivations
– Risk and protective factors in family, individual, context
– Relational understanding of family

2. How does the problem “function” in the family relational system?

3. What are the major themes/reframes that organize therapy?

4. Individualized change plan...potential “outcome sample”


– Behavior change targets
– Implementation of behavior change plan

5. What are the multiple systems involved that impact maintenance


and support of change
Session Planning Protocol (Specific plan)
1. What phase….?
2. Goals of that phase? (my process goals for this
session)
• Which goals are important for this session ?
• What progress have you made toward the goals?
• Process issues to address (e. g.
negativity/resistance)?

3. What do I need to assess? (my assessment goals for


this session)

4. What major theme/reframe organizing the


case
- What part to develop? How to add to it
5. How should I intervene?..Targets for the
session
– Which phase goals are targets for session?

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