Functional Family Therapy Clinical Training Program Case Conceptualization & Case Planning Webinar...
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Transcript of Functional Family Therapy Clinical Training Program Case Conceptualization & Case Planning Webinar...
Functional Family TherapyClinical Training Program
Case Conceptualization & Case Planning
Webinar #3
Thomas L. Sexton, Ph.D., ABPP
Functional Family Therapy Associates Inc.
Training Goals
1. Discuss the role of case conceptualization as a foundation for FFT treatment
2. Identify the critical elements of case planning • Planning for the case• Planning for the phase• Planning for the session
3. Review the role of the Progress Notes & Case Planning guides in case conceptualization and planning
What does it take? A therapist that……
• Looks through a “lens”• Follows a Model……follow the “map”• Creates and implements a “unique case plan” for each
family• Use “in the room” experiences to promote
change (change mechanisms)
• Creatively Adapt.....• Matching to the client• adapting next response to”
• match client/context• add what was not understood/missed
• Iterative Process….evolves over time
Doing FFTwhat you do in the room
-reframing problems/blame/negativity-interrupting negative behavioral patterns
-promoting the use of new behavioral competencies
-generalizing change
Thinking FFTWhat you do outside the room
• Case conceptualization• Put client story into core principles
• Thinking through the lens
PlanningWhat you do outside the room
1. Case planning2. Session planning
• Goal (which one is most important)• Progress (progress in achieving the goal)
Keys to success in FFT
• Model specific Case conceptualization• Model & client driven planning• In a way that….
• Matches the family process• Matches the families way of functioning• That is relevant and important to them• That helps reduce risk factors• Reduces the likelihood of future behavior problems• Empowers the family to keep changes going
Functional Family Therapy
Case ConceptualizationWhat lets you make model specific and client center actions that
help
Case Conceptualization
• Understanding the Family through the FFT “lens”– Presenting Problem– How the family functions
• Problem definitions• Relational patterns• Relational functions
– The multisystemic context….• Of the problem• Of the family
– Risk and protective factors
Example
• Regina (14 years old)• Referred to mental health center from juvenile court• History of difficulties
• Early school problems• Hospitalization
• Most recently….– Drug use (mj)– Drug rehab residential treatment
• Other problems in the family
Initial Questions
• Is this an FFT case?• How and what “lens” to use in understanding
Regina• Where to start (in FFT)• How will therapy proceed?• What is a possible outcome?
(much of this you know….without any more information!) by listening with FFT “ear”
Listening with an FFT ‘ear’
Client Story (Events)
(details of the case….history….purpose for the
referral)
Translating into relational patternRelational Patterns
(holistic understanding/where to intervene)
Relational Function(to match to client)
Problem Definitions(to translate into Family Focused
organizing theme-identifyWhat is “important” to
the individual
Risk & Protective Factors(what to add to BC)
Context(multisystemic context-
Who is involved)
What to ask yourself ….• “What does this tell me about what is important to this person?”
– The answer to this question helps the therapist know what to acknowledge in reframing.
• “What does this tell me about their relational patterns and how they link the family members together?” – This assessment helps the therapist develop a family-focused way of
understanding how the presenting problem functions.
• “What does this tell me about the biological, historical, and relational things that family members bring to any interaction that will help me understand why they are reacting this way?” – This assessment helps the therapist determine where the energy and
emotion might come from and also helps identify what to acknowledge in the reframing process.
• “To what cause are they attributing the problem? What is the problem definition?” – This assessment helps the therapist identify the target for blame and form a
target for reframing.
Internal WorldBiological
Substrate/Learning History/individual
traits
Clinical Symptoms/Behaviors
Family Relational System
Ecosystemic SystemPeer/school/community/extended family
Ecosystemic SystemPeer/school/community/extended family
(Sexton & Alexander, 2004)
Culture
Mom/mother figure
Dad/father figure
Adolescent
How does the family Function/what role does the problem play
Environmental ContextEcosystemic system
Peer GroupSchool
Community
Risk Factor
Risk Factor
Risk Factor
Risk Factor
ProtectiveFactor
ProtectiveFactorProtective
FactorProtective
Factor
Why are things so important?
•Where people come from (relational context)– Types of relationships…with parents/family
•What people are made of….(biological context)
•The environment in which they live (ecosystemic context)– Peers/schools/mental health system/community
Client StoryThe “why” things are so important,
meaningful, etc.
Anja: “ Regina have you done…””you know you are getting behind”….”you need to take some responsibility” (escalating the longer she doesn’t answer)
Regina: “Whatever….later, I am going out…., I’ll be home…..”
Anja: “there is no going out for you….it just isn’t good for you…..you know you can’t say no to those friends of yours…”
Regina: “At least I have friends…later…” he goes out.
Anja: (to her husband)…”I can’t do anything with him…and you don’t help. I would at least like your support
Anja: is hurt by his comment…goes to her room…watches TV…worries and “feels” bad about her situation……
Stepfather: …continues watching the football game…worries about his wife…gets angry with Peter…..”
Regina: (comes home 5 hours late. Comes in the house and goes upstairs…on the stairs his mother comes out of her room…
Stepfather: …”I am tired of this…what is the matter with you…don’t you know how this hurts your mother?”
Peter: “Fuck off..” the typical argument ensues until Peter goes to his room
Anja: “What are we going to do..I can’t take this any more…”
Regina: “I am sorry Mom…but, I can handle it”
Anja: “I just worry about you” (she feels comforted that he understands)
Regina: “I can handle it Mom…just keep that bastard away from me…” (he feels better about his Mom….he directs his anger at his step father….). The next night he goes out again….
Stepfather: …When she talks, he continues to watch to TV…..he listens quietly and say…”what do you want me to do…he wasn’t raised right…”
Relational PatternsCommon/typical “way” they interact
• “Problems” are embedded in the context– They are relationally based
• Family has been functioning for some time….encountered problem that has become “part” of the family….now “functions” as a central part of how they relate
– Not what they “want”– Not what they “need”– They way in which they have come to “be” in response to the
“problem”
What is the Problem?
Story takes the form of problem definitions
Mom/mother figure
Dad/father figureAdolescent
Referral Behavior
Problem “definition-what the problem is
-why its an important problem-what should be done about it
Problem “definition-what the problem is
-why its an important problem
-what should be done about it
Problem “definition-what the problem is
-why its an important problem-what should be done about it
What does this tell you
Family “problems” are relational problems
In their attempt to solve/deal with the problems….• Family come to therapy with a “definition” of what is the
problem– Result of each family members experience and thinking/working to understand
their life/problems– Natural part of finding a solution
• This definition is usually:– focused on “a person” (attributional component)– has negativity attached (emotional component)– is accompanied by blaming interactions that have become central to the
relational patterns of the family (behavioral component)
•
Relational Functions• Functional outcomes of these patterns
• Relational “glue” • Stable and consistent
Mom/mother figure
Dad/father figureAdolescent
Clinical Symptoms
Match to…
The goal….Reduce the future
Probability ofthe “problem behavior”
Targets of Change-underlying patternsof FAMILY behavior
Relatedness Assessment
Mom
Adol
Dad
33
1
13
1
Mom
Adol
When X relates to Y, the relational pattern (behavioral sequences in the relationship ) of X’s behavior
is characterized by:
RelationalIndepende
nceAutonomy:
distance,Independenc
e,Disengagem
ent)
high
low
Interdependency: closeness, dependency, enmeshment
low high
12
4
5
3 Mid-pointing
Case conceptualization in the “real world”
• Given all you have to do…..thinking in this complex way is very difficult
• In the “real world”…• What you do out of the room• Aided by the FFT progress notes
– Walk you step by step through case conceptualization– Make sure you don’t get lost– Help you overcome your own values and biases
– Happens over time….Iterative– Not as a stage….but as treatment is going on– Building a “picture of the family” in which you add more
and more
Functional Family Therapy
Case PlanningWhat to do in the next session, session, phase etc.
Treatment Planning
• Understanding the Change process…the map of change– Phases (what is first, second, third….)– Mechanisms to use in achieving the phase goals– Family focused/driven outcomes that are
obtainable and relevant
• planning is the way to bring the content and the process of therapy together
Treatment Plan
Early Middle Late
Reduce within family
risk factors
-negativity/blame
-hopelessness
-build engagement/
reduce dropout
Behavior ChangeMotivation
Engagement Behavior Change Generalization
Generalization
Build within family
protective factors
-behavior competencies
-interaction change
-that increase probability of
- behavior
Build family to context
protective /reduce risk
factors
-peers/school/
community
Early Middle Late
Assessment
Intervention
Case Planning
• Systematic process that includes– Next session planning
• Goals of the phase• “What needs to be done next?”
– Long term goals…..• Obtainable change• What matches the family• The smallest change that will make a differences
Session Plan
Motivation
Intervention
Assessment
Engagement Behavior Change
Behavior Change
Generalization
Generalization
Early Middle Late
Goal-phase/intermediate objectives
Skills -therapist actions that have high probability
of reaching those goals
Goal-phase/intermediate objectives
Skills -therapist actions that have high probability
of reaching those goals
Goal-phase/intermediate objectives
Skills -therapist actions that have high probability
of reaching those goals
What therapy changes
Individual
Mom/mother figure
Dad/father figure
Adolescent
1. Most critical issuesolved…and
2. Prepared for the next “problem”
-cope/deal with in a new way-empowered with a “way”
To solve future
Long Term Outcome Goals
• The behavioral outcome goals of therapy are those that are obtainable and lasting
• not healthy families but……..• obtainable behavioral changes
• ...are those that are:– obtainable behavioral changes …– for these people …– with these resources …– and these value systems …– in this context
Case Plan
• Based on:• the model• matching to the client• Case conceptualization--understanding clients
relationally--understand problems relationally
• FFT’s Systematic Change Model• A model focused yet client/clinically responsive process….
– Systematic and flexible… – The therapist “anchor” and “lens”….– The source of therapist creativity
Example
• Regina– Early goals:
• Alliance-common problem definition, goals & bond• Shared family focused problem definition• Reduction in blame/negativity
– Intermediate goals:• Problem solving• Conflict management
– Long Term goals• Family can manage supervision, work out problems
Engagement/Motivation Sessions
Goals• reduce within family
blame• reduce within family
negativity• build therapeutic
alliance• redefine problem as
family focused• increase
hope/expectation for change
Assessment• problem definitions• Problem sequence• How they “function”
or work together
Interventions
• reframing • Develop an
organizing theme that is family
focused• diverting and
interrupting• structuring session
to discuss relevant topics
Behavior change sessions
Goals• Specify the
behavior change “individualized
plan”
• Link BC targets to the organizing theme to build relevance and
motivation
• Build compliance
• match to the client
• check if the BC target works to solve conflict
Assessment• Identifying prosocial
family based skill that fits youth/family
problem sequence
• Find barriers to adoption of BC skill
• Determine if the target is being
performed (compliance)
Interventions
• reframing • Modeling• Teaching• Overcome barriers/adapt
Discussion focused on:
-homework, going out with peers,
curfew-specific spot in the
sequence
Problem Solving
Communication-direct and concrete
communication
Parenting-monitoring and supervising
Where they use:
Work out problems…our
focus is on their process of doing so
Parent Adolescent
With components of….to individualize to the family
Targets of FFT Behavior Change
Conflict Management
Generalization Sessions
Goals• Generalize the BC target skills to
other areas
• Maintain change through relapse
prevention
• Access external resources to
support change
Interventions• Relapse prevention
(if the family is falling back into
problem behaviors)
• Linking new problem situation
to BC skill• Linking family to
relevant outside resources
Assessment• Identify external family systems to
apply BC skills• Identify contextual
barriers to maintaining the BC
target• Find areas to
generalize• Identify relapse
points
Using the FFT Progress Notes
Using the FFT PN
Process/Phase Goals Importance over time
Blame reduction
Negativity reduction
Alliance Family Focus
problem
0
0.5
1
1.5
2
2.5
3
3.5
4
session 1session 2session 3session 4
Using the FFT Session Planning Guides
Using the FFT Session Planning Guides
Using the FFT Session Planning Guides
Keys to success in FFT
• Model specific Case conceptualization• Model driven planning• In a way that….
• Matches the family process• Matches the families way of functioning• That is relevant and important to them• That helps reduce risk factors• Reduces the likelihood of future behavior problems• Empowers the family to keep changes going
What does it take? A therapist that……
• Looks through a “lens”• Follows a Model……follow the “map”• Creates and implements a “unique case plan” for each
family• Use “in the room” experiences to promote
change (change mechanisms)
• Creatively Adapt.....• Matching to the client• adapting next response to”
• match client/context• add what was not understood/missed
• Access change....did it work?
• Questions?• Next Steps