Alexander2010 (Fase Terapi)

10
Functional Family Therapy

A Phase-Based and
Multi-Component Approach
to Change
James F. Alexander and Michael S. Robbins
Functional Family Therapy (FFT) is all about helping youth and families
who are in trouble. Central to FFT is the belief this can be accomplished by
changing family interactions and improving relationship functioning as the
primary vehicle for changing dysfunctional individual behaviors. FFT shares
many similarities with other systems approaches; however, FFT offers a
comprehensive framework for understanding adolescent behavior problems
that is quite unique. This framework provides the context for integrating
and linking behavioral and cognitive intervention strategies to the specific
familial and ecological characteristics of each family. As such, FFT is also
about therapists, about training and supervision, and about treatment and
other (educational, judicial, religious, cultural, political, economic, market-
ing) systems that surround families, therapists, and agencies.
Like all coherent models of change, FFT is phasic and developmen-
tal. Every system, ranging from human beings (and all animal life) to all
created products (cars, symphonies, clay figures and so on) begins in
a different form than what it later becomes. Physical systems and most
conceptual systems undergo phases which build upon each other, and
this development usually follows a specific pattern. So too do families
and therapists as they undertake and complete their journey together
toward positive family change. For over 3 decades, FFT itself has evolved
from the experiences and results of clinical research, critical review, and
James F. Alexander ● University of Utah

Michael S. Robbins ● Oregon Research Institute
R.C. Murrihy et al. (eds.), Clinical Handbook of Assessing and Treating 245
Conduct Problems in Youth, DOI 10.1007/978-1-4419-6297-3_10,
© Springer Science+Business Media, LLC 2010
246 James F. Alexander and Michael S. Robbins
dissemination across populations, cultures, and treatment contexts. Not

surprisingly, across multiple contexts, research teams, and clinical pro-
viders there is a core philosophy or value about the critical importance
of research and evaluation and accountability. This value epitomizes our
ultimate focus on providing the highest quality of care possible to youth
and families by monitoring and studying all aspects of training, supervi-
sion, and implementation.
The purpose of this chapter is to help readers understand the essen-
tial philosophy and components of FFT. In doing so, we describe how FFT
systematically matches interventions to the unique and special quali-
ties of each youth, family, culture, and treatment system. In addition, we
describe how findings from research studies have led to evolutions in the
clinical model.
BRIEF HISTORY OF THE DEVELOPMENT OF FFT

AS AN EVIDENCE-BASED INTERVENTION
FFT is viewed as an empirically supported model for adolescent drug

use and behavior problems (Barton, Alexander, & Sanders, 1985; Waldron &
Turner, 2008). However, the emergence of FFT as an empirically based inter-
vention did not occur suddenly, nor is it complete. Since the early 1970s, the
conceptual development of FFT and research on FFT has been inextricably
linked. Moreover, this dynamic and reciprocal process persists today as FFT
is currently being implemented and evaluated in numerous contexts. These
processes continue to shape the clinical model by providing new results and
experiences that enhance our ability to understand and communicate about
the essential components of successful implementation. From examining
moment to moment experiences of therapists in the room with families, to
working with state agencies to support community treatment centers and
clinical teams, these experiences continue to shape FFT.
The first published articles on FFT established the efficacy of the
approach, compared to alternative treatments, for adolescents with
delinquent behavior problems (Alexander, Barton, Schiavo, & Parsons,
1976; Alexander & Parsons, 1973). Over time, the efficacy of FFT for ado-
lescent delinquency has been replicated across sites and settings (cf.
Barton, Alexander, Waldron, Turner, & Warburton, 1985). FFT has also
been established as an efficacious treatment for adolescent substance use
disorders (Waldron & Turner, 2008). Moreover, evidence has been found for
the preventive effects of FFT for siblings of problem youth (Klein, Alexan-
der, & Parsons, 1977) and for the long-term effectiveness of the interven-
tion into early adulthood (Gordon, Graves, & Arbuthnot, 1995). Research
has shown that FFT is associated with improvements in family communi-
cation patterns and relationships (Parsons & Alexander, 1973; Waldron,
Slesnick, Brody, Turner, & Peterson, 2001). Finally, one of the advantages
of FFT, relative to other family based models, is that it has been shown to
be effective when implemented by professionals with diverse backgrounds
and training and that effectiveness has been demonstrated across cultural
groups (Alexander, Pugh, & Parsons, 1998; Waldron et al., 2001).
Functional Family Therapy 247
As evident in the references above, FFT has been profoundly influenced

by many individuals. The model was first fully described by Alexander and
Parsons (1982). However, the clinical experiences and research findings of
numerous individuals and research teams have continued to shape and
refine FFT. With respect to research, for example, the independent repli-
cations of the efficacy of FFT by numerous research teams in the United
States (Waldron, Gordon) and Sweden (Hansson), has led to FFT receiving
numerous designations such as “Level 1 Model Program” (Youth Violence: A
Report of the Surgeon General, 2001), “Best Practice” (Thornton, Craft, Dahl-
berg, Lynch, & Bear, 2000 – Centers for Disease Control), “Evidence-Based
Effective program” (OJJDP Juvenile Justice Bulletin; December, 2000), and
“Promising Strategies to Reduce Substance Abuse” (U.S. Department of
Justice, Office of Justice Programs, 2000). FFT was also designated by the
Center for The Study and Prevention of Violence (CSPV) as one of 12 Blue-
print Programs for treating adolescent delinquency, substance use, and
violence. The Blueprints initiative (Elliott, 1998; Elliott & Mihalic, 1997)
involved a thorough and rigorous review of the research literature to iden-
tify effective programs for helping troubled youth. This initiative has had a
profound influence on the treatment of adolescents with behavioral prob-
lems by influencing state and local policy and funding, requiring the devel-
opment of user-friendly treatment manuals and training and supervision
programs, and by providing a context for providers, model developers, and
policy makers to work together to bridge the gap between research and
practice and provide research proven services to youth in need.
In 1998, FFT was included in the Blueprints series (Alexander,
Pugh, & Parsons, 1998). Since that time, numerous FFT replications
have been supported and guided by the Blueprints initiative. To main-
tain pace with training and dissemination demands, an independent
company was formed, Functional Family Therapy LLC (FFT -LLC). FFT -
LLC has trained more than 270 local, state, national, and international
organizations to implement FFT. In this work, FFT -LLC has supported
over thousands of therapists who have served over 60,000 adolescents/
families across the globe. At present, large-scale projects (10 plus sites)
are ongoing in California, Washington, Pennsylvania, New York, Florida,
and the Netherlands.
In response to the needs of community providers, several variations of
FFT have been developed to facilitate the implementation of FFT-informed
interventions with diverse clinical providers and populations. For example,
Functional Family Probation (FFP) was developed and has been adopted as
case management model for Juvenile Justice Systems statewide in Utah
and Washington. In this variation, probation officers receive specialized
training in FFT Engagement, Motivation, and Relational Assessment prin-
ciples to facilitate their ability to engage adolescents, work with the youth’s
family, and effectively plan and implement case management strategies to
address the multiple needs of youth. Also, in our current efforts to sustain
and extend FFT to new populations and challenges, FFT-LLC is involved
in programs working with youth and parents in the Child Welfare system
(FFT-CW) as youth are being reunified or reintegrated with their families
(FFT-Reunification Services).
CLINICAL MODEL OVERVIEW
FFT consists of five major components in addition to pre-treatment

and post-treatment activities (see Fig. 10.1): (1) Engagement in change;
(2) Motivation to change; (3) Relational/interpersonal assessment and
change planning; (4) Behavior change; and (5) Generalization across behav-
ioral domains and multiple systems (Alexander, Waldron, Barton, & Mas,
1983; Alexander et. al., 1998; Barton et. al., 1985).
Pre-treatment Preparation
Prior to seeing or contacting the family, therapists engage in linking
with referral sources, gathering information about the youth and fam-
ily, and preparing/planning for the initial contact. The therapist, upon
receipt of a referral, first contacts the referral source(s) to acknowledge
the referral and to solicit all information (including impressionistic as
well as formal assessments) available. In the case of formal legal involve-
ment (e.g., Juvenile Justice System), the therapist also clarifies system
expectations and requirements, as well as issues of confidentiality. In
situations where the therapist might not have experience with the cul-
ture or other characteristics of the referral, s/he will contact additional
resources within or outside of the treatment system to become better
informed. The ultimate goal of these activities is to be fully ready to assist
the youth and family, and to anticipate potential barriers and utilize
strengths to create a positive initial impression and experience for family
members.
The Big Picture: Integrating FFT with Other Systems *

Pretreatment Posttreatment
System Integration
FFT Direct Treatment System Integration
Phase Phases Phase
Assessment Assessment Assessment
- Engagement
Referral, - Motivation Boosters,
Preparation, - Relational > Behavioral Maintenance of
Pretreatment Assessment links w/ Youth
Linking w/ Mgt Systems,
- Behavior Change
Youth Mgt Positive close
- Generalization / Ecosystemic
Systems
Integration
The Youth / Family Management System(s):

Juvenile Justice, Drug Court, Welfare, Mental Health:
(PO’s, Case Managers, Trackers, Contingency Managers)
* Based on Alexander et al, 1983; Barton et al, 1985; Waldron et al, 2001
Fig. 10.1. The phases of FFT within treatment and community systems.

The First Phase: Engagement in Change

The Engagement Phase begins prior to first contact, and quickly blends
into the Motivation Phase. Engagement refers to any activity that can facil-
itate the family’s willingness to attend early sessions (or allow an inter-
ventionist into their home). Engagement also involves creating an initial
positive reaction to the therapist. These activities can include “superficial”
but important activities such as wearing clothes that seem appropriate
for family members and “matching” therapists to families with regards to
ethnicity and gender. If a desired match is not available, therapists must
be as culturally competent and work to help family members feel comfort-
able and respected. FFT therapists also make their own initial appoint-
ments via telephone so therapists can listen for potential problems such
as transportation difficulties, distrust of and resistance to treatment, and
confusion about the referral and/or treatment goals. Thus, the Engage-
ment Phase is less characterized by a formal set of therapeutic techniques
than it is of an attitude on the part of FFT therapists that families should
be shown as much respect as possible and be made to feel comfortable
during the initiation of the process of intervention.
Pre-intervention Information and Assessment. Referral information is
generally already available about youth and families. Sometimes this infor-
mation consists only of a name and a reason for referral (e.g., runaway;
found in possession of drugs at school; parent called expressing concern
that youth is becoming uncommunicative; social services receives referral
regarding possible neglect). At the other extreme are cases involving youth
with extensive diagnostic test information and perhaps even behavioral
records in institutions, and families with a history of many social service
contacts. FFT therapists review such information, along with as much
demographic information as is available, to understand as much as pos-
sible about the context in which intervention is to occur. For example:
“Is there information available that might facilitate cultural sensitivity,
enlighten about multisystem pressures (e.g., poverty) and resources, and
that might suggest individual constraints (e.g., learning disability, illiteracy)
which must be considered?”
The Second Phase: Motivation for Change

The Engagement Phase consists primarily of transitory activities that
are designed to get the process of intervention “off on the right foot.” As
direct contact is initiated in the first session, FFT therapists quickly move
to more powerful motivational interventions. The primary objective of the
Motivation Phase of intervention is to create a motivational context within
which change can occur; the family members are helped to experience
a reduction in change-interfering negativity (anger, blaming, and hope-
lessness), coupled with an increase in change-enhancing hopefulness.
Decreasing negativity is essential in this early phase of intervention prior
to initiating formal behavior change techniques because family members’
intense negative emotions can preclude them from making a realistic com-
mitment to change. Often family members have developed a rigid defensive
schema through which all information is filtered, and their interactions

are characterized by cycles of coercive and defensive interchanges that
reinforce their automatic negative processing patterns.
FFT addresses the early session (Engagement and Motivation) risk fac-
tors for drop out by engaging in two major domains of activity: Changing
Focus and Changing Meaning. Change Focus techniques include (a) Divert
and Interrupt, (b) Point Process, (c) Sequencing, and (d) Strength-based
Relational Statements. Change Meaning techniques include (a) Relabeling,
(b) Reframing, (c) Creating Themes, and (d) Offering Theme Hints.
Change Focus Techniques

Change focus interventions are intended to disrupt negativity and
unproductive family interactions by shifting, stopping, or redirecting com-
munications. Change focus interventions are relatively simple interven-
tions to implement, and are often used when the therapist is still getting
a sense of how to effectively intervene with the family, but recognizes the
need to attempt to address negative behaviors in the session.
Divert and Interrupt. The most basic change focus techniques are
divert and interrupt. Although simple, disrupting family members’ negative
interactional sequences through divert/interrupt represents a major inter-
personal maneuver, which helps families deescalate their toxic negativity.
Therapists divert family negativity when they intercept a negative speech
act made by a family member instead of allowing the family member to
whom it was directed to answer. Therapists interrupt family negativity when
they do not allow a family member who is making a negative or defensive
speech act to complete a blaming diatribe. In our prior research, we have
found that if a therapist simply diverts or interrupts a family member’s
negative speech acts, then the subsequent family member’s speech act is
almost twice as likely to be positive than if the therapist allowed another
family member to respond to the negative statement (Robbins, Alexander,
& Turner, 2000). In FFT, divert and interrupt interventions require an
active and involved therapist that is highly attuned to the meaning and
nature of interactions in the family. As such, these interventions are used
in a manner that is sensitive to the current interactions, and – although
they involve interfering or speaking over family members – they are delivered
in a manner that is respectful and accepting of the family.
Pointing Process. Another change focus technique is pointing process.
As therapists observe and attend to each family members’ perception of
within-family and extra-family interactions, they can comment on the proc-
ess of how family members relate to each other. This is especially important
with respect to those interactions that are characterized by negativity and
blaming. By pointing process, especially in a non-blaming (and if possi-
ble strength-based) manner, therapists are able to make explicit the inter-
relatedness of family members’ feelings, thoughts, and behaviors. These
interventions often serve to defuse negativity by shifting the focus from the
specific content being discussed to the underlying relational aspects that
underlie, but are hidden from family members in the current moment.
Sequencing. The third change focus technique, sequencing behavior

or circular questioning, is a method used to assess what happens and
who does what within a family with regards to the specifics of a presenting
problem. Because information is drawn out in a sequence and in a circular
fashion, it is visually easier to see the context in which behavior occurs.
Sequencing interventions create depth of knowledge about all the family
members involved in a presenting problem, including the action each took,
and the meaning of each participant’s behavior in relation to one another.
When a sequence is completed to include what occurs before, during, and
after an event, there is often an identifiable outcome that can be tied to a
theme or function of the participants (see Reframes and Themes below).
When used in a relationally focused and non-blaming way, the focus of
sequencing is not on the presenting problem or other problems, but on
family members’ interactions. That is, the focus is not on the content or
problem that occurred, but rather on family relationships and the meaning
of relationships and behaviors to individual family members. For instance,
when a father steps into harshly punish his son after he has talked back to
his mother, a problem focus would be to understand why the son’s behavior
was disrespectful. In contrast, a relationally focused sequencing interven-
tion would focus on framing the father’s actions as a way of protecting and
supporting the values of the family. When used in the Motivation Phase of
treatment the goal of this sequencing is for the father to feel acknowledged
for having a positive intent – even if his “way of doing it” might have been
harsh and non-productive. Sequencing reveals family patterns, which lead
to either positive or negative familial outcomes. Sometimes the sequence
when drawn (e.g., on paper) and shown to the family can in itself act as a
reframe (see below), particularly when the sequencing is accompanied with
non-blaming, contextual description. Sequencing also occurs when thera-
pists focus on adding depth to sequences that result in positive behavioral
outcomes. Systematically focusing on positive sequences creates a work-
ing climate in the session in which family members gain a new perspective
about themselves and each other. In many respects, the lens is shifted
from the negative behaviors and problems, which they enter treatment
with to the positive aspects of relationships that have been overwhelmed
by the negativity. This shift in focus helps family members to begin to see
what they do “through different eyes.”
Strength-Based Relational Statements. Strength-based relational state-
ments include interventions that ascribe a positive (even noble) attribution
about one person’s efforts toward another person. This includes seeing
the positive side of apparently negative relational patterns: For example
(to parent and child who are beginning to argue loudly with each other),
“OK – I’m going to jump in here for a second. You both are angry right now,
and pretty much yelling. I’m sure that at times you or someone else wants
you to stop yelling. But for now, I want to note that you seem to be at least
on the same page … no one seems to be holding back much, and both of you
are honest in expressing your anger. Lots of families tend to go underground
with their anger … but with you two, I can trust that you will bring it out and
deal with it directly. That gives me something to work with that often I don’t
have. Now, I wonder …” This strength-based relational focus pervades
FFT interventions. Even simple reflections or acknowledgements of

family members are expected to convey a strength-based relational focus.
For example, instead of acknowledging a mother’s anger about her daugh-
ter’s truancy by simply stating “I can hear how angry you are,” therapists
may rather state “Your exasperation is even more difficult for you because
you have such high expectations and ideas for how she can excel in school.”
Both interventions serve to acknowledge the mother’s anger, but the lat-
ter goes further by highlighting the strength-based aspects evident in the
mother’s anger.
Change Meaning Techniques

Like change focus interventions, change meaning techniques are
intended to disrupt negativity and unproductive family interactions. How-
ever, change meaning techniques involve attempts to change the meaning
of how family members understand themselves and each other. The goal of
change meaning techniques is not cognitive change, but rather is to create
the opportunity (or possibility) of a different frame. Thus, these techniques
are not intended to challenge “maladaptive” cognitions or provide an inter-
pretation for a family member’s behavior. Rather, the focus is on providing
a non-blaming, even positive perspective about behaviors that creates an
opportunity in the session for family members to experience one another
in a new way.
Relabeling. The therapist relabels by reflecting to family members a
similar, but less harmful explanation for a behavior, for the purpose of
shifting some of the negative intensity in the meaning of that behavior.
Consider a teenage son’s complaint about his mother arising in an early
(Engagement and Motivation Phase) session, “As soon as I walked in the
door she just went off on me!” and the therapist’s response of, “So she let
you know right off the bat that she had an issue with you.” While these
statements may seem quite similar, “she just went o f f ” conjures up a
more intense image than “she let you know right off that she had an issue
with you.” This relabel also added a “softer” relational component (“she
… with you.”) rather than the more “attacker – victim” tone of “she … on
you.” Relabels set a tone that is less negative and provide the therapist
more positive avenues to pursue. They also represent an intervention style
that families generally experience in more positive ways than therapist
interventions that amplify the negativity with which they already struggle.
In addition, they do not involve any element of blaming or suggestion that
the behaviors will need to change.
Reframing. Reframing is generally described as a “technique,” and
although its elements may differ across therapy models, the process of
reframing seems to transcend most family-based intervention models. Many
in fact consider it a “core technique” for all family therapy approaches. As
defined by Paul Watzlawick and colleagues, a reframe is a change of “...
the conceptual and/or setting or viewpoint in relation to which a situation is
experienced and to place it in another frame … and thereby change its entire
meaning” (Watzlawick et al., 1974). As an evidence-based model, FFT has
worked to describe precisely the process of reframing as we have used it
in our clinical trials and multiple replications. Research on reframing has

further helped to articulate the immediate effectiveness of reframing in
the session (Robbins, Alexander, Newell, & Turner, 1996; Robbins et al.,
2000). This in-depth knowledge has helped us to develop consistency in
the training and supervision process across agencies, therapists, and
treatment populations. In the process of doing so we have realized that
reframing is not only a technique; it is also an attitude, a perspective, and
a belief system that helps FFT therapists facilitate positive change even
when all of the technical elements of a reframe cannot be presented.
Reframes, as defined in FFT, add two components to the change mean-
ing process (a) acknowledgment of the negative, and (b) proposal of a possi-
ble alternative (and perhaps benign or even “noble but misguided”) motive.
These components add significantly to the therapist’s ability to impact
upon family negativity while maintaining an overall non-blaming relation-
ship with all family members. Reframes include a clear acknowledgement
of the negative aspects of a behavior (thereby supporting those that are
negatively impacted by the behaviors in question). This acknowledgement
does not include an agreement with the family member. Rather, the focus
of the acknowledgement is to establish that the therapist is attuned to and
understanding of the relevance of the negative behavior or problem to the
family member. After the acknowledgement, therapists then offer an alter-
native and possibly more benign motive for the behavior.
In our experience, the most powerful reframes acknowledge nega-
tive behavior, but rather than offering an alternative neutral or benign
motive for the behavior (e.g., mom’s frustration) the hypothesized motive
is labeled as “noble” in its intent. Usually the noble intentions are seen
as “misguided” but they are nonetheless well intended. As we move from
relabeling reframes with noble intent, the complexity and level of inference
increases. We are not concerned that we do not “know” if family members’
motives are “truly” positive or noble in order to suggest they might be. In
fact, hopeless families often are surprised and feel more supported when
therapists seem willing to “see the strength and possible nobility” in them
even when it is not apparent.
Creating Themes. To generate behavioral themes, therapists identify
sequences of several problem family member interactions in which all of
the negative elements are identified but reframed (or at least relabeled).
This focus has the advantage of helping create a family (versus individual)
focus, and because all members are subject to reframing the therapist
can identify negative interactions and yet still “come across” as seeing the
possible benign intent of each member. In this way, the therapist avoids
taking sides with family members, and prevents defensiveness that typi-
cally occurs when only an individual’s negative behavior is the focus. Rela-
tional themes are so called because they switch the focus to relationships
rather than behaviors. Of course, specific behaviors may be noted, but
often they are not. Instead, relational patterns, and how they have been
experienced, become the major focus. And while relational themes main-
tain the basic elements of reframes (acknowledge negative, reframe intent
or meaning in more benign if not noble terms), they often seem more like
“stories” and even “myths” than specific sequences of negative behaviors.
Coupled with our core generic principles of matching and respectfulness,

our powerful change meaning techniques help families move quickly to
being open and responsive to techniques that change behavior (in both
the short and long term).
Assessment in Early Phases (Engagement and Motivation):

Relational Functions
By the time FFT receives referrals for dysfunctional behaviors, the
relational functions expressed in important relationships are usually well
established and easy to recognize; rarely do adolescent disruptive behav-
iors or parenting “styles,” nor “challenges” emerge “all of a sudden.” As a
result, FFT therapists look for stable patterns, first assessing the rela-
tional functions. These “relational functions” represent inferred internal
motivations of family members based on overtly expressed (behaviorally,
verbally, emotionally, physiologically) patterns within the family. This
notion has had diverse articulations and controversies within our field for
decades (and centuries if one considers the early philosophers), but for us
it is fairly straightforward and is illustrated nicely in an analogy about
motivations for eating. We reflect a pattern of eating food when we experi-
ence hunger, anxiety or loneliness. While the exact dynamic factor may
take a while to detect (usually through understanding the pattern) it is
usually straight forward; and yet still an inference based upon the pattern.
Of course, where the sense of “hunger” (or whatever it is we infer as a moti-
vation) comes from may be arguable, but most theorists (and people) do
not have too much of a problem with the explanation that we eat because
we are hungry. In the same way, family members relate to one another
based on their own inferred internal motivations. In the assessment proc-
ess of FFT, the focus is not on the inferred internal process, but rather on
the resultant patterns that emerge from family interactions.
The assessment process in FFT also examines the functional relation-
ships and problem behavior patterns outside the family (especially with
peers). FFT does not attempt to change the relational function itself, but
we do change the cognitive, physiological, emotional, and behavioral strat-
egies in which the youth or parent engages to meet relational functions.
If a child acts out to “get attention” FFT does not work hard to elimi-
nate children’s need for attention! Instead, we change the means through
which this attention is elicited. This of course usually requires dealing
with the rest of the system(s) involved with the youth, because “comfort”
or “attention” may only be (or at least seem to be) available through mala-
daptive behavioral patterns.
Relational Connection: Contact/Closeness Versus Distance /Autonomy /
Independence. The first and most salient category for determining Rela-
tional Function is the degree of interpersonal connectivity that is expressed
in the behavior patterns that directly or indirectly impacts another person
(or persons) in the family (and other systems). The degree of connection
can range from “close” and highly interconnected to “distant” and quite
independent or autonomous. These dimensional anchors are not consid-
ered to be fixed and invariant points on a dimension; they are instead
the central tendency (or apparent “default mode,” or “average”) behavioral

pattern that best characterizes the ongoing relationship. Imagine a couple
in an ongoing relationship: They are not always close or always distant
or always a mixture of both. In general; however, couples can be dis-
tinguished in terms of whether their pattern is generally close and con-
nected, generally distant and autonomous, or generally variable. Whatever
the behavioral pattern is over time, FFT’s intervention philosophy, that is,
“the respectful acceptance of the diversity that all family members bring,”
is what we identify as Relational Functions. All three of the aforemen-
tioned relational states can be adaptive, and all three can be maladaptive.
The problem is not what the relational function is, but how it is expressed
and met.
The Second Dimension: Relational (“Relative Power”) Hierarchy. Rela-
tional Hierarchy reflects the pattern of relative influence parents and
youth have over each other in terms of “controlling” each others’ behavior.
With adolescent conduct problems, it is common to use such phrases as
“S/he’s out of control.” However, FFT examines more than the behavior
patterns of one individual. Instead, we examine the relative balance of
control and power rather than simply isolating our focus on whether or
not the parent can control the youth. When we broaden our focus to look
at the relative balance of power, it is not uncommon to find that some-
times a youth is able to exert more “control” over a parent’s behavior than
vice versa. In other families, the youth, although “acting out,” is not able
to control the parental behavior any more than the parent can control the
youth! Thus the power differential is more one of balance than of one or
the other “in control.” Interventions that fail to examine the relative bal-
ance of the interpersonal “control” in these relationships often fail repeat-
edly if all they attempt to do is to increase the “control” the parent has
over the youth.
Of course, in many ways parents experience the “power” issue as the
most salient in raising adolescents. However, FFT asserts that primarily
what parents want is a sense of being able to control (if not help) their
youth. As a result, when therapists provide alternative ways to influence
youth, hierarchy itself becomes less salient. In fact, many parents are quite
pleased when their kids begin to comply because the relationship with the
youth has been repaired and the youth now wants to maintain a positive
and less blaming relational pattern with the parent(s). Power and conse-
quences are important and have their role, but often are more difficult to
change and certainly less positive than relational changes that motivate
youth to comply and develop positive behaviors.
Unlike the concept of personality, which presumes a core underly-
ing motivational structure, FFT assessment of functions often identifies
important differences in motivation within one person. The FFT therapist
understands, for example, that the motivational needs of a parent with dif-
ferent children can be markedly different. As a result, child behaviors that
would be comfortable for the parent with respect to the “close” child could
be quite unacceptable with respect to the “distanced” child (or vice versa).
Thus, prescriptions for good parenting cannot be homogeneous, because
the behaviors through which effective parenting is carried out will differ
depending on the child in question.
Finally, the assessment of relational functions is essential if therapists

want to ensure rapid compliance with change interventions. Prescribing
tasks or change strategies for one family member with respect to another
member will elicit considerable resistance if the prescriptions are implic-
itly or explicitly inconsistent with the family members’ functions. Simply
put, the more divergent the techniques are from the relational functions,
the more resistance (e.g., poor participation and dropout) the therapist will
face, and the more external forces will be needed to facilitate and maintain
change. As an empowerment model, FFT offers a more relational and less
oppositional belief system and intervention philosophy.
Transitioning between Engagement & Motivation

into Behavior Change
Over the years, FFT has utilized two broad classes of techniques for
Behavior Change. The first class is represented by general skill-building
processes such as communication training, problem solving, and conflict
management techniques. We use these techniques in almost all families,
and they represent skill development, which is useful to family members
when they interact, but also generalize nicely to other extra-family systems
(school, work, friendships). The second class of techniques represents prob-
lem-specific techniques, which may apply to some people and families but
not others including: (a) “internal” coping techniques for people with anger
impulse problems, and cravings; (b) techniques for overcoming challenges
unique to some families, such as a single parent with a physical disability
which precludes the use of many parenting strategies; and (c) techniques
specific to youth with developmental disorders. Special techniques or
unique configurations of Behavior Change approaches also may be utilized,
for example, when severe trauma has been experienced by a youth (or par-
ent, or both), or when youth spend time with two active parent figures who
live separately and who may have their own new family relationships.
Specific Elements of Behavior Change

Communication Training. Communication training is commonly used in
FFT. In some families, the training represents a focus on a true skill deficit;
family members do not know the basics of interpersonal communication.
In many other families; however, family members know how to communi-
cate (e.g., some have been effective teachers, professors, clergy, Girl Scout
leaders, etc.), but in the current context are unwilling or unable to commu-
nicate in the effective ways they can demonstrate in other contexts. With
family members who truly are characterized by skill deficits, emphasis is
on explaining and practicing the positive elements of communication listed
below. When the problem is one of performance rather than ability, empha-
sis is placed on reattribution (e.g., reframing) interventions, and providing
constant reminders of the rationale behind effective communication.
The most common examples of communication training in FFT are not
unique to the model but rather are core elements of effective communication
that are described in many behavioral intervention programs. A common
feature of communication training in FFT is to enhance Source Responsibil-

ity. Individual family members are encouraged or coached to express their
needs and reactions in “I” statements which facilitate the centering of respon-
sibility on the speaker. Family members are helped to avoid “non- I” state-
ments such as, “In this house …,” “Kids shouldn’t …,” “It’s not right for you to
…,” and “It would be nice if ….” Instead, family members are taught to say, “I
want …,” and “When (this particular) thing isn’t done, I feel …” Keeping state-
ments at a personal level reduces blaming and defensive communications.
In addition, family members are guided to be direct and specific in their
communications. Source Directness complements source responsibility and
involves the specific identification of “you” in expressions. This helps avoid
third-person comments, innuendo, and inappropriate generalizations. To be
avoided are such “non-you” expressions as, “No one around here …,” and a
wife in front of her husband, “He never ….” In place of this third-person invis-
ible process, families are encouraged to directly say, “I don’t want you to …,”
and the like. In either circumstance, brevity is encouraged. Communications
must be short to avoid overloading and facilitate listening. Family members
are often literally asked to state their needs or reactions in 10 words or
fewer. By requiring family members to do this, it reduces unnecessary state-
ments and the opportunity to blame others or make provocative accusations.
Statements such as, “I want you to help around the house,” instead of “You
never do anything around here, except come home and read the paper, and if
you think the lawn stops growing just because you’re at work, you’re crazy,”
reduce defensiveness and increase the opportunity for change. An effective
therapist will quickly seize on the idea that mowing the lawn and doing some
evening chores will provide the husband with distance and private time while
giving his wife the necessary help, thus providing desired change without
disrupting functions which regulate intimacy levels.
Abstractions such as “being responsible” must be translated into
specific behaviors to be performed at specific times. When trust is only
emerging, or still not present, an ambiguous situation provides too many
opportunities for failure. Concreteness and Behavioral Specificity helps
family members translate their feelings and demands into specifics to
facilitate negotiation, contracting, and presenting alternatives. Family
members are helped to present messages that are Congruent, or consistent,
at the verbal, non-verbal, behavioral, and contextual levels. For example,
an assertion from a husband that he wants his wife to spend more time
with him should be spoken in a friendly manner, and he must make it
contextually possible by being available. Family members are assisted by
the therapist to provide congruent verbal and non-verbal cues, and then
taught how to help each other do this in the absence of the therapist.
Family members are also taught how to Present Alternatives when
making requests, and moving away from rigid non-negotiable demands.
Presenting Alternatives creates flexible and open problem-solving focus in
the session. For example, the statement “I want you home every night at
8:30, or if you’d prefer coming home four nights at 8:00 and staying out one
night until 10:00” presents a message of flexibility and openness. In this
way, the presenter is able to retain a sense of control, yet also provide the
recipient with a sense of having options.
Therapists help family members to be more effective Active Listeners

by providing guidance about how to use cues during and after the time
someone else communicates. These cues reflect accurate listening and
include eye contact, nodding, leaning forward, and restating or rephrasing
what was communicated, in content as well as in the feelings expressed.
Good listening and expressiveness is not an innate skill, however, and
must be practiced. At the beginning of training active listening is practiced
one sentence at a time. In addition, therapists guide family members to
provide Impact Statements in response to someone else’s communication.
Impact statements provide feedback about one’s personal reaction that
requires no justification from either party. By training family members to
be specific in their reactions, therapists help to break the established links
between feelings and behavior that characterize relationships. This is par-
ticularly important because the standard, automatic emotional reactions
are often negative or hostile, which leads to maintaining high conflict in
the interaction. By breaking this link, therapists are able to reduce nega-
tivity, increase the accuracy and specificity of communication, and facili-
tate the emergence of new behavioral sequences that are not charged with
the same emotional negativity. Examples of impact statements include:
“When you do ______, the effect on me is _______”; “The impact on me when
______, is that I feel _______.”
Basic Parenting Principles/Techniques

Forehand et al. (1979), Patterson (1974), Patterson and Reid (1973),
Webster-Stratton (1992), Chamberlain and Mihalic (1998) and many oth-
ers provide technical descriptions of numerous basic behavior change tech-
niques and concepts. Positive reinforcement/praise, negative reinforcement,
ignoring, distracting, clear limit-setting with consistent follow-through and
a reasonable number of limits, parent–child special time, and parental mon-
itoring of activities are applied when deemed appropriate during the Behav-
ior Change Phase of FFT. On their own, parent management techniques
appear to be more effective with younger rather than older adolescents.
Because FFT is a systemic model and all family members are included in
therapy, choosing and relaying these techniques to family members must
be done in a sensitive and flexible way. The educational descriptions of rein-
forcement principles that are sometimes used in parent training are likely
to come across as manipulative to an adolescent who is in the session, and
should be rethought/rephrased by the therapist prior to presentation in
the family setting. In general, the use of these basic parenting principles is
encouraged in FFT through incorporation into the more systemic and col-
laborative techniques of response-cost and contracting. Therapists should
keep these principles in mind, but their application is more commonly
conducted through more systemic means than classic parent training.
Contracting. Contracting involves having family members identify spe-
cific things they would like other family members to do in exchange for
interactions/behaviors or tangible rewards. This procedure is especially
important with adolescents (as opposed to children). In fact, other than
basic communication training, contracting is the parent–youth interaction/
influence technique that is most commonly used by FFT therapists because

it is systemic (e.g., involves considering the idea of reinforcement/reward
for all members of a system or subsystem), it can be initiated inside the
therapeutic environment, and it can be adapted for use with youth at
almost all developmental levels. Contracting should initially be conducted
within the therapy session since therapists need to do a number of things
to make early contracting as positive an experience as possible.
Therapists also need to monitor contracts to make certain they are
attainable based on the functional relationship needs of each participant.
Finally, therapists need to monitor the in-session contracting process to
maintain the decreased negativity attained during the Motivation Phase.
To this end, therapists often refer back to specific reframes and themes
that were particularly helpful in creating positive attributions in family
members during the Motivation Phase. If communication training was
conducted earlier in the Behavior Change Phase, the therapist will also
model and remind the family to use communication techniques during
their in-session contracting discussions.
Response Cost Techniques. Especially effective with children and pre-
adolescents, the specific approach to reward and punishment identified by
Webster-Stratton and Herbert (1994) as Response-Cost Techniques provide
a framework that helps a parent or parents learn how to set clear penalties
(typically loss of privileges/current rewards) for inappropriate child behav-
iors or failures to perform. Expected behaviors and penalties should be fair
and clearly stated, and augmented by visual aids whenever possible.
Additional Intervention Strategies. In addition to providing communica-
tion and additional skill training, FFT interventionists prescribe specific
activities and behaviors that will enhance the family’s experience of posi-
tive change. In particular, interventionists utilize as many technical aids
as possible. These technical aids include such simple items as sticky-type
notes that can be put on mirrors to remind family members about a par-
ticular behavior, audiotape recordings of communication practice sessions
that can be taken home for review, commercially available manuals on
parenting, a wide range of similar free parenting information provided by
social service agencies, training in the use of answering machines and cell
phones to leave messages for family members, a schedule of reminder tel-
ephone calls made by a volunteer to families who need additional structure
to change old behavior patterns, and so on. As programs have replicated
FFT formally and informally, the various technical aids and props that have
been adopted seem endless, and interventionists can become very creative
in developing materials that are consistent with the particular needs, abili-
ties, and resources of the specific population with whom they deal.
Interventionists also are reminded to be very creative and energetic
with respect to providing specific and concrete resources for families as
they enter the change process. We do not want to send families (many of
whom have only limited resources and low motivation for change) out of
sessions with little more than suggestions about how to change behav-
ior. Instead, we are in some ways “controlling” (or “educational”), ensur-
ing that the client is given very clear information and directions during
Behavior Change. In fact, FFT agencies often buy sticky-type notes and
inexpensive audio cassettes to give to families to consolidate techniques
between particular sessions. We also often ask social services and educa-
tional agencies to forward pamphlets, and so forth.
The shift in therapist style, during Behavior Change, is to a much
more structured, direct, and in some ways more hierarchical style than
during Engagement and Motivation. In addition, FFT interventionists pre-
scribe specific interpersonal tasks often involving technical aids. As has
been discussed throughout, these interpersonal tasks (e.g., setting up a
specific plan to supervise homework) must be tailored to the interpersonal
needs and abilities of all family members involved.
Using Technical Aids. A number of technical aids are frequently used
to facilitate behavior change in FFT. Examples of technical aids include
(a) tape recordings of sessions, therapist handouts for family to take home
and review, (b) reminder cards, post-it notes, charts, message centers on
refrigerators, pictures, “corny sayings,” symbols to remind family members
about the behavior in question, (c) school-home feedback report sheets
with detailed tasks and timelines, and (d) answering machines, beepers,
two-way radios, cell phones.
Problem Solving. Behavior Change techniques often follow a very specific
sequence for resolving problems. First, therapists help to focus on a spe-
cific problem to be addressed. In this process, the therapist helps family
members to punctuate the nature of the problem, who it involves, and
narrows the focus to a manageable goal that can be accomplished in the
session. Second, therapists help family members to utilize the principles
of communication described above to help family members clarify desired
outcomes and agree/negotiate to accomplish the task. Therapists actively
anticipate ways in which problem-solving attempts can be derailed and
provide relational based, non-blaming interventions to maintain a posi-
tive working context. At the conclusion of problem solving, therapists help
family members to review the process of problem solving and to discuss
any agreements or plans that were resolved.
The above examples represent the more common techniques used by
FFT therapists. However, just about any structured activity can repre-
sent a useful technique in FFT Behavior Change, as long as the behav-
iors they create and maintain are consistent with Relational Functions.
Over the years FFT therapists have utilized a wide range of techniques
(e.g., cognitive-behavioral, trauma-focused and experiential) along with
already established cultural practices (e.g., preparing meals together) as
contexts for FFT Behavior Change. Once they become comfortable with the
core construct of “matching,” FFT therapists have found that almost limit-
less techniques are available during this phase of FFT intervention.
The Generalization Phase of FFT

The FFT Therapist as “Family Case Manager.” Families are intertwined
in a vast array of social, legal, cultural, economic, community, and other
systems. FFT not only recognizes this fact, but also incorporates specific
principles which govern the inclusion (as well as exclusion) of these systems
in the treatment planning process. Unlike generic treatment planning which

sometimes wraps services around families and family members with little
consideration of family dynamics, FFT focuses on each individual fam-
ily’s interpersonal and systemic needs when considering adjunctive sup-
port services. In addition, before ideas with face validity are implemented to
advance a treatment plan, it is necessary for a therapeutic alliance to exist
for the family to view these ideas as valid, and the idea must be based on
an understanding of the functional aspect of family behavior. For example,
job training for a 16-year-old male may be viewed as valuable in that it
increases protective factors, supports emancipation, and provides neces-
sary skill building. However, participation in such a program may not be
supported by the mother if it replaces the father’s role with his son and
in doing so enables the father to further disengage from the family. Often,
situations like this are associated with low support by key family members
(e.g., mother becomes too busy or forgets to drive the son to the job training
site on the third day). According to FFT, this noncompliance is predictable
if the son’s previously disruptive behavior functioned to pull the father
into parenting and more importantly into supporting the mother. If for this
same mother, however, taking her son to the job training program is cou-
pled with increased support and involvement from the father to the mother,
then she will be likely to facilitate the increased system involvement of job
training. Again, this paragraph stands as a reminder that the phases of FFT
are developmental, synergistic, and dependent upon one another.
Summary of Generalization Phase. FFT extends or exports family func-
tioning into a variety of community systems, which helps the family as well
as the community. It is our belief that facilitating and managing appropriate
links to adjunctive services often (or usually) must be developed in order
for the treatment effects to be generalized outside of the treatment context
and sustained over time. In doing so, the FFT therapist helps anchor the
family and the family members to a larger supportive community.
We also believe that if this is done without consideration of the family
relational functions these efforts will fail. Because of this, successful inter-
vention cannot begin with this phase of intervention. To simply wrap serv-
ices around a family or family member without considering the impact
on family functioning is to risk destabilizing an already precarious family
process. Thus, the accomplishments of the Generalization Phase are pre-
dicted on successful handling of therapist-family core therapy processes
described above and again summarized below.
BRIEF SYNOPSIS OF THE IDEAL FFT INTERVENTION
Session 1: Engagement, Intake, and Assessment

1. Further develop relationship with all family members that began
during phone contacts, initiate
2. Intake and assessment (if done by the FFT therapist). Otherwise,
Session 1 consists of establishing the relationship with the family.
3. Initiate Motivation Phase by using Change Focus and Change
Meaning techniques.
4. Begin assessment of Relational Functions and observation of family

interaction patterns.
5. End Session with assessment protocol and intake documentation;
schedule next session within 3 days.
Between Sessions 1 and 2

1. Review each family member’s behavior, feelings, and beliefs and
consider additional cultural match issues.
2. Identify unclear relationship dynamics within family and with
extended family or other caregivers.
3. Identify resistance patterns of family members/caregivers.
4. Hypothesize Relational Functions for each family member.
5. Plan specific techniques and strategies to complete assessment.
6. Plan specific therapeutic interventions based on the above.
7. Have additional conversations with all systems involved with the
family (e.g., child welfare worker, school officials/teachers, proba-
tion officers, other treatment providers) to develop relationships and
further the therapist’s understanding of their perspective and expec-
tations of case.
Sessions 2 and 3
1. Repeat techniques from Session 1 and continue to match and build
relationships with family members.
2. Continue to use Change Focus and Change Meaning interventions.
3. Continue assessment.
4. If possible complete Motivation Phase goals.
5. Reschedule next session as needed; high risk families are resched-
uled within 3 days.
Between Session 3 and 4

1. Develop intermediate and long-term change goals that will address
family relational
2. Pattern deficits (e.g., problem solving skills, communication skills,
parenting skills, parent and youth well-being, including specific
issues such as PTSD and substance abuse).
3. Establish positive alternatives that provide a rationale and behav-
ioral focus that matches all family members’ Relational Functions.
4. Review and develop specific behavior change and educational
techniques that will lead to fulfillment of intermediate and long
term goals.
Middle Sessions
1. Apply Behavior Change technology consistent with Relational
Functions to family members.
2. Resistance is feedback that one or more family member’s Relational

Functions have not been met – therapist must return to Motivation
and Assessment.
3. Develop increased family initiative in behavior change and continue
to match Relational Functions.
4. Prompt, look for, and support appropriate family member compe-
tence with steadily decreasing assistance from therapist.
Later Sessions
1. Identify relevant systems and specific individual issues (e.g., voca-
tional deficits).
2. Relapse prevention work is initiated.
3. Generalize specific behavior changes to other family situations.
4. Facilitate independence that is consistent with Relational Func-
tions of family members.
5. Maintain and create new links with extra-familial systems to general-
ize positive intra-family changes.
6. Evaluate quality of life issues and plan for future.
Termination
1. Problem cessation: determined by verbal report and therapist
observation.
2. Spontaneous family process: new interaction styles and attributions
for all family members are observed.
3. Primary risk factors, including safety issues, reduced or eliminated;
protective factors enhanced.
CHANGE MECHANISMS: PROCESS RESEARCH

ON THE CLINICAL INTERIOR OF FFT
One hallmark of evidence-based interventions is the clear articulation

of the presumed underlying mechanisms of action that are responsible
for change, including an understanding of the client processes that need
to be addressed and the therapeutic strategies necessary to alter these
processes. Treatment manuals provide rich theoretical descriptions and
examples for how these clinical processes are manifested within sessions
and over the course of treatment. Intensive research on the clinical inte-
rior of treatment has been an essential component in the development
of FFT. In fact, for over 3 decades, the articulation and understanding
of mechanisms of action in FFT has evolved through a systematic pro-
gram of research and clinical practice. As FFT has matured, the lens for
understanding the mechanisms of action has broadened (as the model
became more complex and multifaceted), but the focus has become even
more sharp and specific (as the targets and treatment strategies became
more well defined and understood). In the section below, we describe
how observational research, including process research, examining what

transpires in therapy sessions, has influenced FFT theory and practice.
Specifically, we present a program of process research that has system-
atically examined the relationship between adaptive (supportive) and
maladaptive (defensive/negative) family interactions and clinical out-
comes, and therapist characteristics and interventions associated with
improvements in these family processes. We conclude this section with
a brief description of our most recent research on building therapeutic
alliances with family members. This program of research has been criti-
cal in the integration of therapeutic strategies for creating a motivational
context for change in FFT.
Research on Understanding and Managing Family Conflict

Specific aspects of negativity and high levels of conflict have been
shown to predict individual, couple, and family problems in both mari-
tal (Gottman & Levenson, 1992; Margolin, Burman, & John, 1989) and
family research (Alexander, Waldron, Barton, & Mas, 1989). In our ear-
liest work with families with a delinquent adolescent, Alexander (1973)
demonstrated that families with a delinquent adolescent expressed higher
rates of system-disintegrating communication (defensive), while families
with non-delinquent youth expressed more system-integrating (support-
ive) communication. Moreover, families with a delinquent adolescent dem-
onstrated higher reciprocity in defensiveness. That is, once defensiveness
was present, there was a greater likelihood that other family members
would respond in like manner, resulting in an escalation or sequences
of strong, pervasive negative interactions. Within the treatment context,
these negative interactions have been shown to be associated with nega-
tive treatment outcomes. For example, Alexander, Barton, Schiavo, and
Parsons (1976) found that the ratio of negative to supportive statements
was significantly higher in cases that dropped out of therapy than among
cases that completed treatment. In turn, premature termination predicted
recidivism in adolescents.
In the field of family therapy; however, research findings suggest that
family conflict/negativity is malleable in treatment. For example, Melidonis
and Bry (1995) demonstrated that therapists could reduce family mem-
bers’ blaming statements and increase their positive statements by asking
questions about exceptions and selectively attending to positive state-
ments. Also, Diamond and Liddle (1996) demonstrated that in successful
resolutions of therapy impasses, therapists were able to create an emo-
tional treaty among family members by blocking and working through
negative affect, and by amplifying thoughts and feelings that promoted
constructive dialogue.
Within FFT, research has not only shown that family negativity is
common among families with behavior problem youth, but also that sys-
tematic interventions aimed at altering the cognitive and affective context
can be highly influential in reducing this negativity. For example, Barton,
Alexander, and Turner (1988) provided evidence about the critical rele-
vance of the current context on family interactions in a basic (non-therapy)
study with delinquent adolescents. This study investigated the effect of

attribution sets on the behaviors of 16 families with a delinquent youth
and 16 families with a non-delinquent youth. Families were audio-taped
during competitive and cooperative experimental situations. As predicted,
families with a delinquent youth expressed significantly lower rates of
adaptive communication in the cooperative set than families with a non-
delinquent adolescent. However, families with a delinquent adolescent
expressed significantly lower rates of negativity in the cooperative set con-
dition than in the competitive set condition.
Alexander, Waldron, Barton, and Mas (1989) further evaluated parents’
data in three studies of families with a delinquent adolescent. Families were
provided with different forms of a positive versus negative interactional
(attributional) context. Study 1 demonstrated that the families exposed
to a negative attributional context demonstrated more negative behaviors
than did families exposed to the positive context when parents interacted
with each other and with their delinquent adolescent. Study 2 demon-
strated that the dispositional attributions of parents were influenced by
the manipulation of set, with a dissatisfied set producing negative blaming
attributions and a satisfied set producing non-blaming, positive attribu-
tions. Study 3 demonstrated that parents’ negative sets regarding their
adolescent’s negative behaviors, once established and discussed by the
family for 5 min, were unresponsive to a subsequent positive reattribution
regarding those behaviors.
Taken together, the data provide some support for reattribution
techniques, which are explicitly focused on expanding the families frame
to include a more workable frame where family members are willing to
try out new behaviors. These observational studies have been critical in
influencing the development (subsequent evolution) of specific interven-
tion strategies, such as relabeling and reframing, and for creating a moti-
vational context conducive to adaptive and supportive family behaviors.
For example, the results of Study 3, demonstrating the stability of defen-
sive interactions, was a precursor to our adoption of a relentless focus on
opening new frames for family members (e.g., systematically attending to
strength-based relational aspects of interactions, reframing, creating rela-
tional themes, particularly during early sessions where interactions are
typically devoid of positive sentiments and affective connections between
family members).
Applying this knowledge to therapy sessions, Robbins et al. (1996)
examined the impact of specific types of therapist intervention (e.g.,
reframing, reflection, and structuring) on family members’ negative
attitude during the initial session of FFT with a delinquent adolescent.
Therapist interventions and family member behaviors were coded at
the speech act level. Family members’ immediate responses to thera-
pist interventions were compared. The results revealed that (a) across
all therapist’s interventions, adolescents demonstrated significantly
more negative attitude than mothers following therapist behaviors, but
(b) adolescents’ attitudes improved from negative to neutral following
therapist reframes. Thus, reframing may be used as a tool for decreasing
adolescents’ negativity in therapy.
In a subsequent investigation, Robbins, Alexander, and Turner (2000)

further examined the impact of therapist interventions on family processes.
Similar to the previous study, the immediate effects of therapist reframing,
reflection, and structuring interventions on family member behaviors were
compared; however, to control for previous family member status, only
those therapist interventions that followed family member defensive state-
ments were included in the analysis. Results demonstrate that reframing
is more effective than reflection and structuring statements in reducing
family members’ negative behaviors. In addition, the results not only rep-
licated the previous finding that adolescents respond more favorably to
reframes than do mothers and fathers, but also provide evidence of the
effectiveness of reframing for all family members.
Within the treatment context, we have also conducted a series of stud-
ies examining the complex relationships between therapist gender and fam-
ily support/negativity in therapy sessions. For example Warburton, Alexander,
and Barton (1980) demonstrated that mothers expressed significantly
higher rates of supportive behaviors to female therapists and that this
gender-linked pattern was not evident with fathers and male therapists.
However, fathers displayed significantly higher rates of negative behaviors
to female therapists. Female therapists likewise showed elevated rates of
negativity to fathers.
Building on this research, Newberry, Alexander, & Turner (1991)
examined the effects of therapist and client sex roles on the behaviors of
34, two-parent families with a delinquent adolescent that received FFT.
In this study, therapist and client behaviors during the first phase of
therapy were transcribed and divided into thought units. Each thought
unit was classified as supportive, structuring (relational command or
demand), pejorative (defensive), or non-therapy related. While molar
rates of coded behaviors did not differentiate effects of therapist or par-
ent gender, microsequential analyses (contingency analysis – Z statistic)
detected different gender-linked sequential dependencies of therapist
and client behaviors. In particular, results indicated that family members
responded differently to male and female therapist behaviors. For exam-
ple, both mothers and fathers were significantly more likely to respond
supportively to female therapist supportive statements than to male ther-
apist supportive statements. Also, fathers were more likely to respond
supportively to therapist structuring than were mothers. Interestingly,
the results suggested that female and male therapists also responded
differently to client behaviors. Specifically, female therapists were more
likely than male therapists to respond to client supportive statements
with structuring statements.
In a recent process study, we examined the relationship between family
members’ alliance with therapists and dropout (Robbins, Turner, Alexander,
& Perez, 2003). In this study, we found that the balance (parent–therapist
alliance minus adolescent–therapist alliance) was a better predictor of
engagement/retention in treatment than the overall level of alliance. In
fact, the overall level of alliance with therapist was actually misleading,
with the highest levels of alliance observed among parents in the families
that dropped out of treatment. Therapists that were able to achieve a more
balanced or similar level of alliance with parents and adolescents were

more likely to keep the families engaged in treatment.
How therapists negotiate early sessions in FFT to build balanced
alliances with family members and manage family negativity is currently
being examined in our most recent evaluation of the clinical interior of
treatment. For example, Robbins, Turner, Alexander, Liddle and Szapocznik
(2010, in preparation) demonstrate that families that engage in treatment
have a significantly higher level of balance in therapist support to family
members (support to parents minus support to adolescent) than fami-
lies that dropout of treatment. And, perhaps more importantly, therapists
in the dropout cases appear to have a higher rate of support to parents
than therapists in the families that are successfully retained in treatment.
In addition, the results indicated that family negativity was significantly
higher for the dropout families than the families that completed treat-
ment. Taken together, these findings suggest that therapists who success-
fully engage families into treatment are able to effectively achieve balanced
alliances with family members by engaging in higher rates of supportive
interventions to adolescents (compared to parents) than are therapists of
cases that dropout of treatment. Support to parents and adolescents is still
critical; however, in that the overall level is more balanced in the completer
families than the dropout families. Given that adolescents are frequently
the target of much of the negativity that is expressed in therapy sessions
(Robbins et al., 2003), it is not surprising that a systematic attempt to
support their perspective is associated with positive outcomes, such as
engagement in FFT.
SUMMARY OF THE FFT MODEL AND CORE ELEMENTS
FFT is a relational, family-based, ecosystemic, communication theory,

and cognitive–behavioral-based model, with consideration of intrapsychic
(or at least intra-individual) factors and biogenic influences. FFT produces
change through a phase-based process (Engagement, Motivation, Rela-
tional Assessment, Behavior Change, Generalization/Ecosystemic focus).
These phases are wrapped in, and informed by core concepts of match-
ing, non-blaming relational focus, balanced alliance and respectfulness
with all family members. Various theoretical models have informed the
development of FFT but none has been adopted in its entirety. Instead,
FFT recognizes that each perspective, and the processes they assume
to be relevant to successful treatment, may be more or less influential
or appropriate in any given family. FFT is an “integrative” model which
allows us to conceptualize families and problem behaviors, as well as
family strengths, from various perspectives depending on a number of
contextual variables. However, these perspectives must not be mutually
exclusive nor represent paradigm shifts or clashes with respect to FFT
core principles.
FFT therapist are trained and supervised to be clear about the overall
principles and perspective that guides the integrative process. Our “default
mode” is relational and respectful, but it is accommodating enough to utilize
other perspectives as long as they are consistent with the core FFT model
and they help the therapist understand and intervene with this particular
family, effectively, at this particular time.
And finally, FFT represents a motivational and a systems model; that
is, the behaviors we address clinically are assumed to be “internally”
motivated by the people evincing them, yet also “co-influenced” by others
in the environment. As such, FFT is both an individual and a relational
model. This fact, in reality, makes FFT a complex and rich interven-
tion, and places demands for accountability and thoughtful behavior on
therapists, trainers, dissemination vehicles, and treatment programs. If
families were simple, so too should be a treatment program. If families
are complex and challenged on multiple levels and domains, successful
treatment requires that our intervention models match those levels and
domains. At the same time, this reality best fits the realities of troubled
families, in which the whole is indeed more than the sum of the parts,
but the parts each contribute their unique variance to the functioning of
the whole.
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10

Functional Family Therapy

James F. Alexander ● University of Utah

dissemination across populations, cultures, and treatment contexts. Not

BRIEF HISTORY OF THE DEVELOPMENT OF FFT

FFT is viewed as an empirically supported model for adolescent drug

As evident in the references above, FFT has been profoundly influenced

CLINICAL MODEL OVERVIEW

FFT consists of five major components in addition to pre-treatment

The Big Picture: Integrating FFT with Other Systems *

Assessment Assessment Assessment

The Youth / Family Management System(s):

Fig. 10.1. The phases of FFT within treatment and community systems.

The First Phase: Engagement in Change

The Second Phase: Motivation for Change

schema through which all information is filtered, and their interactions

Change Focus Techniques

Sequencing. The third change focus technique, sequencing behavior

FFT interventions.­ Even simple reflections or acknowledgements of

Change Meaning Techniques

in our clinical trials and multiple replications. Research on reframing has

Coupled with our core generic principles of matching and respectfulness,

Assessment in Early Phases (Engagement and Motivation):

the central tendency (or apparent “default mode,” or “average”) behavioral

Finally, the assessment of relational functions is essential if therapists

Transitioning between Engagement & Motivation

Specific Elements of Behavior Change

feature of communication training in FFT is to enhance Source Responsibil-

Therapists help family members to be more effective Active Listeners

Basic Parenting Principles/Techniques

influence technique that is most commonly used by FFT therapists because

The Generalization Phase of FFT

in the treatment planning process. Unlike generic treatment planning which

BRIEF SYNOPSIS OF THE IDEAL FFT INTERVENTION

Session 1: Engagement, Intake, and Assessment

4. Begin assessment of Relational Functions and observation of family

Between Sessions 1 and 2

Between Session 3 and 4

2. Resistance is feedback that one or more family member’s Relational

CHANGE MECHANISMS: PROCESS RESEARCH

One hallmark of evidence-based interventions is the clear articulation

how observational research, including process research, examining what

Research on Understanding and Managing Family Conflict

study with delinquent adolescents. This study investigated the effect of

In a subsequent investigation, Robbins, Alexander, and Turner (2000)

balanced or similar level of alliance with parents and adolescents were

SUMMARY OF THE FFT MODEL AND CORE ELEMENTS

FFT is a relational, family-based, ecosystemic, communication theory,

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FFT interventions. Even simple reflections or acknowledgements of