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Functional Family
Therapy for Adolescent
Behavior Problems
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Functional Family
Therapy for Adolescent
Behavior Problems
James F. Alexander
Holly Barrett Waldron
Michael S. Robbins
Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication may
be reproduced or distributed in any form or by any means, including, but not limited to, the
process of scanning and digitization, or stored in a database or retrieval system, without the
prior written permission of the publisher.
Published by
American Psychological Association
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The opinions and statements published are the responsibility of the authors, and such
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Psychological Association.
Library of Congress Cataloging-in-Publication Data
Alexander, James F.
Functional family therapy for adolescent behavior problems / authored by James F. Alexander,
Holly Barrett Waldron, Michael S. Robbins, and Andrea A. Neeb.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4338-1294-1 ISBN 1-4338-1294-0 1. Functional Family Therapy
(Program) 2. Family psychotherapy. 3. Behavior therapy for teenagers. I. Title.
RC488.5.A432 2013
616.89'156dc23
2012038947
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
http://dx.doi.org/10.1037/14139-000
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Contents
Introduction................................................................................................... 3
I. Clinical Foundations and Research Support....................................... 15
Chapter 1.
Chapter 2.
Chapter 3.
Chapter 5.
Engagement Phase............................................................ 77
Chapter 6.
Motivation Phase............................................................. 87
Chapter 7.
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Chapter 8.
Chapter 9.
Chapter 10.
Chaper 12.
Chapter 13.
References.................................................................................................. 233
Index.......................................................................................................... 247
About the Authors.................................................................................... 259
vi contents
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Functional Family
Therapy for Adolescent
Behavior Problems
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Introduction
Adolescents with behavior problems go by various labels, such as difficultto-treat adolescents, juvenile delinquents, at-risk youth, violent youth, and youthful offenders. They may have disruptive behavior disorder or substance abuse
disorder, and they may be involved with the criminal justice system. These
youth have problematic behaviors, emotions, and ways of thinking that often
affect not only their families, but also their community. These youth, their
families, and their successful treatment represent the focus of this book.
Whatever labels are used to describe them, these adolescents represent
one of the most difficult and recalcitrant treatment populations. Although
family members are often dissatisfied with the youths behavior and intensely
focused on the need for him or her to change, the youth rarely self-refers and
often seems undisturbed by his or her own behaviors. The impetus for treatment often stems from problems that are identified in the youths immediate
social spheres (e.g., family or school) or formal social systems (e.g., juvenile
DOI: 10.1037/14139-001
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett
Waldron, Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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Because families often resist change, FFT first seeks to motivate family members to change and strengthen family interactions. Only after these
initial goals are met does FFT proceed to target the presenting problem (i.e.,
the adolescents problem behavior). Obviously, in most instances, the specific
bottom-line outcomes that are desired by FFT therapists, the parents, and
the referral source (e.g., juvenile justice or mental health system) are heavily
influenced, if not defined, by the nature or source of the referral. Therapists
and treatment systems usually are asked to target such goals as preventing
rearrest, reducing recidivism, preventing self-cutting, getting youth back into
school, preventing out-of-home placement, eliminating drug abuse, and the
like. However, FFT adds a broader view of the change process and clinical
outcomes. In FFT, treatment consists of a series of phases, each involving
a set of intervention processes (assessment and implementation of specific
techniques) and relevant outcomes. The phases are designed not only to
meet immediate, externally imposed outcome criteria but also to help recalibrate family interaction patterns so that more positive family relations will
continue beyond treatment, thus encouraging family members to establish or
reestablish and then maintain new, positive trajectories.
FFT is highly effective. It has been evaluated in more than two dozen
treatment outcome studies focusing on a range of adolescent problem behaviors. The efficacy and effectiveness of FFT have been replicated across sites
and settings (e.g., Barton, Alexander, Waldron, Turner, & Warburton, 1985;
Gordon, Graves, & Arbuthnot, 1995; Waldron & Turner, 2008), across different ethnic and cultural groups (e.g., Alexander, Pugh, & Parsons, 1998;
Flicker, Waldron, Turner, Brody, & Hops, 2008; Waldron, Slesnick, Brody,
Turner, & Peterson, 2001), and across service providers with diverse backgrounds and training (e.g., Barton et al., 1985). FFT is associated with higher
engagement and retention in treatment (e.g., Gordon, Arbuthnot, Gustafson,
& McGreen, 1988; Waldron et al., 2001) and is a well-established treatment
for juvenile delinquent youth and for adolescents with conduct and substance
use disorders (cf. Alexander et al., 1998; Waldron & Turner, 2008). Moreover,
evidence has been found for the preventive effects of FFT for siblings of problem youth and for the long-term effectiveness of the intervention (Klein,
Alexander, & Parsons, 1977). Usually, this prevention effect consists of parents and younger siblings avoiding the behavior patterns of the referred youth.
These results have led the Center for Substance Abuse Prevention and
the Office of Juvenile Justice and Delinquency Prevention to identify FFT as
an exemplary program for both substance abuse and delinquency prevention
(Alverado, Kendall, Beesley, & Lee-Cavaness, 2000). Similarly, the Center
for the Study and Prevention of Violence reviewed more than 1,000 programs
to identify research-based prevention and treatment programs for youth
violence and drug abuse (http://www.colorado.edu/cspv/blueprints/). FFT
introduction
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E
n
g
a
g
e
m
e
n
t
PreTreatment
Behavior
Change
Motivation
Relational
Assessment
Generalization
Session
8+
PostTreatment
up by the time they see an FFT therapist. The degree to which family members
remain in treatment relates to the extent to which therapists are able to
modify negative attributions, reduce conflict, build balanced alliances with
family members early in treatment, and create a framework for families that
spurs their desire for better relationships and better outcomes. This frontloading differentiates FFT from the majority of community-based treatment
approaches, and we believe it is largely responsible for our high retention and
completion rates with families who historically are low in both.
Brief descriptions of each phase follow. Table 1 provides a quick summary of the goals, targeted factors, therapist skills, intervention focus, and
indicators of success for each phase.
Engagement Phase
The goal of the initial Engagement Phase is to enhance family members
perceptions of responsiveness and credibility. As Figure 1 shows, the goals
and techniques of this phase are in effect before the first session begins. From
the first telephone contact with the family, therapists demonstrate a desire to
listen, help, respect, and respond to the family. This phase includes launching therapy in a way that is respectful of any potential issues that may arise in
relation to culture and ethnicity, including factors such as the racial and ethnic sensitivity of therapists and family members and the need for treatment in
the family members language of choice. Thus, from the outset, interventions
are designed to ensure cultural competence and respect.
The main skills required are demonstrating qualities consistent with
positive perceptions of clients, persistence, and cultural and population sensitivity. The therapists focus is on immediate responsiveness and maintenance
of a strength-based relational focus. Therapist activities include ensuring high
8 functional family therapy for adolescent behavior problems
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introduction
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Therapist skills
Maximize familys
initial expectation of positive
change
Engagement
Goal
Element of
each phase
Intelligence
Perceptiveness
Individual skills
or behaviors
associated
with problem
behaviors
Intrafamilial and
extrafamilial
patterns of
behavior
Family negativity
and blame
Hopelessness
Balanced alliances
Interpersonal
skills (validation,
positive reattribution, reframing, relational
skills)
Identify relational
functions
(connectedness, hierarchy)
in the family
Relational
Assessment
Motivation
Directive, teaching,
structuring skills
Modeling
Setting up, leading,
and reviewing
in-session tasks
Assigning homework
Youth temperament
Parental pathology
Beliefs and values
Developmental level
Parenting skills
Conflict resolution and
negotiation skills
Level of family support
Peer refusal skills
Facilitate individual
and interactive/
relational change
Behavior Change
Intervention phase
TABLE 1
Anatomy of Functional Family Therapy: Phases of Intervention
(continues)
Interpersonal and
structuring skills
Family case
management
Generalization
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Intervention focus
Element of
each phase
Manage intake
processes to
presenting
agency, self,
and treatment
in a way that
matches to
inferred family
characteristics
Enhance perception of credibility
Engagement
Reduce negativity
and blame
Create hope
Enhance motivation to change
Motivation
Elicit descriptions
of relational
sequences
Relational
Assessment
Facilitate individual
and interactive
or relational change
Behavior Change
Intervention phase
Table 1
Anatomy of Functional Family Therapy: Phases of Intervention (Continued)
Access appropriate
formal and informal community
resources
Anticipate and plan for
future extrafamilial
stresses
Maintain and expand
individual and family
change
Facilitate change in
multiple system
links
Expand domains and
targets for improved
skills within the family and in community
relationships
Reach out to assist in
follow-up and individualized services
Generalization
introduction
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Indicators of goal
attainment
Family members
are willing to
engage in at
least one session (i.e., they
show up!)
Therapist can
identify relational functions
(connectedness
and hierarchy)
in the family
Therapist can
identify and
articulate
predictable
patterns in
problem-related
behaviors and
sequences
Therapist can
conceptualize alternative,
more positive
behaviors that
will serve the
same interpersonal function
New or strengthened
relationships and
communications are
observed with positive peers and community resources
Active participation of
youth is observed in
school or vocational
institutions
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session using the therapists notes and possibly consultation with other FFT
therapists, whereas the Motivation Phase takes place in the therapy session.
The goals of relational assessment include analyzing information pertaining to individual characteristics and the ways these characteristics impact
relational processes. Specifically, the therapist analyzes whether each family
members statements and behaviors serve to (a) increase connection or contact versus autonomy or distance and (b) establish hierarchy versus influence.
If therapists are to accomplish the goals of this phase, the skills of perceptiveness and an understanding of relational processes and interpersonal
functions are critical. The FFT therapist focuses on intrafamily and extrafamily characteristics and capacities, including family member values, attributions, functions, interaction patterns, sources of resistance, resources, and
limitations. These often are not at all the same for all family members, and, as
such, they create an important agenda for the therapist to address and resolve
in later phases. Therapist activities involve observing and questioning, making inferences regarding the functions of negative behaviors, and switching
from an individual problem focus to a relational perspective.
Behavior Change Phase
Therapist goals during the Behavior Change Phase consist of reducing
or eliminating referral problems through a variety of strategies. Interventions
may include skill building and changing habitual problematic interactions
and other coping patterns at both the individual and the relational levels.
Therapist skills such as structuring, teaching, organizing, and understanding behavioral assessment are required. Therapists often focus on providing
communication training, using technical aids, assigning tasks, and providing training in conflict resolution, negotiation, and problem solving. Phase
activities are focused on modeling and prompting positive behavior, providing directives and information, and developing creative programs to change
behavior, all while remaining sensitive to family members abilities and interpersonal needs. In general, the specific techniques involved in this phase are
based on the extensively developed literatures on behavioral and cognitive
behavioral techniques. However, some of the specific techniques used by various FFT therapists may be more commonly associated with gestalt, narrative
or postmodern, and other client-centered programs. Over the decades, we
have noted that some therapists with quite different backgrounds, such as art
therapy, have been able to incorporate elements of those traditions into the
Behavior Change Phase. Of course, therapists using such seemingly creative
approaches must do so with a clear picture of how such techniques relate
specifically to the unique qualities of each family and how they are in sync
with the familys relational patterns and strengths.
introduction
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Generalization Phase
The primary goal of the Generalization Phase is to maintain and expand
individual and family change and facilitate change in multiple system links. In
doing so, the therapist (a) extends the positive changes in individual behaviors and family functioning that were achieved in previous phases into new
situations and contexts, (b) plans for future challenges that increase the risk
for relapse, and (c) incorporates community systems into the change process.
Requisite therapist skills include understanding larger systems, establishing links with diverse community resources, maintaining energy, and
providing outreach. The primary focus is on relationships between family
members and multiple community systems. In addition to extending the positive changes of the Behavior Change Phase, Generalization Phase activities
involve knowing the community, developing and maintaining contacts, initiating clinical linkages to new systems, creating relapse prevention plans,
and helping the family develop independence.
Overview of the Book
As we describe the FFT phases and the techniques and therapist qualities involved in each, our strategy in this book is to move from a broad focus
to a narrow focus, then back again to a broad focus. Thus, the book is divided
into three parts.
We begin this journey in Part I, which explains FFTs diverse theoretical
and clinical roots (Chapter 1), as well as our rigorous research into change
mechanisms (Chapter 2) and outcome effectiveness (Chapter 3). Part II
represents the core of the bookthe FFT model. Chapters in this section
present the FFT model in detail, including general parameters for intervention (Chapter 4), the Engagement Phase (Chapter 5), the Motivation Phase
(Chapter 6), the Relational Assessment Phase (Chapter 7), the Behavior
Change Phase (Chapter 8), and the Generalization Phase (Chapter 9).
Clinical examples are provided throughout Part II, and a special chapter
illustrates all phases of FFT using a single in-depth case study (Chapter 10).
Finally, Part III addresses broader considerations in administering FFT,
including general implementation issues (Chapter 11), training and supervision (Chapter 12), and application of FFT to special treatment populations
such as gang-involved youth or youth in the child welfare system (Chapter 13).
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I
Clinical Foundations
and Research Support
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1
Early Influences: The Cultural,
Conceptual, and Intellectual
Zeitgeist of FFT Development
At the time that Functional Family Therapy (FFT) emerged, few clinical options were available with respect to difficult adolescents and family
dysfunction, regardless of their ethnicity, family structure, and myriad other
dimensions. As a result, it seemed important to learn more about the youth
and familiesthe cultures, populations, and belief systems involvedand
how they might be related to (and reflect) clinical or abnormal levels of
functioning and expression. As a result, choosing a particular clinical approach
simply seemed premature, if not impossible, until considerably more basic
research as well as clinical model development occurred. Thus, we synthesized seemingly different treatment and research literatures to provide more
effective services to children and youth. The development of FFT reflects the
attitude of integrating and synthesizing rather than polarizing. This was an
important aspect of FFT model development, and it continues as a core value
in the model today.
DOI: 10.1037/14139-002
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
17
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Psychodynamic, Behavioral,
and Social Learning Theories
The late 1960s and 1970s witnessed the emergence of promising new
theories and avenues for the effective treatment of dysfunctional behavior
problems of children and youth. Until that time, the predominant framework
that the majority of clinicians professed to use was psychoanalysis or one of
its derivatives, and problem behaviors were identified as reflections of individual psychopathology. The early psychodynamic influence on FFT has been
maintained during its four-decade history despite some obvious flaws in the
practice of psychoanalysis with adolescents.
In the psychodynamic framework, at least at the time, both positive
and negative behaviors are seen as expressions of an internal motivational
state. To treat difficult adolescent and family populations, therapists cannot merely engage in what has been identified using such terms as social
engineering without careful attention to the internal dynamics that contribute to behavior. Similarly, the individual, according to FFT, cannot
have complete control of his or her behavior, irrespective of the environment. However, the environment alone cannot determine an individuals
behavior.
Also relevant to FFTs development was the fact that psychotherapy
during the 1960s and early 1970s predominantly involved adult populations.
Treatment outcomes with adolescent populations, especially those with disruptive behavior disorders, were not considered to reflect high effectiveness
or efficacy. Certainly during this time, adolescents seemed to fit the labels of
difficult to treat and treatment resistant. Given the interest in helping adolescent populations and their families, the psychodynamic perspective alone
was not enough, although some of its core was retained.
A strong conceptual shift was offered in the conceptual, clinical, and
research applications of behavioral and social learning strategies and techniques to families. Early pioneers such as B. F. Skinner (1957, 1981) proposed relatively linear causeeffect models, which later visionaries more
formally extended to couples and families (e.g., Patterson, 1982; Stuart,
1971). Albert Bandura (1977) had a strong impact on the treatment community when he proposed a more elaborate cognitive framework that included
a more formal emphasis on reciprocal and bidirectional influences on
behavior both within and between people, in general, and family members,
specifically.
In addition, the shift to behavioral and social learning strategies included
a strong emphasis on empirical demonstrations and replications of core techniques with empirical support and enhanced technical clarity regarding
specific interventions. Although many clinicians were uncomfortable with
early influences
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what they perceived as a technical as opposed to a clinical focus in the behavioral and cognitivebehavioral approaches, the behavioral perspectives insistence on empirical replication and support provided the basis for a strong
shift in the treatment field.
In particular, this strong stance provided a persuasive and easily adopted
foundation for FFT during its formative years. At the same time, we felt it
critical that we not lose the more individual dynamic foundation of the
psychoanalytic perspective. As you will see when we discuss the specifics
of the FFT model, especially relational functions, the contributions of each
individual family members internal representations are coequal to those of
the environment, and each must be incorporated into positive change.
Family Systems and Communication Theories
During the 1970s, family systems and communication theories
(Erickson & Rossi, 1976; Haley, 1976; Minuchin, 1974; Watzlawick, Beavin, &
Jackson, 1967) also were emerging. These perspectives placed less emphasis on internal representations and empirical demonstrations of specific techniques than did psychodynamic and behavioral perspectives, respectively.
Instead, family systems and communication approaches provided more holistic, family-level perspectives that emphasized roles and relationships as a
central, if not causative, aspect of problem behaviors in adolescents.
Probably the most familiar term widely adopted from family systems
therapy was the identified patient, which implied that a referred adolescent
should be considered to reflect a process beyond the adolescent, and it led
to questions about why parents would identify such a role for their son or
daughter. This framework obviously is related to the social learning perspective, which identifies parental influences on adolescent problem behavior,
but it changes the clinical focus to the relational functions of all family members behaviors relevant to an adolescents problem behavior. This emphasis,
adopted as core in FFT, requires that clinicians go beyond referred adolescent behavior patterns to an inclusion of how and why these behaviors are
maintained by not only the adolescents but also the parents in dysfunctional
families.
To relate a simple example, once clinicians adopt the larger systems
perspective, they often notice that an adolescents problem behaviors pull
the parents together (to deal with the kid) to a greater degree than did the
adolescents positive (premorbid in medical terms) behaviors. As a result, the
relational impact of the problem behavior (e.g., adolescent drinking) goes
beyond the youth; it also impacts the parental relationship. This perspective
is elaborated considerably in later chapters.
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Additional Influences
FFTs formative clinical constructs emerged during the time that psychodynamic, behavioral, and systems perspectives represented strong alternatives
to one another. In fact, early versions of FFT were identified as systems
behavioral (Alexander & Barton, 1980). Very quickly, however, other developing and established conceptual and clinical frameworks, in addition to our
own and others emerging research findings, further influenced the developing
FFT model.
Neuropsychology
The growing literature on biological substrates of adolescent dysfunction ranging from learning disabilities to attention-deficit/hyperactivity disorder (e.g., Sciutto, Nolfi, & Bluhm, 2004; Singh, 2008) provided a reminder
that greater detail at the individual, even endogenous, level could help clinicians better prepare to undertake the more holistic treatment strategy necessary to deal with troubled adolescent populations. This literature reminded us
of the dynamic organization of the adolescent brain. It also helped us broaden
the scope of our focus in terms of trying to understand the ways familial,
social, hormonal, and biochemical forces could impact, for better or worse,
the developing adolescent. Although elaborating the rich information base
provided by this literature is beyond the scope of this book, we wanted to
remind readers of its existence and benefit to us in clinical practice.
Family Interactions With Schizophrenic Youth
In a related vein, during FFTs formative years, we also were informed
by the small but growing literature on family interaction patterns in families
with schizophrenic young adults. The early work of clinical theorists and
researchers such as Jay Haley related specific patterns of family functioning
to schizophrenia. Haley (1963) proposed a novel perspective on relationship
hierarchy in which schizophrenic adolescents and young adults communicated in one-down (e.g., deviant) ways that actually gave them more control
in the relationship with their parents. Complementary (i.e., one-down)
behaviors thereby created a metacomplementary (i.e., one-up) position for
the schizophrenic offspring. Although the specifics of this perspective have
not been retained in FFT, it made us aware that often the superficial aspects of
a behavior may not be the same as that behaviors relational impact. Similarly,
whereas hugging may represent affectionate behavior between a father and
his adult child, giving a hug to a similarly aged female colleague can represent
sexual harassment.
early influences
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metrical position. In addition, it was evident that the parenting tasks during
adolescence (e.g., helping develop gender identity, facilitating good choices
regarding peer groups and educational goals) are much less clear than are the
parenting tasks of childhood (e.g., teaching word recognition, inhibiting selfinjurious behaviors such as sticking forks in electrical outlets). Adolescence is
a time of exploration, ambivalence in various role relationships both within
and outside the family, and often painful social comparison processes involving other youth. Alexander and Parsons (1982) therefore set out to develop
FFT along lines that motivated, taught, and helped parents develop leadership styles that are more relational than hierarchical, thereby being more
developmentally appropriate with teenagers.
Relational Functions
Consistent with FFTs evolving interest in integrating internal and
environmental influences on problem adolescent behavior, anthropologists
(e.g., Watzlawick et al., 1967) and interpersonal theorists (Benjamin, 1993;
Leary, 1957) described the intersection of individual dynamic forces and the
interpersonal context. According to these perspectives, both internal and
interpersonal dynamics come into play when one is trying to understand
human behavior. FFT, as a fundamentally relational model, adopted a version of this both/and perspective with respect to motivation. Consistent
behavior patterns, whether adaptive or maladaptive, are maintained over
time because they function to meet the individual and the contextual or relational needs. As a simplistic example, consider a child who misbehaves to get
attention; the misbehavior functions to elicit attention. The person in the
environment (e.g., the parent) who gives the attention also has a functional
payoff in the temporary cessation of the attention seeking.
This process has been beautifully articulated in the coercion framework of Patterson (1982). As noted earlier, the motivation for the specific
attention-seeking behaviors (mands, according to Skinner, 1957) was seen as
a property of the misbehaving child; the expression of the behavior is heavily
determined by the parent response. If the parent responds with attention to
the childs whining but not to the childs frequent questions, the child will
quickly increase the rate of whining but not of questioning. According to
this perspective, to understand and change the problem behavior pattern (in
this case, whining), the FFT therapist would want to understand the motivation and interpersonal function of this interaction for both participants.
Further, in many situations, intent, as experienced and verbalized by family
members involved in such a pattern, may give little clue as to motivation. For
example, when a parent yells in response to a childs whining, the parent usually intends to stop the childs whining. However, observers of the interaction
early influences
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note what seems to be the opposite effectthat is, the yelling seems to add to
(reinforce) the whining behavior via the attention. Bandura (1986) captured
such processes in the construct of reciprocal determinism. The co-occurrence
of these frameworks with that of the developing FFT model reflected a major
paradigm shift, or at least a new avenue to pursue with challenging clinical
phenomena such as adolescent conduct problems.
As a result, FFT developed a framework to capture the effects or outcomes of problem behaviors as well as the individual factors involved. We
(Alexander & Parsons, 1982, and later Alexander, Waldron, Barton, & Mas,
1989) organized the myriad variables involved into two relational configurations, or domains, similar to and informed by Leary (1957) and later Benjamin
(1993). The first domain represents the degree of interpersonal connection
involved, which ranges from low connection (autonomy) to high connection (considerable interdependency). If constant whining produces constant
attention (e.g., soothing or yelling), FFT posits that the function or purpose
of whining is to achieve greater connection with the parent. If, in contrast,
whining produces consistent parental avoidance or withdrawal, the function
is posited to be lower connection or interpersonal autonomy.
The second relational domain of FFT represents the degree of relational
hierarchy involved, which ranges from one-up, to symmetrical, to one-down.
If a youths pattern of being rude to a parent typically produces an argument
with the parent about whos in charge in this house, FFT posits that the
function of the childs pattern of rudeness is to elicit similar behaviors in
the parent (arguing and being rude in return), creating a more symmetrical
relational configuration. If, however, the parent typically backs down and
gives in to the youth when he or she is rude, such a pattern would reflect
greater relational power on the part of the youth (i.e., one-up in relation to
the parent).
Ecological Theory
Finally, during the evolution of FFT, we were heavily influenced by
Bronfenbrenners (1977, 1986) ecological theory of human development,
which embeds an individuals behavior in the influences of surrounding systems (see also Berk, 2000). This theory provides an overarching framework for
understanding the influence of risk and protective factors at multiple levels of
the adolescent social ecology. Although FFT focuses heavily on the family, it
does not limit the risk and protective factors to the family. Adolescent temperament and neurologically based challenges, parental pathology, permissive parental attitudes toward substance use, lack of youth bonding to school,
association with deviant peers, neighborhood crime, poverty, and unemployment are among the individual family and extrafamily risk factors that have
24 functional family therapy for adolescent behavior problems
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been shown to be related to adolescent substance use and adolescent disruptive behavior disorders up through and including violence and gang involvement. The Behavior Change Phase of FFT targets risk and protective factors
directly. Additionally, the FFT practice of matching (described in Chapter 4)
represents a way to approach the specific families and members with sensitivity
to their particular sets of risk and protective factors.
Conclusion
The diverse theoretical and clinical perspectives of the 1960s and 1970s
often seem contradictory. However, they have been synthesized and made
compatible via the phase-based strategy of FFT (Alexander, Barton, Waldron,
& Mas, 1983). Neither in life nor in specific clinical cases can one pursue
many goals at once, especially if the goals might represent paradigm clashes
and mutual exclusivity. However, by phasing or sequencing treatment goals
and the steps to attain them, therapists can engage in an orderly process to
pursue multiple goals. This must be done in a way that follows a developmental and synergistic trajectory, and, to that end, we adopted a strategy that parallels the development of successful relationships in many forms. In the case
of successful therapeutic journeys, beginning the process successfully involves
different assessments, different clinical techniques, sensitivity to different
qualities of clients, and a different therapeutic focus than do later stages in
the journey. FFTs phase-based model represents and articulates the various
phases and therapeutic tasks necessary for successful outcomes with families
of (often) challenged and challenging youth and family circumstances.
early influences
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2
Research on Change
Mechanisms
DOI: 10.1037/14139-003
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
27
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new behaviors. These observational studies have been critical in influencing the development or articulation of specific intervention strategies for
creating a motivational context conducive to adaptive and supportive family
behaviors.
Effects of Specific Therapy Interventions on Family Negativity
The next step in our program of clinical research was to examine the
impact of specific interventions on within-family negativity in therapy sessions. A major focus of this research was to examine how therapists can
operate as agents of change to interrupt negativity and conflict and create a
context that is conducive to change. Specifically, the motivation techniques
described in Chapter 6 are, in large part, derived from research demonstrating that it is possible to change negativity by altering the context in which
family members interact.
Applying the knowledge learned in our prior basic interaction studies
to actual therapy sessions, Robbins, Alexander, Newell, and Turner (1996)
examined the impact of specific types of therapist intervention (e.g., reframing, reflection, structuring) on family members negative attitude during
the initial session of FFT with a delinquent adolescent. This study explicitly focused on identifying effective strategies for altering within-family
negativity, as evident in family members immediate responses to therapist interventions. As in prior research, the results demonstrated the high
rates of negativity that are common among families with delinquent youth.
Moreover, in therapy sessions, adolescents were more likely than mothers to
respond in a negative way following therapists interventions. This is interesting because, quite frequently, adolescents are the target of within-family
negativity, and their behaviors are the focus of change. The results suggested,
however, that their responses varied as a function of specific interventions.
For example, adolescents attitudes were more likely to improve following
therapist reframes compared with alternative intervention strategies such as
reflection and acknowledgment. Thus, we learned that reframing may be used
as a tool for decreasing adolescents negativity in therapy even without other
prior behavioral changes.
Robbins, Alexander, and Turner (2000) further examined the impact
of therapist interventions on family negativity. 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 the immediate effect of other family members statements, we looked specifically at the following behavioral sequences in families with a delinquent
adolescent: family defensive therapist intervention family behavior
(defensive vs. nondefensive). As in the prior study, the results demonstrated
research on change mechanisms
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that reframing was the most effective strategy for reducing the likelihood
of family negativity. And because these data were gathered in the first FFT
sessions, the results not only replicated 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.
In addition, they demonstrated that such effects could happen very quickly.
Another interesting set of findings that emerged in this research was
that therapist structuring and reflection interventions were no better than
nondefensive family statements in reducing subsequent negativity (e.g., family defensive therapist intervention or family behavior family defensive). Only therapist reframing was associated with a significant reduction in
family negativity.
Effects of Balancing Therapist Support for Parents
With Therapist Support for Adolescents
To further investigate the relationship between in-session therapy processes and outcome, Robbins, Turner, Alexander, and Perez (2003) examined
differences in treatment processes for families retained in treatment versus
those who dropped out of treatment. This work has provided information
about the critical importance of building working alliances with family members and reducing family negativity in preventing dropout. We found that the
balance or similar alignment of therapists with parents and with adolescents
(vs. unbalanced alignment, in which therapists were more closely aligned
with parents than with adolescents or vice versa) was a better predictor of
retention in treatment than the overall level of alliance. In fact, the overall
level of alliance with the therapist was actually misleading, with the highest
levels of alliance observed among parents in the families that dropped out of
treatment. Therapists who were able to achieve a more balanced or similar
level of alliance with parents and adolescents, regardless of whether the alliance was strong or relatively weaker, were more likely to retain the families
in treatment.
These findings are particularly important in guiding FFT therapists in
the first few sessions of therapy, especially with two-parent (or parent figure)
families. It is not uncommon for parents to enter therapy with a strong initial
positive reach out to therapists while the adolescent is quite withholding.
In light of our early session data regarding balance of alliances, however,
it is important for the therapist to avoid going with the flow and responding positively to the parents. This easily can serve to push the adolescent
even further away, consistent with the high dropout rates reported in many
family or individual therapies with adolescents (Kazdin, 1990). A similar
32 functional family therapy for adolescent behavior problems
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situation arises when one parent and the referred youth enter with a strong
alliance with each other whereas another parent is not part of that strong
bond. Further, such a parent (often a stepparent or some form of boyfriend)
often presents as unmotivated to integrate the family. For many of them,
unfortunately, having the adolescent removed or emancipated is their goal
because they never developed much of a positive parentchild bond. Rather
than being unmotivated for a family-integrating intervention, they in fact
enter treatment as antimotivated for such change. It is particularly important for the therapist to create a balance of alliances with all family members
in such difficult and frequently encountered contexts. As a result, therapists
often must work hard to not be especially supportive of one family member or
a dyad if that support is taken by another family member as taking sidesthat
is, facilitating an unbalanced alliance.
How well therapists negotiate early sessions in FFT to build balanced
alliances with family members and manage family negativity is directly associated with dropout. For example, Robbins, Turner, Alexander, Liddle, and
Szapocznik (2012) demonstrated that families that complete treatment have
a significantly higher level of balance in therapist support to family members (support to parents minus support to adolescent) than do families that
drop out. Therapists who worked with families that completed treatment
compared with therapists who worked with families that that dropped out of
treatment engaged in approximately 5 times more supportive interventions
directed to adolescents. Conversely, therapists in the dropout cases appeared
to provide a higher rate of support to parents than did therapists in the families that were successfully retained in treatment; support for parents may
serve to alienate the referred youth, who is frequently the target of parental
negativity. Finally, with respect to family negativity, the results indicated that
family negativity was significantly higher in the dropout families than in the
families that completed treatment.
Taken together, these findings suggest that therapist level of support to
both parents and adolescents is critical and must be approached strategically.
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 intermediate outcomes such as retention in FFT.
In our most recent process study, Freitag, Alexander, and Turner (2010)
demonstrated that differences in within-family bonding (alliances between
family members), as observed in therapy sessions, were associated with treatment dropout. By the end of the second session, statistically higher rates of
bonding communications occurred between parent and adolescent in families
that completed treatment than in dropout cases. This finding is particularly
salient because it provides empirical support that FFT influences patterns of
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his or her ability to facilitate positive change are essential ingredients of effective implementation. Ultimately, however, this knowledge, commitment, and
self-efficacy must be translated into interventions in the room with family
members. Theory and principles are relevant insofar as they provide therapists
with a sense of what to do in sessions with families.
Zeroing in on what happens in the room has facilitated our development of the essential elements of FFT. The observational focus of our program
of research has been useful in describing various aspects of the treatment
process, including concrete representations of therapist interventions, family
behaviors, and therapistfamily interactions. Moreover, the results of these
research studies have provided support for implementation of motivationinducing interventions during the initial sessions of treatment. In fact, these
studies have helped identify not just what these interventions look like but
when and how these interventions appear to have a positive effect on family and therapy processes. We have evidence, for example, that behavioral
changes, such as reductions in negativity, increased family bonding, and the
formation of balanced alliances, are particularly positive indicators of treatment outcome when observed by the end of the second session.
The results of process studies have fed directly into our clinical training
and supervision manuals used to train and monitor therapists in controlled
clinical trials and in community-based implementation. Irrespective of the
context of training (research project or real-world implementation), this
research has provided the impetus for the development of complex quality
assurance and monitoring procedures for ensuring that therapists are able to
develop and maintain their competent adherence to FFT.
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3
Research on FFT Outcomes
DOI: 10.1037/14139-004
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett
Waldron, Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
37
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Alexander and
Parsons (1973)
Salt Lake City, UT
Alexander and
Barton (1976,
1980); Parsons and
Alexander (1973)
Salt Lake City, UT
Reported sample
characteristics
Alexander (1971)
Salt Lake City, UT
Random assignment:
a.FFT, n = 20
b.Client-centered family
therapy, n = 10
c.No treatment control,
n = 10
Random assignment:
a. FFT only, n = 10
b.Individual Therapy (IT)
only, n = 10
c.FFT + IT, n = 10
d.No treatment control,
minimal probation
supervision
Random assignment (ad):
a.FFT, n = 46;
b.Client-centered family
groups, n = 19
c.Psychodynamic family
therapy, n = 11
d.No-treatment control,
n = 10
e.Post hoc selected
controls, n = 46
f.National sample controls,
n = 2,800
Treatment and
comparison conditions
618 months
Posttreatment
Risk/protective process:
Family therapy plus
individual therapy
produced significantly
greater improvements in
communication style than
other conditions.
Treatment outcomes
Posttreatment
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT
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Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 2)
Salt Lake City, UT
Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 3)
Salt Lake City, UT
Barton, Alexander,
Waldron, Turner,
and Warburton
(1985, Study 1)
Salt Lake City, UT
Nonrandom assignment:
a.FFT, n = 30
b.Alternative treatment,
n = 44
Nonrandom assignment:
a.FFT with trained
therapists, n = 109
b.Community-based social
workers with limited FFT
training, n = 216
Nonrandom assignment:
a.FFT, n = 27
b.District juvenile justice
base rates
15 months
Posttreatment
13 months
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Siblings in 99 families of
delinquent youth (see
Alexander & Parsons,
1973)
N = 99
1316 years old
Drug-abusing adolescents
N = 135
1421 years old
(mean = 17.8)
89% non-Hispanic White,
11% other
Friedman (1989);
Stanton and
Shadish (1997)
Philadelphia, PA
Lewis, Piercy,
Sprenkle, and
Trepper (1990)
Lafayette, IN
Reported sample
characteristics
Posttreatment
15 months
Random assignment:
a.FFT, n = 91
b.Parenting group
intervention, n = 75
Random assignment:
a. Purdue Brief Family
Therapy
b. Family Drug Education
3040 months
Follow-up
period
Random assignment:
a.FFT, n = 46
b.Client-centered family
therapy, n = 19
c.Psychodynamic family
therapy, n = 11
d.No treatment control,
n = 10
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued )
Treatment outcomes
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Posttreatment
30 months;
60-month followup of adult
convictions
Random assignment:
a.FFT
b. Group therapy
c.No-treatment control
group, n = 10
Gordon (1995,
Study 1); Gordon,
Arbuthnot,
Gustafson, and
McGreen (1988);
Gordon, Graves,
and Arbuthnot
(1995); Gustafson,
Gordon, and
Arbuthnot (1985)
Southeastern Ohio
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Reported sample
characteristics
Chronic offenders, average of 34 prior institutional commitments
N = 49
1718 years old
Gordon (1995,
Study 2); Gordon
and Arbuthnot
(1990)
Southeastern Ohio
Gordon (1995,
Study 3)
Ohio
Lantz (1982)
Salt Lake City, UT
Random assignment:
a.FFT, n = 22
b.Alternative treatment,
n = 24
Matched assignment:
a.FFT, n = 27
b.Probation services as
usual, n = 25
Nonrandom assignment:
a.FFT, n = 49
b.Statistical control:
empirically derived risk
of recidivating based
on age, age of onset,
number of offenses
Treatment and
comparison conditions
Posttreatment
16 months
1218 months
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued)
Treatment outcomes
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Community-based sample
of multiproblem delinquent youth and their
families
N = 62
Hansson, Cederblad,
and Hk (2000)
Lund, Sweden
Hansson, Johansson,
Drott-Engln, and
Benderix (2004)
Lund, Sweden
Matched assignment:
a.FFT, n = 45
b.Social work services as
usual, n = 50
Random assignment:
a.FFT, n = 40
b. Treatment as usual, n = 49
18 months
24 months
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Reported sample
characteristics
Random assignment:
a.FFT
b. Individual CBT (ICBT)
c. Group CBT (GT)
d. Integrated FFT + CBT
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued)
Treatment outcomes
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Delinquent youth
N = 750
Flicker, Waldron,
Turner, Brody, and
Hops (2008)
Albuquerque, NM
12 months
Posttreatment
Assignment (nonrandom)
based on caseload capacity:
a.FFT, n = 427
b. Wait-list controls, n = 323
Random assignment:
a.FFT
b. Integrated FFT + CBT
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Slesnick and
Prestopnik (2009)
Albuquerque, NM
Reported sample
characteristics
Random assignment:
a.FFT
b.Probation services
as usual
Random assignment:
a.Home-based ecological
family therapy, n = 37
b. Office-based FFT, n = 40
c. Services as usual, n = 42
Treatment and
comparison conditions
12 months
15 months
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued)
Recidivism: Overall, no
differences were found
between FFT and services as usual. However,
when therapist adherence
to the model was high,
FFT showed significantly
greater reductions in
felonies (35%) and violent crimes (30%), with
a marginally significant
reduction in misdemeanors (21%), compared with
services as usual.
Treatment outcomes
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Waldron, Brody,
Turner, and
Ozechowski (2012)
Albuquerque, NM
19 months
19 months
Random assignment:
a.FFT
b. Individual CBT (ICBT)
c. Group CBT (GT)
d. Integrated FFT + CBT
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Waldron,
Ozechowski,
Brody, Turner,
Hops, and Scherer
(2012)
Albuquerque, NM
Treatment and
comparison conditions
Random assignment to postFFT aftercare condition:
a.FFT + home aftercare
(FFTHA)
b.FFT + group CBT
aftercare (FFTG)
c.FFT + telephone
aftercare (FFTTA)
Reported sample
characteristics
Youth with substance use
disorders, moderate to
heavy use
N = 74
1318 years old
(mean = 16.4)
40% non-Hispanic White,
54% Hispanic, 6% other
12 months
Follow-up
period
TABLE 3.1
Study Characteristics and Treatment Outcomes for FFT (Continued)
Treatment outcomes
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Waldron, Brody,
Turner,
Ozechowski, and
Hops (2008)
Albuquerque, NM
16 months
611 months
Random assignment to
supervision:
a.FFT, supervision as usual
+ observation-based
feedback to therapists
b.FFT, supervision as usual
(no observation-based
feedback)
19 months
Note.ADHD = attention-deficit/hyperactivity disorder; CBT = cognitive behavior therapy; FFT = Functional Family Therapy; GT = group therapy; SES = socioeconomic status. Data
from Waldron, Robbins, and Alexander (2012).
Dually diagnosed
depressed and
substance-abusing
youth, moderate to
heavy use
N = 170
1319 years old (mean
=16.4)
54% non-Hispanic White,
32% Hispanic, 4%
African American, 10%
other
Rohde, Waldron,
Turner, Brody, and
Jorgensen (2012)
Albuquerque, NM
Portland, OR
77
77
77
77
77
77
77
77
77
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across studies remains consistently positive, one can have greater confidence
in the models effectiveness.
Treatment outcome findings obtained through randomized clinical
trials and other research provide the basis for establishing FFT as an EBT.
Although some of the early FFT studies were limited by small sample sizes or
nonrandom assignment to treatment, these studies represented the standard
for outcome research at that time and provided a foundation for increasingly sophisticated clinical trials of FFT. FFT has now been evaluated by a
number of independent investigative teams using more rigorous design and
methodological standards that have affirmed the promise of the early studies.
Moreover, when all of the research evidence is considered as a whole, the
consistent pattern of positive findings for FFT that has emerged across investigators, populations, and settings establishes a formidable cumulative record
of empirical support for FFT.
Early FFT Outcome Studies
The first controlled trial of FFT was conducted with 40 delinquent
adolescents between the ages of 13 and 16 years who had been arrested and
detained for truancy, ungovernable behavior, or running away from home
(Alexander, 1971). Youth were randomly assigned to one of four comparison
conditions: FFT, individual therapy (IT), FFT plus IT, or minimal contact
with probation staff. FFT and FFT plus IT were associated with significantly
greater improvements in family functioning than the other two conditions at
a 10-week follow-up assessment. A second FFT evaluation of youth similar
to those in the prior study (Alexander & Parsons, 1973) compared outcomes
for youth and families who received FFT with outcomes for youth who participated in community-based treatment programs involving either a clientcentered family therapy condition or an eclectic psychodynamic family
therapy condition and outcomes for youth in a no-treatment control condition. Recidivism rates, examined at baseline and at a measurement point
occurring between 6 and 18 months after program completion, were significantly lower for the FFT group than for the other intervention conditions
(p .025), with recidivism rates as follows: 26% for the FFT group, 50% for
the no-treatment group, 47% for the client-centered family therapy group,
and 73% for the psychodynamic family therapy group. FFT was also associated
with significantly greater improvements in family functioning compared with
the other three conditions. It is interesting that neither of the ongoing treatment programs, although widely used in the community, was more effective
than no treatment, and the eclectic psychodynamic family therapy condition
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produced negative (i.e., iatrogenic) effects. Because both studies involved random assignment to treatments and focused on key outcomes (i.e., family functioning, recidivism), the importance of these studies in forming the empirical
foundation for FFT has endured over time.
Subsequent research built on the early studies, evaluating FFT across new
settings and populations of clients and therapists. For example, in a 3-year
follow-up investigation of families participating in the study, Klein, Alexander,
and Parsons (1977) evaluated the impact of FFT on recidivism and sibling
delinquency. The findings revealed the primary prevention benefits of FFT. FFT
was associated with significantly lower recidivism rates for siblings (p .005)
relative to the other conditions. The rates of legal involvement of siblings were
20% for those involved in FFT, 40% for no-treatment controls, 59% percent
for the client-centered family therapy group, and 63% for the eclectic psychodynamic family therapy group. In a series of three studies, Barton, Alexander,
Waldron, Turner, and Warburton (1985) replicated the FFT findings with less
formally trained clinicians, with a seriously disturbed delinquent population,
and within a cost-effectiveness context comparing FFT with out-of-home
placement for youth referred for treatment through the family court (dependency) as opposed to the juvenile justice (delinquency) system. Although each
of the replications had methodological limitations relative to current research
standards, taken together they provided support for the generalizability of FFT
across client populations, therapists, and measures.
Given the span of years, contexts, and investigators represented in the
outcomes reported above, it is important to note that the core phase-based
FFT model has remained constant. What has changed, in a programmatic and
evolving way, is the detail used to describe the phases, techniques, and intervention strategies. Initial research undertaken during the first decade of FFT
focused on basic components of the model (see Chapter 4, this volume) and
simple demonstrations of positive outcomes and were done in house (i.e., in the
clinic within which the model was developed and tested initially). Because of
this, we shared a common language and way of thinking, which were described
in the first formal articulation of the model (Alexander & Parsons, 1982).
However, as others outside of our system expressed interest in our early positive
outcomes, we were obligated to articulate more fully the philosophical bases for
the model as well as the specifics of implementation. The designation of FFT
as a Blueprints for Violence Prevention model program (Elliott, 1997, 1998)
necessitated, by specific request, that we further and more completely elucidate
the model, especially the phases and techniques involved.
To use one example, the construct of reframing was used in the 1973
(Alexander & Parsons, 1973; Parsons & Alexander, 1973) and 1976
(Alexander, Barton, Schiavo, & Parsons, 1976) research publications but was
not well developed or articulated until the 1982 book (Alexander & Parsons,
52 functional family therapy for adolescent behavior problems
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Another study evaluated FFT combined with intensive probation supervision for serious multiple offenders released from state institutions (Gordon
& Arbuthnot, 1990). A 21-month follow-up revealed a 30% recidivism rate.
A statistical comparison of youth matched on number of prior offenses and
age at first offense would have yielded an expected recidivism rate of 60% to
75%, providing further independent evidence for the effectiveness of FFT for
delinquent youth.
Independent replications of FFT effectiveness have also been conducted
in Sweden by Kjell Hansson and his colleagues. In one of the first randomized
studies on juvenile delinquency in Sweden, Hansson, Cederblad, and Hk
(2000) examined the efficacy of FFT compared with treatment as usual with a
sample of 89 delinquent youth and their families. Results indicated that FFT
was significantly more effective than treatment as usual in reducing behavior
problems both at 1- and 2-year follow-up, according to official registers. FFT
was also shown to have a positive influence on the psychiatric health of both
the young people and their mothers. The authors concluded that FFT seems
to be an effective method for treating early juvenile delinquency by diminishing the relapse rate by 50%. Hansson, Johansson, Drott-Engln, and Benderix
(2004) replicated these findings in a community-based setting. In this replication, FFT was delivered within a framework of cooperation between social
welfare, child psychiatry, and a drug treatment unit. Compared with treatment as usual, the FFT condition showed improved family functioning and
fewer psychiatric symptoms (both internalizing and externalizing) after treatment. Both parents and youth showed higher optimism and valued the treatment highly. The pattern of results in this community-based replication was
similar to that of the earlier university-based research with the same method.
The impact of FFT with drug-using adolescents and their families has
been extensively tested in several clinical trials and a meta-analysis. Friedman
(1989) conducted a randomized clinical trial comparing FFT with a parenting skills group intervention for 135 families of youth between the ages of
14 and 21 years with heavy alcohol and drug use (e.g., daily cannabis use).
For families who received treatment, results for both the FFT and parenting
groups showed significant reductions in substance use of more than 50% at
follow-up, with improvements in other areas of functioning as well. However,
the rates of engagement in treatment differed dramatically, with 93% engagement in FFT versus 67% in the parenting condition. In a reanalysis of the
entire intent-to-treat sample in which families who terminated treatment
prematurely were included as treatment failures, Stanton and Shadish (1997)
found significantly greater substance use reductions for the FFT than for the
comparison condition.
Later evaluations of FFT for adolescent substance use disorders were
conducted by Holly Waldron and her colleagues in New Mexico and Oregon.
54 functional family therapy for adolescent behavior problems
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FFT + CBT. The findings indicate that there are multiple pathways to change
in adolescent substance use and provide further empirical support for FFT
for this population. The relatively poorer findings for the integrated FFT +
CBT intervention may have been due to an inadequate dose of FFT or to
negative or deleterious effects in combining these two theoretically disparate
approaches. Overall variability in treatment responding, including significant posttreatment relapse, was also observed for a number of youth, pointing
to the need for continuing care for youth to maintain their treatment gains.
The third trial, a two-site study conducted in New Mexico and Oregon,
evaluated the two 14-session interventions examined in the previous study,
individual CBT or integrated FFT + CBT, for 245 adolescents and their families (cf. Hops et al., 2011; Waldron & Turner, 2008). Both treatments showed
significant reductions in marijuana use through the 18-month follow-up,
with Hispanic youth responding significantly better to FFT + CBT than to
CBT. Anglo youth improved equally well in both interventions throughout
the follow-up period. These findings are consistent with the earlier trials and
demonstrated that Hispanic substance-abusing adolescents and their families have as good or better outcomes with interventions involving FFT than
Anglos do.
In a more fine-grained examination of ethnicity outcomes, Flicker
et al. (2008) identified 43 families from the earlier trials who had an ethnically matched FFT therapist (14 Hispanic and 29 Anglo families and therapists) and 45 nonmatched families (i.e., 30 Hispanic families with Anglo
therapists and 15 Anglo families with Hispanic therapists). Although both
Hispanic and Anglo youth achieved significant drug use reductions, ethnically matched Hispanic adolescents demonstrated greater decreases in their
substance use relative to Hispanic adolescents with Anglo therapists. Ethnic
match was unrelated to treatment outcome for Anglo youth. Compared with
Anglo therapists, Hispanic therapists may be more attuned to core cultural
values in Hispanic families and may be more able to tailor the way they interact
with Hispanic adolescents and parents in accordance with such values. Taken
together, the findings suggest that FFT is a particularly good fit for Hispanic
youth and families, especially when delivered by a therapist similar in ethnic
background.
The clinical trials examining FFT for substance-abusing youth were
included in a recent meta-analytic study (Waldron & Turner, 2008). In this
meta-analysis, 46 different treatment conditions that included 2,307 adolescents treated for substance abuse disorders were examined. The combined
sample evaluated several therapy models, including FFT and other empirically oriented family therapy approaches, group CBT, individual CBT, and
a minimal treatment condition. The effect size associated with reductions
in drug use was significantly larger for the family therapy condition relative
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State. They also provided a more detailed description of the adherence rating
procedures (see also Sexton, Alexander, & Mease, 2004, for a description of
the protocol). In both the Barnoski (2002) sample and the expanded Sexton
and Turner (2010) sample, adherence ratings were completed for a portion
of participating families and sessions. Therapists each presented one active
case per week in supervision meetings and, on the basis of these presentations, clinical supervisors later completed ratings of low to high FFT model
adherence on a 6-point Likert-type scale. The rating system was designed to
measure the knowledge of core FFT principles therapists reflected in their
presentations, their understanding of the family within the FFT framework,
and their compliance with the manual-specified goals for each phase of the
clinical intervention (Sexton et al., 2004). As in Barnoskis preliminary
study, positive outcomes were found only for competently adherent therapists. However, Sexton and Turner noted several methodological weaknesses
in the study. Ratings were dependent on the supervisors clinical judgments of
therapist adherence to the FFT model, which were sometimes reconstructed
from memory long after therapist case presentations (Barnoski, 2002).
Moreover, therapist representations of their in-session behavior could have
seemed adherent to supervisors even if therapists were not actually engaging
appropriately in the behaviors they described.
Clearly, measuring FFT adherence is critical for ensuring that FFT is
implemented in community settings with integrity. The link between therapist adherence and outcome is well-known. One of the single most significant challenges associated with implementing EBTs in community practice
is establishing therapists competent adherence to a treatment model and
sustaining fidelity (Forgatch, Patterson, & DeGarmo, 2005; Henggeler,
Clingempeel, Brondino, & Pickrel, 2002; Hogue et al., 2008; Mihalic &
Irwin, 2003; Rogers, 2003). To address the key issue of enhancing treatment
competence, FFT LLC recently developed and implemented a sophisticated
Web-based application designed to monitor highly structured FFT therapist
progress notes and supervisor and client ratings of therapist competence. The
process helps maximize sustainability for community programs by limiting
costs. Hence, the supervision process involves feedback to therapists based
on the progress notes and therapistsupervisor discussions of therapist performance. The current supervision and adherence monitoring system, changed
as a result of the problems detected in the Barnoski (2002) and Sexton
and Turner (2010) studies, is designed to enhance therapist adherence and
improve overall treatment effectiveness.
The effectiveness of this new adherence monitoring system is currently
being evaluated in a randomized clinical trial of FFT effectiveness being
conducted by the authors of this volume in a collaborative effort involving
Oregon Research Institute, FFT LLC, and the California Institute of Mental
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Health. The study will examine the impact of two distinct supervision strategies on therapist competent adherence and clinical outcomes: the supervision
approach currently used by FFT LLC and an observation-based supervision
approach in which therapists sessions are recorded and reviewed weekly by
supervisors. The study has significant implications for establishing parameters
to achieve positive outcomes in practice settings in that observation-based
supervision may lead to greater therapist adherence that is linked to better
outcomes, but the approach is also associated with higher costs that may not
yield greater cost-effectiveness. More important, the study reflects our ongoing commitment to FFT evaluation research and the desire to attain optimal
care for families.
Adaptations of FFT
A number of investigations have examined FFT in an adapted form
or examined the therapeutic conditions that influence FFT efficacy and
effectiveness (Lewis, Piercy, Sprenkle, & Trepper, 1990; Sexton & Turner,
2010; Waldron et al., 2001). Any implementation of an intervention that
deviates meaningfully from the model followed in each of the clinical trials
used to establish that intervention as an EBT is considered an adaptation.
Recognizing adaptations of FFT as distinct from the original model (e.g.,
Alexander & Parsons, 1982; Alexander, Pugh, & Parsons, 1998; Barton &
Alexander, 1981) is important because the research evidence supporting the
original model cannot be presumed to extend to the adapted or revised version.
There is general consensus among treatment researchers and scholars (e.g.,
Bellg et al., 2004; Blakely et al., 1987; Byrnes, Miller, Aalborg, Plasencia, &
Keagy, 2010; McHugh, Murray, & Barlow, 2009; Mihalic & Irwin, 2003) that
interventions are effective only when they are implemented with high levels
of fidelity and that, when elements of an EBT are modified, the research evidence supporting an intervention cannot be extended to the adapted model.
Moreover, disseminating and implementing an adaptation of an EBT as
if it derived from the same empirical evidence as the original model could
easily backfire and undermine public confidence in scientific claims that we
have programs that work (Elliott & Mihalic, 2004, p. 52). Thus, we are cautious in discussing adaptations to the model and emphasize that adaptations
require their own systematic research to establish independent empirical
support. Yet adaptations can be an extremely valuable source of information regarding how FFT may be tailored to unique populations or settings to
achieve enhanced outcomes. We consider here some FFT adaptations that
have been evaluated, the evidence there is to support them, and what we
might learn from them.
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Lewis et al. (1990) developed an intervention integrating FFT strategies and structuralstrategic therapy and evaluated the intervention
relative to a parenting skills intervention with 136 substance-abusing
youth. The integrated family therapy and parenting skills intervention
both showed significant reductions in drug use, with a greater percentage
of youth in family therapy decreasing their use. Because Lewis et al. did
not include an FFT-only intervention, the differential effectiveness of the
adapted intervention relative to FFT is unknown.
In the clinical trials conducted by Waldron and her colleagues (reviewed
in Waldron & Turner, 2008), the integration of FFT with individual CBT
sessions for drug-abusing youth was compared with FFT as a standalone treatment. Taken together, the findings from these studies provide some empirical support for the integrated intervention. However, compared with FFT as
a standalone treatment, the overall effects appeared weaker for the adapted
version of FFT, suggesting that not all attempts to integrate FFT with other
intervention approaches are successful.
These findings are consistent with preliminary findings from a study
involving 180 youth with co-occurring substance use disorders and depression (Rohde, Waldron, Turner, Brody, & Jorgensen, 2012). Adolescents
referred for substance abuse treatment and receiving diagnoses of comorbid
depression were randomly assigned to one of three treatments involving a
group CBT intervention for depression and FFT for substance abuse. All
adolescents received 12 sessions of group CBT and 12 sessions of FFT, with
group CBT followed by FFT in one treatment condition, FFT followed by
group CBT in the second condition, and an integrated combination of
FFT sessions and group CBT sessions in the third condition. From baseline to the first follow-up, the study revealed large effect sizes (p < .01) for
reductions in depression for all three treatment sequences among dually
diagnosed youth with more severe depression (average d = 1.45), with no
significant differences between conditions. Among less severely depressed
youth, moderate but significant (p < .05) effect sizes for change were found
(average d = 0.53) for reductions in depressive symptoms, also with no differences by sequence condition. With respect to substance use, FFT showed
a greater reduction than did CBT or integrated treatment (d = 1.41 for FFT
vs. d = 0.56 and 0.48 for CBT and integrated treatment, respectively) at
the first follow-up. For the more severely depressed youth, offering CBT
first followed by FFT was associated with greater substance use reductions.
Taken together, the findings support the efficacy of FFT in reducing both
depression and substance use for youth with co-occuring depressive and
substance use disorders, with some evidence that offering CBT before FFT
may produce better outcomes for the most severely depressed youth who
have dual diagnoses.
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II
The FFT Clinical Model
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4
Matching and General
Parameters of FFT
The scope and diversity of specific behavioral and larger-system (ecological) targets of Functional Family Therapy (FFT) change are well articulated in the extensive literature on high-risk youth, especially those with
externalizing disorders. The extensiveness of such targets, however, can quickly
overwhelm policymakers, program developers, and therapists. Years ago,
Hawkins, Catalano, and Miller (1992), for example, identified numerous risk
and protective factors that cut across multiple levels (biological, behavioral,
cognitive) and domains (individual, familial, extrafamilial). The list has not
become shorter over time!
Determining which of these factors to address in any given intervention
or how to aggregate resources and programs to address them all is daunting,
to say the least. Sadly, early research with adolescents with disruptive behavior
problems demonstrated that the overall success in treating these youth was
disappointing. During the past two decades, however, several effective programs
DOI: 10.1037/14139-005
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have emerged for working with troubled youth. Not surprisingly, these programs
are based on comprehensive, systemic theories that provide a framework for
organizing and understanding the interrelationships among multiple risk and
protective factors across clinical domains. As shown in the overview table in
the Introduction, FFT targets common risk and protective factors in each phase
of treatment. Additionally, FFTs technique of matching is used in every
phase of treatment to relate effectively to each unique family. In this chapter,
we discuss both matching and the general parameters of FFT.
Matching
A critical strategy that FFT therapists use to approach each family (and
individual family member) on the basis of their particular sets of risk and protective factors is called matching. Matching in FFT means attempting to create
an interpersonal relationship in which family members are in sync with the
therapist and are consequently able to move through subsequent steps in
the process with the fewest impediments. Matching is related to but not the
same as the construct of mirroring, which also is widely used in the treatment
field. Matching, like mirroring, requires attention to the clientsin the case
of FFT, to the youth, to the parent system, and to the ways they are embedded
in the community. However, the meaning of matching in FFT often is quite
different from that of mirroring.
As noted by Haley (1963), in cases in which one person is behaving in a
hierarchically one-up or one-down way, the relationship can be stable, positive,
and adaptive when another person behaves in a complementary waythat
is, in a manner that matches or is congruent with the behavior. To use but
one example, the parentchild relationship normally proceeds well when the
parent is comfortable and competent in one-up parenting (teaching, setting
limits, supporting from a position of knowledge and experience). If the child
matches with one-down behaviors (seeking knowledge, accepting information,
following limits), interactions are smooth and positive. If, in contrast, the child
challenges the one-up position of the parent by refusing to comply and instead
attempts to set his or her own rules, struggles ensue. The so-called terrible 2s
seem to represent such a process, and this phase is developmentally quite
common. The issue is not that such challenges occur; for us, the issue centers
on how they are resolved, both in childhood and throughout development.
Clinical Examples of Matching
In FFT, the therapist reflects (but in a positive way) the same inter
personal distance or reaching out embedded in the others communication.
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culturally held beliefs about single mothers. Single mothers undoubtedly face
serious challenges, yet our research demonstrated that single mothers could
parent as effectively as married mothers do. To do so, however, they needed to
adopt different parenting styles as necessitated by their context-specific parenting role relationships. Yet although the parenting context of single mothers
clearly is different from the parenting context of married mothers, most
parenting manuals and treatments available in the 1970s simply instructed
mothers with regard to parenting techniques with little (if any) attention paid
to the parenting context or family structure! Also, in perusing the self-help
books of the time, we noted that the focus rarely included the unique challenges
of single versus married mothers. Instead, the single parent literature seemed
primarily to lament such situations as broken homes and fatherless boys.
Facing this, we sought to develop an alternative using adaptive and effective
single parents as our models for change.
To create a strategy for dealing with such challenges and goals, as well
as the changing demographics of many referred families, FFT thus became a
context-driven and family-specific intervention rather than a unitary or
standard protocol approach applied uniformly to all families. To be successful in
such a contingent approach, we recognized the need to be familiar with and
help different families develop a large number of different parenting techniques and strategies that are individualized for the many configurations of
parents and youth we see. These configurations include single mothers, single
fathers, married or cohabitating different-gender adults, same-gender parents
or parent figures, and a grandparent still raising a child who has a child of her
own. Adding diversity based on culture and ethnicity, socioeconomic status,
and health challenges to the mix makes it clear that intervention must be
matched to the unique circumstances of each family struggling with adolescent problems.
Structured Parameters
The phase-based nature of FFT also implies a generic structure regarding the parameters of treatment. By parameters, we mean how FFT is linked
to other systems, who participates in treatment, where sessions are located,
what the average number of sessions is in the typical course of treatment, and
how booster sessions are used. In the remainder of this chapter, although we
discuss these general parameters, it should be noted that these parameters are
not fixed, rigid expectations. FFT is intended to be applied in a contingent and
responsive way with each family. Therefore, the clinical process and general
parameters unfold in a unique way for each family. These parameters are
intended to provide merely a rough estimate of the typical or average course
matching and general parameters of fft
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Pretreatment
System Linking
Referral,
Pretreatment
Assessment,
Linking
Posreatment
System Linking
Boosters,
Referrals,
&
Linking
Figure 4.1. The big picture: Linking Functional Family Therapy with other systems.
Based on Alexander et al. (1983), Barton et al. (1985), and Waldron et al. (2001).
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back into community systems, as we discuss later in this chapter, the better
the pretreatment linking is, the better we can help them maintain positive
changes long after FFT is complete. Educational, juvenile justice, and mental
health systems represent examples of systems with which FFT therapists link
often, and when those links are well developed, families are much less likely
to fall between the cracks.
Who Participates in FFT Sessions?
The decision about who participates in FFT sessions is based on an
understanding of which family members will be important in the therapy
process to begin change or hinder the process of change occurring with the
referred youth. It is seen as being a functional decision rather than based on
who lives in the home or whom everyone considers to be part of the family.
Information received at referral becomes crucial in aiding the process of making
this decision. It is important for communication to occur between FFT therapists and referral agents and systems to gather relevant information about the
referred youth and potential family members who may be involved.
FFT includes those family members who are believed to play a major
role in the dysfunctional behavior of the referred youth. These family members
include those capable of interfering with and willing to hinder the treatment
process and also those who are necessary to begin change in the referred youth.
In general, FFT includes parent figures, siblings, and other family members
(and even nonfamily members) who live in the home and who have regular contact with the referred youth. With respect to siblings, FFT ordinarily
includes preteens and older siblings who live in the household. When referral
information is ambiguous about such roles, especially regarding who seems to
impact the dysfunctional patterns that represent the raison dtre for referral,
FFT therapists attempt to bring everyone to the first session and then try to
sort it out if someone does not need to be there (e.g., individuals who do not
appear to be involved in the problem sequences).
A common challenge in determining who participates in treatment
sessions occurs in circumstances of blended, step, and divorced households.
Like all other aspects of the model, there is not an absolute rule that therapists
are expected to follow in these circumstance. Rather, therapists are expected
to determine what family constellations need to be included in treatment
and plan their sessions accordingly. We have observed that a wide range of
different constellations can lead to successful outcomes. For example, we
have conducted FFT sessions with two full blended households that included
four parent figures (mother, stepfather, father, and stepmother) and multiple
siblings and stepsiblings, with divorced parents and their children, and with
grandparents. All of these variations can lead to successful outcomes. Therapists
matching and general parameters of fft
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should be driving decisions about whom to include and making these decisions on the basis of their observations about who the necessary individuals
(and subsystems) are that are directly involved in the problem sequences.
Location of Services
FFT can be conducted in a variety of settings and locations. In particular, FFT therapists attempt to provide services in locations that will best suit
the needs of the family. The range of locations includes the office or clinic
setting of the provider site, the home, and a location within the community
where the family lives. The flexibility of therapists to be mobile in where
they conduct sessions becomes an essential component in the engagement
of family members in treatment. Many families are limited in their resources
for transportation. Therefore, it is important that the FFT therapist minimize
or potentially eliminate any transportation barriers that would exist for the
family members. For example, for a family that does not have a means of
transportation to attend sessions in the provider agencys office or clinic, the
therapist could conduct sessions at the familys home or in a local library close
to the familys home. The provider agency may also be able to provide bus
passes or tokens for public transportation to enable families to attend sessions
conducted in the office.
Number of Sessions by Phase
The average length of treatment in FFT is 12 to 14 sessions over 3 to
4 months, with an increased number of sessions or client contact for more
severe cases (e.g., gang involvement, parent psychiatric disorder). Once FFT
begins, the length of each phase is based on successful progress toward phase
goals and representative changes in within-family behaviors and interactions.
On average, we expect that the Motivation Phase is two to four sessions.
Then, consistent with earlier discussions and model depictions in which the
Behavior Change and Generalization Phases overlap, their representation
in sessions is best characterized as five to nine sessions in which the primary
focus is behavior change and an additional three to four sessions in which the
primary focus is generalization.
Therapists must tailor the length of treatment to the individual needs
and dynamics of each family. For example, in one family, intense conflict,
hostility, and blaming interactions may be significantly higher, so the therapist needs to spend three to four sessions in the Motivation Phase to create
a motivational context for change, whereas in another family that presents
with significantly lower levels of hostility and conflict, the Motivation Phase
may take only two sessions.
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Timing of Sessions
The timing of sessions is a critical factor in FFT given the highly conflicted nature and risky behaviors of the family. In the early part of treatment,
the spacing of sessions should be considered along with the level of risk and
protective factors present within the family members and their relationships.
FFT looks for immediate change, first in within-family attributions and other
expressions of positivity, then in terms of more concrete, specific behavior
changes. With high-risk families, we have found that it may be necessary to
have more than one session per week during the first 2 weeks of therapy to
facilitate immediate changes in motivation and stabilization of the family.
The spacing or number of days between the first, second, and third sessions
depends primarily on (a) the severity of risk factors of the family members, in
their relationships, and in their ecosystemic environment; (b) the immediate
availability of protective factors and resources; and (c) the therapists judgment
of how long the family can maintain without a major conflict, crisis incident,
or disruption.
Increasing the density of services in the first 2 weeks with high-risk families
sets the stage for starting behavior change as quickly as possible. By rapidly
responding to the needs of the family with frequent and intense motivationfocused sessions, therapists immediately reduce negativity, enhance feelings
of hope, and establish working relationships with family membersall of which
set the stage for increased family member willingness to change the high-risk
behaviors that prompted the intensification of services. A benefit of tailoring
the density of services to family risk is that the therapist can maintain the
focus on clinical issues that underlie the problem behavior rather than be driven
solely by safety concerns or crises.
After the Motivation Phase goals have been met and the Behavior
Change Phase begins, sessions can be held once a week, and sometimes even
less frequently. Spacing sessions a week apart provides opportunities for family
members to begin to develop new skills and implement these new behaviors
in their relationships on a daily basis. Toward the end of treatment, in the
Generalization Phase, the spacing of sessions can remain at once per week or
be expanded to 2 weeks apart. The increase of days between sessions can allow
for ongoing skill practice and competence development, forced empowerment
and independence of the family from the therapist, and a focus on relapse
prevention planning for the family as a goal for the termination of treatment.
Booster Sessions
Booster sessions can be conducted as an extension of the Generalization
Phase. Booster sessions, whether conducted in person or via telephone, allow
matching and general parameters of fft
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the therapist to monitor family progress and to access or plan for the use of
any community resources that can help the family address new problems or
sustain prior gains. It is important that booster sessions be used as planned
opportunities to aid the family through the natural process of change, allowing the family to revisit previously learned skills and continue to apply them
to diverse situations and problem areas that arise in the future. Booster sessions
should not be seen as a new treatment episode. The FFT therapist should remain
focused on the use of learned skills and their application and maintenance.
Therefore, the number of booster sessions should be minimized, and the
length of time between treatment termination and potential booster sessions
should also be a consideration.
Flow of Treatment by Session
We offer the following template for the flow of FFT. In doing so, however,
we understand that these outlines and figure representations do not actually
tell readers how to do FFT. Consider an aviation metaphor: The runway is
solid and fixed in place, the aircraft is well designed and built, its systems are
functioning well, and there is sufficient fuel to land. However, crosswinds and
other weather factors still require considerable pilot expertise for a successful
landing. In this chapter, we have introduced the fixed aspects of FFT, but we
all become pilots when we enter a room with a family. We know where we
want and need to go, but we nonetheless require great skill to manage the
elements that can push us and the family off course.
Session 1
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Termination Criteria
The termination criteria depend on the specific case and treatment system, as would be expected. Many referral systems ask only that the problem
behaviors (e.g., substance abuse) cease. Others ask FFT therapists to address
specific risk factors such as parental neglect and failure to monitor problem
behaviors such as truancy. In yet other circumstances, FFT therapists are asked
to report back to authorities (e.g., judges, case managers) regarding such aspects
of treatment as youth participation in sessions and missed appointments. In
all cases, FFT therapists work to clarify all such issues prior to or immediately
at the beginning of the first clinical session.
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5
Engagement Phase
Engagement is the short and oft-forgotten or ignored phase of intervention. It is particularly critical when attempting to help traditionally
difficult to treat individuals and families like those typically addressed by
Functional Family Therapy (FFT). Undertaking FFT, or any other evidencebased therapy for that matter, without careful attention to system and family
engagement is not unlike painting the walls of ones house without preparing
beforehand. It is possible to simply open the paint container, grab a brush,
and begin painting. However, the process results in much better outcomes if
time and attention are devoted to preparationfor example, taping around
moldings and covering articles to protect them from splatters. In this chapter,
we present two critical aspects of the engagement process. In the first section,
we describe the framework and strategies for working with key systems that
youth and families are typically involved with at the point of initial referral
and over the course of treatment. In the second section, we describe the
DOI: 10.1037/14139-006
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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how to match the families culture and initial styles of relating to treatment
systems. This also helps therapists anticipate and minimize families initial
sources of resistance. All is not lost if the treatment process gets off on the
wrong foot, but the journey is more difficult and, with some families, may not
even begin.
Assessment: Pretreatment and During Engagement
Referral information is generally already available more or less extensively for youth and families. Sometimes this information consists only of a
name and a reason for referral (e.g., runaway, possession of drugs at school,
parent concern that youth is becoming uncommunicative, social services
receipt of 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 interventionists review such information, along with
as much demographic information as is available, to gain as much understanding as possible about the context in which intervention is to occur. For
example, is there information available that might facilitate cultural sensitivity, that might be informative about multisystem pressures (e.g., poverty)
and resources, and that might suggest individual constraints (e.g., learning
disability, illiteracy) that must be considered?
After initial pretreatment formal assessment, FFT uses formal assessment (e.g., diagnostic tests, formal self-report instruments) only when necessary to answer specific questions that cannot be answered in direct clinical
contact or when additional information necessary for legal or recordkeeping responsibilities is required (e.g., drug screens, documentation of reading
scores to establish improvement or appropriate school placement). Specific
agencies and systems, such as individual juvenile court systems, have added
their own assessment devices to meet their larger system needs, such as validating their own assessment instruments, relating youth characteristics to
census tract data, or providing diagnostic information to funding sources.
Finally, beyond the generic assessment typically obtained in educational, juvenile justice, and social service and mental health contexts, FFT
emphasizes the identification of the interpersonal impact of behavior on each
family member, at first only tentatively hypothesized on the basis of referral
information and reports of such colleagues as referring probation officers and
school personnel. As therapy unfolds, FFT therapists also engage in extensive
relational assessment, designed to provide them with a clinical road map for
how to organize behavior change interventions. In fact, therapists do not
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tive picture of the relational impactthat is, the relational functionsof the
behavioral patterns that characterize the referred youths primary relationships. The relational patterns of parents and other highly influential people
in the youths life are, in turn, mapped in terms of how they fit and do not fit
the youth. Because of the importance of this construct, its operationalization
in FFT, and its role in guiding therapist activities, we discuss it separately, and
in detail, in Chapter 7.
Engaging the Family System
The goal of the Engagement Phase is to maximize family members initial
expectations of positive change. This goal is accomplished through (a) high
availability to meet with families at times and locations that are convenient
to them; (b) effective management of intake processes to present agency, self,
and treatment in a way that matches to inferred family characteristics; and
(c) presentation of treatment and self in a way that enhances family members
perception of the therapists credibility. In this section, we describe how to
accomplish these goals in FFT.
FFT therapists want to engage, at the outset of FFT, those believed to
be the major players in the youths referral and problem behaviors. Once
FFT actually begins, other individuals may be found to be highly involved in
the youths behavior, especially the problem behaviors, and therapists sometimes add them into the therapeutic process. In general, however, referral
sources are sufficiently involved and informed regarding the high-risk youth
and families they refer, and they can be quite reliable sources regarding the
first family treatment focus. For example, live-in boyfriends of mothers with
referred delinquent sons rarely offer to participate and, if asked to do so, often
respond along the lines of he wont listen to me...he isnt even my kid.
And sadly enough, many referral systems, including juvenile justice, often
do not even attempt to involve these live-in father figures, especially if the
adult relationships are inconsistent or conflicted or involve any substance
use. However, these individuals may have a significant impact on the referral
youth and other relevant family members.
For FFT, such situations are exactly the sorts of ecological contexts that
must be engaged from the outset to launch successfully a positive course of
treatment. This is especially important when relationships are loaded with
immediately proximal risk factors, flash points, and recurrent crises. Such
circumstances certainly loom large in the lives of many of our referred youth
and their parents or parent figures. So FFT therapists work very hard to find
a way to connect with them and engage them in the FFT process. Often this
involves asking, Would you be willing to attend one session so I can get a
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broader picture of what is going on? I think your perspective will be very valuable. Many treatment-resistant people are willing to come in when given
this message, whereas they are almost certain not to be willing to begin if
asked to come to therapy to help with James. Although it is certainly beneficial for them to attend more than the first session, they need to at least get
into a first session for the FFT therapist to begin to motivate them to come
back for more sessions. Stated differently, having an influential but highly
unmotivated family member in the first session at least gives FFT therapists
a chance to begin the motivation process with this person and to facilitate
system change. Referred youth do not live in isolation and often are in farfrom-perfect living situations. Thus whatever FFT therapists can do to see
parents or a single parent conjointly with the child from the outset of treatment is well worth the effort because family retention rates and ability to
move more quickly through FFT stages improve considerably. In particular,
having the parents involved from the outset allows the therapist to begin
quickly to incorporate the more powerful and long-lasting change-focus and
change-meaning techniques that are described in detail in Chapter 6.
Where?
Although FFT is most often conducted in the home or office, many
providers are able to be creative in going to and arranging family transportation to other venues. Over the years, alternative venues have included jails,
detention centers, residential treatment facilities of youth nearing release,
community shelters, and schools. Such flexibility can increase slightly the
cost of intervention but also increases dramatically the billable hours for
providers.
The First Call
With high-risk youth and families, first impressions count! The goal
in the Engagement Phase is to enhance the perception of responsiveness
and credibility and to demonstrate a desire to listen and help in ways that
match them. FFT therapists do not automatically adopt a particular style
when they call; an angry family member requires a different style than a
hopeless or frightened family member. The skills or qualities required during
this first call are simply the qualities consistent with positive perceptions of
clients, particularly persistence and matching. The focus during the first call
(and subsequent calls if necessary) is on the family members expectations,
and the goal is to be immediately responsive. The FFT therapists needs to
keep a strength-based relational focus, reflect a nonjudgmental attitude, and
demonstrate respect for individual and cultural characteristics and diversity.
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Schedule first sessions as quickly as possible and, again, offer to go to the home
if necessary.
The FFT therapist does everything possible to reach out to all relevant
family members, taking care not to demean, denigrate, or confront in the
process. Contact as many of the major player family members as possible
and attempt to send a very clear message that I am here to hear and respect
you on your terms first and foremost. Note that due to gender, age, cultural,
and ethnic differences, diverse FFT therapists engage and match to family
members differently depending on their gender, age, cultural, and ethnic differences. As soon as FFT therapists begin to get cues about youth and families
as individuals, they also add consideration of their cognitive and emotional
styles during their attempt to match them and who they are.
Beginning with the first call, good FFT is not linear or standardized.
The goal is to create the conditions necessary for all the key family members
to attend the first session. Engagement is not therapy; the only goal is to get
them into the session so therapy can begin. Keeping the focus this narrow and
specific enhances greatly FFTs success rate in getting started with the family
members needed on board to produce long-term change. Yes, engagement is
merely the first step in a challenging process, but without success in that first
step, the process begins in ways that limit greatly therapists ability to help
the youth and families referred to us.
We have found over the decades that FFT therapists are dedicated clinicians. Yet although mastering engagement would be easier with a protocol or
standardized set of techniques to use with family members from the very beginning of contact, such a prescriptive approach is not possible. All FFT therapists
begin the engagement process with a similar knowledge base regarding FFT,
and all (we hope) are passionately invested in engaging families successfully
in the change process and experience satisfaction when the therapy journey
begins successfully. At the same time, each call, colored by the therapists
style and set of skills, must be matched to the unique characteristics of each
family and family member and to the treatment setting. Above all, FFT therapists are clinicians who listen to the emerging details and challenges families
share as they work to schedule the first session and problem solve as flexibly
and creatively as they can within the structure of FFT.
Intervention Strategies of the Engagement Phase
Additional techniques include anything and everything that must be
done to get all of the major players together for that first critical session.
Often all that is necessary is for the therapist to match, listen, and present a
short, strength-based, positive message for all the major players to be willing
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to attend the first session. This process can involve various forms of what
may be flippantly referred to as schmoozing because the ultimate goal is
to present or position the therapist and treatment in a way that increases
the likelihood that family members will participate in the treatment process.
This involves working hard to cajole (respectfully), remind the resistant family members about how achieving the treatment goals will make their lives
easier and better, and listen for clues as to what would motivate the family
member to attend the session. For many therapists, this also can involve the
use of several change-meaning techniques, especially relabeling and perhaps
reframing, that they already use in the Motivation Phase of FFT. For example,
an exhausted and overwhelmed single mother might say, I dont think I can
do this anymore; hes exhausted me. He wont change anywayhis new family
is [gang name]. To this, the therapist might respond,
I can almost feel your exhaustion over the phone. This has been so hard.
But please tell me if I am wrong when I say that perhaps this is your way
of telling me that you are willing to let go a bit....You desperately need
help since you cant do it alone any more. If this is true, I am here for
youyes, here for [sons name] also, but for you.
In such a circumstance, the therapist likely will also need to contact the son
perhaps through the probation officer, or preferably directly with permission
from the officer:
Hello, [sons name]. This is Terry Z, and Id like to talk to you for a second
or two. I work for [agency name], and for starters, yes, Im White. I hope
that isnt too much of a problem, but if it is let me know, and Ill see what
I can do to find another therapist you feel more comfortable with. In the
meantime, Im worried about your mother since Ive talked with her. Im
also worried about you a bit based on what Ive been told, but I dont
know you at all, so you may change my mind about that. I like to not
worry. But I do know from the referral I got that you are in the spotlight
right now. If I may ask, how are you doing?
[Then soon thereafter:] Can I come over, or will you come and meet
me somewhere else with your mother? And, if I may, when I come to
[district name], I stick out like a sore thumbIm sure there is a younger
mans way of saying that. Do you mind if I call you right before I get there
so you can meet me outside, or would you rather I just come to your door?
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then motivating, relevant family members. Also note that we dont ask the
youth to acknowledge his moms concern in our example; we just state it and
in our words and actions avoid taking sides.
In sum, during family engagement, the therapist uses every skill to get all
the major players together to work with them directly and begin immediately
the Motivation Phase. Such strategies as change focus and change meaning
(see Chapter 6) can and should be used if necessary. However, they are not
explicitly prescribed for the Engagement Phase because, strictly speaking,
they arent necessary for successful engagement, whereas they are necessary
and clearly prescribed for the Motivation Phase.
As a matter of course, FFT therapists line up their immediate in-session
goals, their intermediate end-of-session or treatment-phase goals, and their
long-term outcomes. By no means is this a simple linear progression, but it
does represent a coherent sequence of implementation steps with families. For
example, in FFT with gang members, therapists do not simply jump directly
into changing the referral behaviors despite the intense pressure on them
to address the most pressing risk factors directly and immediately. Instead,
they first pave the way by engaging family members in treatment. Then they
quickly begin inducing or motivating family members to change by creating a
context that is less negative and even hopeful. They also must assess how the
referral problem behaviors relate to the rest of the familys relationships and
needs (relational assessment) before they can undertake the powerful change
trajectories that will be necessary.
engagement phase
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6
Motivation Phase
Creating a motivation context for change in the initial sessions is fundamental for subsequent behavior change. That is, motivation represents the
gateway for lasting change. For this reason, we have front-loaded Functional
Family Therapy (FFT) with numerous techniques and strategies for negotiating interactions with family members in these critical early sessions. In this
chapter, we describe the goals and tasks of the Motivation Phase, including an
overview of the interpersonal characteristics and the overarching strengthbased relational framework that pervades interventions in this phase. We
also describe specific interventions for achieving the goals of the Motivation
Phase and provide examples of each technique.
DOI: 10.1037/14139-007
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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When they begin therapy with FFT therapists, family members have
developed rigid or defensive cognitive schemata through which all information
is filtered. These views influence and sustain the highly coercive and defensive
interchanges that serve to further solidify individual family members negative
attributions and blame. Over time, these interactions become so familiar and
habitual that they are virtually automatic.
The notion of automatic processing provides a useful nonblaming perspective for understanding family communication processes. Take an example
from everyday life. Can you remember when you first learned to drive a car?
Every action required considerable planning and thought, and for all of us,
learning to drive a car required all of our mental resources. With experience,
however, many of the tasks that once required complete focus and attention
could be accomplished with little thought. What required our full attention
at one point has become so habitual that it has now become automatic, and
we often are not even aware of the cognitive processes involved. Recurrent
negativity, in the families we see clinically, seems to operate in the same way.
Disrupting such repetitive negative interactions and their representational schemata is a critical first step in the FFT treatment process. The goal
is to first intervene in the moment to create a different experience that disrupts the familys automatic responses. This then allows for more controlled,
deliberate, or thoughtful processes. Initially, the disruptions may be accomplished by simply interrupting family members, but because the FFT therapist
cannot keep intruding alone, he or she must quickly transition into intervening in ways that build relationships and consistently introduce a strengthbased, relational focus into the session. As interventions become more complex
and involved, and as therapists builds relational capital (i.e., better therapeutic alliances) with family members, they are then able to take the initiative to introduce new ideas into the session. Often, these ideas would have
been rejected prior to the introduction of a strength-based, relational focus.
Over time, however, family members individual blaming attributions are
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transformed in such a way that family members gain a renewed sense of positive and adaptive connection to each other as well as the experience that
change is both possible and worthwhile.
Thus, at this early juncture in the treatment process, the intent is not
necessarily to change attitudes, attributions, or other cognitions but rather
to disrupt rigid, negative patterns and create an opportunity for family members to experience that something new and more hopeful is possible. Specific
techniques are designed to reduce family negativity and create positive and
balanced alliances in which each family member feels that the therapist sided
with him or her and each experiences that there is something personal to
gain by participating in treatment. In addition to the specific techniques we
describe in detail later in this chapter, therapists accomplish this through
adopting an overall nonblaming relational role in which family members
experience that the therapist is more interested in hearing and respecting
family members than in examining what they do wrong or how they need to
change to make things better. At the conceptual level, what holds the skills
and techniques in this phase together is a persistent strength-based and family relational focus through which family members experience one another
in new and more adaptive ways.
Therapist Characteristics: Adopting
a Strength-Based and Relational Focus
The emphasis of FFT in the early sessions is on creating a context in
which family members begin to experience one another in new and more
positive ways. The most immediate goal is to systematically replace negativity, blame, and hopelessness with a strength- and relationally based focus
that introduces more positive and adaptive attributions and emotional links
within and between family members. The strategies therapists use are relationally real, powerful, and often unexpected by families who are used to
problem-focused (and even blaming) interventions from the service providers or systems with whom they have had the most frequent contact.
Over the years, we have found that in diverse treatment populations,
agencies, and treatment contexts, the immediate Motivation Phase interventions are as much about therapist attitude as they are about specific techniques. Fundamentally, therapists must believe in and be committed to a
relational and strength-based approach, even when positive strengths and
goodwill in the family are not at all apparent. Part of the challenge for therapists is reflected in the intensity of the behaviors that often bring families
to treatment (e.g., verbal and physical abuse, neglect, rejection, abandonment, sexual abuse). These behaviors can push therapists personal buttons
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or elicit responses that pull them away from their relational goals, thus going
far beyond the traditional construct of countertransference.
Facing such behaviors, therapists can fall into the trap of taking sides or
challenging a maladaptive behavior to protect a vulnerable family member.
Quite often, these natural and even understandable tendencies on the part of
therapists lead to interventions that support and validate one family member
but blame and distance another. A therapist may engage in a disproportionate
amount of supportive interventions toward the family member whom they see
as being the victim in the current situation. Or, just as commonly, the therapist
may directly challenge bad behaviors of the family member they view as being
the perpetrator or instigator in the family. In either case, specific interventions
can become individually focused and, to some degree, confrontational, which
our research and clinical experiences have shown results in immediate negative outcomes such as increased within-family conflict, resentment, walking
out on the session, and dropout.
In FFT, a strength-based, positive enhancement of family relationship
issues pervades all interventions, from simple acknowledgments to development of complex themes. With respect to the former, for example, a
therapist may go beyond a simple individual-focused acknowledgment of
a mothers negative feelings (It sounds like you feel hurt) to include a
relational focus (This seems to have hurt you even more because you have
such special feelings for your son). Both acknowledge negative feelings
and serve to help build an alliance with the mother, but the latter statement
acknowledges both her negative feelings and the special feelings she has for
her son, feelings that are often hidden or disregarded when negativity and
hostility emerge in the family. This shift to a benign relationship focus is at
the heart of the specific Motivation Phase interventions described in the
next section.
The implementation of these interventions requires that therapists have
considerable relationship and interpersonal skills to build alliances with individuals who are often in overt conflict with one another. Just as important,
therapists must be able to interact with family members in a nonjudgmental,
accepting, nondefensive way, even when family members are doing or saying things to one another that pull the therapist into the system to protect,
defend, chastise, or take sides with individual family members. Therapists
must have considerable courage and resilience to stick with this relentless
relational focus in a way that is sensitive to the diversity of individuals and
issues presented in the context of treatment.
We have coined the phrase fearless empathy to describe the approach
that therapists must take to deal with negative, helpless, hopeless, and other
wise dysfunctional families. Empathy begins with sending family members
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Change meaning
Relabels theme hints
Theme hints
Reframes
Reframes + (noble intent)
Themes
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ity 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 members
negative speech act, then the subsequent family members speech act is almost
twice as likely to be positive than if the therapist allowed the family member
to respond to the negative statement (Robbins, Alexander, & Turner, 2000).
It is important to note that divertinterrupt techniques are not defined on
the basis of the content of the therapists verbal behavior (as is the case for the
change-meaning techniques described in the next section). That is, regardless
of what the therapist says, therapist behaviors are considered to be divert
interrupt whenever a therapist disrupts negativity by intercepting, blocking, or
redirecting communication. Divertinterrupt interventions require an active
and involved therapist who is highly attuned to the meaning and nature of
interactions in the family. Therefore, these interventions are used in a manner
that is sensitive to the current interactions, and although they involve interfering with or speaking over family members, they are delivered in a manner that
is respectful and accepting of the family.
Pointing Process Technique
Pointing process involves commenting on interactions or events that
occur during therapy sessions. As FFT therapists share their observations and
attend to each family members report about family processes and extrafamily
interactions, they can comment on the process of how family members relate
to each other, thereby making explicit the interrelatedness of family members feelings, thoughts, and behaviors. However, rather than simply describing interactions that are characterized by negativity and blaming, therapists
selectively choose nonblaming, preferably strength-based descriptors. This
can serve to defuse or at least lessen negativity by shifting the focus from the
specific content being discussed to the relational aspects that underlie it but
are hidden from family members in the current moment. In a session with one
family, for example, the therapist made the following comment to the father:
I noticed something Id like to check out with you. When you talk to
Tommy, you tend to lean forward a little bit, whereas with Chris, you
often point toward him with your finger. I cant figure out if you think
Chris wont get the message if you dont emphasize it, or if you are already
discouraged because you think he wont pay attention, or maybe you
point to let him know that reaching him is still very important to you.
Maybe the three of you know how to interpret all this, but Im still trying
to find out how this works for you.
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teases his brother. In either example, pointing process serves to take the focus
off an individuals behaviors to instead focus on connections or relational processes between family members. The content of these interventions can be
useful for developing alternative hypotheses about the meaning of behaviors.
For example, the therapist might follow the basic observation noted at the
beginning of this paragraph with a more complex question or observation that
draws attention to the youths connection or sensitivity to his moms pain.
Sequencing
The change-focus technique of sequencing involves examining repeated
patterns of behavior that occur within the family, such as arguments or other
manifestations of conflict between family members. Sequencing differs from
pointing process in that the latter refers to interactions that occur in front
of the therapist. Although sequencing often is used to assess what happens
with regard to the specifics of a presenting problem, it can be applied to a
wide variety of issues or complaints the family brings to the session. In fact,
sequencing often can be introduced simply to create a positive tone as context for subsequent interactions in a session. The therapist often begins with a
series of questions such as When did this happen? How did it start? What
happened next? and, to a seemingly uninvolved family member, Where
were you when all this was going on?
Because information is drawn out in a sequential and circular fashion,
families are helped to see more clearly and experience the context in which
behavior occurs. To the surprise of family members, asking about who was not
involved in a problem sequence often can open up new avenues for exploration
or change. For example,
Therapist: So, Rubn [son], you walked in an hour after curfew, and
you two [mom and son] report things got out of control very
quickly. Right so far? [Mother and son nod.] Now [to stepfather], Toms, did you see or hear any of this? Where were you?
Mother:
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tive elements, are able to process information rapidly and not miss the subtle positive messages that are often embedded in the negative interactions.
Sometimes positivity is not embedded in the negativity, but the therapist
can work to infer or imply it might be. Stated bluntly, it is our job, not the
familys, to seek out and develop hope and more positive attributions. From
the familys perspective, our seeing more than the negative statements is the
first step in a healing and transformational process both in the moment and
for the future. These interventions thus serve to broaden family members
narrow focus to include their positive views about themselves (especially in
the case of depression) and other members of their family. This, in turn,
develops a more positive go-to place for the family as members experience
new challenges.
An example would be a sons interruption of a statement being made
by the stepfather:
Stepfather: Hes been this way before I ever set foot in this house. His
mother told me he was even like this with...
Son:
Therapist:
Wowthat was clear! Let me get this straight. Mr. X, did you
notice how quickly Daniel jumped in to correct you? I agree
it was rude and argumentative, but he gave you a clear invitation to get more information before you said anything else. So
if I may, Daniel, what is it that your stepdad doesnt know?
The therapists interruption served to break up a possibly intensifying interaction, and rather than focusing on the rudeness of the sons interrupting, it
instead asked him for more input. This is consistent with the therapists goal
of creating a tone of inquisitiveness rather than blaming.
When therapists are uncertain about how to interrupt and divert a
negative interaction as it unfolds, it is important to remember that not all
of the behaviors on which a therapist can comment are verbal. Therapists
should pay attention to facial expressions, meaningful looks between family
members, and sequences (who follows whom?). Many of these can be used
in the moment to refocus interactions onto positive elements. For example,
the therapist may remark, When your son was talking, I thought I might
have seen how proud you were that he was able to stand up for himself. Or,
I noticed that every time he gets angry, you adjust your tone and speak more
quietly and in a soothing way. Systematically focusing on positive sequences
creates a working climate in the session in which family members gain a new
perspective about themselves and each other. Again, the lens is shifted from
the negative behaviors and problems with which families enter treatment
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change-meaning techniques also involve attempts to create a positive motivational context for change by altering the meaning of how family members understand and experience themselves and each other. To use a parallel
example that many nonproblem families experience, even fit and nonsmoking people understand that regarding smoking and unhealthy eating
patterns, people easily become engaged in the desire and even commitment
to change. However, maintaining the change, which is notoriously difficult
to do, requires much more than initial superficial or fear-based motivation.
Change-meaning techniques address those more complex and important levels of motivation everyone needs to undertake difficult change journeys.
The in-depth descriptions of change-meaning techniques described in
the rest of this chapter are based on decades of clinical research and experience. The categorical nature of these descriptions is helpful in understanding
the FFT model, but they do not necessarily reflect the moment-to-moment
thought processes of therapists as they are matching interventions to the
unique needs of individuals and families. Therefore, therapists are not necessarily expected to use all of these techniques all of the time. However, by
being precise at the training or learning stage, we hope to provide sufficient
detail to help therapists integrate and use a range of change-meaning techniques with difficult families.
Theme Hints
Theme hints are therapist interventions that telegraph or represent a
more complete nonblaming relational theme. For example, in response to a
youths inappropriate behaviors in the session when his mother and father
begin to fight, a therapist might use a theme hint about the meaning of his
distracting behaviors by saying, You seem to have a protective streak in
you. In this example, the theme hint is protection. However, the theme is
not fully developed or linked in relational ways to other family members or to
problematic relational sequences. Nonetheless, a theme hint can lead family
members to look at the therapist in wonder or even confusion. If so, it has
done its job: It has disrupted the escalating argument and opens a window for
a therapist intervention without it having to be as intense.
Another example can be found in our work with a mother and her
16-year-old son, who were arguing about the son not attending his older
brothers college graduation. The mother said, He lacks compassion. You
know? He just lacks what most humans have. He has no feelings. The therapist responded by saying, As a mother of both kids, you are in a very complicated situation. The mother immediately acknowledged the trap she felt
she was in (implied in the therapists statement) by saying, I love both my
kids, and I saw this as a chance to bring our family back together again. The
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ior, nor did it directly address or challenge her views that he lacks compassion; rather, the therapist shifted the lens to focus on her role as a mother
to both of her kids. In this case, doing so evoked a more nurturing, adaptive
statement (I love both my kids).
Relabeling
Therapists relabel by reflecting to family members a similar, but less
harmful, explanation for a behavior in which they have engaged or are
engaging. The goal of relabeling is to shift some of the negative intensity in
the meaning of that behavior. Consider a teenage sons complaint about his
mother arising in an early sessionAs soon as I walked in the door, she just
went off on me!and the therapists response, So she let you know right off
the bat that she had an issue with you. Although these statements may seem
quite similar, she just went off conjures up a more intense image than she
let you know right off the bat that she had an issue with you. This relabel
also added a softer relational component (she had an issue with you) rather
than the more attackervictim tone of she just went off on me. Relabels 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 models, in fact,
consider it a core technique for all family therapy approaches. As defined
by Watzlawick, Beavin, and Jackson (1967), a reframe is a change of the
conceptual and/or emotional setting or viewpoint in relation to which a situation is experienced and to place it in another frame...and thereby changes
its entire meaning (p. 95). Reframes, as defined in FFT, add two components to the change-meaning process: acknowledgment of the negative and
proposal of a possible alternative (and perhaps even benign) motive. These
components add significantly to the therapists ability to reduce family negativity while maintaining an overall nonblaming relationship with all family
members.
Reframes include a clear acknowledgment of the negative aspects of a
behavior (thereby supporting the people who are negatively impacted by the
behaviors in question). However, the acknowledgment does not include an
agreement with the family member. Rather, the focus of the acknowledgment is
to establish that the therapist is attuned to and understanding of the relevance
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Son: As soon as I walked in the door, she just went off on me!
Therapist: So she let you know right off the bat that she had an issue
with you.
Son: She always has issues with me when I come home! Im
getting to the place where I dont even want to come home
any more. If it werent for my brother, I wouldnt.
Therapist: Ah, yes, your brother. Well, first of all, I want to thank you
for having that commitment to your brotheroften I dont
see that support between brothers in here. [Note that this
is an overt reaching out with positivity and support for the
identified patient son, and that alone can help with his
negative feelings at this moment.] And [to mother] I presume you know he loves his brother? [to son] Youve said this
to her before, right? But I think I might see a sad sequence
herewhere you [mother] may feel overwhelmed or unappreciated at home, or maybe even lonely, and certainly worried about your son since he got into trouble. So you look
to your son to show you support and reassurance by coming
home on time and such, but when he does come home, it
seems that he may caring more about his brother than for
you. This, of course, makes sense! You are the one who has
had to set limits, worry about keeping food on the table,
respond to the school, and so on. So you start to get noisy
[note the relabel] when he comes home, and it does get his
attention. But now it is negative attention, and he hears
more what he calls nagging or going off than what you
might be feeling underneath, which is your [moms] concern
for him and his future. And if I may, this might also include
concern about his not being as close to you as when you all
were first struggling with not having Dad around.
So, may I ask how it came about that you [to mother]
dont feel OK about asking for his support more directly?
Sometimes it starts out innocently enougha lot of mothers dont want to add burdens to their sons, so you [note the
switch from the generic mothers to you] protect them
from your own feelings of hurt and abandonment. [Note the
sense of noble intent of her nondisclosing behavior.] But
then moms get scared or feel unappreciated when their kids
come home and dont reach out to them. And thenwell, it
is sad and ironic that for many of us, it is easier to express our
pain through anger, like going off, rather than just saying,
Im lonely; Im scared. And to make matters worse, lots of
motivation phase
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new ways. Remember, however, that reframes are not presented to avoid the
issue of negative behavior. It is essential that therapists, prior to presenting reframes as possible alternative explanations for behaviors or motivations, first validate the negative impact of the behavior. Reframing does not
minimize the negative impact of bad behavior; bad behavior is bad! Instead,
reframes add a focus on the possible motivation that implies that the motives
may not be completely evil or malevolent. This distinction is key to helping
interventionists respond to negative behavior but in a way that lowers defensiveness and resistance and enhances alliance.
For example, as part of the referral information, the therapist is informed
that one family member slapped another, and the therapist must first validate
the physical and emotional pain:
Clarice, you must have felt awful, physically and emotionally. Lots of people who hit dont realize that it is humiliating as well as painful [validation
of behavioral impact, which then can be followed by the reframe]. John,
when you hit Clarice, did you imagine how it would hurt her, or were
you more focused on your own feelings, like maybe feeling out of control
because she was getting the upper hand?
Note this is mostly a relabel, not a reframe and certainly not a reframe +.
In this example, the victims pain was first validated, and then the situation
was broadened to suggest motivations (or at least experiences) on Johns part
beyond simply inflicting pain.
Reframes such as this do not excuse the behavior, but they provide
more of an affiliation and alliance-based attempt to motivate change rather
than the message you are a bad person for hitting; you must stop this
behavior; when you feel anger like this you must.... The relabel allows
the therapist and family, especially the person who did the slapping, to
clarify the underlying motivational structure and develop alternative sets
of internal and external cues as a basis for change. Not all such relabels
and reframes are successful in the moment, but therapists willingness to
offer them, whether or not they are clinically rich and effective, predicts
significantly the likelihood that all family members will return to continue
the journey of change.
Occasionally, some clinicians and criminal justice workers have expressed
the concern that reframes will be taken as excuses by that subset of youthful
offenders, abusive and neglectful parents, siblings, or others identified with
such labels as sociopath. However, reframes have been developed as a key
component of the Motivation Phase, and if reframes do not serve to motivate
positive change, then they should not be used again and again. All therapists
understand that persistence alone will not help troubled families change. If
something is not working, therapists must flexibly develop alternative specific
strategies to meet Motivation Phase goals.
motivation phase
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Or, if the clinician has not been there, he or she might say,
Ive sat in this room with too many people in the same pain you are in,
and Ive seen what finally comes out after all the rageso Im not fooled
by all your anger, even if you are still fooling yourself. How do the rest
of you [other family members] express your pain? [note the relabel of
anger as an expression of pain]...getting angry like Dad? getting
high? feeling helpless?
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that typically occurs when only an individuals negative behavior is the focus.
At the same time, these types of themes are obviously fairly difficult to create
because they move the focus from one to another negative behavior on the part
of more than one person. However, as therapists are successful with the previously described change-focus techniques, the family as a whole is much more
positively responsive in ways that they would not have been earlier, when the
focus was almost exclusively on negative behaviors.
Relational themes are so called because they switch the focus to relationships rather than behaviors. Relational patterns and how they have been
experienced become the major focus. And although relational themes maintain the basic elements of reframes (i.e., acknowledge the 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.
They also tend to describe emotional states and misguided attributions,
including cognitive distortions, transference-based processes, and stereotypic
thinking, rather than reality-based awareness.
Examples of Relabels, Reframes, and Themes
The following far-from-exhaustive list of short relabels, reframes, and
themes provide examples of how FFT therapists reinterpret family relational
patterns in a new light:
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positive reason for the nagging, so all the others hear is the
criticism.
Pain interferes with listening. When someone seems insensitive,
selfish, and so forth, it may reflect the fact that they are in too
much pain (or fear, or sadness) to be able to consider others. This
is particularly hard to understand when people cover their pain
with anger, selfishness, and other negative behaviors.
Fear can imply differences. Some individuals are afraid of differences because they fear that differences will lead to lack of
commitment, loss of control, and unwillingness to continue the
relationship. People are frightened by differences because they
do not trust the process of dealing with differences.
Bad behavior can imply protection. Sometimes people do bad things
(e.g., fail to support their mate, act out) to protect someone else
by taking the focus off of him or her or forcing the family to get
outside help.
Note that these simplistic examples, often offered in some form to many
families, do not focus on specific behaviors per se. Instead, they seem to reflect
more the challenges of being human, of struggling in inefficient but not meanspirited ways, and of perhaps needing help to change more than needing the
embarrassment, humiliation, oppressive control, and punishment they often
experience. It helps to understand that relational themes borrow from many
intellectual, philosophical, anthropological, and even spiritual frameworks
rather than traditional behavioral, cognitive, and even systems perspectives. For
some therapists, relational themes therefore represent a major reach both intellectually and stylistically. Those therapists can still be quite competent in FFT,
but they use other change-meaning techniques more than relational themes.
Other therapists find the ability to move away from the stark reality of
problem behaviors to be quite freeing, and they often can create experiences
in families, even in early sessions, that are quite dramatic. Relational themes
often become more like songs, poetry, and movies in that they can move
people, albeit only temporarily, into places of positive experience and hope.
The burden of hopelessness, resentment, and anger toward another family
member is huge, and sometimes through themes we can give family members
a brief sense of relief from this burden. Because we provide this relief when
the family members are all present, they can and often do have a remarkable
synergistic effect. To the FFT therapist as well as the family members, this
effect is almost palpable. Coupled with the core generic principles of matching and respectfulness, these powerful change-meaning techniques help
families move quickly to being open and responsive to techniques to change
behavior (in the short and long term), to be described later in this chapter.
motivation phase
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family members for the purpose of building alliances and setting the stage for
change-focus or change-meaning interventions.
And once again, attending to emergent processes and issues requires
that therapists are fearless in their empathy and support of family members.
When therapists see smoke, they are likely to find fire. A key aspect of training
involves teaching therapists to trust their own emotions and instincts in the
session. When they feel threatened or on the spot, it is critical to identify the
source of their discomfort. It is easy for therapists to avoid a difficult family
member, a contentious family relationship, or a hot topic. This, unfortunately,
only delays the emergence of the inevitable or, if missed too many times, leads
to premature dropout because treatment will lack immediacy and relevance to
family members. Therapists must address meaningful issues by going quickly to
the individual and relationship processes that are generating the most negativity. The first step of this process is acknowledging the negative aspects of the
communication to establish that the therapist understands, although does not
necessarily agree or disagree with, individual family members perspectives.
Once this understanding has been established, family members become more
open to change. More important, because the therapist has listened closely to
what family members have said, he or she has a better sense of how to tailor or
match reframes and themes to each family member.
Indicators of Successful Outcomes
in the Motivation Phase
The Motivation Phase is expected to be brief (two to three sessions,
sometimes within as few as 710 days) and to target very specific clinical processes or outcomes. Although the specific ways that outcomes are expressed
are unique depending on the qualities of each family, the desired outcomes
are common across just about all families. In FFT, change-focus and changemeaning techniques are used to achieve very specific observable behavioral
goals, including
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When these outcomes are achieved to at least some extent, the FFT therapist
prepares to move into the Behavior Change Phase, which is designed specifically to change the referral and related problem behaviors (e.g., attitudes,
emotional reactions) and the processes that elicit and support these problems.
Please note the above phrase at least to some extent: After a mere two or
three sessions, we are not expecting that the family has achieved perfection.
This phase is about helping families move quickly to a good enough place
emotionally and attitudinally that they are willing to begin the behavior
change processes that FFT provides. So sometimes we would use the phrase
less discouraged rather than hopeful to describe a family ready to move into the
Behavior Change Phase. They need not be wildly enthusiastic but rather only
willing to give things a try without undermining the processes before they can
even begin to change behaviors.
This, of course, sounds fairly modest, but we remind the reader that
this approach differs dramatically from some others that seem to take sides
(e.g.,Were going to show you how to get control of your son or How can
you expect your daughter to stop acting out when you yourself are entertaining boyfriends and drinking at home?). We also do not make promises like
we have seen in some marketing films (Our program will teach you how to
get your child back under control. No more arguing, no more disrespect, no
more drugs...). FFT also differs from programs that offer possibly demeaning or insensitive initial stances with family members (e.g., First, lets take
off the hat and earphones or Mom, we need to turn off that TV show
were here to do family therapy). Rather, FFT therapists jump in and begin
working quickly, fearlessly, relationally, and positively.
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7
Relational Assessment Phase
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nor do they push to help all youth become independent from their parents.
FFT therapists do not intend to make all mothers close to their kids or to
make them all become less involved with their kids. FFT therapists do not
intend to make fathers more like a friend to their kids or less like a friend
and more like a parent. FFT therapists do not intend to create adult relationships (e.g., marriage, partnership) that are all symmetrical or all one-up or
one-down. In sum, FFT therapists do not become involved in the lives of dysfunctional families to make them into something they are not or something
someone else says they have to be.
Instead, what FFT does is to help dysfunctional families become functional and better versions of themselves: Families with delinquent youth
become families with nondelinquent youth; families with abusive parents
become nonabusive families; and families with depressed and overwhelmed
parents become families with parents who are happier, are coping better, and
have a sense of hope and self-efficacy. FFT therapists accomplish these goals
by working with the relational configurations the families have already have
developed, but they then provide families with alternative, more adaptive
ways to express these configurations.
As human beings, we learn from experience what sorts of interpersonal
and family-based behavioral patterns and strategies work to attain certain
specific motivated goals in certain conditions. The process begins in early
childhood. For example, a baby may learn that throwing a tantrum makes
his or her mother pay attention to him or her. Then, as children move into
the outside world, they bring with them well-rehearsed strategies that may
or may not continue to work in these new contexts (Reid, Patterson, &
Snyder, 2002). It is during these times that, in retrospect, families can begin
to see relational patterns both within and outside of the family that increasingly emerge as important predictors of adaptive versus maladaptive behavior patterns in adolescence. In turn, as peer influences become increasingly
salient during preadolescence, adolescence, and youth, young individuals
learn even more strategies for attaining motivated goals. Like the strategies
learned as a baby, the strategies learned as a child may be prosocial or more
problematic. When the behavioral strategies are problematic, the families
experience increasing behavior problems, which get them into FFT or a multitude of other interventions. Thus, by the time an FFT therapist receives a
referral for dysfunctional behavior patterns, the relational functions the patterns reflect in important relationships usually are well established and easy
to recognize. As a result, the therapist looks for stable patterns, first assessing
the relational functions on the basis of inferences from the relational behavior patterns within the family and then repeating the assessment process for
relationships and problem behavior patterns outside the family, especially
with peers.
116 functional family therapy for adolescent behavior problems
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High
Degree of Autonomy
Autonomy
Midpointing
Low
Closeness
Low
High
Degree of Closeness
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Why and how do people develop these patterns over time? Sometimes
therapists know or can find out; other times, we never know. As noted several
times already, individuals are not always consciously aware of what motivates
their behavior. Often, in fact, what they seem to understand about why they
behave the way they do is at odds with the understanding of other observers.
FFT, for better or worse, has developed in a manner that can and does allow
these various etiological theories and perspectives to inform how we think
about the here and now.
At the same time, this perspective does not require us to take a strong
stance in favor or disfavor of any particular etiological model or a specific
technique. This, in turn, helps with our flexibility and accommodation to an
extremely wide range of referral youth and contexts. For example, we may
never know why a stepfather seems to be so closed off emotionally from his
wife, the mother of the referred youth. He may have had early experiences
that set him up to fear emotional closeness with a woman, or his first wife may
have betrayed him and used his emotional closeness as a reason for doing so,
or he may be depressed. He may even be simply living up to self-expectations
based on his interpretations of his cultures demands and expectations of men.
What we do know is that his pattern of distance, autonomy, and shutting
down is problematic for his wife, so we work toward a new interpersonal style
with his wife that she experiences as more open and available, yet one in which
he still feels that his vulnerability (expressed as autonomy) is protected and
even respected. Notice that in this example, we did not require that the wife
give up on her need to be closer to her husband. However, we work on ways
in which she can ask for or elicit more behaviors that she experiences as close
but without him experiencing them as overwhelming or dangerous. These
examples should remind readers that FFT requires creativity and flexibility.
In turn, this flexibility results from one very simple yet profound aspect
of FFTs intervention philosophy. That philosophy can be summarized as the
respectful acceptance of the diversity that all family members bring us in
terms of relational functions. Again, as noted above, to help youth and their
families, we do not require them to represent one particular kind of relational
function. We instead believe that youth can be adaptive and happy whether
their relational need with a parent is for more contact, closeness, and inter
dependence than is the norm for their age or culture; or for more autonomy
and independence than is the norm; or for a relational function that represents a balanced expression of contact and autonomy.
All three of those 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. A parent who is emotionally and physically close and
heavily focused on his or her adolescent youth can represent the icon of positive parenting (e.g., Parents: It is 10 p.m.; do you know where your child is?
122 functional family therapy for adolescent behavior problems
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Parents: Be willing to do the tough thing. Know your adolescent, know his
friends, know where she isask questions.). However, another parent with
a similar relational function of contact, closeness, and interdependency, if she
expresses it in other ways, faces being identified as enmeshed, overbearing,
overcontrolling, even codependent. So for FFT, it is not the degree of attachment but rather the means through which the parent maintains the relational
function and how it fits with the relational function of the youth.
To continue with a very different example, consider the parent who
generally reflects a relational pattern of more autonomy than closeness with
the child. This parent can face the label of being uninvolved or uninterested
or can be praised for being able to raise the type of adolescent to which he
or she can grant a fair amount of autonomy. A parent can monitor a youths
behavior directly and with an emotional overtone (contact/closeness), or the
parent can monitor just as effectively but from a less directly close style via
notes, text messages, and written rules and checklists. Both involve monitoring activity, but one involves direct contact (high connectivity) with the
possibility of emotional expression, whereas the other represents monitoring
from a safer (for some youth and parents) distance, which reflects greater
autonomy. Each of these patterns, in turn, matches different teenagers well
or poorly depending on the youths own interpersonal functions.
Thus, the relational functional patterns of youth must also be considered because they codefine the transaction between them and their parents.
Some youth are quite attached behaviorally to a parents, and the attachment is
expressed in positive terms. Others are quite attached but do so in ways that are
labeled dependent, unwilling to emancipate, and so forth. At the other extreme,
some of the most troubling teenagers are autonomous and even dangerously
so (e.g., spend most of their time with gangs and deviant peers); others are
autonomous but in very adaptive and effective ways (e.g., spending lots of time
studying on their own, engaging in sports or a job after school, spending lots of
time with prosocial friends without the need for supervision). Again, it is not
the degree of connection or autonomy but rather how parents and youth manage to attain, grant, and manage the autonomy. Given this, FFT therapists are
particularly sensitive to matching specific behavior change techniques within
the family (see Chapter 8, this volume) and in situations involving relationships outside the family (see Chapter 9, this volume) to the relational functions
that are determined during this Relational Assessment Phase.
Finally, often the intensity of a relational function is wrongly confused
with the intensity of an emotion. Sometimes extreme situations of, for example, distance/autonomy are paralleled by very high emotional intensity. An
abused woman fleeing from her abuser with her child in her arms is doing
everything possible to create distance, often permanently, from the abuse.
These attempts also are coupled with strong emotions of fear, avoidance,
relational assessment phase
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Me (person
doing the
behavior)
You (person
receiving
the behavior)
One-up behavior
You (person
receiving
the behavior)
Me (person
doing the
behavior)
One-down behavior
You (person
receiving
the behavior)
Me (person
doing the
behavior)
Symmetrical behavior
Figure 7.2. Relational functions: Hierarchy.
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and the quality of the relationship. FFT therapists work hard to create processes in which youth are influenced by parents because they love the parents
and want to please them, as opposed to being influenced or controlled primarily because negative behavior will lead to negative consequences. We want
youth to want to please their parents, and we want parents to want to provide
guidance through caring, not just through a need to control the youth.
For example, increasing parental monitoring of peers is widely recognized as an important risk and protective factor for youth externalizing
behaviors and therefore is often a target of change programs. However, many
programs offer a linear strategy for impacting parental monitoring by teaching or training parents to implement monitoring skills. This strategy may be
effective in a parentyouth relationship in which the parent has relatively
more relational influence or power than the youth but may not be particularly
effective when the youth has more relational influence than the parent. In
the latter configuration, a more effective strategy may be to increase parental
nurturance and warmth to create a relational context in which the more
powerful youth is willing to disclose his or her activities to the parent. As is
evident in this example, increasing parental monitoring is an important goal;
however, the means through which this is achieved must take into account
the assessment of relational hierarchy in each relational dyad in the family.
That is, interventions are delivered in a way that matches the relational
configurations.
Simple examples of recurrent hierarchical patterns are seen often in
adultadult (as well as parentyouth) interactions with respect to problem
solving. Imagine a couple in which, most of the time, the man asks the woman
for her opinion of what they should do with respect to child rearing and then
follows the womans advice most of the time. That would represent, at least
with respect to child rearing, a female one-up hierarchical pattern. In contrast, there are also situations in which a man not only rarely asks the woman
for her opinion but usually dictates what he thinks they should do as a couple.
This represents a male one-up pattern. Some couples, over time, are characterized by more give-and-take discussion, and if the outcomes of these discussions are tracked, it seems that sometimes the womans opinion represents
the path they follow, and other times it is the mans. This is a symmetrical
relationship pattern. Note that gender is not the issue here; we could just as
easily use malemale couples or femalefemale couples. Naturally, in family
therapy for parentchild relationships, we use exactly the same framework.
How Do You Know?
How does a therapist obtain and trust sufficient information to determine relational functions? Relatedly, how do we know what the antecedents
126 functional family therapy for adolescent behavior problems
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and consequences are of youths and family members behaviors? In the face
of denial, distortion, fear of disclosing, and the like, all of which are part and
parcel of many of our high-risk referrals, the therapist must rely on what gets
these youth and families into treatment in the first place: patterns. As family
members begin to relate their own, often conflicting, perspectives on past
behaviors and the attributions they believe explain each others motives,
therapists begin to listen for and ask questions about patterns. As they do
so, therapists are careful to not ask potentially inflammatory questions.
Instead, they ask strength-based questions and make inferences that potentially capture relevant patterns. These questions and inferences are organized
around an apparently simple question: In recurrent problem-related patterns,
what happens when the dust settles? That is, before a behavior problem incident, are these family members close together but afterward are they further
apart? Or were they relatively more characteristically independent, but when
problem patterns occur, are they, at least temporarily, closer together?
Many working parents understand this process all too well. As they
increase their attention to work issues, the children often begin acting out,
which functions to elicit (demand) more attention. In contrast, highly attentive parents with lots of time to devote to their adolescent children begin to
experience various forms of walling offthat is, increased autonomyfrom
their children. Complicating this pushpull process between a youth and
parent is the fact that when more than one parent figure is involved, often
the relationship is different between the youth and each of the parents. For
example, arguments with a stepfather put the mother in the middle, serving simultaneously to push the stepfather away (a function of distance, not
unexpected according to the research literature on blended families) and to
keep the mother closer as she attempts to bridge the two.
Further complicating the inferences therapists must make is the fact that
most recurrent problems, with their chicken and egg quality, often require a
time frame beyond a particular problem sequence. A delinquent son who
repeatedly comes home late may experience a seemingly distancing sequence
with a tired and stressed parent. Loud arguing, which leads quickly to cursing
and the youth storming into his room, would appear to be best described as a
distancing maneuver (function) for both teen and parent. However, if, after
things settle down, the parent typically comes to the youths room and apologizes for the cursing, we must wonder if the function of the problem might be
to elicit more closeness from the parent.
To answer this question, the nonproblem aspects of their relationship
must also be examined. If this tired and stressed mother typically responds very
little to the youth when problems are not occurring, then it would appear that
the function of the curfew violation and the arguments is to elicit attention
that otherwise might not be present. In contrast, if the parent is typically very
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attentive and pays a lot of attention to the youth when curfew isnt broken,
it suggests that the function of the curfew violation and arguing could well be
to produce more autonomy for the youth, autonomy that, in fact, is seen as
developmentally appropriate. Again, it is not the function (more closeness or
more distance) that is the problem, it is the manner in which this parentchild
dyad has learned to deal with their contact and autonomy needs.
As noted many times already, FFT does not force one or another family
member to submit their relational needs to those of other family members.
Instead, therapists work to develop new behavior patterns that are consistent
with the needs of all family members. Parents can be helped to develop systems in which they still feel in control and close to their children when the
youth are seeking autonomy. Coincidentally, this is currently easier than it
was in previous eras when texting (for example) was not available. Youth can
literally send a real-time picture of where they are to their parents and text
briefly what they are doing and yet feel more independent than if they had
to be physically at home. Further, such technology does not place as much
pressure on trust, which also is challenged more often in adolescence.
Conversely, a parent invested in work or church, when dealing with
a youth who is still fairly dependent (i.e., relational function of closeness),
can call, text, and support others (e.g., friends) who can and will be with the
youth to avoid feelings of loneliness, for example. Strategies such as these
are described in much greater detail in Chapter 8 (on behavior change). At
this point, the take-home message is that dysfunctional patterns, with their
typical interpersonal payoffs, give therapists a window into the relational
motivations of the participants. As this window is emerging in therapeutic
discussions, therapists are simultaneously motivating the family members to
begin the change process.
Finally, FFT therapists are prepared for unexpected twists. Families are
complex. Therapists can produce much more reliable, higher quality outcomes
when armed with an assessment framework as a guide. Moreover, as therapists practice skills and the FFT way of thinking about families, they become
more efficient and better able to handle all of the unexpected twists and turns
with which complex clinical situations challenge us. As readers will see in
Chapter 12, this is one of the reasons we urge clinicians undertaking FFT to
work, or at least meet regularly, in mutually supportive supervision groups. In
this way, therapists expertise can include a much wider range of assessment
and treatment challenges (i.e., learning opportunities) than isolated therapists
can achieve.
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Behavior Change Phase
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intense interactions with his parents might thus be incompatible with the
familys relational functions, and resistance to behavior change strategies
would be expected.
Thus, although the targets of a change plan involve the specific problem
behaviors and risk and protective factors that need to be addressed in a particular family, the way in which those changes are made is uniquely crafted
to fit the relational functioning of individual families. The goal of our behavioral interventions is not to change the relational functions of behaviors but
instead to change the maladaptive manifestation of these functions. To the
extent that relational functions represent preferences among family members
for how they interact with one another, making intervention techniques fit
the family relational system allows the therapist to develop change plans that
family members are more likely to embrace. The manner in which the therapist addresses communication problems in families, for example, could range
from techniques that require nightly family meetings (contact/closeness),
occasional as-needed checkups between family members (midpointing), or
greater reliance on written notes, texting, and voice mail to convey messages
(distance/autonomy).
Transitioning to Behavior Change:
Cycling Back to Motivation
Therapists know that the family is ready to move to the Behavior
Change Phase when they hear expressions of increased hope in the family and negativity and blame have decreased. Family members often display more positive body language (e.g., open body position, increased eye
contact), increased expressions of positive family connectedness, and more
positive attributions (though often not well formulated or certain) regarding
one anothers behaviors. When these indicators of change readiness appear
and you have at least tentative ideas about the relational functions of each
family member with every other family member, you are ready to move into
behavior change.
The transition to behavior change and return to motivation can be a process that is repeated more than once. When initial behavior change attempts
go awry, several sources for the problem should be considered. The first possibility is that the therapist may not have been sufficiently clear, directive,
or informative for family members to be able to carry out the change plan. A
second possibility is that the familys relational functions have not been met
by the change plan. A third consideration is whether the therapist needs to
cycle back to the Motivation Phase to reduce remaining negativity in the
family and further develop treatment readiness.
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the plan becomes more definitive, providing a road map that can be followed fairly systematically over a series of behavior change sessions. Targets
of change include family relational patterns and behavioral deficits, as well
as strengths that can be augmented.
Behavior change plans also need to include strategies that are developmentally appropriate for the youth in the family. As youth move through
adolescence, cognitive skills, emotional maturity, and social functioning are
changing, autonomy increases, and parentadolescent communication moves
toward symmetry. Change plans also take into account the intellectual functioning and cognitive development or sophistication of other family members. Implementation of change plans varies according to the relative levels
of complexity and can range from simple, concrete approaches to more intricate or sophisticated techniques using the same match-to-sample concept
consistent with prior chapters. Thus, issues such as how privileges are negotiated or how contingencies are managed vary widely depending on the age of
the adolescent and the developmental levels of each family member.
In typical adaptively functioning families, the power differential between
parents and children changes over time as youth transition from preadolescence to adolescence to young adulthood. Normatively, parents and adolescents engage in more symmetrical, less hierarchical interchanges about family
issues than do parents and younger children. Thus, communication training
and negotiation skills are more often included in change plans with families
of older adolescents because independent decision making and responsibility
tend to increase throughout adolescence in a developmentally appropriate
fashion. Contingency management strategies such as time-out are rarely used
with older youth but are more common with preadolescents and younger
children.
Families often encounter difficulties during periods of developmental
transitions. This often results from parents reverting to parenting behaviors
that worked when the children were younger rather than adopting new parenting strategies that meet the development needs of maturing adolescents.
The difficulties also add to parents levels of stress and reinforce the common belief that the transition to adolescence is a particularly tough one for
both youth and parents. Parents find that the strategies they used when the
child was younger no longer produce the same outcomes. If parents are unable
to adapt and develop new skills, interactions may become increasingly conflicted, hostile, or even violent; parents will likely experience increasing hopelessness and may ultimately give up. Negative coercive cycles; inappropriate
and inconsistent reinforcement; failure to supervise and monitor adequately;
excessive permissiveness; or harsh, punitive, or inconsistent parenting are
all common manifestations of families of youth with disruptive behavior
problems that are likely to be targeted during the Behavior Change Phase.
behavior change phase
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Learning Theories
To prepare for creating change plans that integrate empirically supported interventions into the Behavior Change Phase, it is essential to review
learning theories and how different learning principles have given rise to
cognitive behavioral therapy (CBT) approaches for a variety of clinical problems. CBT modes conceptualize family problems as learned behaviors that
are largely initiated and maintained in the context of the environment.
For example, much research has examined classical conditioning in the
acquisition of problem behaviors (e.g., Davey, 1992; Sherman, Jorneby, &
Baker, 1988). Anger may emerge as a response to stimuli that push family
members buttons or trigger an explosive outburst. Interventions involving
stimulus control may focus on recognizing potential triggers or stimulus cues
and using strategies to increase self-control or avoid situations that place family members at elevated risk for an explosive outburst.
The operant learning perspective (Skinner, 1974) views maladaptive
behaviors as developing and being maintained in the context of the consequences that follow the behavior. Attention, for example, whether through
praise or yelling, can serve as a powerful reinforcement for desirable and
undesirable behaviors. The vast majority of parenting approaches are based
on the operant learning model (ODell, 1974; Patterson, 1971, 2002). The
principles of positive and negative reinforcement, strategies for managing
disruptive behaviors, and related issues such as intermittent reinforcement
schedules or the appropriate ratios of positive remarks versus verbalizations
intended to correct the behaviors of others have been refined over many years
of parenting skill training program development.
The social learning model (Bandura, 1977) incorporates classical and
operant learning principles, acknowledging the influence of environmental
events on the acquisition of behavior. The social learning model also recognizes the role of cognitive processesthat is, how environmental influences
are perceived and appraised in determining behavior (Bandura, 1977). From
a social learning perspective, family members learn behaviors by observing and imitating others (Patterson, 1975). According to the stresscoping
model (R. S. Lazarus, 1966), for example, families may uniformly engage in
maladaptive strategies such as conflict avoidance as a way to cope with the
stress they experience when problems in the family arise. Such poor coping
may stem from modeling the avoidance behaviors observed in others, punishing behaviors delivered by family members if direct confrontation occurs, and
a lack of alternative appropriate coping models. Learning new behaviors and
skills can be facilitated using social learning concepts such as fostering positive attitudes toward the behaviors to be learned and a sense of self-efficacy
to master the behaviors.
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Both of these examples are brief, are specific to the familys own experiences, and provide a context of reason to ground talking with the family
about positive activities.
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activities, describe some common activities, ask the family to generate examples of activities they enjoyed in the past or might enjoy exploring together,
and provide coaching and feedback to the family in the development of a
plan for something they might do together prior to the next session.
All family activities should be tailored to ensure that the relational
functions of each family member are respected sufficiently to avoid resistance
or, worse, sabotage. For example, a mother who works late hours and often
spends weekends visiting her boyfriend may be more open to briefer activities such as going to a movie rather than full-day activities with her teens.
For the family of a teen who wields substantial power, an activity that the
teen chooses and the parent is willing to try might ultimately be more successful than an activity a parent suggests. Positive family activities can be
incorporated into homework assignments throughout the Behavior Change
Phase. However, the seeds for growing positive change may be planted even
earlier in therapy. A common homework assignment for early sessions, for
example, is asking family members to secretly observe others in the family
and come to the next session prepared to share one thing they noticed in
each family member that they appreciated. The discussion of this homework
assignment at the next session has multiple purposes, including providing
clues to relational functions in the family and fostering hopegoals of the
Assessment Phase and Motivation Phase, respectively. However, the process
of sharing positive observations and talking about behaviors they appreciate
in one another begins to introduce the idea of enhancing the familys experience of positive change.
Parenting Skills and Parent Training
The foundation of parent training and contingency management is
to help parents use reinforcement strategies to encourage desirable behaviors, use effective discipline techniques to discourage undesirable behaviors,
and allow natural consequences for adolescent misbehavior to occur when
appropriate. The first step in encouraging desirable behaviors is to set the
stage for success by helping parents provide clear expectations for behavior,
overtly clarify limits, and provide the appropriate context for their youth to
comply with instructions and requests. For example, easily distracted youth
often need chore requests provided in writing because they remember the first
request to take out the trash but forget the second and third requests to empty
the dishwasher and rake the lawn. Behavior change sessions may include discussions about the types of chores that are developmentally appropriate and
ways parents can maximize the likelihood that their expectations will be met.
A common parent refrain when discussing chores is He knows what hes
supposed to do; I shouldnt have to tell him, and this view often results in a
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increases; if the behavior does not increase, then the consequence is not a
reinforcer.
Table 8.1 provides examples of the various types of reinforcement and
punishment strategies that may be integrated into FFT. As the table shows,
reinforcement can be categorized as positive or negative. These are not value
labels. Rather, the terms positive and negative refer to whether the consequence involves the presentation of something (positive) or the withdrawal
of something (negative). Specifically, negative reinforcement occurs when
a behavior is followed by the removal of an aversive stimulus (e.g., nagging stops), thereby increasing that behaviors frequency. The commonality
between positive and negative reinforcement is that both serve to increase
behavior, and hence negative reinforcement is not punishment. Punishment
can also involve the delivery of something (i.e., presenting something aversive) or can take the form of withdrawing something or the cessation of something (i.e., removing something pleasant or desired) as a means to decrease
unwanted behavior, although the terms positive and negative are not typically
used to distinguish punishment involving the presentation or removing of
consequences.
With respect to the delivery of a consequence, then, offering praise
could serve as positive reinforcement, whereas assigning extra chores represents delivery of a punishment. A parent could also reinforce a childs use
of normal voice tone by ceasing to engage in planned ignoring when the
child begins speaking normally after previously whining. The parent could
signal this connect to the child by saying, I have trouble hearing you when
youre whining. I listen better when you use a normal tone of voice. In this
example, the termination of the parents ignoring behavior is a negative
reinforcer if the childs use of the normal voice increases. Loss of video-
Table 8.1
Behavioral Parenting Strategies
Consequence
Something is given
Something is removed
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Contracting
Contracting involves having family members identify specific things
they would like other family members to do in exchange for interactions or
behaviors or tangible rewards. This procedure is especially important with
adolescents (as opposed to younger children). Contracting is one of the
most commonly used parentyouth interaction influence techniques in FFT
because it is systemic (e.g., involves considering the idea of reinforcement
or reward for all members of a system or subsystem), and it can be initiated
during therapy and subsequently adapted for use independently at home after
therapy is completed with the referred youth as well as with other children
at almost all developmental levels. In some cultures, the concept of parents
and youth negotiating on more or less equal terms may violate families belief
in relatively impermeable boundaries between parents and adolescents and
values that include a firm parental hierarchical structure. In such families,
contracting or other negotiation strategies may need to be reframed for the
family in terms of helping the adolescent transition to adulthood or learn
how to communicate his or her needs in a respectful way so the parents can
know how to better meet the youths needs or using some other culturally
sensitive approach.
Contracting should initially be conducted within the therapy session
because therapists need to do a number of things to make early contracting as
positive an experience as possible. Therapists need to collaborate with family
members to identify desired actions and rewards that are specific and realistically attainable. A family that decides to contract with an older child to
provide a family trip to Disney World in exchange for good behavior throughout the school year is likely to experience failure. The goal is too global and
distal; the good behavior desired by the parents is too vague to be monitored
and subject to each persons individual definition of what represents good
behavior. The goals of all parties also may not be attainable. The parents
might not realistically be able to provide a trip to Disney World (or they
might provide it regardless of the childs behavior), and unless the end of
the school year is near when the contract is entered, the child will quickly
determine that it is unrealistic to be good for such a long period of time. A
more specific and attainable contract would involve having the child call a
parent to report his whereabouts after school and be home by 6:00 on school
nights in exchange for a desired activity on the weekend.
Again, 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 from
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do not know the basics of interpersonal communication. In many other families, however, family members know how to communicate quite well (e.g.,
some have been effective teachers, professors, clergypersons, Girl Scout leaders, or even counselors). However, in the current individual, family, and community context, they are unwilling or unable to communicate 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 instead
the problem is one of performance rather than ability, emphasis is placed on
practicing the reattribution (e.g., reframing) interventions described earlier
and providing constant reminders of the rationale behind positive and effective communication.
Almost every family benefits from various elements of communication
training, but one aspect typically receives greater emphasis, and the different emphases lead to sessions that look very different from one another. It
should also be noted that communication training requires emphasis whenever two powerful members of a family system are unable to resolve problems
verbally. Thus, in two-parent families in which there is serious marital or
relationship strife, communication training requires a special focus within
that marital subsystem, regardless of the developmental level of the referred
child. Marital subsystem is used as a conventional relational form, but the
principles apply to any system in which two adult figures represent the parenting context for a child or even adolescent figures who are in the position
of having responsibility for parenting a child. Note also that in many cases,
two adults do not overtly acknowledge parent status (e.g., a single mother
and occasional live-in boyfriend), but during the Behavior Change Phase,
interventionists must take into account the influence of the nonparent on
the behavior, emotions, and beliefs of the youth.
Positive communication includes the following elements:
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rather than You must solve this for me. They allow the presenter to retain a sense of control yet also provide the recipient
with a sense of having options.
Active listening: The art of active listening as developed by
Rogers (2003) and others involves the presentation of cues
by the listener both 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
are not innate skills, however, and must be practiced. At the
beginning of training, it is best to practice active listening one
sentence at a time.
Impact statements: In response to someone elses communication, impact statements provide feedback in terms of personal
reaction that requires no justification from either party. Their
expression helps family members break up what often seems to
be wired-in relationships between feelings and behavior. Examples of impact statements include When you do ______, the
effect on me is _______ and The impact on me when ______
is that I feel _______.
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Negotiation
Source
Responsibility +
( I )
Want
Directness
(you
you)
Behavioral
Specificity/
alternatives
Validation
Active
Listening
(you want)
Brevity
Impact
Statements
Feel
Active
Listening
(you feel)
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evaluate how good or bad the ideas are. It is more helpful to write them on
a whiteboard so the entire family can review them together when deciding which one to try. The family should be encouraged to list all of their
ideasmore is better. As more ideas are presented in the open, the family
can consider several possibilities without rejecting any of them too hastily.
A good solution involves compromise in the family. Therapists help
the family identify the most probable and promising approaches, considering
the potential outcomes for each solution and the anticipated positive and
negative outcomes, both long and short term. The therapist considers what
factors may be used as resources to help the family implement each approach
and what factors may interfere with each approach. All of the potential solutions are arranged according to their consequences and their desirability.
The solution that maximizes positive consequences and minimizes negative
consequences is the one to implement first.
Once a solution has been selected and implemented, the therapist revisits the solution with the family in the next session. The therapist helps the
family evaluate the strengths and weaknesses of their approach. If they are
not getting the expected results, the therapist and family refine the solution
or move on to the second-choice solution, following the same implementation and evaluation procedures for the new solution. It is important to assist
families in selecting one problem at a time and using problem solving for
discrete, manageable problems. For example, it is beyond the scope of problem solving to address depression, but problem solving might be useful in
addressing a mothers concern that her daughter is often down on herself
and makes self-deprecating statements. The therapist can help the mother
and daughter brainstorm strategies to generate possible responses from the
other that could be effective in reducing the daughters negative self-talk.
Use of Technical Aids
In addition to providing communication and additional skill training, FFT interventionists prescribe specific activities and behaviors that will
enhance the familys experience of positive change. In particular, interventionists use as many technical aids as possible. These technical aids include
such simple items as sticky notes that can be put on mirrors to remind family
members about a particular behavior; audio recordings of communication
practice sessions that can be taken home for review; commercially available
manuals on parenting; a wide range of similar free information provided by
social service agencies; training in the use of answering machines, texting
devices, and cell phones to leave messages for family members; a schedule of
reminder telephone calls made by a volunteer to families who need additional
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cated FFT formally and informally, the various technical aids and props that
have been adopted to aid in implementation seem endless, and interventionists can become very creative in developing materials that are consistent with
the particular needs, abilities, 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 few good work habits) out of sessions with
little more than suggestions about how to change behavior. Instead, we are
much more direct and in some ways controlling (or educational) during the
Behavior Change Phase. In fact, FFT agencies often buy sticky notes and
inexpensive audio cassettes to give to families to use between particular sessions. We also often ask social services and educational agencies to forward
pamphlets and other learning material.
FFT interventionists prescribe specific interpersonal tasks, often involving the 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. The
following is a recent clinic example: A mother who worked as an accountant
and a stepfather, a manual laborer, were intent on improving their sons
math performance, which was several levels below his current grade. With
respect to the parents abilities, the mother was the clear choice to tutor her
son. However, her interpersonal needs with this son were more distant or
autonomous than were those of the stepfather. The son, in turn, seemed to
have ambivalent needs regarding both parents and expressed this ambivalence through midpointing behaviors. Thus, the FFT therapist suggested
that stepfather and son struggle with the math together, with the stepfather
consulting with the mother when necessary. This interpersonal task was
certainly less efficient in terms of talent but was much more consistent with
the interpersonal need configuration the participants had with respect to
each other. Note also that the sons midpointing function was respected in
that stepfather and son would, in the beginning of the program, work for
only 30 minutes together, stopping even if nothing had been accomplished.
Over time, of course, successful experiences allowed both the stepfather and
the son, and then the mother, to increase positive contact time as well as
improve grades.
This example once again demonstrates the functional nature of FFT;
early behavior change targets are those that can provide successful experiences, even if they are considered modest by others standards. In the long
run, FFT theory asserts that these successful experiences provide a basis
for accelerated future change. In contrast, more impressive but unrealistic
behavior change phase
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change goals, if promoted early in the Behavior Change Phase, are more
often associated with failure, frustration, and decreased alliance. Thus, FFT
works first to develop inner strength and a sense of possible self-efficacy in
families, even if only modestly at first, to provide a platform for change and
future functioning that can extend beyond the direct support of the interventionist and other social systems. In the long run, this FFT philosophy
leads to more self-sufficiency, fewer total treatment needs, and considerably
less cost.
The above examples represent some common techniques used by FFT
therapists. However, nearly any structured activity can represent a useful technique in FFT behavior change, as long as the behaviors they create
and maintain are consistent with relational functions. Over the years, FFT
therapists have used a very wide range of cognitivebehavioral techniques,
trauma and experiential techniques developed in other contexts, and already
established cultural practices (e.g., preparing meals together, observing birthday and holiday traditions) as contexts for FFT behavior change. Once they
become comfortable with the core construct of matching, FFT therapists
have found an almost limitless number of techniques available during this
phase of FFT intervention.
Additional Behavior Change Techniques and Frameworks
Although the diverse expressions and iterations of CBT approaches
initially were developed primarily for working with adults, they are increasingly being extended successfully to children and adolescents. In particular,
symptom patterns identified with anger management problems, adolescent
substance abuse, depression, anxiety, and trauma and posttraumatic stress
disorder have been reported and replicated. Because emotions, thoughts, and
behaviors are all linked (A. Lazarus, 1996), various CBT elements allow therapists to intervene in different domains to disrupt maladaptive behavioral
cycles. FFT has taken these diverse contributions, involving a wealth of specific protocols, a step further by integrating them into our family-based intervention and doing so through a relational lens (i.e., relational functions).
Rather than working with only one family member directly on his or her own
behavior, FFT therapists also can intervene with a particular family member to impact the emotions, cognitions, or overt behaviors of another family
member when weekly conjoint sessions cannot be maintained throughout
the course of treatment. This includes an often-overlooked resource in that
youth can be taught, following a successful Motivation Phase for all family
members, to influence positively and proactively the emotions, cognitions,
and behaviors of a parent or other caretaker. This principle also extends to
larger systems, which are addressed in the Generalization Phase.
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children were moving away but still needed financial help from her. Thus,
helping a child was already consistent with her value system and, while helping with this youth, she also received help with job-related kitchen duties in
return. The therapist also shared with the manager that he and the female
employee should always feel free to say and do what they felt was right but
asked that they also recognize that this young man had already declared himself gay and still needed acceptance. The woman understood, accepted, and
was even enthusiastic about helping this lost young man. As a result of the
therapy experience, the youth ended up enrolling in a community college
cooking school.
These examples make it clear that the Behavior Change Phase is neither ritualized nor boring! Behavior change requires considerable creativity,
an understanding of each individual family, an understanding of each familys unique configuration of relational functions, and a diverse repository of
specific change strategies. No one can give the therapist a prescription for
how to integrate the vast bodies of knowledge that have been accumulated
over many years, in many cultures, and in many contexts with respect to
specific evidence-based behavioral techniques. Families just want the conflict
and pain to end and the bad behaviors to stop. The Behavior Change Phase
provides the latitude and flexibility for therapists to match strategies and
techniques to individual families to bring them as close to their goals as they
can. In the process, therapists can decrease and eliminate the danger referred
youth pose to each other and others in the community and enhance their
ability to function well in their families and communities.
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9
Generalization Phase
DOI: 10.1037/14139-010
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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from others such as group leaders into the plan, minimizing high rates of
direct and often emotion-based contact between mother and adolescent.
Developing New Community Links
The focus on multisystemic resources is not new. Traditional social work
approaches have included a heavy community focus, including problem
solving how to link potential resources to people in need and facilitating the
establishment and strengthening of those links. In fact, the role of the FFT
therapist in this phase has been described as family case manager rather than
family therapist. This phase of FFT often involves more time on the telephone
with community resources than direct session time with the family. Also during
this phase, the treatment manual is augmented by lists of each specific communitys resources, their requirements regarding service, and contact persons.
As therapists continue to work in particular communities, they also reach out
at a personal level, sometimes revisiting relationships they already have with
community resources and sometimes working hard to develop new ones.
Examples of community-based resources often used by FFT therapists
include but are by no means limited to, parenting classes, resources for rent
assistance, community or religious institution support systems and groups,
positive social media resources, school-based and after-school programs for
specific academic issues, and 12-step facilitation programs. In other words,
the Generalization Phase of FFT represents good old-fashioned social work
in the best meaning of the phrase. It requires specific skills and attitudes on
the part of therapists and the systems within which they work. For this effort
to be successful, therapist salaries and treatment system reimbursement must
support these activities; if therapists are paid only on the basis of therapy sessions
conducted face to face, they will not be able to engage successfully in this case
management phase of FFT.
Indicators of Success: Moving Toward Termination
Maintenance of within-family changes and generalization to community
contexts are the primary indicators of success in the Generalization Phase.
At the same time, increased independence from the therapist is another
indicator of successful resolution of this phase. For example, one important
criterion for considering positive termination is the spontaneous appearance
of family memberinitiated new skills, techniques, and strategies that they
have considered trying on their own and perhaps even tried between sessions.
This, as an aside, is tremendously rewarding for therapists who have felt the
pressure of motivating families for change and then directing that change.
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job in FFT is not to create ideal families, only normal onesjust as many
therapists live in normal rather than ideal families.
Using this standard, during the Motivation Phase, all family members
need not attain glowing and positive attributions about one another. However,
the negativity, distrust, and feelings of abandonment and betrayal must be
reduced sufficiently that they are able to once again engage in positive interactions that are rewarding for all. During the Behavior Change Phase, not all
youth become avid readers who carefully do homework without being told,
but they are helped to develop enough behavioral skills that they can learn
what they need to learn and attain goals consistent with their needs and those
of the culture and society around them. Parents need not become smooth and
elegant with parenting, but they do need to learn how to parent in productive
ways associated with positive outcomes. In the Generalization Phase, neither
youth nor their parents are required to embrace or even agree with everyone
in the community or in the systems with which they are involved. However,
therapists do target their learning to teach them how to deal with major differences they may have with the community or systems in ways that are not
destructive to themselves or others.
To be clear, FFT works to eliminate behaviors that are dangerous and
illegal, and, in the process, FFT works to build in as many strengths as possible
to enrich the familys protective factors when they face the inevitable challenges that they still will face. Often these challenges are more severe than
we as therapists will have to face in our own lives and possibly more difficult
than we ourselves might be able to manage. However, many of our referred
families have histories that have also provided them with resiliencies that
may surpass our own as well.
How Much Change Is Enough?
Judges, probation counselors, educators, and public health workers often
provide all the needed goal anchors. In our experience, educators do not ask us
to make sure these youth get into a top-ranked university. Correctly, however,
they do expect us to do what is necessary so the youth are open to learning,
have resources in place when they face challenges in that process, and have
developed the basic home-related skills to function in school. Judges do not
ask us to turn youth or the parents that appear before them into community
ideals. Rather, they ask us to do what is necessary so I dont have to see this
kid, in handcuffs, in front of me again. They ask us to help a parent become
a positive resource and an agent of positive control for the youth. And public
health workers do not ask us to ensure that all the youth are married before
they have sex. However, they do ask us to help youth develop the attitudes
and parenting processes that prevent (or stop) unprotected sex with multiple
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partners and drug use and abuse. The goal is to help families become open to
any positive resources in the community that can provide needed support.
As FFT comes to an end, termination is best considered a positive
launching pad for healthier, happier, and more productive youth and families.
FFT therapists review, informally or formally, the lists of risk and protective
factors relevant for the particular family they are seeing, and they make a
judgment that they have helped the family develop protective factors and
community supports sufficient to support positive future behavior patterns.
They also ensure that the risk-related processes that were relevant to pretreatment maladaptive functioning are significantly reduced or eliminated.
If a parent continues to abuse alcohol or marijuana, for example, we ensure
that other protective factors are in place so that the parent risk will not
inevitably produce youth dysfunction. Of course, therapists also, especially
during the Generalization Phase, work to help such parents attain sobriety.
However, if the parent is unwilling or unable to change during the short time
therapists see him or her in FFT, therapists are not willing to give up on the
goal of doing what they can for the referred youth to be able to function well
even with a drinking parent.
Similarly, if a youth referred for delinquency still exhibits symptoms of
attention-deficit disorder, therapists ensure that protective factors ranging
from psychopharmacological to external structure and internal coping strategies
are in place so that school failure need not be inevitable. Whatever issues or
concerns have been noted during the course of treatment, therapists ensure
that sufficient internal, within-family, and external protective factors have
been developed and strengthened so families can deal with the inevitable risk
factors that continue to surround them. In this way, FFT is an approach that
accepts people where they are and develops positive coping strategies for them
to be successful. Not all kids with attention problems inevitably fail, not all kids
with alcoholic parents become juvenile delinquents or alcoholics themselves,
and not all youth with a parent who has anger problems inevitably become
violent themselves.
Are there hard and fast criteria and rules for successful FFT? Obviously,
yes! We have reviewed them for each phase. Although FFT does not have a
set formula for independently determining what those criteria must and will
be for any given youth and family, the model provides a road map to follow so
that as communities, states, neighborhoods, and cultures each set their own
standards, FFT works within the prevailing contexts to ensure that families
can match the expectations in ways that are healthy and adaptive for the
families in those settings.
generalization phase
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10
Anthony: A Case Example
DOI: 10.1037/14139-011
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett
Waldron, Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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both in treatment. In reviewing the referral information, the therapist recognized the importance of speaking directly to Anthony to set up the initial
appointment. He had already had past negative experiences with school officials and teachers, and the therapist wanted Anthony to experience, even
if only by phone, that his perspective was valued and respected. Also, information from the probation counselor suggested that Lynn did not have a
hierarchical or highly connected relationship with Anthony. Therefore, the
therapist was not confident that Lynn would be able to bring Anthony into
treatment. So instead of working directly through Lynn to schedule the initial appointment (as is the case with many agencies), the therapist reached
out directly to Anthony.
During the first telephone conversation with Anthony, the therapist
introduced herself to Anthony and provided information about how she had
received the referral from probation. She asked him directly to tell her what
he knew about the referral and his views about treatment, both in general
as well as for this specific episode. Anthonys response was respectful but not
expansive. For example, he said that the probation counselor wants me to
stop being a problem. The therapist acknowledged Anthonys statement
by noting that he was right in that the conditions of his probation involved
increasing his school attendance and eliminating his delinquent behaviors.
However, the therapist shifted the focus back to Anthony by asking him,
What is it that you would like to have happen? Anthony responded by
saying, I want to get everyone off my back. I am sick of being on probation.
The therapist used this opportunity to maximize Anthonys expectations that
therapy could work to benefit him directly by noting that this could be
something that she could help him with.
The therapist also expanded the focus from Anthonys referral problems
by beginning to focus on his family. She again acknowledged him by noting
that he said one of his goals was to get everyone off his back and then asked,
Does this include getting your mom to stop being so concerned about you?
As is evident in the choice of wording, the therapist was already shifting the
focus from nagging or overinvolvement to something more nurturing. This
also shifted the focus from behavioral goals to relational goals. During this
conversation about his relationship with his mother, the therapist identified
that one of his strengths was that he was very respectful of his mother. He did
not openly criticize her, and he seemed genuinely interested in meeting her
expectations for him.
In contrast to the initial ease the therapist had in contacting Anthony,
she had to make several phone calls and leave several messages before finally
conversing with Lynn. During their first conversation, the therapist recognized
the importance of offering a sense of understanding and respect for Lynns busy
schedule by emphasizing how well she was managing working several jobs and
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still finding time to spend with her children. In doing so, the therapist was
concerned that Lynn felt guilty or blamed by the system for her sons behavioral problems. Therefore, on multiple occasions, the therapist highlighted the
moms commitment to providing the best for her family and presented herself
as an ally in helping reduce the problems her son was experiencing.
Both Anthony and Lynn agreed on a date and time for the first appointment 4 days following the phone conversations. On the basis of their reactions during the call, the therapist felt confident that Anthony and Lynn
would be at the home for their session. Nonetheless, on the day prior to the
session, the therapist called them both and left reminders on their voice mail.
The therapist did not press the issue of Anthonys 6-year-old sister participating in the session as she was not seen as key to the treatment process, was not
described as having any ongoing behavior problems, and had no relationship
difficulties with Anthony or Lynn.
Motivation Phase
As noted in Chapter 6, the goals of the Motivation Phase are to decrease
negativity and blame, increase hope, and build balanced alliances. This is
accomplished by systematically creating and infusing a strength-based relational focus through the use of change-focus and change-meaning interventions. On the basis of the information provided by the referring probation
counselor, the therapist was able to prepare for the first session by anticipating some motivational strategies, including relational focus and reframing, to implement in the first session. For example, given that the timing of
Anthonys problems coincided with the contact with his biological father,
the therapist was ready to introduce reframes or themes about his connection
to family members. This preparation helped the therapist move forward more
quickly with the family.
Session 1
Although the therapist had reached out directly to Anthony prior to
starting treatment, he was not present when she arrived at the home for the
first visit. Lynn explained that Anthony had decided that therapy is worthless and that he was not coming downstairs from his room. Lynn appeared
withdrawn and lethargic and had flat affect. She reported having just finished
working a double shift. It was obvious to the therapist from Lynns tone of
voice and the sarcasm she used in repeating what Anthony said that she was
not pleased with her sons behavior. The therapist refrained from expressing
empathy toward the mother or siding with her vis--vis Anthonys behavior
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but instead acknowledged and relabeled her by thanking her for her attendance and noting how this was evidence of her commitment to help her son
through his probation requirements, even though she knew it would not be
easy for her given her busy schedule. Without additional prompting, Lynn
went upstairs to make another request for Anthony to join the session downstairs. After a brief delay, Anthony joined the session.
At first, Anthony appeared agitated about having to participate and
vocalized his opinion about therapy being useless and a waste of time; nothing is wrong with me. Lynn rolled her eyes at this comment and began to
exhibit frustration with his behavior. She was openly hostile toward him and
launched into a number of statements that included content about how useless he was; how he never helps around the house, doesnt go to school,
and is secretive about everything in his life; and how he was a habitual
liar. She ended her comments with the statement that he probably was
going to end up just like his father. Anthony immediately reciprocated her
attacks by turning to her and screaming, Shut up! Lynn appeared visibly
stunned and said nothing while Anthony began to vocalize his complaints
about her, including her lack of support of him, how she was never around,
and her poor choice of boyfriends.
The therapist recognized the need to immediately intervene to disrupt
the escalating conflict. Initially, the therapist interrupted and diverted the
attacking comments by responding to each family members comments before
the other person had a chance to respond. This helped break the sequence of
escalation, which would have led to the conflict becoming unmanageable in
the session. With this family, as with many, disrupting the negativity was not
accomplished in a single interruption. Rather, the therapist had to systematically, contingently, and persistently step into the interactions to disrupt the
hostility as mother and son continued to attack and blame one another. The
relentlessness with which the therapist was required to hang in with the family, diverting; interrupting; making relational connections between family
members behaviors, thoughts, and feelings; and attempting to change the
meaning of their attack on one another, left the therapist with the all-toocommon feeling of being alone in the room.
As the therapist interrupted interactions between Anthony and Lynn,
she began to shift the focus from blame and negativity to relational connection. This started with simple comments such as, You have very clear ideas
about what you need from your mom or Even though you are angry, you
still have not given up trying to have a positive impact on him. The focus
was not on contradicting their statements but rather on expanding them to
aspects of their relationship that were not currently evident in the discussion. For example, the therapist noted how much Lynn based her feelings
of being a good mom on how well Anthony was doing, expanding the focus
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to include how much she valued being a good mom. Her response was an
emphatic Yes. I want the best for my son. It is killing me to watch him throw
his life away. The therapist immediately observed that Anthony became
much more positive following these statements from his mother and pointed
process by saying to Lynn,
Even though it is painful for you to have less contact with Anthony than
you would like, he does seem to be very connectedor at least tuned
into you. When we started, you were clearly frustrated by his not coming downstairs, and you seemed embarrassed by his statements about
treatment. It was almost like you felt the need to protect me from his
behavior. He immediately showed his connection to you by responding
with all the things you do to frustrate him. Now, when we start talking
about the positive parts of your being a mom, he calms right back down.
Has he always been this connected to your feelings and actions?
The therapist further focused on the familys strengths, making comments such
as, From what I was told, you two do not let things escalate beyond control.
You choose to walk away from each other rather than staying in an argument.
Lynn then acknowledged that this had occurred just the evening before.
As the therapist focused on positive behaviors and on the relationship between mother and son rather than on the content of their complaints
about one another, Lynn and Anthony became less hostile toward each other.
The cessation of attacks allowed the therapist to ask questions about behavioral sequences to gather more information about interaction patterns that
tended to recur and, in particular, to ask about the progression of arguments
between the two. Anthony relayed that he tended to walk away or become
more aggressive with his mother so she would stop questioning his behaviors.
Because it was important to maintain a relational focus, the therapist turned
to Lynn and asked what she did next when Anthony became aggressive. She
reported that she tended to give up and withdraw to her room. Then neither
would speak to the other for a period of time until Lynn reinitiated some level
of conversation a day or two later. Further information was gained in later sessions that Lynn consistently reengaged in conversation with Anthony after a
period of limited contact between the two.
Lynn and Anthony appeared similar in the intensity of their anger
toward one another. The therapist commented on their anger as something
you share in common, and she commented that anger often indicates underlying hurt feelings and suggested that the extremes of anger suggested that
both mother and son were experiencing a lot of pain. Lynn agreed that she
had felt very hurt for a long time in her life, not only with Anthony but in
other relationships, and that she just gives up trying to make those relationships better. This statement from his mother was met with silence from
Anthony, an indication that his combativeness had lessened and that he was
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considering what his mother had said. The therapist recognized that an alliance was developing and that the timing to use reframing might be optimal
to further reduce blaming and negativity regarding the described behaviors
Anthony and Lynn had expressed, so she introduced reframes. To Anthony,
recalling Lynns previously defined complaint of his behaviors of lying and
not talking with her, the therapist said,
When you purposely withhold information about your life from your
mother, such as where you were last night, it angers her. She continues questioning you, and you get even angrier. On one hand, it makes
both of you feel worse, but on the other hand, maybe you dont tell her
everything because you may be worried that some of your behaviors will
disappoint your mother, and if you dont tell her, she wont have to feel
like she is a bad parent.
Over the course of the session, both Anthony and Lynn became less
defensive and resistant. Anthony vocalized his knowledge that his mother
worked hard for them as a family. Lynn held firm to her complaints about
Anthony but was able to make some positive comments about his behavior
as well, offering a compliment about him being good with his younger sister. After acknowledging and highlighting this positive interaction between
Anthony and Lynn, the therapist ended the initial session, asking them to
meet again in 2 days to follow up quickly on the gains made in the session
and avoid having them fall back into their longstanding pattern of arguing
and exchanges of anger.
The therapist also made a call to the family between the first and second sessions to speak with both Anthony and Lynn and caught them both
at home. Lynn relayed her frustration with Anthony that day as he had not
attended school: I wish he would just do what I say. Why doesnt he get that
it so important to go to school? This was an opportunity for the therapist to
revisit the strength-based relational statements and themes used in first session: that they both worried about each others well-being and continued to
remain committed to finding a different way of working together.
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Sessions 2 and 3
In the second and third sessions, the therapist worked with the family
to further reduce negativity between Anthony and his mother and to build
hope and increase the bonding between them. To make progress toward these
goals, the therapist used the time between the first and subsequent sessions to
develop additional and better informed reframes and themes. The information
she gathered about Anthonys and Lynns behavioral patterns and relationship
dynamics included the following: Anthonys withholding of information from
his mother and being noncompliant; Lynns not always being there for Anthony,
especially when he was younger; Lynns perceived inability to provide Anthony
with empathy or support when he was in trouble at school or with the law; and
the ongoing anger that both shared with one another. The therapist also decided
to revisit Lynns past history of poor choices in her relationships but would doing
so through a strength-based theme. Two themes were presented to the family in
both the second and third sessions. Theme 1 was presented as follows:
For years, you both have been stuck in a fairly tight pattern with each
otherone in which you, Anthony, may feel you can never do enough
to show your mother you are a competent kid and in which you, Lynn,
continually have to make sure that he is OK. So Lynn, you have been
working very hard at this by questioning each and every step he makes,
being overbearing at times (even when he was 3 years old), and hovering
over his every step with constant correction and discipline but maybe
focusing only on the negative behavior he has done. Part of it is about
yourself and your worry that because of the choices you made in your life,
you feared Anthony would suffer, so you wanted always to protect him
from those same choices. It is almost as if, by being so dismissive of him,
Anthony would learn to do things on his own, and if he learned not to
rely on you, he would learn to be strong and independent.
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By the end of the third session, Anthony and Lynn had significantly
decreased the complaints and negative statements toward one another. They
expressed feeling more hopeful and positive about their relationship, shared
more openly during sessions, and reported positive interactions they had with
one another in between sessions.
Relational Assessment Phase
During the first three sessions, the therapist directly observed the interactions between Anthony and Lynn and elicited information about the typical
pattern of interaction and behaviors, particularly those sequences surrounding behavior problems such as truancy, curfew violations, and arguments in
the home. This information served as the basis for analyzing the patterns
of interactions, behaviors, emotions, and cognitions to determine the core
motivating factors or functions of each of them with the other.
One of the primary patterns identified was that when Anthony and
Lynn were in conflict or when there was an issue of concern that Lynn had
about Anthony, she would spend considerable energy and efforts to question Anthony, initiate discussions with him, and reach out to him in any
way she could. This would result in Anthony becoming annoyed, which
brought on a brief period of intense conflict that was rapidly followed by
his leaving, either going to his bedroom or leaving the home altogether, for
a significant period of time. During his absences, Lynn would send him text
messages on his cell phone, and Anthony would not respond. Lynn would
then go to work or begin concentrating on her daughters needs but would
harbor feelings of anger toward Anthony. Anthony, for his part, would continue about his day and be more focused on himself and his friends than
his mother. However, when Anthony observed times when Lynn expressed
her feelings of sadness or when she commented on his positive behaviors,
Anthony would respond to Lynn. On an average day, Anthony would spend
much of his time with friends or in his room while Lynn was working. They
would talk briefly when she returned home between shifts, and these discussions, most of the time, would end up in escalations and arguments.
On the basis of the information about patterns of interaction the therapist
obtained, she identified Anthony as having a function of distance/autonomy
in his relationship with his mother and Lynn as midpointing in her relationship with Anthony:
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behaviors of each other. This symmetry was not typically expressed in overtly
disrespectful ways. In fact, Anthony respected his mother and responded well
to her nurturance. However, neither Anthony nor Lynn was particularly
effective in influencing one anothers behaviors.
Behavior Change Phase
Having achieved the goals of the Motivation Phase and having completed
a relational assessment, the therapist planned to initiate behavior change activities in the fourth session. To prepare for the Behavior Change Phase, the therapist
sketched out a plan to address problems at several levels. The first level involved
eliminating the individual referral problems of the adolescent (e.g., truancy,
theft, noncompliance, defiance toward authority). The second level involved
developing and implementing interventions to help Anthony and Lynn learn
alternative and adaptive strategies for getting space (instead of withdrawal) and
expressing assertiveness (instead of hostility). At this level, interventions were
designed to improve family communication and conflict resolution. These relational targets were viewed as essential for reducing risk associated with a negative family climate leading to a rejection of mother and an increase in time spent
with deviant peers. However, improving these interactions was also necessary
to directly reduce Anthonys referral behaviors because they created a relational
context and provided concrete skills for Anthony and Lynn, such as decision
making, anger management, and behavioral contracting.
Session 4: Communication Training and Conflict Management
The first step in the Behavior Change Phase was to directly address the
communication patterns that were interfering with adaptive behaviors. As
is done with many families seen in FFT, the therapist started with a communication training task that focused on building basic communication skills,
such as brevity and specificity in their questions, statements, and requests
and active listening (i.e., reflective statements, appropriate verbal and nonverbal responses). Because Anthony and Lynn were both quite articulate
and interpersonally savvy, most of this exercise was devoted to helping them
use a few simple techniques that would disrupt highly conflicted exchanges.
Thus, in this session, the therapist also introduced additional conflict management skills to further reduce the escalation of the conflict by building and
practicing skills that helped Anthony and Lynn resolve conflicts. These skills
included staying on one topic at a time, avoiding negative attacks or statements about each other, refraining from bringing up past failures or history of
negative behaviors, and using active listening skills.
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It should be noted that although the therapist may use the themes from earlier sessions as part of the rationale for behavior change, the themes that are
used do not have to line up with the relational functions for the case. For
example, the therapist may use a theme of nurturance and support in the
family but continue to maintain relational distance or midpointing.
Anthony and Lynn were very hesitant at first, but because their alliances
with therapist were both positive and balanced, they stated their reluctance
in session. Anthony was the most vocal with his concerns, even resorting
back to blaming statements of Lynnfor example, She will never try something different. The therapist quickly acknowledged Anthonys concerns
and noted her expectation that both he and Lynn would have reservations
about trying something different for fear it may not work (matching). With
that, the communication skills of brevity, specificity, and active listening
were introduced to Anthony and Lynn by the therapist. She provided them
with a handout that described the communication skills and reviewed this
during the session introducing the skill or task. The handout also provided a
technical aid to Anthony and Lynn to review outside of sessions when they
practiced the skills. It was helpful for them to begin practicing these skills
immediately in the session as the therapist wanted them to experience some
level of success in trying them out (skill practice and rehearsal). Mother and
son seemed awkward at first. Lynn, in particular, had difficulty being brief.
The therapist asked her to state a concern she had with Anthony in two
sentences or less and she did so, smiling slightly. For his part, Anthony smiled
when he reflected to Lynn what he had heard her say. The therapist commented that this was one of the first times since beginning therapy that they
both seemed to be enjoying each others company, even though practicing
these skills was challenging (strength-based relational statements).
After two more attempts at practice of the newly introduced skills, the
therapist offered feedback to Anthony and Lynn (review and provide feedback). Anthony was given significant praise for his patience with his mother
and for not looking as though he was getting frustrated with the concerns she
had. Lynn was also given praise for her attempts to reduce her overexplaining
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of the concerns and keeping the statements centered on how she felt about
the issue versus blaming or attacking Anthony. Both needed to continue to
use more brevity and watch the congruence between what they said and their
body language, especially Anthony, as he had a tendency to roll his eyes at
Lynn during the practice.
After modeling and facilitating practicing communication and conflict
management skills in the session, Anthony and Lynn were given homework
to practice these skills in their daily lives. However, to maintain the relational
functions of Anthonys distance/autonomy with Lynn and Lynns midpointing
with Anthony, time limits were set on the interactions between them. They
were asked to meet daily to discuss any issue of concern Lynn had, but for only
short periods of 10 to 15 minutes at a time. If the issue could not be resolved
using the learned skills in that time, they were instructed to take a time-out
until the next day. This strategy helped maintain the sense of autonomy needed
by Anthony while also giving Lynn some measure of contact/closeness and
relational influence with Anthony. Positive time together was also incorporated as a reward for Lynn if they were successful in using learned skills, therefore meeting the contact/closeness need of her midpointing function with
Anthony. For example, the plan included dinner together two times per week
without the technological distractions of cell phones, televisions, and video
games. The therapist found it unnecessary to focus further on the parentchild
hierarchy because Andrew and his mother were seemingly equally influenced
by the others actions and did not exhibit behaviors of a power struggle.
Session 5: Review and Anger Management
In Session 5, the therapist maintained her focus on within-family behaviors and interactions but extended the focus to include concrete anger management skills that were conceptualized to be directly relevant not only for
improving family functioning but also for reducing Anthonys behavior problems outside of the home. With respect to the latter, for example, anger management skills were seen to be protective for his fighting at school as well as
for the assertiveness needed to resist peer influences.
The session started with a review of the homework from the prior week.
Both Anthony and Lynn said that they did not practice as much as they had
initially planned, so the first part of the review involved helping them identify
the barriers that kept them from practicing as well as the times or conditions
that made it easier to do the homework. From this discussion, they were able to
identify times or situations that were optimal to meet and, perhaps even more
important, times when one or both of them needed space (e.g., immediately
after Lynn returned home from work). The review also involved examining
what went well in their discussions, how they felt, and what they were doing
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After exploring with Anthony and Lynn what phrases they each might use as
self-talk, the therapist guided them to think about the situation (e.g., What
gets me angry? Is this really a personal attack or insult? What will be the
consequences if I act aggressively? What good could come out of controlling
my anger?). Then the therapist helped them review options in terms of using
anger as a signal that it is time to do some problem solving (e.g., What can I
do?). The therapist discussed how relaxation, communication skills, a timeout, or other coping skills might be useful for Anthony and Lynn and they
formulated a plan to try out before the next session.
Sessions 6 to 8: Functional Analysis of Behavior, Decision Making,
andContracting
The improvements in communication and conflict resolution skills in
the prior sessions provided a context to focus on building skills that were
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Lynns need for midpointing, the contract was clear about her communication expectations while Anthony was spending this additional time with
peers. For example, the contract stipulated that Anthony had to inform Lynn
about where he was going and whom he was with and that he had to text her
at least once per hour. This met his need for relational distance and provided
him with a valued reward, and it was also consistent with Lynns midpointing
relational function.
Generalization Phase and Termination
The goals for the Generalization Phase were to aid the family in extending and generalizing their learned skills to other relationships outside their
immediate family, maintaining new and positive behaviors by planning for
and responding to relapses in negative behaviors, and supporting the maintenance of positive changes with linkage to resources and other services to
address remaining risk factors of the family and individuals in the family. The
therapists planning for generalization focused on three areas: (a) generalizing
communication, conflict resolution, anger management, and decision-making
skills to other relationships in Anthonys and Lynns lives; (b) developing steps
to get Anthony to attend school regularly and remain in good standing; and
(c) anticipating future barriers to prevent the reemergence of negative behaviors and maintain the positive behaviors in their relationship.
Session 9: Extending Skills to Peers
In the ninth session, the therapist focused on generalizing new communication, conflict management, and decision-making skills to relationships
beyond the family. Given the history of fighting at school, the therapist started
by helping Anthony and Lynn discuss the antecedents and consequences of
Anthonys behaviors and develop alternatives and plans for addressing these
situations in the future.
The therapist also introduced plans for communicating with school personnel about the behavioral contracts that were put in place with Anthony
regarding his truant behavior. Specifically, the therapist coached them on
how to engage and discuss this issue with the school counselor to ensure
that everyone had the same expectations for Anthony. During this process,
the therapist directly addressed Lynns feelings of embarrassment and shame,
which were interfering with her contacting the school to reestablish positive
communication and feedback processes. The therapist and Lynn role-played
this conversation, and Lynn was given the homework assignment of contacting the school prior to the next session.
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that they develop a behavioral contract for these two areas that specified each
of their responsibilities.
Session 12: Termination
In the final session, the therapist began by reviewing the skills that
Anthony and Lynn had learned and demonstrated. Lynn was appreciative and,
beaming at her son, said, I am proud of him, and of us....It hasnt been
easy....It still isnt at times, but we keep trying. Anthony had set a personal
record (at least for the last 2 years) of school attendance, having attended for
2 months without a single missed day or late arrival. Anthony relayed that he
was anxious for spring break as he was going to focus on looking for a weekend
job. The therapist remarked, Lynn, it looks like he heard you. Did you let him
know directly how much you appreciate this? Lynn commented, Well, I dont
see him very often. The therapist responded by saying, I knowhow about
just texting him or leaving a note? and Lynn replied, Sure, I can do that. The
therapist turned to Anthony and asked, So do you need a big hug from Mom,
or would a note do? Anthony turned to Lynn and said, seemingly sarcastically
but in an appropriate way, Oh, please, write a note! Everyone laughed.
The family reviewed the challenges they faced; Anthony still needed to
complete community service hours but had been working with his probation
counselor on a plan to complete them and expressed his intent to do so. Lynn
was laid off from one of her jobs, so they were going to be financially strapped
for a time, but she was happy to report this did not cause her to retreat into
her usual sadness.
The therapist had asked Anthonys probation counselor to attend the session by phone. Anthony and Lynn were required to maintain this relationship
until Anthony had completed all his sanctions, so this provided an opportunity
for the probation counselor to hear directly the progress made by both and
have an understanding of their plan to maintain positive skills and behaviors.
The counselor reported, I still need to see it to believe it, but this is the best
report weve seen for 2 years. Anthony, youve done well. Anthony shrugged
his shoulders but looked down and smiled. The therapist commented on this to
the counselor, who responded, Anthony, you just keep in touch the way you
are supposed to. I want to sign that release form and get you out of my hair.
Everyone, including the therapist, experienced this as a positive response, and
the exchange had a light tone. The therapist thanked the counselor and ended
the session by saying, I hope youll feel free to call me if you want me to do
anything else, but Im ready to get them out of my hair also...and vice versa,
I think. Anthony responded, with a smile, You got it.
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III
Administering and
Extending FFT
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11
Features of Successful
FFT Implementation
DOI: 10.1037/14139-012
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett Waldron,
Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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and feedback. Also, Simpson (2004; Simpson & Flynn, 2007) highlighted
training and supervision as critical elements that contribute to intervention
effectiveness.
Research also shows that organizational readiness acts as the foundation for the successful implementation of EBTs (Fuller et al., 2007; Saldana,
Chapman, Henggeler, & Rowland, 2007). According to the framework
described by Simpson and Flynn (2007), program climate is considered to be
critically important during the implementation phase. Research on aspects
of program climate supports this position (Joe, Broome, Simpson, & RowanSzal, 2007). In the sections below, we provide information about program
characteristics we have found to be favorable to the implementation of FFT
in community settings. Consistent with our fundamental philosophy about
using research to inform practice, the recommendations in this section are in
part influenced by the extant research on the organization variables described
above. However, these recommendations are also based on our extensive
experience disseminating FFT with more than 250 agencies and thousands
of therapists and families.
Organizational Characteristics
Favorable to Implementation
FFT has been successfully disseminated in many settings, including
juvenile justice, mental health, substance use, child welfare, and schools.
Each of these settings presents unique challenges at multiple levels, including
variations in the types of youth and families that are referred (delinquency,
mental health, drug use, trauma, abuse or neglect), philosophies about the
conditions necessary to achieve change (punitive vs. supportive, individual
vs. relational), or commitment to implementing evidence-based practices
(open vs. defensive). It is therefore not surprising that successful implementation requires a careful tailoring of training, supervision, and ongoing
monitoring to meet the needs of each individual system. However, we have
found that the processes involved in achieving successful outcomes actually
are consistent across settings. Thus, although the specific details or content
involved varies by systems or agencies, the larger patterns are predictable.
Agency and Funding Source Buy In
According to Fixsen et al. (2005),
Without hospitable leadership and organizational structures, core implementation components cannot be installed and maintained. Without
features of successful fft implementation
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Many FFT therapists work within organizations or systems, and these systems can have a profound influence, directly or indirectly, on the day-to-day
practice with youth and families. Respecting the influence of these larger
systems and working in coordination with administration are therefore paramount goals of successful implementation. In fact, any dissemination process
to an organization or system begins with information sharing and an open
dialogue between agency administration (and relevant staff and community
stakeholders) and trainers. Within the context of this dialogue, the parameters and expectations about costs, staffing, resources, training, supervision,
ongoing monitoring, communication plans, and so forth are reviewed and
tailored to the unique structures of agencies and systems. In FFT, there are
core principles that are ubiquitous across contexts, such as the clinical content of the model, the delivery of information via training workshops, and
weekly consultation and supervision; however, there is also flexibility in the
process to ensure that training is most effective for the system, therapists, and,
ultimately, families that are served by an agency.
Building agency commitment and buy in to a relational approach is an
essential part of the initial startup process. Even in ideal circumstances, when
agency leadership values evidenced-based practice and believes that working
with families is critical to helping youth in need of services, the expectations that members of the system have can become a major obstacle to the
implementation of FFT when there is a discrepancy between the agencys
standard operating procedures and the recommended course of action in FFT.
For example, when working with child welfare systems, a primary focus often
is centered on the safety and well-being of children and youth in the family.
Unfortunately, this safety-first focus often undermines the treatment process
and leads to immediate negative outcomes for youth and families, most notably the removal of individuals from the home. Although these interventions
may remove immediate risk (e.g., abuse, neglect), they typically have no effect
on creating changes within the family that are sustained over time, and youth
and families remain at risk. Moreover, these interventions often lead to ruptures in the therapeutic relationship that further increase family members risk
for dropout from treatment.
By contrast, FFT therapists work to ensure that the same safety goals are
met, but the focus is on creating lasting change in the family, which can lead
to qualitative differences in how safety plans are implemented at the agency.
For example, in early sessions with high-risk cases, the frequency of sessions
is increased to ensure that immediate motivational goals are met and that the
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learn the model unless they have ample opportunities to work with families.
To ensure the rapid adoption of FFT during training and the maintenance of
FFT over time, we recommend that therapists maintain at least five active
cases at all times. Our experiences suggest that dedicated FFT therapists are
much better able to implement the FFT model with higher fidelity. However,
in many contexts, therapists have many roles and responsibilities and provide
a range of services to youth. These therapists are also able to implement FFT
with high fidelity when they have sufficient cases and time to participate in
supervision or consultation and planning for future sessions.
At the process level, we have found that a number of indicators are
associated with successful outcomes in community agencies. For example,
high initial responsiveness appears to be related to long-term recidivism and
rearrest rates. Responsiveness includes time between the initial referral and
the first and subsequent contacts (e.g., first session) with the family. The phrase
strike while the iron is hot seems appropriate for organizing FFT services:
The more rapidly contacts are made with the family, the more likely families
are to engage and complete the course of treatment. In addition, tailoring initial sessions to the level of risk and protective factors of the family when they
enter treatment is also critically related to the successful completion of treatment. As noted above, this may include scheduling multiple sessions during
the first 10 days after the initial referral for high-risk cases. Such intensity of
clinical services is one way that FFT is able to address issues of safety while
simultaneously creating a context that is conducive for achieving long-term
changes in the family system.
Regularity or density of services is also critically related to outcomes
as the potency of treatment is diminished when there are long gaps between
sessions and it takes 8 months, rather than 4 to 5 months, to deliver these sessions. Time between sessions results in a loss of clinical momentum, and it is
often necessary to cycle back to motivation or early behavior change strategies.
Therapists who are able to engage in frequent contacts with family members
between sessions are able to keep the family actively involved in the treatment
process and, as a result, turn over a larger number of families with greater success over the course of a year. Regular tracking of the number of contacts,
sessions, length of treatment, time to initial contact, and so forth is a valuable
tool for therapists and the agency because it helps provide a justification for
keeping caseloads at a manageable level and yields evidence administrators
can use to sustain or obtain funding for FFT services.
All of these features are relevant only insofar as they lead to model
fidelity. Youth and families do not benefit from interventions they do not
receive! And the impact of any intervention is weakened when the quality
of implementation is poor. Training and supervision provide a context for
providing feedback, direction, and support for therapists to help ensure that
features of successful fft implementation
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FFT is implemented with the highest quality (see Chapter 12, this volume).
The effectiveness of training and supervision on everyday practice, however,
is also heavily determined by therapists openness to learning new information and willingness to try out new procedures and strategies in the sessions
with families. The learning process can be frustrating and anxiety provoking. For experienced therapists who undertake the journey to learn FFT, it
is a natural part of the training process to drift back toward their standard
practices (pre-FFT), particularly with difficult cases. For novice therapists,
feelings of hopelessness or ineffectiveness can be common. However, learning a complex model like FFT takes practice. Patience, a thick skin, and a
supportive supervision and organizational context serve as the foundation for
building fidelity over time.
Interface With Community Systems and Stakeholders
The interface between therapist and agency and the larger community
systems or stakeholders is another important feature that contributes to successful implementation and positive clinical outcomes. The relationship to
larger systems has implications at many levels, including funding, appropriateness and number of referrals, disruptions of the treatment process, and
integration of services. With respect to referrals, for example, collaborating
with other systems to develop screening processes and tools can lead to substantial improvements in the efficiency of referral processes and can ensure
not only that appropriate youth and families are referred to the agency but
also that they are referred in a timely and efficient manner. Working together
with community systems, therapists, and agencies can minimize the dangers
of overscreening cases (i.e., applying numerous rule-out criteria, based on
agency tradition, that are neither required nor appropriate for FFT), a process
that often results in an insufficient number of referrals for provider therapists.
Insufficient referrals lead to issues of underutilization for agencies, reductions
in model fidelity for therapists, and implications for the agencys meeting
outcome expectations for contracts around number of youth served, which
can lead to a loss of funding dollars for youth and family services.
Ongoing communication with the appropriate community stakeholders
is a necessary part of the FFT implementation process. Some agencies have
dedicated staff members who function in liaison roles with external systems.
Many agencies that serve youth from the juvenile justice system have a staff
representative with an office or space in the juvenile court to establish an
ongoing presence that is useful for generating referrals and supporting the
treatment process. With respect to the latter, for example, this liaison may
be helpful in facilitating clinically informed disposition outcomes when a
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youth has violated probation, failed a urine screen, or otherwise come to the
attention of the justice system again. Similar agency liaisons can be useful for
working with schools, child welfare, residential facilities, local or state agencies (family services, mental health, alcohol and drugs), and others.
Irrespective of whether an agency provides dedicated staff or whether the
responsibility falls on the shoulders of FFT therapists (or FFT teams), developing and nurturing relationships with community systems and stakeholders
require careful planning and time. Attending a single meeting with a community agency or stakeholder typically does not lead to any lasting change.
Regularity and consistency in communication are essential. Individuals in
external systems are typically overwhelmed with multiple responsibilities and
tasks; for example, probation officers may have more than 100 youth on a
caseload. A therapist or agency that is out of their sight (so to speak) will
quickly fade out of their minds.
Therefore, it is vitally important to establish a mechanism that gives therapists access to key players in the system. Keep in mind, however, that this is not
a one-way street. Therapists should try to figure out how they or their agency
can help address key concerns these players have. This may be as simple as
filling an important treatment need for a segment of youth or families. Or
it may involve conducting presentations or trainings that count toward professional requirements for licensing. Approaching systems like the school
system with this quid pro quo perspective can be highly effective in meeting
both agencies needs and the needs of the external system.
A first step in building effective working relationships with community
stakeholders involves providing a rationale or education about the FFT model
or way of working. This is not simply providing information about FFT; rather,
this involves tailoring the goals of FFT to the specific needs of each system.
For juvenile justice providers, the initial conversation must include a focus on
how FFT directly addresses delinquent behaviors and concrete details about
expectations of youth, family members, and communication with probation
officers. For school systems, a focus on addressing truancy or conduct issues
may be represented in the development of coordinated behavioral and communication plans with teachers or school counselors. In either instance, the
notion is to match the conversation to the unique needs of the system.
The same principles that are involved in building working alliances
with adolescents and family members apply to developing working relationships with community stakeholders. Therapists should approach all of these
relationships with openness and respect, listen to the needs or issues that are
being generated, and contingently respond in ways that acknowledge the
multiple perspectives that are involved. However, unlike families, the professional context in which these relationships occur requires that therapists
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Conclusion
Organizational climate and support from community stakeholders are
critical factors in the successful adoption and sustainability of FFT. Moreover,
the policies and practices of agencies have direct and indirect influences on
model fidelity and clinical outcomes. Therefore, attending to these features
and nurturing positive processes are critical elements of successful implementation. Agencies can use existing administrative structures to support
implementation or develop new operating procedures to support familybased work. Throughout this process, successful organizations are able to
adapt their agency culture and treatment philosophy to accommodate to
the family-focused, respect-based work that is at the heart and soul of the
FFT model. In doing so, agencies provide a supportive work environment for
therapists to learn and adopt FFT as their clinical intervention. This support
is represented in tangible features, such as therapist caseloads, time for completing case notes, participation in supervision, and planning for sessions, but
also in intangible ways, such as therapists feeling that their unique skills as
FFT therapists are viewed as a valuable resource by leadership in the agency.
These direct and indirect features have a dramatic effect on clinical practice
and, more important, on the process of improving the lives of the youth and
families therapists serve. For youth and families with juvenile justice involvement, offering FFT in the context of ancillary FFT-based services such as
FFP provides promotes coordination of services around a unitary approach
and ensures complementarity of services across the treatment and probation
domains.
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12
Training and Supervision
Family therapy has a rich history of developing and implanting innovative strategies for training and supervision (e.g., H. A. Liddle, 1991; Storm,
McDowell, & Long, 2003). The emergence of distinct schools of family therapy gave rise to unique training philosophies and models (e.g., Aponte & Van
Deusen, 1981; Haley, 1976; Minuchin & Fishman, 1981; Pirotta & Cecchin,
1988), which profoundly shaped the practice of generations of family therapists (H. A. Liddle, 1991). Over the past two decades, the movement toward
providing empirically based services in the mental health field has further
influenced the emergence of highly specialized training and dissemination
models that are necessary to replicate the rigorous clinical standards that are
the hallmark of implementation in controlled studies in community settings.
Because of this, evidence-based approaches have needed to be sensitive and
responsive to the realities, challenges, and complexities of real-world, and
worldwide, implementation.
DOI: 10.1037/14139-013
Functional Family Therapy for Adolescent Behavior Problems, by James F. Alexander, Holly Barrett
Waldron, Michael S. Robbins, and Andrea A. Neeb
Copyright 2013 by the American Psychological Association. All rights reserved.
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Prerequisites:
Knowledge
Commitment
Performance
(Fidelity):
Adherence
Competence
Outcome:
Effectiveness
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Knowledge
Knowledge is a prerequisite for model fidelity. Without a clear understanding and working knowledge of the core principles of FFT, it is unlikely
that therapists will be able to successfully implement the essential components of FFT in an adherent and competent manner. The knowledge aspect
of model fidelity includes a basic working knowledge of the core principles of
FFT. These principles are an important part of therapist fidelity because they
form the background of all therapists clinical actions. Although adherence
and competence are primarily represented by the therapists actual performance in sessions with youth and families, therapist use of his or her knowledge of the model to discuss cases, plan for sessions, and critically review his
or her own performance (and that of other members of their clinical team) is
an important benchmark in therapist development.
Knowledge is not simply about the facts. It is about the degree to which
the therapist uses the FFT model as a foundation to understand youth and
families and then applies this understanding to address the unique needs of
each client. Thus, more generally, therapist knowledge is in part a reflection
of the therapists commitment to and belief in the fundamental principles of
FFT. Training and supervision are designed to foster therapists knowledge of
FFT theory and techniques and to enhance therapists belief in the efficacy
of FFT and their commitment to implement FFT with high fidelity. When
viewed broadly, fidelity includes an assessment of therapists overall knowledge of the FFT model.
Performance
Ultimately, knowledge and commitment are meaningless if therapists
are not able to implement the model. The ultimate benchmark of fidelity
is therapist performance. The bottom line for evaluating therapist fidelity
is whether the therapist is able to apply his or her knowledge in the room
with families. Performance is the degree to which the therapist is doing FFT
(clinical model) as prescribed with families at every stage of the process, from
pretreatment planning and contact to direct contact with families in sessions
to additional contacts with other systems. Knowledge without performance
is not fidelity. Only what therapists put into action in their clinical work
matters.
At a general level, performance involves the extent to which the
therapist implements interventions in a manner that is consistent with the
foundational principles on which FFT is built. Are interventions relationally
focused and respectful (e.g., warm, nonjudgmental, accepting, sensitive)? Are
interventions delivered in a way that matches to family relational functions?
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At the therapist level, the supervisor reviews what areas the therapist
or team is struggling with and develops a plan to structure opportunities for
feedback to address these needs. For example, thinking about themes for a
case, reviewing a slide, or leading a structured role-play using a case as an
example are all possible strategies for building skills. In planning supervision
sessions, we encourage supervisors to attend to the makeup of the supervision group. A group with less experienced or lower-fidelity therapists requires
more direction and feedback. A group with more experience or higher fidelity
(greater competence) may require less direction but more facilitation. With
respect to the latter, for example, the supervisor functions as a guide who
initiates discussions and moves the session along to ensure that all goals are
met but does not necessarily provide feedback or recommendations. A group
with mixed levels of experience and fidelity requires sensitivity to all needs
enough directives to support therapists with more basic needs without losing
the interest of or learning opportunities for the more competent therapists.
Supervisors also are expected to review features of the site or context
that support or interfere with team performance. Issues such as whether therapists have adequate time to participate in supervision, plan for sessions, and
complete paperwork; whether the site values and rewards therapist performance; and whether funding for FFT services is secure are critical considerations for helping the team function at peak efficiency.
The weekly clinical supervision sessions are typically divided into two
key activities: fidelity review and case planning. The goal of both activities is
to enhance the quality of implementation; however, the focus varies. Fidelity
review focuses on the quality of what was done in prior sessions. Case planning focuses on what the therapist is going to do next.
The supervisors fidelity review is guided by several assumptions. First,
the impact of FFT is driven by what therapists do with family members. This
perspective respects the therapists role as an agent of positive change for families. Second, supervision is a critical way to enhance the quality of what therapists do. This perspective places a high value on the goals of the supervision
process. Third, the more cases that are reviewed in supervision, the broader
the impact of supervision on therapist fidelity and, in turn, on clinical outcomes. This perspective assumes that every case can benefit from having
extra eyes reviewing what has been done and planning for future sessions.
Fourth, therapists learn as much from their successes as from their failures;thus, supervision (and fidelity review) cannot solely focus on difficult
cases. This perspective conveys a strength-based focus that values all aspects
of the therapists work. Fifth, what defines fidelity varies by phase of treatment, so fidelity review should include a range of cases across phases. This
perspective respects the unique skills that are required of therapists at different points in the treatment process.
training and supervision
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visory group not get bogged down in extensive discussions about historical
features or characteristics of individual family members. These discussions of
content may be interesting but often serve to derail a focus on interpersonal
or relational issues. Second, a cursory review of what has been implemented
with the family is often a useful way to orient the team about what to do next
with the case. For example, how has the therapist progressed through the
Motivation Phase, what themes seemed effective in reducing conflict, and
how has the plan been tailored to match the relational functions? Third, the
team should help the therapist determine the relational and behavioral goals
for the next session. In part, this means helping the therapist identify the
most pressing issues that need to be addressed for the family. Fourth, the
team should help the therapist develop individualized plans to accomplish
the goals in the next session. Finally, it may be useful to practice specific
skills to be used in the next session (as described above).
Establishing and Maintaining a Working Team
Supervision is a relational process that is geared toward the goal of providing the highest quality of care to youth and families. As such, despite
the relational nature of the process, supervision is inherently task oriented.
It is the supervisors responsibility to create a context in which individual
therapists, the working group of therapists, the agency, and community partners are working toward a common goal. Like the FFT clinical model, there
are foundations and principles for the supervision process that remain relatively stable, which include respect for the individual and unique differences,
strengths, and characteristics of each therapist and a genuine acknowledgment of the professional role of each therapist who has chosen the path of
working with troubled youth and families.
Enhancing Motivation to Practice With the Highest Fidelity
Supervising team members and colleagues is not simply about building relationships. It is about influencing therapist behaviors. In the case of
supervision, it is about getting therapists to continue their development to
competently implement FFT. The early work in this process involves building effective working relationships and enhancing therapists motivation to
practice FFT with the highest quality. This is accomplished by establishing a
personal connection with each therapist, creating a coherent team that works
together and accepts the supervisors role, strengthening or building relationships between therapists, enhancing therapist confidence, and establishing a
structure for supervision.
training and supervision
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directions rather than the more concrete teaching approach required for less
mature therapists. Therapists with high levels of fidelity demonstrate performance of FFT with both high adherence and competence. These therapists
review their cases in a model-focused manner and demonstrate high levels
of participation and learning in group supervision. For these therapists case
reviews, the clinical supervisor monitors and suggests, with little need for
directing them with concrete task feedback.
Keeping all therapists with different levels of fidelity engaged, participating, and learning in a group setting can be tough. If the supervisor remains
focused only on basic adherence development, he or she may lose the attention of therapists with high fidelity. Conversely, if the supervisor remains
focused only on competence development, he or she may lose the attention
of and learning opportunities for the therapists with low fidelity. The supervisor needs to be creative and thoughtful about how to match and support
the learning needs and participation styles of all therapists during a group
supervision session. The working group must ultimately be a source of peer
support, identity, and model fidelity development.
Intervening to Enhance Adherence and Competence:
Quality Improvement
Building adherence and competence requires an ongoing commitment to quality assurance and quality improvement. Quality assurance is a
monitoring- and tracking-based task. Supervisors constantly monitor and
assess the levels of adherence and model competence during each formal
supervision encounter (e.g., staffing) and in each informal case discussion.
Systematically assessing the knowledge and performance issues overall and
phase-based adherence and competence forms the basis of supervision interventions. Quality improvement is the action of the supervisor to improve the
delivery of FFT by the therapist. Quality improvement interventions take
place each time the supervisor makes suggestions or gives input to a case discussion, each time the supervisor talks with a therapist, and each time the
supervisor focuses a working group on specific issues of adherence and competence. Quality improvement may be teaching oriented (e.g., discussing a
principle or issue of the clinical protocol) or discovery oriented, taking the
form of guided discussions (led by the supervisor) or a group brainstorming
discussion. All quality improvement processes are intended to address specific
issues that match to the therapists level of skill and learning style. Initially,
the primary focus of most supervision sessions is to enhance adherence and
deal with specific adherence challenges. As therapists become more consistently adherent to FFT, the focus of supervision shifts to include issues of
clinical competence and sophistication.
training and supervision
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and directed discussion to help the therapist shift the focus back onto what
needs to happen in the session (from the FFT model perspective).
Case-specific suggestions are another way to improve either adherence
or competence through direct suggestions for the specific case under discussion. In fact, the majority of feedback in FFT during supervision is delivered via case-specific, focused suggestions. These suggestions are important
at every level of model implementation, from engagement to generalization
and from assessment to implementation. All case-focused suggestions are
aimed primarily at improving the performance aspect of either adherence or
competence. When targeting competence, the goal is to help the therapist
match to the unique family and apply the FFT model contingently so that it
meets the unique requirements of that specific case.
One supervision technique to provide case-specific suggestions and
tasks is to facilitate a role-play with therapists. Some therapists thrive and
seek this type of practice, whereas some shy away from role-playing. Thus,
it is important to use role-playing in supervision in a contingent manner.
Role-playing provides a unique opportunity to see how therapists perform in
the momentdo they stumble, do they get overwhelmed, do they attempt
to use the various phase-based techniques, are they responsive to the cues
and reactions of the family members? For therapists who are strong in the
knowledge domain but weak in the performance domain, role-playing can
help build performance skills.
Maintenance Process
As the adherence and competence of individual therapists grow, the
clinical supervisors leadership style changes. Most teams experience therapist
attrition and the addition of new team members over time, and so team relationship building and motivation development (and maintenance) always
remain important. As teams change, the supervision goal remains constant;
that is, the focus continues to be on therapist fidelity across a range of clients
and situations. The supervisors role remains an active one as he or she helps
therapists continue to advance their competency levels and watches for drift
in the application of the model. Using the tools described in this chapter,
supervisors carefully monitor each therapist to identify model drift when it
occurs and to strategically use team members with higher fidelity to create
peer-to-peer case-level supervision. In addition, supervisors must continue to
monitor the service delivery context within the agency, advocating for the
team and a delivery context that supports FFT.
The supervision goals of competence development and maintenance
continue for the life of the team. It is usually when a team member leaves or
when a new member is added that the overall group dynamics change to the
training and supervision
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degree that the supervisor may need to begin with a renewed focus on early
team alliance and motivation development and help the new therapists (and
sometimes even therapists who have been on the team for some time) move
quickly into the development of adherence and competence.
The clinical supervisor must assess individual needs and group needs on
a continual basis to ensure that the group remains focused on adherence and
competence. It may be that in a stable group with growing competence, the
supervisor can become less and less directive overall. However, to continue
the development of the group, the supervisor may still find it useful to review
selected clinical chapters or assign homework tasks that will help therapists
develop knowledge and skills in new areas. For example, it may be beneficial
to have the team identify resources for behavior change that are relevant for
the clinical populations being served at their agency.
Strategies for Addressing Common
Supervision Experiences
Experiences commonly encountered in supervision include therapists
defensiveness regarding feedback, their focus on the details of content, and
their experience of feedback as overwhelming. The following sections discuss
each of these issues in turn.
Therapist Defensiveness Regarding Feedback
For therapists, supervision is a relational process that involves the courage to review their work and make a commitment to change. During this
process, therapists may take constructive feedback and recommendations
personally. It is common for therapists to see these comments as a criticism
of their professional capabilities. As such, therapists may experience some
negative emotions over the course of their evolution in FFT. These emotional reactions can be exacerbated by the inherent challenge of working
with very difficult clients. These reactions are a natural part of the journey
for therapists. At any time, one, several, or all of the therapists on a team
may be struggling with implementing the model. And, just as with families,
when faced with such challenges, it is a common reaction to externalize the
problem on some other source. This is a natural process for all of us. This
externalization may take the shape of criticisms directed toward the model,
the supervisor, the agency, or other issuesall of which can serve to derail
the focus on enhancing the adherent and competent delivery of FFT. Thus,
it is the supervisors role to systematically monitor this process and redirect
therapists back to the goals of the working group. In doing so, the supervisor
214 functional family therapy for adolescent behavior problems
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time keeping their eye on the immediate session goals and overall treatment
goals for the cases they are presenting in supervision. This can result in larger
numbers of sessions per phase, longer duration of time in meeting phase goals,
or loss of family motivation. Pointing process is a tool that can be used to
appreciate therapists tendency to become overly focused on details of their
cases. Pointing process allows the supervisor to refocus therapists on the relational aspects of the family. The supervisor needs to be clear and specific with
feedback; for example,
As you discuss what you did in your last session, it sounds to me that
you are getting caught up in the behavioral details of that specific crisis
and losing sight of the chronic family patterns. In doing so, you can miss
opportunities to use the relational interventionsspecifically, changemeaning interventions like reframing or themesto respond to that
story in a way that helps you progress toward your session goals of reducing blame and negativity between the parent and adolescent.
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13
Application of FFT to
DistinctPopulations
219
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Turner, & Peterson, 2001; Waldron & Turner, 2008). There are a variety of
behavior change techniques for the unique problems associated with substance
abuse. However, the behavior change program selected for families is based on
the specific problems associated with each family and on the family functions
identified during the Engagement, Motivation, and Relational Assessment
Phases. When both the adolescent and the parent are involved in substance
use, conducting a functional analysis of their use behavior (i.e., identifying
antecedents and consequences of use, as well as the quantity, frequency, and
circumstances surrounding use) can help reinforce the relational nature of the
substance use problems and identify specific ways in which the adolescent and
parent can support each other in reducing use. This technique can be effective in motivating parents to address their own use and can be introduced as
an informational exercise for parents who resist changing their own behavior.
Positive family activities, communication training, and problem-solving
skills training are considered core behavior change topics in FFTAD to
improve family relationship functioning. Despite improvements in family
relationships, however, helping a youth achieve abstinence or meaningful
reductions in drinking or drug use can be challenging when the youth experiences urges and cravings to use illicit substances. Skills training for coping
with urges and cravings include identifying triggers (i.e., antecedents) of use
and implementing a variety of strategies to avoid high-risk situations. Another
strategy, referred to as urge surfing, involves an imagery technique that helps
youth overcome urges by observing them and becoming immersed in them
during the brief moments urges typically last. All family members with addictive behaviors can participate in activities focusing on coping with urges and
cravings, and family members without addictive behaviors can be included
in discussions during sessions and at home in ways that fit their relational
functions in the family. If the adolescent has a contact or midpointing function with one or both parents, it may be possible to have the adolescent seek
support from the parents, who may or may not have addiction or recovery
experiences themselves, to help monitor and cope with urges to use. Similarly,
relapse prevention techniques can be discussed with the entire family, and
specific responsibilities can be assigned to family members to help support
the adolescents sobriety. For example, when an adolescent girl is invited to
a party, if the mother has a distancing function, she could help her daughter
identify triggers for drug use the daughter might encounter at the party and be
available by phone to pick the daughter up as part of a safety plan.
Communication between the adolescent and the parent is often compromised because of escalated reactions to the adolescents drug use. A common
FFT behavior change strategy to help individuals regulate negative moods
and emotions (e.g., anger management, coping with negative thoughts) can
be effective in this situation. The process involves examining and challenging
application of fft to distinct populations
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By challenging the belief that Justin will follow the same path as the moms
uncle, the therapist can help her develop alternative thoughts to support positive copingfor example, Justin isnt the same person my uncle was, and
he probably doesnt appreciate the comparison. Im just going to thank him
for coming home on time. This process deescalates emotional responses and
helps the family implement more effective communication strategies. The particular menu of behavior-change topics and strategies addressed will depend
on the substance-related issues of the adolescent and other family members.
The implementation of specific topics will depend on the openness of family
members to being supportive of the recovery process and on the appropriate
matching of change strategies to relational functions in the family.
FFT With Contingency Management
for AdolescentDrug Involvement
Contingency management (CM) is an individualized, empirically supported, and behavioral approach that is based on a conceptualization of
substance use and related problems as learned behaviors that are, in part,
initiated and maintained in the context of environmental factors. FFTCM
integrates elements of CM into FFT services by providing low-cost tangible
items (e.g., gift cards for books, restaurant coupons) to youth who regularly
demonstrate a targeted behavior change while enrolled in FFT. Sometimes
incentives take the form of vouchers that can be exchanged for cash or
other goods or services. The incentives are always contingent on evidence
of the desired behaviors, typically abstinence from substance use but also
other identified goals of treatment, such as treatment attendance, homework
compliance, or job-seeking behavior. This specific treatment intervention is
based on clinical research that has demonstrated its effectiveness in reducing
substance use disorders and increasing treatment attendance.
As in all FFT behavior change sessions, the process of completing a functional analysis, discussing urine analysis results, and discussing incentives in
224 functional family therapy for adolescent behavior problems
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Aspects of these models are adapted for families of youth with disruptive
behaviors and are delivered in the sequence and depth necessary to match and
meet the needs of individual families. Specific topics included in the Behavior
Change Phase may include normalization, affect regulation, communication,
cognitive processing, and integration. FFTTF has been implemented successfully with families referred through juvenile justice and is currently under
going pilot testing in preparation for a formal randomized clinical trial.
FFT in Child Welfare Settings
FFTCW is an innovative specialization of FFT theory, principles,
and intervention strategies for children, adolescents, and families served
in child welfare settings. FFTCW is an evidence-informed practice that is
based on FFT. As such, the core features of the model are relational, systemic,
cognitive, and behavioral. Several adaptations were made to the FFT model
to address the complex needs of children and families with a documented
history of abuse or neglect. At the organizational level, program developers
recognized that the cost of family therapy may be too high for it to be used
with all clients. Moreover, the complexity of evidence-based family therapy
requires a level of clinical sophistication that exceeds the skill level of many
case planners who serve youth and families in these settings. Thus, the first
adaptations involved developing (a) a lower cost, less intensive version of
FFT for low-risk clients that matched the skill level of case planners and
(b) a higher cost, more intensive version of FFT for higher risk clients. In
doing so, the primary goal was to improve functioning for all child welfare
clients by tailoring treatment to the clients needs. This approach created
an infrastructure to provide risk-sensitive, family-focused services. The integration of these interventions in a single continuum has the potential to
achieve greater effectiveness and economy in preventive services by delivering the most appropriate, most fiscally efficient, and least invasive or restrictive intervention in response to changing family dynamics and situations. A
second adaptation involved integrating a developmental focus to meet the
needs of youth across the entire age range (018 years). FFT is a relational
approach that matches interventions to the relational configurations of families. With delinquent or substance-abusing adolescents, this often involves
accommodating families in which youth have considerable power to engage
and motivate family members into treatment. However, with younger children in FFTCW, it is necessary to implement more parent-driven intervention strategies to build skills and create a family context in which youth can
flourish. A third adaptation involved expanding the primary treatment focus
from a target youth (e.g., delinquent adolescent) to all family members. This
application of fft to distinct populations
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Behavior change in families struggling with a member who has depression involves strategies to address family relationship functioning, such as
communication and problem-solving skills, as well as targeted interventions
for managing depression and other negative moods. Particular skills are trained
using a menu-driven process, integrating techniques used in evidence-based
treatments for depression in the literature. FFTDEP has relied heavily on the
evidence-based approach called coping with depression (Clarke, Lewinsohn,
& Hops, 1990). Specific topics may include mood monitoring, social skills,
relaxation training, pleasant events, and cognitive therapy sessions.
Social skills sessions focus on conversation techniques, planning for
social activities, and strategies for making friends. Social skills are spread
throughout the Behavior Change Phase to better integrate them with other
skills (e.g., pleasant activities). Relaxation sessions, which teach deep muscle
relaxation and breathing techniques, are taught fairly early in the Behavior
Change Phase because they are relatively easy to learn and provide family
members with an initial success experience, which may increase perceived
self-efficacy (Bandura, 1977), a critical component of successful interventions (e.g., Zeiss, Lewinsohn, & Munoz, 1979). In addition, family members
tend to find these techniques helpful in accomplishing other skills (e.g., social
activities). Pleasant events sessions are based on the hypothesis that low rates
of response-contingent positive reinforcement are a critical antecedent for
depression (Lewinsohn, Biglan, & Zeiss, 1975). Many depressed youth and
families have a limited repertoire of non-drug-related pleasant activities.
The cognitive therapy sessions are based on the hypothesis that depression is both caused and maintained by negative or irrational cognitive schemata. FFTDEP incorporates elements of interventions developed by Beck,
Kovacs, and Weissman (1979) and Ellis and Harper (1961) for identifying
and challenging negative and irrational thoughts. Through a series of progressively more advanced exercises, family members are taught to apply cognitive techniques to their own thinking with the goal of learning to generate
their own effective, positive counterarguments to negative beliefs. Family
members are also taught to correctly identify depressive symptoms so they
can appropriately address the triggers of depressed mood rather than focus on
their own reactions to the behavior. Communication skills training may be
expanded for depressed families by helping family members work together to
constructively interpret and correct negative behavior patterns.
Skills are introduced in a manner designed specifically to be in keeping
with the familys assessed functions and presenting problems. Thus, the same
skill may be implemented very differently in families with self-cutting, suicide attempts, and other intense behaviors than in families characterized more
by extreme sad affect, social withdrawal, and lethargy. The therapists focus is
on helping the family work together to develop skills. Because many parents
230 functional family therapy for adolescent behavior problems
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of depressed youth also suffer from depression, the Behavior Change Phase
includes strategies to address negative moods as a family issue. For example, the
entire family, including nondepressed members, can participate in the identification of distorted thinking patterns, and all can participate in planning effective strategies for challenging these patterns when they occur at home.
Conclusion
If imitation is the highest form of flattery, we would like to believe
that specific specialized applications of the FFT model are a reflection of the
widespread and solid basis that FFT represents now and for the future. Each
of the specializations described in this chapter reflects requests from other
treatment systemssystems already familiar with and confident in the ability of the core FFT model to provide an effective and sustainable treatment
approach to diverse clinical challenges involving youth.
To conclude, the only caveat remaining is that of the need for all clinicians to do their homework. As clinicians apply FFT or any other treatment
strategy to new populations, we ask that they first develop knowledge of the
populations and syndromes involved. As noted in the beginning of this book,
FFT has always looked to more than mental health treatment resources for
knowledge regarding treatment populations: Sociology, psychiatry, anthropology, psychology, and literatures pertaining to gestalt theory and dynamic
systems theories together represent perspectives on what should be done in
any particular clinical situation. These perspectives are not equally relevant
to all cases, but it is the clinicians job to sort through the dynamics of each
specific clinical case to determine which balance of perspectives best serves
the clinical process. We have done that in FFT with respect to high-risk,
difficult-to-treat adolescents and their families, and we hope that as we have
described the result of this work, we have provided a service to a great and
diverse range of clinicians.
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Index
After-school programs, 162
Agencies, buy in from, 189191
Alcohol-abusing runaway youth,
outcome research for, 46, 57
Alcohol use and abuse. See Substance
use and abuse
Alexander, J. F., 2224, 2935, 3740,
5052, 62, 68, 78, 220, 226
Alliance(s)
of therapist with parents/adolescents,
3234
working, 195196, 215
Alternatives, presentation of, 147148
Androgyny, 120
Anger
reframing of, 108
and stimulus-control interventions,
136
Anger management (case example),
179, 180
Anglo families, outcome research for, 56
Anthony (case example), 167184
Behavior Change Phase, 177182
Engagement Phase, 168171
family demographics, 168
Generalization Phase, 182184
Motivation Phase, 171176
referral information, 168
Relational Assessment Phase,
176177
termination, 184
Aos, S., 45
Appreciation, in Behavior Change
Phase, 140
Appreciation, of therapist efforts, 215
Arbuthnot, J., 41, 42, 53
Arguing, 127
Arrested youth, outcome research for, 43
Assigned tasks, in supervision, 208
Attachment, self-regulation, and
competency (treatment
approach), 226
Attention
acting out for, 154
and maladaptive behavior, 136
247
13190-16_Index.indd 247
2/8/13 11:14 AM
248 index
13190-16_Index.indd 248
2/8/13 11:14 AM
Community systems
linking FFT with, 70, 71
and success in FFT implementation,
194196
Competence
defined, 203
enhancing, with supervision, 211213
maintenance of, 213214
monitoring of, 205
Competence levels, and supervision,
202203
Complementary behaviors, 21
Compromise, problem solving with, 150
Concreteness, of communication, 147
Conduct disorder, 225
Conduct-disordered youth, reframing
for, 106
Conflict management (case example),
177179
Confusion
about feedback, 215216
from reframing, 106
Congruence, of communication, 147
Connection, relational, 120124
Contact/closeness, 120, 121, 123
Contingency management (CM),
224226
in Behavior Change Phase, 141143
hierarchy for, 153154
Contracting, 144145, 181182
Control, balance of, 124
Controlling behavior, reframing of, 108
Cost analyses, in outcome research, 41,
44, 45, 53, 58
Cultural issues, with negotiation/
contracting strategies, 144
Davidson, K., 225
Decision making skills, 181
Defensive behavior, reframing of, 108
Defensiveness, therapist, 214215
Delinquency (delinquent youth)
non-delinquent vs., 29
in outcome research, 48
outcome research for, 3839, 42, 45
and within-family negativity, 31
Density, of services, 193
Depressed youth
matching with, 67
outcome research for, 49, 61
index
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Family characteristics
and Behavior Change Phase,
130131
and intervention effectiveness, 205
Family context, 4
Family dysfunction, and depression, 231
Family functioning
observations of, 28
in outcome research, 51
Family members, 4
cognitive schemata of, 8889
developmentally-appropriate change
plans for, 133
expectations of, 81
motivation of, 5
of referred clients, 7980
as session participants, 7172
Family negativity, 6
change-focus interventions for,
9294, 9699
in process research, 2932
Family systems, 4, 8183
Family systems theory, 20
Fathers
and gender factors in therapy, 3435
step-, 127
Fear, reframing of, 109
Fearless empathy, 9091, 111
Feedback
in Behavior Change Phase, 138
confusion about, 215216
in supervision and training, 201202
and therapist defensiveness, 214215
Female one-up hierarchical pattern,
126
FFP (Functional Family Probation), 196
FFT. See Functional Family Therapy
FFTAD (Functional Family Therapy
alcohol and drugs), 220, 223
FFTCM (Functional Family Therapy
contingency management),
224226
FFTCW. See Functional Family
Therapychild welfare settings
FFTDEP (Functional Family Therapy
depressed youth), 220, 230
FFTG (Functional Family Therapy
gang-involved youth), 220
FFTIR (Functional Family Therapy
integrated reentry), 220
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Needs, 119
Negative behavior, reframing motivation
for, 101107
Negative reinforcement, 142, 143
Negativity
in case example, 172, 175177
therapists reflection of, 104
within-family, 6, 2932
Negotiation strategies, 144145
Neuropsychology, 21
Newberry, A. M., 35
Newell, R. M., 31
New York City, 225
Noble intentions (reframing), 102107
Nonblaming-relational themes, 99102
Nondelinquent youth, delinquent vs.,
29
Nonverbal behaviors, systematically
attending to positive elements
in, 97
Normal, helping challenged families
become, 163164
Observational approach (process
research), 28
Office of Juvenile Justice and Delinquency
Prevention, 5
One-down behavior, 124, 125
One-up behavior, 124, 125
One-up parenting, 66
Operant learning model, 136
Oppositional defiant disorder, 225
Oregon Research Institute, 59
Organizational readiness, 189
Organizational variables, 189196
agency and funding source buy in,
189191
and clinical outcome, 188189
community/stakeholder interface,
194196
process of therapy, 192194
therapist, 192
time and flexibility, 191192
Organizing themes, 62
Outcome monitoring, 205206
Overscreening, of cases, 194
Overwhelming, therapists experience of
feedback as, 215216
Ozechowski, T. J., 44, 47, 48, 49
254 index
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Siblings
delinquency of, 52
as session participants, 71
Simpson, D. D., 189
Single mothers, matching with, 69
Site-related characteristics
and intervention effectiveness,
205206
reviews of, 207
Skills and skills training, 230231
extending, to peers, 182
family memberintitiated skills, 162
in Generalization Phase, 158
and interventions, 222, 223
parenting skills, 228
relationship skills, 90
therapist skills, 132
Skinner, B. F., 19
Slesnick, N., 44, 46, 57
Social context, family negativity and,
2930
Social engineering, 19
Social learning model, 136
Social learning strategies, 1920
Social media sources, 162
Socialrelational leadership style, 22, 23
Social skills sessions, 230
Social work, 162
Sociopaths, 105106
Source directness (communication
training), 146147
Source responsibility (communication
training), 146
Specificity, communication, 147
Sprenkle, D. H., 40, 41
Stakeholders, and success in FFT
implementation, 194196
Stanton, M. D., 40, 54
Stepfamilies, 71
Stepfathers, 127
Stereotyping, gender, 120
Stimulus-control interventions, 136
Strategies, 116, 162
Strength-based interventions
and therapist characteristics, 8991
for therapists, 215
Strength-based models, 4
Strength-based questions, 127
Strength-based relational statements, 98
Stresscoping model, 136
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of Mental Health, the National Institute on Drug Abuse, and the University
of Utah. He has published three books on FFT and more than 80 articles and
chapters and has given hundreds of presentations and webinars nationally
and internationally.
Holly Barrett Waldron, PhD, is a senior scientist at the Oregon Research
Institute (ORI) and director of the ORI Center for Family and Adolescent
Research. She has been involved with Functional Family Therapy (FFT)
clinical development and research for over 30 years, including the early
efforts of the FFT team at the University of Utah and later the development
of the FFT Blueprint for Violence Prevention model for the University of
Colorado Center for Violence Prevention. She began training FFT therapists
in the clinical psychology and licensure for alcohol and drug abuse counseling
programs at the University of New Mexico in 1988.
Dr. Waldron also established a program of research evaluating FFT
through a series of clinical trials funded by the National Institutes of Health. To
date, she has conducted more than a dozen randomized clinical trials and other
investigations examining the efficacy and effectiveness of FFT. Her research
and clinical efforts have focused on the implementation of FFT for adolescent substance use disorders, delinquency, depression, and HIV risk behaviors.
The investigations she and her colleagues at ORI have conducted have led to
innovations in FFT, including specialized behavior change technologies for
substance abuse and depression, evidence-based strategies for integrating motivational incentives into FFT to promote abstinence, and strategies for reducing drug use relapse and recidivism through an FFT aftercare program. She is
currently directing research to evaluate FFT supervision using observational
training methods and evaluating the delivery of FFT to rural families via a webbased video link. As a scientistpractitioner, Dr. Waldron is actively engaged
in FFT dissemination and has extensive experience training and supervising
FFT therapists in community settings. She has developed a Spanish-language
training system for FFT and has trained FFT therapists working with Spanishspeaking families in the United States and in Latin America. Dr. Waldron
is currently disseminating FFT through Leading Implementations in Functional Family Therapy Co. (LIFFT). The primary focus of LIFFT is to expand
the adoption and reach of the FFT model nationally and internationally,
with an emphasis on treating drug abuse and related problems.
Michael S. Robbins, PhD, completed his doctorate in clinical psychology at
the University of Utah and a clinical internship at the University of Miami
School of Medicine. He served as research associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Miami
School of Medicine for 15 years. He is currently a senior scientist at the
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Oregon Research Institute and research director for Functional Family Therapy,
LLC. Dr. Robbins has many publications in the area of family therapy for
adolescents with behavior problems. He has extensive experience conducting clinical research on family therapy with drug-using, delinquent adolescents and their families, including innovative process studies that involve the
examination of in-session processes across three empirically validated family
interventions as well as large multisite trials examining the impact of family
therapy in real-world settings. He has directly overseen the training of hundreds of family therapists both nationally and internationally. Dr. Robbins is
a frequent lecturer and consultant and is recognized as a leader in the areas of
process and outcome research in adolescent drug abuse treatment.
Andrea A. Neeb, MS, received her master of science degree from Nova
Southeastern University in 2001 and became a licensed mental health counselor in 2004. Over the past 10 years, she has worked with Functional Family
Therapy (FFT), LLC, as a trainer and consultant. She has been involved in
the dissemination and training of the FFT model to organizations throughout the United States and Europe. Ms. Neebs primary focus of work has
been in the clinical development of therapists in their practice of the FFT
model with diverse client populations and settings.
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