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