Functional Family Therapy

Clinical Training Program Case Conceptualization & Case Planning

Webinar #3 Thomas L. Sexton, Ph.D., ABPP Functional Family Therapy Associates Inc.

Training Goals

1. Discuss the role of case conceptualization as a foundation for FFT treatment 2. Identify the critical elements of case planning • • • Planning for the case Planning for the phase Planning for the session 3. Review the role of the

Progress Notes & Case Planning guides

in case conceptualization and planning

What does it take? A therapist that……

• • • • Looks through a “lens” Follows a Model……follow the “map” Creates and implements a “ unique case plan” for each family Use “in the room” experiences to promote change (change mechanisms) • •

Creatively Adapt.....

• Matching to the client •

adapting next response to ”

• match client/context • add what was not understood/missed

Iterative Process….evolves over time

•

Thinking FFT

What you do outside the room

•

Case conceptualization

Put client story into core principles • Thinking through the lens

Doing FFT

what you do in the room

-reframing problems/blame/negativity -interrupting negative behavioral patterns -promoting the use of new behavioral competencies -generalizing change • •

Planning

What you do outside the room

2.

1.

Case planning Session planning Goal (which one is most important) Progress (progress in achieving the goal)

Keys to success in FFT

• • • Model specific Case conceptualization Model & client driven planning

In a way that…

.

• • • • • • Matches the family process Matches the families way of functioning That is

relevant

and

important

to them That helps reduce risk factors Reduces the likelihood of future behavior problems Empowers the family to keep changes going

Functional Family Therapy Case Conceptualization

What lets you make model specific and client center actions that help

Case Conceptualization

• Understanding the Family through the FFT “lens” – – Presenting Problem – • • How the family functions • • Problem definitions Relational patterns • Relational functions The multisystemic context….

Of the problem Of the family – Risk and protective factors

Example

• • • • • Regina (14 years old) Referred to mental health center from juvenile court – – History of difficulties • • Early school problems Hospitalization Most recently….

Drug use (mj) Drug rehab residential treatment Other problems in the family

Initial Questions

• • • • • Is this an FFT case?

How and what “lens” to use in understanding Regina Where to start (in FFT) How will therapy proceed?

What is a possible outcome?

(much of this you know….without any more information!) by listening with FFT “ear”

Listening with an FFT ‘ear’

Client Story

(Events) Translating into

(holistic understanding /where to intervene) organizing theme-identify What is “important” to the individual Context (multisystemic context Who is involved) Relational Function (to match to client) Risk & Protective Factors (what to add to BC)

• • • •

What to ask yourself ….

“ What does this tell me about what is important to this person?” –

The answer to this question helps the therapist know what to acknowledge in reframing .

“What does this tell me about their relational patterns and how they link the family members together?” –

This assessment helps the therapist develop a family-focused way of understanding how the presenting problem functions.

“What does this tell me about the biological, historical, and relational things that family members bring to any interaction that will help me understand why they are reacting this way?” –

This assessment helps the therapist determine where the energy and emotion might come from and also helps identify what to acknowledge in the reframing process .

“To what cause are they attributing the problem? What is the problem definition?” –

This assessment helps the therapist identify the target for blame and form a target for reframing.

Ecosystemic System

Peer/school/community/extended family Clinical Symptoms/Behaviors Family Relational System Internal World Biological Substrate/Learning History/individual traits ( Sexton & Alexander, 2004)

Ecosystemic System

Peer/school/community/extended family

How does the family Function/what role does the problem play

Environmental Context

Ecosystemic system

Risk Factor Risk Factor

Culture School

Protective Factor Protective Protective Factor Factor Protective Factor

Peer Group Community

Risk Factor Risk Factor Adolescent Dad/father figure Mom/mother figure

Why are things so important? • Where people come from (relational context) – Types of relationships…with parents/family • What people are made of ….(biological context) • The environment in which they live ( ecosystemic context) – Peers/schools/mental health system/community

Client Story

The “why” things are so important, meaningful, etc.

Anja: “ Regina have you done…””you know you are getting behind”….”you need to take some responsibility” (escalating the longer she doesn’t answer) Regina: “I can handle it Mom…just keep that bastard away from me…” (he feels better about his Mom….he directs his anger at his step father….). The next night he goes out again….

Regina: “Whatever….later, I am going out…., I’ll be home…..” Regina: “I am sorry Mom…but, I can handle it” Anja: “I just worry about you” (she feels comforted that he understands) Anja: “there is no going out for you….it just isn’t good for you…..you know you can’t say no to those friends of yours…” goes out. Anja: “What are we going to do..I can’t take this any more… ” Regina: “

Relational Patterns Common/typical “way” they interact

like your support

Regina:

(comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room…

Stepfather:

Peter…..” …continues watching the football game…worries about his wife…gets angry with

Anja:

is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation…… Stepfather: … When she talks, he continues to watch to TV…..he listens quietly and say…”what do you want me to do…he wasn’t raised right…” Stepfather: … mother?” ”I am tired of this…what is the matter with you…don’t you know how this hurts your

Peter

: “Fuck off..” the typical argument ensues until Peter goes to his room

What is the Problem?

• • “ Problems” are embedded in the context – – – – They are relationally based Family has been functioning for some time….

“functions” as a central part of how they relate encountered problem that has become “part” of the family….now Not what they “want” Not what they “need” They way in which they have come to “be” in response to the “problem”

Problem “definition -what the problem is -why its an important problem -what should be done about it

-what the problem is -why its an important problem -what should be done about it

Referral Behavior Adolescent Dad/father figure Mom/mother figure Problem “definition -what the problem is -why its an important problem -what should be done about it

• What does this tell you

Family “problems” are relational problems

• •

In their attempt to solve/deal with the problems….

Family come to therapy with a “definition” of what is the problem – Result of each family members experience and thinking/working to understand their life/problems – Natural part of finding a solution This definition is usually: – – – focused on “a person” ( has negativity attached

attributional component

) (

emotional component

) is accompanied by blaming interactions that have become central to the relational patterns of the family (

behavioral component

)

Targets of Change -underlying patterns of FAMILY behavior Clinical Symptoms The goal….

Reduce the future Probability of the “problem behavior ” Adolescent Dad/father figure Mom/mother figure Match to… Relational Functions • Functional outcomes of these patterns • Relational “glue” • Stable and consistent

Relatedness Assessment

3 1 3 3 1 Dad 1

When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by:

high Relational Independence Autonomy: distance, Independence, Disengagement ) 1 2 3 Mid pointing low low Interdependency: closeness, dependency, enmeshment 4 5 high

Case conceptualization in the “real world” • • Given all you have to do…..thinking in this complex way is very difficult In the “real world”… • • What you do out of the room Aided by the FFT progress notes – – – Walk you step by step through case conceptualization Make sure you don’t get lost Help you overcome your own values and biases – Happens over time….

Iterative

– – Not as a stage….but as treatment is going on Building a “picture of the family” in which you add more and more

Functional Family Therapy Case Planning

What to do in the next session, session, phase etc.

Treatment Planning

• • Understanding the Change process…the map of change – – – Phases (what is first, second, third….) Mechanisms to use in achieving the phase goals Family focused/driven outcomes that are obtainable and relevant

planning is the way to bring the content and the process of therapy together

Treatment Plan

Engagement Reduce within family risk factors Early negativity/blame -hopelessness -

build engagement/ reduce dropout

Motivation Behavior Change Generalization Build within family Assessment protective factors Middle Build family to context

-that increase probability of - behavior

Behavior Change factors -peers/school/ community Generalization Early Middle Late

Case Planning

• Systematic process that includes – • • Next session planning Goals of the phase “What needs to be done next?” – • • • Long term goals…..

Obtainable change What matches the family The smallest change that will make a differences

Session Plan

Engagement Motivation Early Behavior Change Generalization Assessment Intervention Behavior Change Generalization Middle Late

What therapy changes

Individual Adolescent Dad/father figure Mom/mother figure 1. Most critical issue solved…and 2. Prepared for the next “problem” -cope/deal with in a new way -empowered with a “way” To solve future

Long Term Outcome Goals • • The behavioral outcome goals of therapy are those that are obtainable and lasting • • not healthy families but……..

obtainable behavioral changes ...are those that are: – obtainable behavioral changes … – for these people … – – with these resources … and these value systems … – in this context

Case Plan

• – – – • • • • Based on: the model matching to the client Case conceptualization--understanding clients relationally--understand problems relationally • FFT’s Systematic Change Model

A model focused yet client/clinically responsive process….

Systematic and flexible… The therapist “anchor” and “lens”….

The source of therapist creativity

Example

• Regina – • • •

Early goals

: Alliance-common problem definition, goals & bond Shared family focused problem definition Reduction in blame/negativity – • •

Intermediate goals

: Problem solving Conflict management – •

Long Term goals

Family can manage supervision, work out problems

Engagement/Motivation Sessions

Goals • reduce within family blame • reduce within family negativity • build therapeutic alliance • redefine problem as family focused • increase hope/expectation for change Assessment • problem definitions • Problem sequence • How they “function” or work together

Interventions

• reframing • Develop an organizing theme that is family focused • diverting and interrupting • structuring session to discuss relevant topics

Behavior change sessions Goals

• Specify the behavior change “individualized plan” • Link BC targets to the organizing theme to build relevance and motivation • Build compliance • match to the client • check if the BC target works to solve conflict Assessment • Identifying prosocial family based skill that fits youth/family problem sequence • Find barriers to adoption of BC skill • Determine if the target is being performed (compliance)

Interventions

• reframing • Modeling • Teaching • Overcome barriers/adapt

Discussion focused on: homework, going out with peers, curfew -specific spot in the sequence Parent Adolescent Where they use: Work out problems…our focus is on their process of doing so Targets of FFT Behavior Change Parenting monitoring and supervising With components of….

to individualize to the family Communication direct and concrete communication Conflict Management Problem Solving

Generalization Sessions Goals

• Generalize the BC target skills to other areas • Maintain change through relapse prevention • Access external resources to support change Assessment • Identify external family systems to apply BC skills • Identify contextual barriers to maintaining the BC target • Find areas to generalize • Identify relapse points

Interventions

• Relapse prevention (if the family is falling back into problem behaviors) • Linking new problem situation to BC skill • Linking family to relevant outside resources

Using the FFT Progress Notes

Using the FFT PN

Process/Phase Goals Importance over time 4 3,5 3 2,5 2 1,5 1 0,5 0 Blame reduction Negativity reduction Alliance Family Focus problem session 1 session 2 session 3 session 4

Using the FFT Session Planning Guides

Using the FFT Session Planning Guides

Using the FFT Session Planning Guides

Keys to success in FFT

• • • Model specific Case conceptualization Model driven planning In a way that….

• • • • • • Matches the family process Matches the families way of functioning That is relevant and important to them That helps reduce risk factors Reduces the likelihood of future behavior problems Empowers the family to keep changes going

What does it take? A therapist that……

• • • • Looks through a “lens” Follows a Model……follow the “map” Creates and implements a “ unique case plan” for each family Use “in the room” experiences to promote change (change mechanisms) • •

Creatively Adapt.....

• Matching to the client •

adapting next response to ”

• match client/context • add what was not understood/missed

Access change.

...did it work?

• • Questions?

Next Steps