1. Functional Family Therapy Clinical Training Program Case Conceptualization & Case Planning Webinar #3 Thomas L. Sexton, Ph.D., ABPP Functional Family Therapy Associates Inc.

2. 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 case Planning for the phase Planning for the phase Planning for the session Planning for the session 3.Review the role of the Progress Notes & Case Planning guides in case conceptualization and planning

4. What does it take? A therapist that…… Looks through a “lens” Looks through a “lens” Follows a Model……follow the “map” Follows a Model……follow the “map” Creates and implements a “unique case plan” for each family Creates and implements a “unique case plan” for each family Use “in the room” experiences to promote change (change mechanisms) Use “in the room” experiences to promote change (change mechanisms) Creatively Adapt..... Creatively Adapt..... Matching to the client Matching to the client adapting next response to” adapting next response to” match client/context match client/context add what was not understood/missed add what was not understood/missed Iterative Process….evolves over time Iterative Process….evolves over time

5. 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 Thinking FFT What you do outside the room Case conceptualization Put client story into core principles Thinking through the lens Planning What you do outside the room 1. 1.Case planning 2. 2.Session planning Goal (which one is most important) Progress (progress in achieving the goal)

6. Keys to success in FFT Model specific Case conceptualization Model specific Case conceptualization Model & client driven planning Model & client driven planning In a way that…. In a way that…. Matches the family process Matches the family process Matches the families way of functioning Matches the families way of functioning That is relevant and important to them That is relevant and important to them That helps reduce risk factors That helps reduce risk factors Reduces the likelihood of future behavior problems Reduces the likelihood of future behavior problems Empowers the family to keep changes going Empowers the family to keep changes going

7. Functional Family Therapy Case Conceptualization What lets you make model specific and client center actions that help

8. Case Conceptualization Understanding the Family through the FFT “lens” Understanding the Family through the FFT “lens” – Presenting Problem – How the family functions Problem definitions Problem definitions Relational patterns Relational patterns Relational functions Relational functions – The multisystemic context…. Of the problem Of the problem Of the family Of the family – Risk and protective factors

9. Example Regina (14 years old) Regina (14 years old) Referred to mental health center from juvenile court Referred to mental health center from juvenile court History of difficulties History of difficulties Early school problems Early school problems Hospitalization Hospitalization Most recently…. Most recently…. – Drug use (mj) – Drug rehab residential treatment Other problems in the family Other problems in the family

10. Initial Questions Is this an FFT case? Is this an FFT case? How and what “lens” to use in understanding Regina How and what “lens” to use in understanding Regina Where to start (in FFT) Where to start (in FFT) How will therapy proceed? How will therapy proceed? What is a possible outcome? What is a possible outcome? (much of this you know….without any more information!) by listening with FFT “ear”

11. Listening with an FFT ‘ear’ Client Story (Events) (Events) (details of the case….history….purpose for the referral) Translating into relational pattern relational pattern Relational Patterns (holistic understanding /where to intervene) Relational Function (to match to client) Problem Definitions (to translate into Family Focused organizing theme-identify What is “important” to the individual Risk & Protective Factors (what to add to BC) Context (multisystemic context- Who is involved)

12. What to ask yourself …. “ What does this tell me about what is important to this person?” “ 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?” “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?” “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?” “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.

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

14. Culture Mom/mother figure Dad/father figureAdolescent How does the family Function/what role does the problem play Environmental Context Ecosystemic system Peer Group School Community Risk Factor Risk Factor Risk Factor Risk Factor Protective Factor Protective Factor Protective Factor Protective Factor

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

16. 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 : “Whatever….later, I am going out…., I’ll be home…..” 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…” Regina: “ At least I have friends…later…” he goes out. Anja : (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support Anja: is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation…… Stepfather: …continues watching the football game…worries about his wife…gets angry with Peter…..” Regina: (comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room… Stepfather: … ”I am tired of this…what is the matter with you…don’t you know how this hurts your mother?” Peter : “Fuck off..” the typical argument ensues until Peter goes to his room Anja : “What are we going to do..I can’t take this any more… ” Regina : “I am sorry Mom…but, I can handle it” Anja : “I just worry about you” (she feels comforted that he understands) 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…. 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…” Relational Patterns Common/typical “way” they interact

17. “ Problems” are embedded in the context “ Problems” are embedded in the context – They are relationally based Family has been functioning for some time….encountered problem that has become “part” of the family….now “functions” as a central part of how they relate Family has been functioning for some time….encountered problem that has become “part” of the family….now “functions” as a central part of how they relate – Not what they “want” – Not what they “need” – They way in which they have come to “be” in response to the “problem” What is the Problem?

18. Story takes the form of problem definitions Mom/mother figure Dad/father figure Adolescent Referral Behavior Problem “definition -what the problem is -why its an important problem -what should be done about it Problem “definition -what the problem is -why its an important problem -what should be done about it Problem “definition -what the problem is -why its an important problem -what should be done about it

19. 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 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: This definition is usually: – focused on “a person” (attributional component) – has negativity attached(emotional component) – is accompanied by blaming interactions that have become central to the relational patterns of the family (behavioral component)

20. Relational Functions Functional outcomes of these patterns Functional outcomes of these patterns Relational “glue” Relational “glue” Stable and consistent Stable and consistent Mom/mother figure Dad/father figure Adolescent Clinical Symptoms Match to… The goal…. Reduce the future Probability of the “problem behavior” Targets of Change -underlying patterns of FAMILY behavior

21. Relatedness Assessment Mom Adol Dad 3 3 1 1 3 1 Mom Adol

22. When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior is characterized by: RelationalIndependenceAutonomy:distance,Independence,Disengagement)highlow Interdependency: closeness, dependency, enmeshment lowhigh 1 2 4 5 3 Mid- pointing pointing

23. Case conceptualization in the “real world” Given all you have to do…..thinking in this complex way is very difficult Given all you have to do…..thinking in this complex way is very difficult In the “real world”… In the “real world”… What you do out of the room What you do out of the room Aided by the FFT progress notes 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

24. Functional Family Therapy Case Planning What to do in the next session, session, phase etc.

25. Treatment Planning Understanding the Change process…the map of change 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

26. Treatment Plan EarlyMiddleLate Reduce within family risk factors - negativity/blame -hopelessness -build engagement/ reduce dropout Behavior Change MotivationEngagement GeneralizationGeneralization Build within family protective factors - behavior competencies -interaction change -that increase probability of - behavior Build family to context protective /reduce risk factors-peers/school/communityEarlyMiddleLateAssessment Intervention

27. Case Planning Systematic process that includes Systematic process that includes – Next session planning Goals of the phase Goals of the phase “What needs to be done next?” “What needs to be done next?” – Long term goals….. Obtainable change Obtainable change What matches the family What matches the family The smallest change that will make a differences The smallest change that will make a differences

28. Session Plan Motivation Intervention Assessment Engagement Behavior Change Generalization GeneralizationEarlyMiddleLateGoal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals Goal -phase/intermediate objectives Skills -therapist actions that have high probability of reaching those goals

29. What therapy changes Individual Mom/mother figure Dad/father figure Adolescent 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

30. Long Term Outcome Goals The behavioral outcome goals of therapy are those that are obtainable and lasting The behavioral outcome goals of therapy are those that are obtainable and lasting not healthy families but…….. not healthy families but…….. obtainable behavioral changes obtainable behavioral changes...are those that are:...are those that are: – obtainable behavioral changes … – for these people … – with these resources … – and these value systems … – in this context

31. Case Plan Based on: Based on: the model the model matching to the client matching to the client Case conceptualization--understanding clients relationally--understand problems relationally Case conceptualization--understanding clients relationally--understand problems relationally FFT’s Systematic Change Model FFT’s Systematic Change Model A model focused yet client/clinically responsive process…. A model focused yet client/clinically responsive process…. – Systematic and flexible… – The therapist “anchor” and “lens”…. – The source of therapist creativity

32. Example Regina Regina – Early goals: Alliance-common problem definition, goals & bond Alliance-common problem definition, goals & bond Shared family focused problem definition Shared family focused problem definition Reduction in blame/negativity Reduction in blame/negativity – Intermediate goals: Problem solving Problem solving Conflict management Conflict management – Long Term goals Family can manage supervision, work out problems Family can manage supervision, work out problems

33. Engagement/Motivation Sessions Goals reduce within family blame reduce within family blame reduce within family negativity reduce within family negativity build therapeutic alliance build therapeutic alliance redefine problem as family focused redefine problem as family focused increase hope/expectation for change increase hope/expectation for change Assessment problem definitions problem definitions Problem sequence Problem sequence How they “function” or work together How they “function” or work together Interventions reframing reframing Develop an organizing theme that is family focused Develop an organizing theme that is family focused diverting and interrupting diverting and interrupting structuring session to discuss relevant topics structuring session to discuss relevant topics

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

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

36. Generalization Sessions Goals Generalize the BC target skills to other areas Generalize the BC target skills to other areas Maintain change through relapse prevention Maintain change through relapse prevention Access external resources to support change Access external resources to support change Interventions Relapse prevention (if the family is falling back into problem behaviors) Relapse prevention (if the family is falling back into problem behaviors) Linking new problem situation to BC skill Linking new problem situation to BC skill Linking family to relevant outside resources Linking family to relevant outside resourcesAssessment Identify external family systems to apply BC skills Identify external family systems to apply BC skills Identify contextual barriers to maintaining the BC target Identify contextual barriers to maintaining the BC target Find areas to generalize Find areas to generalize Identify relapse points Identify relapse points

37. Using the FFT Progress Notes

38. Using the FFT PN

39. Process/Phase Goals Importance over time

40. Using the FFT Session Planning Guides

43. Keys to success in FFT Model specific Case conceptualization Model specific Case conceptualization Model driven planning Model driven planning In a way that…. In a way that…. Matches the family process Matches the family process Matches the families way of functioning Matches the families way of functioning That is relevant and important to them That is relevant and important to them That helps reduce risk factors That helps reduce risk factors Reduces the likelihood of future behavior problems Reduces the likelihood of future behavior problems Empowers the family to keep changes going Empowers the family to keep changes going

44. What does it take? A therapist that…… Looks through a “lens” Looks through a “lens” Follows a Model……follow the “map” Follows a Model……follow the “map” Creates and implements a “unique case plan” for each family Creates and implements a “unique case plan” for each family Use “in the room” experiences to promote change (change mechanisms) Use “in the room” experiences to promote change (change mechanisms) Creatively Adapt..... Creatively Adapt..... Matching to the client Matching to the client adapting next response to” adapting next response to” match client/context match client/context add what was not understood/missed add what was not understood/missed Access change....did it work? Access change....did it work?

45. Questions? Questions? Next Steps Next Steps